| The scarcity of health resources and inefficient allocation in china have given birth to the important problem of people's livelihood that has long plagued China,especially the problems of great cure for minor illnesses,repeated treatments,poverty due to illness,and returning to poverty due to illness further aggravate the difficulty of solving the problem.The state is also actively seeking solutions.Among them,hierarchical medical system,as an organization and coordination mechanism,can solve the existing medical resource allocation and efficiency problems at a deep level,and is considered to the key to solving the problem of “expensive medical treatment and difficult medical treatment”.However,Hierarchical medical system as an important institutional arrangement implemented by the state,the research on the effect of hierarchical medical system mainly focuses on local case studies and mathematical description statistics,and lacks the use of national micro-database as an analytical sample.This paper studies the empirical model based on the classic foundation,and uses a large microscopic database(CFPS)covering the whole country to analyze the impact of hierarchical medical system on health and family medical economic burden,and conduct field research on the implementation of hierarchical medical system in two city,and puts forward policy suggestions in the light of foreign experience.The main research contents are as follows:First,research on the effect of hierarchical medical system to improve residents' health.Health is the initial motivation for medical service demand.Health is the fundamental purpose of implementing a hierarchical medical system.Based on Grossman's health needs theory,this study builds an analytical model between hierarchical medical system and health,and empirically analyzes the health of residents in a hierarchical medical system.The impact of the focus is on self-rated health,chronic illness and mental health.Second,the study on the effect of hierarchical medical system to reduce the economic burden of family medical care.As an important part of the new medical reform,the hierarchical medical system is a good solution to the problem of “expensive medical treatment”.The family medical economic burden is the proportion of the household's self-paying medical expenses to the household disposable income or expenditure.The research uses the Andersen medical service utilization model to construct an analytical model between the hierarchical medical system and the family medical economic burden.Through the two part model and the instrumental variable method,to study the impact factors of hierarchical medical system such as the first treatment in the community on the economic burden of family medical care.Third,the case study of typical domestic areas of the hierarchical medical system.It is necessary to conduct in-depth research in areas with distinctive characteristics and academic significance,which is necessary for the study of the effect of the hierarchical medical system.Select the developed areas in the east and the underdeveloped areas in the west as case studies,conduct in-depth field research on typical areas,obtain firsthand information data,summarize the results of hierarchical medical system through quantitative data research and qualitative analysis,and provide experience for other cities.Fourth,international experience in hierarchical medical system.China's g hierarchical medical system started late,still in the exploration and development period,and some developed countries have formed a relatively mature hierarchical medical system.China has a special national condition and needs to develop a hierarchical medical system that is in line with China's actual conditions.The international typical countries of the United Kingdom,Germany and the United States are selected to study the practical experience of hierarchical medical system,and summarize the advanced practices and success factors around the first treatment in the community,two-way referral and family doctors.The main findings are as follows:First,first treatment in the community has significantly improved the health of residents,especially for mental health and chronic diseases.Residents who choose the first treatment in the community can increase the self-evaluation health of residents by10.1%,and the level of mental health and chronic disease health of residents at the grassroots level is 11.3% and 3.69% respectively.First treatment in the community establishes a health management file based on the health gatekeeper system,timely intervention for people with chronic diseases and mental illnesses,reducing the probability of disease occurrence and reducing the risk of worsening the disease.Second,first treatment in the community has greatly reduced the economic burden of family medical care.First treatment in the community is the most important representative variable of hierarchical medical system.The empirical analysis using the tool variable model shows that the selection of the first treatment in the community can significantly reduce the medical burden of the residents.The first treatment in the community will lead the residents to the primary health care institutions for diagnosis and treatment,and the primary health care institutions.Relatively low fees can reduce the family medical economic burden.Third,the hierarchical medical system has a stronger effect on the health improvement of vulnerable areas or vulnerable groups.In the urban and rural subsample analysis,the primary health care of the low-income group is particularly obvious in the primary clinic.The rural population is 11.3% higher than the urban9.19%.The medical level improves the health level of the residents.The rural population is 2.87% higher than the urban 1.14%.In the western subsample analysis,the improvement of health at the time of diagnosis and medical treatment also showed that the central and western regions were stronger than the eastern region;among the low-income people,first treatment in the community was 10.8% higher than the middle-level primary level(9.62%)and the high-income group was 6.39%.The lowincome group showed strong sensitivity in the willingness to see a doctor,medical level,and trust in doctors.Fourth,family doctors have a significant role in health management and referral services.Family doctors are an important part of the hierarchical medical system.Health management and referrals provide residents with health protection and reduce the family medical economic burden.Through empirical research,the degree of trust and satisfaction of family doctors are positively related to health,and also have a significant impact in heterogeneity analysis.The residents in the survey area have higher recognition and signing rate of the family doctor system.The average score of the surveyed doctors who provide medical services for themselves is 3.89 points(out of 5 points),and the family doctors are in health management and the satisfaction of referral services is higher.Fifth,the proportion of medical insurance reimbursement has a significant impact on reducing the economic burden of family medical care.The reimbursement results of different patients have a significant difference in the economic burden of family medical care.The number of residents with chronic diseases within half a year is 2.0times that of patients without chronic diseases.The residents who have hospitalization experience within one year are 5.5 times without hospitalization experience,reflecting that residents are sick.Then highly sensitive to the reimbursement ratio.The main countermeasures are as follows:First,moderately improve the level of diagnosis and treatment of grassroots health technicians.The soft power of primary health care institutions is effective in improving the hierarchical medical system.Based on the division of labor,the level of diagnosis and treatment of health care personnel in primary health care institutions should be appropriately improved,and the service capacity of primary health care institutions should match their functional positioning.On the one hand,by increasing the intensity of national policies,it is encouraged to set up general practitioners in colleges and universities,and to improve the level of doctors from the root causes;on the other hand,develop medical associations and encourage high-level doctors to sink to the grassroots level.It promotes the two-way flow of doctor resources,enhances the ability of diagnosis and treatment,and the level of diagnosis and treatment,so that match basic medical and health service functions such as basic medical care,prevention,health care,rehabilitation and health education,and assume the responsibility of the first line of defense for residents' health protection.Second,establish a long-term mechanism for grading diagnosis and treatment and health alleviation.First of all,all localities establish a new medical association,and the high-quality comprehensive medical institutions docked in the poverty-stricken areas of the grassroots medical and health institutions,to create a pattern of a regional central hospital to help the county hospitals,regional central hospital helps the county hospital;second,promote poverty population “one-on-one” family signing service,provides full coverage of family doctors for the economically disadvantaged groups,and each poor family has a special service team composed of rural two-level medical and health personnel.Finally,for the central and western regions,in rural areas and some lowincome groups,in terms of payment,it is necessary to consider lowering medical expenses,not setting up payment lines,and rationally adjusting the proportion of medical insurance payment insurance or personal payment.Third,expand the family doctor team with market mechanisms.First,the introduction of private doctors to join the family doctors,support the practice of general practitioners to run a general practice clinic,and implement a filing system,the introduction of social medical power,private doctors can play a subjective initiative;Second,vigorously promote doctors and nurses Practice,allowing doctors to regularly practice at the registration site according to the type of practice and practice;once again,colleges and universities should “recognize” the task of cultivating general practitioners,complete the training of clinical training bases and community teaching bases,and the early stage of enrollment It can focus on students from disadvantaged areas.The school gives a certain policy of enrollment and encourages students to return to the place of origin after graduation.Finally,use market-based competitive compensation to retain family doctors,set minimum wage levels and give family doctors Personnel recruitment,job title promotion,job hiring,etc.are treated in the same way as clinical medical practitioners,and an additional tilt policy is formulated in terms of job title evaluation and promotion.Fourth,improve the level of medical services in remote areas through “Internet+”.On the one hand,establish and improve the information management system of medical institutions in remote areas,and provide information exchange between medical institutions at all levels in remote areas and large hospitals in developed regions to achieve seamless integration of superior resources and information technology;on the other hand,use telemedicine to promote the promotion and popularization of big data and artificial intelligence in the field of grading diagnosis and treatment,establishing a “basic network” for remote consultation,creating a flat,zero-distance telemedicine system,connecting urban hospitals with remote hospitals,and letting large hospitals and remote counties Medical institutions are connected to comprehensively improve the medical service capacity of underdeveloped areas or areas with poor medical resources.Fifth,increase the proportion of reimbursement for medical expenses for major and chronic diseases in residents.On the one hand,medical insurance reimbursement has the role of an important “baton” in the grading diagnosis and treatment system.The innovative medical insurance payment method is an important means for the residents to spontaneously “willing to go” to the primary hospital,and set up medical insurance according to the actual needs of the grading diagnosis and treatment.The payment method fully supports the insured residents to carry out contracting services with the general practitioners of the primary health care institutions;on the other hand,the focus is on the reimbursement rate of patients with major and chronic diseases.The chronic disease is the entry point for the hierarchical medical system,and the serious illness is the cause of the residents.The key factors of disease-induced poverty and returning to poverty due to illness,so it is of great significance to further increase the proportion of reimbursement to the grassroots stage during the initial diagnosis of the chronic disease and the rehabilitation of major illnesses.Research attempts to innovate in the following ways:First,the study builds variable systems and empirical analysis models based on classical theories and models.It is an extension and new attempt of existing classical theories and models.Based on the Grossman Health Needs Theory and the Andersen Medical Service Utilization Model,a model for the impact of hierarchical medical system on residents' health impact models and hierarchical medical system on family medical economic burden was established.Based on the system framework of prerequisite factors,enabling factors and demand factors,the system of hierarchical medical system factors,demand difference factors and basic attribute factors has been established,which makes the classical theoretical model have further extended application,and also makes the research on the effect of hierarchical medical system classic.The theoretical basis of support.Second,research establishes econometric models and uses large-scale microdatabases covering the entire country as data support.Although the existing literature mostly considers that hierarchical medical system is a key measure to solve the problem of “difficult to see a doctor and expensive to see a doctor”,it is limited by the difficulty of field investigation,and is mainly based on statistical descriptive analysis of small samples in the region.The study relies on the nationwide China Family Panel Studies(CFPS)2014 and 2016 data,using large micro-databases for large-scale research and analysis.Third,on-the-spot investigation of typical areas in China and strengthening the practical significance of research.The survey selected eastern developed regions and western underdeveloped regions,with two cities as examples.In S city,we investigated medical supervision institutions,first-class hospital at grade 3 and primary medical institutions,and conducted a one-week questionnaire survey and interview in T city,and visited 12 villages in 4 towns and towns under the jurisdiction of T city to collect the most important originals.First-hand data enhances the practical significance of research. |
PDF Full Text Request