Implementation And Impact Of Family Doctor Policy In Changning District

Since implemented in 2009, the new health care reform has focused on guaranteeing the basic medical insurance, improving grassroots medical institution and establishing the health care system. It calls for the further change and enhancement in the community health service. A family doctor system (FDS) becomes the significant foundation of the new reform of health care. The local innovation in FDS comes from the newer urban medical care system, which brings order and efficiency, centered with family doctors and based on the community services. It targets to guide the order of medical service, improve the management of disease, and control the cost of health care, and thus solve the three fundamental problems in the health care sector. The first is short of medical service due to the structural imbalance of demand and supply, the second is increasing health care cost led by excessive medical treatment and induced demand, and the third is the difficult change in the medical service model face with the high incidence of chronic disease with the aging population.In 2011 the State Council promulgated the "Guiding Opinions on the Establishment of a General Practitioner System (GPS)", affirmed the current significance and necessity to establish the FDS, and also indicated the direction and destination on the way to deepen the reform of community health services. Pilot cities gradually explored and practiced the FDS construction under the guidance, however, because of different endowment in local health service development, as well as lack of systematic and scientific research in FDS construction, they have little cognition and comprehension of the whole map of the system depicted by the objective, value, and logic of the policy, and the contents, mode, and quality of the health service, on the road to carry out the FDS. Therefore, it is quite significant to summarize a set of theory and share the experiences of the model by examining and summarizing from both theoretical and empirical aspects of the FDS. In this paper, Changning District is taken as a typical case, and its policy effects as well as the constituted theory model will be tested by the empirical data provided during policy implementation. The research is to provide a referential mode of GPS construction, and also some particular policy advice to its implementation in China.Firstly, in this paper, they are examined and then summarized that the logic and design in FDS construction policy from the practition in Changning. It considers that after constituted the standards and implemented the reform in service mode of GP, Changning has completed the first and the second phase of FDS construction, which then paves the way to the innovation in the reform of FDS, by the means of stimulating the needs of medical service among the residents and improving the supply of medical service in community in the way of training a lot of general practitioners of enough knowledge and skills. Based on this, Changning began in 2009 to explore the FDS construction, in the ways of establishing the contractual relationship when the family doctors supply contracting service to the residents. It was the main part of policy implementation, which tried to realize three policy goals on the foundation of one system and two mechanisms. The system is the medical service system with the core of family doctors, based on the Family Doctor Studio and Local platform of Synergistic Services. It defines the limits of work and responsibility to make the family doctor take total responsibility to the limited resident group, and meanwhile complete the reform of creative service model(3rd phrase) and construction of synergistic platform(4th phrase) by supplying supports of resources, information, skills, service, and so on by synergistic services. Then one of the two mechanisms is competition in contracting service market based on the balance between rights and obligations, and the other one is evaluation and stimulant mechanism based on capitation payment. The two constitute a dynamic and incentive mechanism, which means that family doctors supply the contracting services to the contracted residents who transfered their free rights of selecting doctors, so that accomplished are the three policy goals, which are the ordered medical service demand, better disease management and medical cost control. In the meantime, the medical insurance assesses and pays the service to the family doctors according to residents’choice, which motivates the doctors to improve their services. This drives the reform of contracting service supplied by family doctors into the virtuous circle of sustainable development, which is the fifth necessary phrase of FDS construction.Secondly, it is analyzed that the effects of FDS implementation through investigating the institutes, families and individuals. The investigation shows that it has reached a certain amount of contracts only in a year of FDS implementation. It leads to that the contracted residents are willing to and orderly served in the community, and have kinds of medical cost less than the uncontracted, and meanwhile they manage the chronic disease more effectively than the uncontracted and also have better effect. Thus some achievements come to the three policy goals of family doctor contracting reform. In the meantime, the whole group of family doctors are optimistic in the implementation of the reform, and participate in the reform with more enthusiasm, but there are significant differences between the individuals. When investigated in the three dimension of individual-organization model, they can obtain high score in the self-rating, but have normal perspective on the reform, and less satisfaction to personal needs, especially least satisfaction to the work reward.Thirdly, the research will test the mechanism of contracted services from both the residents and family doctors in the model of demand and supply of contracted services. It applies regression analysis on the factors driving residents to sign the contract to find that demanding, cognizing, and rating are the main factors to make the contract decision, and there is a big space to spread the contract service. Then the study approves by structural equation modeling (SEM) that it can increase the initiative of family doctors to work in ways of bettering the satisfaction of demand and comprehension of reform for the family doctors, with the help of mediator effect of work expectation, and that there is the biggest room to improve the satisfaction of demand, especially the satisfaction in reward of work. At last, through relative analysis of supply and demand of contracting service, it considers that the more participatory family doctors are, the more satisfaction, and higher rate of signing, and also higher rate of valid signing are there in the group of residents served in the community health center. Thus it verifies the positive cycle in the double power mechanism of contracting service.Finally, on the basis of the analysis above, this study summarizes the policy implementation logic in the five phases of FDS construction in Changning, and proposes to promote the branding effects of family doctors of high quality service, better the contracting service contents, expand the coverage of contracting service, strengthen the construction of talent team of family doctors and improve the distribution rules and the incentive mechanism of two-way referral among the family doctors.