| BackgroundWith the development of economy and society,residents’ health risk and medical demand are increasing,which has caused a huge economic burden to the society.In 2009,the medical reform put forward the hierarchical diagnosis and treatment,and established the reform strategy of "Strengthening Primary Medical Institutions",which required guiding common patients to seek treatment at the grassroots level.Guiding residents to seek treatment at primary medical institutions is the essence and goal of the hierarchical diagnosis and treatment,and is also the cause and consequence of primary medical service ability.In 2016,Ningxia became a national pilot of medical reform.In recent years,many reform practices had been carried out.However,Ningxia still faces difficulties of the invalid hierarchical diagnosis and treatment,the weak primary medical service ability and the disordered selection of medical institutions.So we need to answer the following questions.What are problems in the implementation of related guidance strategies?What should be optimized about the primary health resources allocation?How to improve the utilization of primary medical treatment?What are key factors in the selection of medical institution?What changes will be made to the primary medical treatment system by implementing strategies of guiding residents to seek treatment at primary medical institutions?ObjectivesThe study of this paper aims to provide examples and references for health decision-making departments from these following perspectives.1.From the perspective of health policy,this paper sorts out the implementation progress and main problems of strategies about hierarchical diagnosis and treatment in Ningxia,to improve the demand attraction of primary medical institutions.2.From the perspective of medical service ability,this paper analyzes the characteristics and weaknesses of the resource allocation and treatment utilization of primary medical institutions,and explores the fairness of medical resources among various regions and regional improvement strategies of primary treatment utilization,to provide decision support for improving the primary medical service ability.3.From the perspective of patients’ seek treatment behavior,this paper analyzes residents’ preference and influencing factors on the selection of medical institutions,and calculates the marginal effect of key factors,to provide references for establishing the reasonable treatment order.4.From the perspective of trend prediction,this paper builds a simulation model of primary medical treatment system,simulates the implementation effect of various optimization strategies,to predict the effect of further guiding residents to seek treatment at primary medical institutions.Data and Methods1.Data Sources:It includes that the academic literature database in Chinese and English,related policy documents from government or department official websites,some interview information from leaders of primary medical institutions,the Health Statistics Bulletin of Ningxia from 2013 to 2018,Ningxia Health Commission Information Center,the Statistics Yearbook of Ningxia in 2019,the sixth health service survey database of Ningxia in 2018,and some other data sources.2.Methods:Statistical methods are used to describe and analyse data,indexes of resource distribution with entropy weight and agglomeration degree are used to evaluate the regional primary medical resource allocation,DEA is used to evaluate the utilization efficiency of primary medical treatment in each region,spatial analysis model is used to explore the spatial characteristics of primary medical treatment utilization,random utility model is used to analyze key factors and their marginal effect of the medical institution selection,and system dynamics is used to construct a simulation model of primary medical treatment system.Results1.The Situation and Problems of Strategies about Hierarchical Diagnosis and Treatment(1)The step-by-step outpatient medical insurance system can guide non-chronic disease patients to seek treatment at primary medical institutions who participate the medical insurance for residents.The problems include that the medical insurance for chronic diseases outpatients has not formed a step-by-step reimbursement ratio,the referral system needs to be further developed,the inpatient reimbursement ratio between different levels of medical institutions is not big enough,the cognition of differential medical insurance reimbursement system needs to be improved.(2)In 2018,the signing rate of family doctor service for all residents and the key group had reached the expected goal.The problems include that all residents’ signing rate was only 40.95%in 2018,which was far away from 100%,service teams for universal family doctor service are short,some residents’ awareness is not high,some contracted residents have low recognition of family doctor service,the family doctor service focuses on health management for the key group.(3)Until 2018,71 medical consortia had been built,covering 90%of primary medical institutions.The problems include that they are all loose service model,and the technology support form and effect for primary medical institutions are limited.(4)The internet medical treatment service and remote diagnosis are main internet medical application forms at primary medical institutions.The problems include that internet medical treatment did not carry out at all primary medical institutions in 2018,the proportion of internet medical treatment in the total medical treatment at the grassroots level was only 0.28%,residents have not formed the awareness of using internet medical treatment at primary medical institutions,and the operation process of internet medical treatment is time-consuming relatively.2.The Situation and Regional Characteristics of the Medical Service Ability of Primary Medical Institutions(1)In recent years,all kinds of primary medical resources has been growing rapidly.However,according to the planning target and further patients’ primary medical treatment demand,some medical resources still need to be optimized.The number of community health centers and village clinics still needs to be increased.There is still room for improvement in the proportion of primary medical institutions reached the infrastructure construction standard or designated medical insurance.Health workers are in short supply.Village doctors is decreasing and general practitioners still need to be increased.Health technicians with high education or professional title need to be increased,especially in township hospitals.The occupational attraction at the grassroots level is limited.The quantity and utilization ratio of equipment at the grassroots level are low relatively,especially in community health service institutions.The quantity and utilization ratio of beds at the grassroots level are at a low level.Medicines available at the grassroots level are connected with the secondary hospital basically.(2)According to the index of resource distribution,there are differences in the primary medical resource allocation among regions in Ningxia,the primary medical resource allocation level in urban areas is lower than that in rural areas(t=-2.265,P=0.035).According to the index of agglomeration degree,various kinds of primary medical resources in different regions are in a state of excess,shortage or balance relative to population distribution respectively.(3)In recent years,the workload of medical treatment at the grassroots level has an upward trend,but the proportion of medical treatment at the grassroots level has a downward trend,which was only 43.63%in 2018.The medical treatment workload of community health service institutions is the lowest.The two-way referral rates are at a very low level,and form the situation like"easy to upward,difficult to downward".(4)According to the utilization efficiency of primary medical treatment,only 45.45%of regions have reached the comprehensive efficiency in Ningxia.By indicators’ projection analysis,these regions that have not reached the comprehensive efficiency all have resources over-investment relatively in different levels.These regions should be key areas for guiding residents to utilize primary medical treatment.From the spatial perspective,the global Moran’s I index of per capita primary treatment utilization is 0.2162(P<0.05),which shows a positive spatial correlation.The spatial lag model indicates that the coefficient of spatial lag factor is 0.624(P<0.01).According to the spatial pattern of each region,four development strategies can be adopted to guide residents to seek treatment at primary medical institutions.3.Study on Influencing Factors of the Residents’ Selection of Medical Institutions(1)According to the single factor test,patients who are in rural areas,45 years old and above,participating residents’ medical insurance,with good health,normal or overweight,without serious diseases like to seek treatment at primary medical institutions.Patients who think that medical institutions are closer in distance,lower technology,poorer equipment condition,shorter waiting time,better service attitude,cheaper expense,more satisfaction,lower Ln(medical expenses)like to seek treatment at primary medical institutions.Patients who have established health records,known or signed family doctor,like to seek treatment at primary medical institutions.(2)According to the random utility model,when other factors of influencing patients’ choice probability of seeking treatment at primary medical institutions are in average,compared to urban patients,rural patients increase the probability by 10.50%;compared to patients with worse health,patients with better health increase the probability by 9.79%.Medical institutions with closer distance,shorter waiting time and lower Ln(medical expenses)increase the probability by 14.28%,22.67%,7.69%respectively.The disadvantages of technology and equipment of primary medical institutions decrease the probability by 29.34%,38.40%respectively.Patients who signed family doctor increase the probability by 8.71%.4.The Simulation Strategies’ Experiment of Primary Medical Treatment System(1)The implementation of "popularize family doctor service","improve medical technology" and "improve equipment condition" will increase the ratio and workload of medical treatment at primary medical institutions,increase the doctors demand and save personal expenses and medical insurance expenses to varying degrees.(2)After the implementing of "popularize family doctor service",the ratio of medical treatment at primary medical institutions will be only 46.73%in 2023,which is far behind the stage target 70%.Compared with the other two simulation strategies,this strategy has a limited guiding effect,and there will be no shortage of doctors.(3)The implementation of "improve medical technology" and "improve equipment condition" will guide residents to seek medical treatment at the grassroots level in a greater degree.In 2023,the ratio of medical treatment at primary medical institutions will reach 66.71%and 75.49%respectively,but the proportion that primary medical institutions can undertake will be only 79.71%and 70.57%respectively,then 1663 and 2781 doctors will need to sink respectively.The undertaking patients’ ability of primary medical institutions will be limited.(4)According to the assumed workload of internet medical treatment at primary medical institutions,the supplement for doctors from internet medical treatment is very limited.If we want to make up the doctors’ gap caused by "improve medical technology" and "improve equipment condition",according to the demand for doctors in 2023,the proportion of internet medical treatment in the total medical treatment at the grassroots level should reach 19.01%and 28.15%respectively.Conclusions and Suggestions1.Conclusions(1)The overall signing rate of family doctor and the workload of internet medical treatment at primary medical institutions need to be improved,and the system or service process of various related strategies still has defects,which result in the guidance role of related strategies has not been fully played.(2)In recent years,the overall growth of primary medical resources is rapid,however,the quantity and quality of some primary medical resources still need to be optimized,the regional distribution of primary medical resources is not balanced well.(3)The performance of primary medical treatment is not ideal.It is more effective to guide residents to seek medical treatment at primary medical institutions in urban areas,areas that have not reached the resource utilization efficiency,areas in a low-high pattern and core areas in a low-low pattern.(4)Patients sign family doctor or not,and the medical technology and equipment condition of primary medical institutions are key factors of guide residents to seek medical treatment at primary medical institutions.(5)Compared with the popularization of family doctor service,improving the medical technology and equipment condition can effectively realize the patient’s sinking to primary medical institutions,but after implementing these two strategies,primary medical institutions will need to face the doctors’ shortage,and primary medical institutions will have limited ability to undertake sinking patients.2.Suggestions(1)Strengthen the responsibility of the government for medical reform and improve various systems or policies.(2)Optimize the medical resources allocation of primary medical institutions,to improve the ability of medical service provision.(3)Balance regional differences of medical resource and medical treatment utilization,to improve the overall performance of primary medical treatment system.(4)Improve medical technology and equipment condition of primary medical institutions,to obtain the residents’ trust.(5)Popularize family doctor service,to cultivate residents’ habits of seeking treatment at primary medical institutions.(6)Promote internet medical treatment service at primary medical institutions,to realize the sinking of high-quality medical resources. |
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