| BackgroundThe County Medical Community is a county-rural integrated medical service model in which the county hospital is the leading hospital,the township hospital is the hub,the village clinic is the bottom of the network,and the three levels are coordinated to jointly meet the medical and health service needs of residents in the county.However,in the process of implementation,there are still problems in the County Medical Community that focus on form over content and quantity over quality,and most medical communities only use technology as a link to form institutional alliances,the structure is relatively loose,and there is still a patient-oriented competition between the tiers.In order to solve the above problems,in 2019 the National Health Commission launched a pilot project to build the Close County Medical Community across the country,in which 47 counties(cities and districts),including Jiyang District in Jinan City,Shandong Province,were included in the scope of the pilot counties.Since the implementation of the reform,Shandong Province has based on the new era of health and health work policy of "focusing on the grassroots",and achieved positive results in enhancing the overall capacity of county health services and the grassroots accessibility of health services,as well as effectively reducing the burden of medical care on the public.However,the reform of the medical and health service system is a social system project involving a wide range and great difficulty,and the construction of the County Medical Community in Shandong Province started relatively late.The development of the Close County Medical Community in each pilot area still needs to be continuously explored and improved in practice.Therefore,it is particularly important to systematically evaluate the effectiveness of the construction of the Close County Medical Community in Shandong Province and summarize the experience in the construction.ObjectiveLearn about the construction progress of the Close County Medical Community pilot project in Shandong Province from four aspects:responsibility community,management community,service community,and interest community.From the perspective of input and output of health resources,the operation efficiency of the Close County Medical Community in each pilot area was analyzed.The reform effect of the Close County Medical Community in each pilot area was analyzed from four dimensions:orderly medical treatment pattern,county-level medical and health service capacity,medical and health resource utilization,and medical insurance fund utilization efficiency.Find out the problems existing in the implementation of the Close County Medical Community in Shandong Province,analyze the causes,and put forward reference suggestions for improving the policy.MethodsThe research took 47 pilots that were included in the national Close County Medical Community in Shandong Province as the research object.And the data comed from the monitoring system of the Health Commission of Shandong Province for the Close County Medical Community from 2019 to 2020,the self-assessment of the Close County Medical Community construction rubric in each pilot,and the public data of each pilot Health Commission.Descriptive analysis was carried out on the compliance rate of 11 indicators in 4 aspects of the evaluation criteria for the construction of the Close County Medical Community in each pilot in 2020.Data envelopment analysis was carried out on the operation efficiency of the Close County Medical Community in Shandong Province from 2019 to 2020;random effect Tobit regression model was carried out on the influencing factors of the operation efficiency of the Close County Medical Community.After describing the changes of 26 indicators in 4 dimensions of the Close County Medical Community monitoring system from 2019 to 2020,the entropy weight-Topsis method was used to comprehensively evaluate the reform effect.Results1.In terms of construction progress.In 2020,A total of 36(76.6%)pilot areas in Shandong Province had reached the standard for the construction of the Close County Medical Community,5.6 percentage points higher than the national average pilot level.The overall construction situation was good,but the overall management of medical insurance still needed to be improved.There were certain differences between regions,and the compact construction in northern Shandong needed to be strengthened.2.In terms of operating efficiency.In 2020,12(25.5%)pilot areas had effective DEA,and their resource input had been fully utilized.There were differences between regions,and the operation efficiency of the pilot in Jiaodong was slightly lower.The bed utilization rate of primary health care(PHC)institutions,and the number of inpatients transferred from the leading hospital to the grassroots were positively correlated with the overall operation efficiency of the Close County Medical Community;the number of leading hospitals and the number of general practitioners with a population of 10,000 in the county were negatively correlated with it.3.In terms of reform effect.In the dimension of orderly medical treatment pattern,the hospitalization rate within the pilot counties of the Close County Medical Community in Shandong Province has increased from 90.1%in 2019 to 93.7%in 2020,which has reached more than 90%of the national requirements;the proportion of hospitalizations within the county was 74.0%,which increased of 0.2 percentage points over the previous year:In the dimension of county-level medical and health service capacity,the proportion of third-and fourth-level surgeries among discharged patients from the lead hospital increased to 48.4%in 2020;the new technologies and new projects that the lead hospital helped PHC institutions to carry out increased to 14.4 in 2020.In the dimension of medical and health resource utilization,the proportion of primary outpatient and emergency departments consultations increased to 50.0%;the bed utilization rate of PHC institutions dropped to 50.8%.In the dimension of medical insurance fund utilization efficiency,the expenditure rate of medical insurance funds in the county area was 59.3%,and there was no significant change compared with the previous year.The comprehensive analysis of entropy weight-Topsis showed that there were differences in the reform effect of various regions,and Jiaodong region was slightly behind;the pilot areas that have reached the compact standard were better than the regions that have not reached the standard;the areas with effective DEA were better than areas that are ineffective.Conclusions and RecommendationsConclusions:While steadily advancing the integration of the Close County Medical Community,Shandong Province had focused on upgrading the service capabilities of medical institutions at the county,township and village levels,and has achieved good reform results.However,there are still some deep-seated problems in the construction process,and it was still necessary to further explore the implementation path according to the specific situation of their own social economy and medical resources.1.The overall operation efficiency of the Close County Medical Community was improved,and there were differences between regions.2.The pattern of medical treatment has been improved,and outpatients in the county have returned to the county and the grassroots level,3.The medical service capacity in the county area has been improved,and high-quality medical resources have been deployed to the grassroots,but the quality of basic public health services has declined slightly.4.The utilization efficiency of medical and health resources has improved,but the utilization rate of primary medical and health resources needs to be improved.5.The medical expenses in the Close County Medical Community have been controlled to a certain extent,but the return of medical insurance funds in the county and the inclination to the grassroots still needs to be improved.Recommendations:According to the research results,it is suggested to improve the construction of a close medical community from the following five aspects:1.Optimize the allocation of health resources and improve the operation efficiency of the Close County Medical Community;2.Balance the interests of all parties in the Close County Medical Community and improve the incentive and guarantee mechanism;3.Strengthen the service capacity building of county-level hospitals,and institutions at all levels should carry out dislocation development;4.Optimize the internal homogeneity management of medical communities and improve the level of grass-roots services;5.Deepen the reform of medical insurance payment methods under the medical community model. |
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