我国“医联体”发展现状与对策研究

发布时间：2018-06-05 22:17

本文选题：医联体 + 医疗资源整合　；参考：《山东大学》2017年博士论文

【摘要】：世界卫生组织指出,卫生服务整合是提升卫生系统的重要途径之一。在我国,卫生服务的整合主要是医疗机构之间的整合,表现为不同层级的医疗机构,以资产或技术等要素为纽带,从横、纵两种方向,通过协作、兼并、重组等不同的方式建立起来的卫生服务提供和管理的联合体。2013年,随着"医联体"这一概念的正式提出,我国开始了医疗资源整合的新一轮探索。"医联体"的界定,"医联体"的优势和问题,"医联体"未来应如何发展等成为了学者们关注的问题。一、研究目的1.梳理我国"医联体"的理论基础。主要包括:总结医疗资源整合的相关理论、对比医疗资源整合在国内外发展的异同、界定"医联体"的概念、分析"医联体"的典型案例等,为实证研究和结论与建议奠定基础。2.对代表性的"医联体"展开实证研究。分别以广度和深度为侧重,展开两个实证研究。通过实证研究,分析不同模式"医联体"在建设中的共性问题以及基层医疗机构在"医联体"中的优势及问题。3.在理论基础上结合实证研究的结果,得出结论并提出政策建议。根据SWOT分析法的相关理论,从当前我国"医联体"发展的优势(Strengths)、劣势(Weakness)、机会(Opportunities)与挑战(Threats)四个方面进行总结,并根据不同的要素组合提出针对性的政策建议。二、研究方法本研究重视社会科学研究方法的科学性,在质性研究与定量研究相结合的思想指导下,根据研究的目的与特点,确立以质性研究为主导,定量研究相辅助的思路。本研究在理论基础的构建中,通过文献复习的内容分析法,严格按确定研究内容、进行文献检索、确定分析单元、制定分析类目、单元编码统计、分析信度检验的六个步骤,对所选的420篇文献进行编码分析,编码结果通过信度检验。在实证研究中,依照质性研究方法和定量研究方法的要求,借助访谈提纲及问卷,收集访谈资料、数据资料及其它材料。对于质性资料,严格按照质性研究中的扎根理论研究法对于资料分析的要求,借助Word和Excel对资料进行一级编码、二级编码及三级编码,最终归纳出模型。在研究的每一个环节,注重对信度和效度的把握,并根据研究方法的要求,通过文献资料和定量资料对一级编码的结果进行了检验。对于实证研究中的定量资料,均使用epidata3.1软件进行录入,并使用SPSS17.0进行规范数据分析。在理论基础上,结合实证研究的结果,根据SWOT分析法的相关理论,从当前我国"医联体"发展的优势(Strengths)、劣势(Weakness)、机会(Opportunities)与挑战(Threats)四个方面进行总结,并根据不同的要素组合提出针对性的政策建议。三、研究结果1梳理了我国"医联体"的理论基础(1)总结并分析了医疗资源整合的相关理论与实践本研究在文献复习的基础上,总结了医疗资源整合的动因和基本要素。并对国内外医疗资源整合的实践进行了总结和对比分析。医疗资源整合的动因主要包括资源结构性矛盾及政府的政策推动,市场经济的发展与竞争压力的加剧,疾病谱的改变与人们需求的增加等宏观动因,以及医疗机构之间优势互补、降低成本提高效率等微观动因。医疗资源整合的基本要素包括整合纽带(资产纽带、非资产纽带)、整合方式(涉及资产的:资产重组、连锁经营、院办院管、股份制合作等,不涉及资产的:帮扶协作、委托代管、新集团化等)、治理结构(董事会(理事会)模式、管委会模式等)、成员构成、合作内容等。对于医疗资源整合的探索,在上世纪6、70年代就在美国展开,并在20世纪90年代开始了以兼并和重组等方式进行的医疗集团的建设,英国和德国也采取了类似的举措。国外学者通过对医疗资源整合的研究发现,医疗资源整合降低了管理成本并促进了医疗机构间技术的交流,医院之间在协作诊疗的过程中提升了治疗效果,但整合也带来了医疗费用上涨、规模不经济、保险更加昂贵等问题。我国的医疗资源整合从上世纪80年代开始,到现在为止大致经历了四个阶段,20世纪80年代处于萌芽阶段,仅形成了医院之间联合的雏形;20世纪90年代处于兴起阶段,一些早期的医疗集团,已经开始通过托管、共建等方式建立起来;21世纪初处于快速发展阶段,在国家政策的支持下,各类的医院集团开始在全国各地涌现;2013年,"医联体"的概念正式提出,各地纷纷进入了探索这种新型医院集团的新阶段。本研究从社会、整合模式、整合参与者、患者、实践过程等五个角度,对中外的医疗资源整合进行了对比。发现西方国家的医疗资源整合偏向于以控制医疗费用为主,并出现了医院与医疗保险公司进行整合的实践,而中国的医疗资源整合更多的以缓解"看病难、看病贵"为主。中西方的医疗资源整合都存在资产整合与非资产整合并存的现象,并且呈现出从最初以应对市场竞争,实现互利共赢为目的向对居民进行全面健康管理为目标转变的趋势,而且发展中遇到了经验不足、组织变革、文化冲突等共性问题。(2)界定了 "医联体"的概念并进行了典型案例分析"医联体"是医疗联合体的简称。目前对于"医联体"并没有一个统一的概念。本研究认为:"医联体"的概念随着其不断发展而处于变化和丰富的过程中。就目前而言,应主要包括以下几个方面:定义:"医联体"应当是不同层级医疗机构组成的,以医疗资源整合为目的的卫生服务提供和居民健康管理的统一体。目的:通过不同层级医疗机构间的联合,将优质资源下沉到基层,提升基层医疗机构的实力,并借助上下级医疗机构之间的密切联系,促进双向转诊的实现。内涵:"医联体"是新型的医院集团,它与医院集团同为医疗机构之间的整合,但更强调上下级医疗机构之间,特别是大医院与基层之间的结合。因此"整合至少包含两个层级的医疗机构"应当是判断"医联体"的标志。外延:"医联体"的发展方向是健康责任体,旨在对居民进行全面的健康管理。在对"医联体"的概念进行界定的基础上,本研究主要选取了比较有特点的安徽省马鞍山市市立医疗集团(管办分开、法人实体的医疗集团的代表),江苏镇江康复医疗集团和江滨医疗集团(同一地域两家不同类型医疗集团并存的代表),南京鼓楼医院集团(传统医院集团向"医联体"转型的代表)及北京世纪坛医院医疗联合体(以"新集团化"方式整合的"医联体"的代表)。旨在通过案例的描述和分析,了解不同类型医院集团的发展历程、特点、优势与弊端等。2.对代表性的"医联体"进行了实证研究(1)山东省"医联体"建设情况分析该研究是本研究的实证研究之一。旨在从类型的广度上对"医联体"进行深入的了解,并以省际范围为单位,概括地域内不同类型"医联体"所存在的共性问题。该研究在对山东省社会经济及卫生事业发展情况和山东省"医联体"建设的相关政策进行简要回顾的基础上,通过访谈和收集相关资料的方式,收集山东省医疗资源整合的总体情况及五家代表性的"医联体":山东省立医院集团、山东大学齐鲁医院医疗联合体、滕-山医疗联合体、"高康"医疗集团和"密康"医疗集团的相关资料,对上述"医联体"的发展现状进行了分析。最后,通过扎根理论研究方法,构建出山东省"医联体"建设存在问题的SMPM模型(体制型障碍(Obstacles of System)机制型障碍(Obstacles of Mechanism)、政策型障碍(Obstacles of Policy)、管理型障碍(Obstacles of Management)。分析结果显示:体制型障碍是其它障碍的根源,主要包括:基层资源匮乏和整合不触动原有体制。机制型障碍和政策型障碍相互影响,机制型障碍包括:医护人员心态不平衡、缺乏联合主动性、付出和回报不对等等。政策型障碍包括:医保未起到激励作用、双向转诊落实缺乏制度保证、缺乏管理和评价制度等。在上述三种障碍下产生管理型障碍,包括:信息化建设困难、患者信任危机、机构间文化冲突、对健康管理缺乏重视、统一管理困难、服务同质化难实现等。(2)深圳市南山区"医联体"改革研究该研究是本研究的另一个实证研究,着眼于从研究的深度出发,把"医联体"中基层医疗机构这一重要成员在联合体中的发展情况及遇到的问题作为深入挖掘的重点。通过对深圳市南山区三家具有代表性的"医联体"进行实地调研,对以资产为纽带的"3+1"及"2+1"模式的"医联体"进行深入剖析。通过对定量资料的收集和处理,对三家"医联体"的资源配置与利用情况(包括基础设施建设、经营状况、人力资源因素、技术支持因素)和社区卫生服务提供及患者需求满足情况(包括基本医疗服务、公共卫生服务、双向转诊及社区首诊的开展情况、后勤保障与集中送检和患者满意度)进行了定量的分析。并通过扎根理论研究方法,分别构建出南山区"医联体"特点及优势的SPFR模型及南山区"医联体"存在问题的3M模型。从制度(System)、人事(Personnel)、财务(Financial)、和资源共享(Resources Sharing)四个层面分析了南山区"医联体"的特点和优势。从宏观(Macro)、中观(Medium)、微观(Micro)三个层面分析了南山区"医联体"存在的问题。最后,本研究根据深圳市南山区"医联体"的发展特点,结合当地具体情况,在医疗资源整合的视角下,提出并命名了"一体两制"(即在不改变社康中心与核心医院隶属关系的基础上加强一体化管理)的改革方案,主要包括:(1)社康中心全额事业单位转变,减轻对核心医院的经济依赖;(2)设立社康中心独立账户,落实收支两条线制度;(3)鼓励"医联体"与社区居民签约,实行医保预付制;(4)实行两级考核机制,注重基层医疗机构的职能落实;(5)细化双向转诊标准,明确"医联体"内各级机构责任;(6)完善信息平台建设,加强"医联体"内信息沟通等六项内容。四、结论与政策建议本研究在理论基础上,结合实证研究的结果,根据SWOT分析法的相关理论,从当前我国"医联体"发展的优势(Strengths)、劣势(Weakness)、机会(Opportunities)与挑战(Threats)四个方面进行f总结。优势主要包括:带动成员机构的发展和资源配置与利用更加合理;劣势主要包括:产权障碍、治理结构和管理机制不健全及对基层成员的重视不足;机会主要包括:"医联体"的建设得到政策的倡导与支持和相关改革正在新医改中逐步推进;挑战主要包括:政府主导未能与市场紧密结合和配套制度建设任重道远。并在此基础上,针对不同的要素组合,提出了四个建议:(1)OS开拓型建议——加强对基层能力的建设:旨在针对目前"医联体"的建设中对基层医疗机构重视不足的问题,建议发挥"医联体"促进优质资源下沉的自有优势,在建设中重点加强对基层医疗机构能力的建设,成为重构我国就诊秩序的重要途径,通过重视基层机构公共卫生职能的落实,使"医联体"逐渐向区域健康管理体转变。(2)TS抗争型建议——以利益为纽带向紧密联合推进:针对目前"医联体"中各成员机构产权不一致等问题带来的障碍,建议在"医联体"的建设中,发挥资源共享等优势,各成员单位首先以利益为纽带,求同存异,并建议有关部门尽快完善相应制度。(3)OW争取型建议——在制度变革中打破整合障碍:目前,去行政化改革、法人治理结构建设、全科队伍建设等政策的逐步推进为"医联体"打破成员间的产权障碍创造了有利条件,当这些政策在医院中逐步成熟,就可以借鉴到"医联体"当中,为"医联体"法人治理结构和管理制度的建设创造条件。(4)TW保守型建议——以目的为导向创新整合形式:当外部环境与内部条件都处于不利因素时,建议从"医联体"促进资源下沉的核心内涵出发,因地制宜,创新医疗资源整合形式。
[Abstract]:The WHO points out that the integration of health services is one of the important ways to improve the health system. In our country, the integration of health services is mainly the integration of medical institutions. It is manifested by different levels of medical institutions, with assets or technology as the link, from the two directions of horizontal and vertical, through cooperation, merger, reorganization and other different ways. The united body of health service provided and managed in.2013, with the formal proposal of the concept of "Medical Union", China has begun a new round of exploration of the integration of medical resources. The definition of Medical Union, the advantages and problems of "medical couplet", the future of "Medical Union", and so on, have become the concerns of the scholars. First, the 1. combs of the research purpose The theoretical basis of medical couplet in China includes: summarizing the related theories of medical resources integration, comparing the similarities and differences of medical resources integration at home and abroad, defining the concept of "medical couplet", analyzing the typical cases of "Medical Union", and laying the foundation for the empirical research and conclusion and suggestions on the representative "medical couplet" to carry out an empirical study. Two empirical studies are carried out with the emphasis on breadth and depth respectively. Through empirical research, the common problems in the construction of "medical couplet" in different modes and the advantages and problems of basic medical institutions in "medical couplet" are analyzed, and.3. is combined with the results of empirical research on the basis of theory. The conclusion is drawn up and the policy recommendations are put forward. According to the SWOT analysis method, Related theories are summarized from the four aspects of the advantages (Strengths), inferiority (Weakness), opportunity (Opportunities) and challenge (Threats) in the current development of "Medical Union" in China, and put forward pertinent policy suggestions according to the combination of different elements. Two, the research method this study attaches importance to the scientific research method of social science, in qualitative research and determination. Under the guidance of the combination of quantitative research, according to the purpose and characteristics of the study, the idea of qualitative research as the dominant and quantitative research is established. In the construction of the theoretical basis, the research is based on the content analysis method of literature review, strictly according to the content of the study, the retrieval of the literature, the determination of the analysis unit, the formulation of the analysis category and the unit compilation. Code statistics, analysis of the six steps of reliability test, the selected 420 documents are encoded and analyzed. The results of the code are tested by reliability. In the empirical study, the interview outline and the questionnaire are used to collect the interview data, data and other materials in accordance with the requirements of qualitative research and quantitative research methods. In the qualitative research, the grounded theory study method for data analysis, using Word and Excel for the first level coding, two level coding and three level coding, finally summed up the model. In every link of the study, it pays attention to the confidence and validity of the data, and according to the requirements of the research method, through the literature and quantitative data to the first level The results of the coding are tested. For the quantitative data in the empirical study, the epidata3.1 software is used for input and SPSS17.0 is used to analyze the data. On the basis of the theory and the results of the empirical study, according to the relevant theories of the SWOT analysis, the advantages of the development of the "Medical Union" in China (Strengths) and the disadvantage (Weakness) are in accordance with the relevant theories of the analysis. The four aspects of opportunity (Opportunities) and challenge (Threats) are summarized, and the pertinent policy suggestions are put forward according to the combination of different elements. Three, research results 1 have combed the theoretical basis of "Medical Union" in China (1) summarize and analyze the related theory and practice of medical resources integration, and summarize medical treatment based on literature review. The reasons and basic elements of the integration of resources are summarized and analyzed. The reasons for the integration of medical resources include the structural contradiction of resources and the promotion of the government policy, the development of the market economy and the intensification of the competition pressure, the change of the disease spectrum and the increase of the people's demand, etc. The basic elements of medical resources integration include integration bonds (asset bonds, non asset ties) and integration methods (assets: assets reorganization, chain management, hospital management, joint stock cooperation and so on, which do not involve assets: assistance cooperation, entrustment management, new collection. The exploration of the integration of medical resources was launched in the United States in the 6,70 years of the last century, and the construction of medical groups, such as merger and reorganization, was started in 1990s, and the UK and Germany have also taken a similar approach. Through the study of the integration of medical resources, foreign scholars have found that the integration of medical resources has reduced the cost of management and promoted the exchange of technology between medical institutions. In the process of cooperative diagnosis and treatment, the hospital improved the effect of treatment, but the integration also brought about the rise of medical expenses, the uneconomical scale and the more expensive insurance. The integration of medical resources began in the 80s of last century. Up to now, it has roughly experienced four stages. In 1980s, it was in the embryonic stage. It only formed the embryonic form of the union between hospitals; in 1990s it was in the rise stage, and some early medical groups have been established by trusteeship and co construction. At the beginning of twenty-first Century, it was at the beginning of twenty-first Century. In the rapid development stage, with the support of national policy, all kinds of hospital groups began to emerge all over the country. In 2013, the concept of "Medical Union" was formally put forward, and the new stage of exploring the new hospital group was entered. This study was from five angles of society, integration model, integration of participants, patients, practice process and so on. The integration of medical resources is compared. It is found that the integration of medical resources in western countries is biased towards the control of medical costs, and the integration of hospitals and Health Insurance Company has appeared, and the integration of medical resources in China is more to alleviate the difficulty of seeing the disease, and the medical resources integration in China and Western countries all have the integration of assets and the integration of assets. The phenomenon of non asset integration coexists, and presents a tendency to change from the initial response to the market competition and the realization of mutual benefit and win-win for the overall health management of the residents. In addition, there are common problems such as lack of experience, organizational change, cultural conflict and so on. (2) the concept of "Medical Union" is defined and a typical case has been carried out. "Medical couplet" is the abbreviation of Medical Union. At present, there is no unified concept of "Medical Union". This study holds that the concept of "medical couplet" is in a changing and rich process with its continuous development. At present, it should mainly include the following aspects: "Medical Union" should be a different level of medical institutions. A unified body of health services and health management for the integration of medical resources. Objective: to sink high quality resources down to the grass-roots level through the combination of different levels of medical institutions, to enhance the strength of grass-roots medical institutions, and to promote the realization of two-way referral by means of close links between the upper and lower medical institutions. "Medical Union" is a new type of hospital group. It is the integration between the hospital group and the hospital group, but it emphasizes the combination of the upper and lower medical institutions, especially the large hospitals and the grass-roots. Therefore, the "integration of at least two levels of medical institutions" should be the symbol of judging the "Medical Union". On the basis of the definition of the concept of "medical couplet", this study mainly selected the relatively characteristic Ma'anshan municipal medical group in Anhui province (separate management office, representative of medical group of legal entity), Jiangsu Zhenjiang rehabilitation medical group and Jiang Bin medical group (the same one) The representative of the two different types of medical groups in the region, the representative of the Nanjing Gulou Hospital group (traditional hospital group to the "Medical Union") and the representative of the Medical Federation ("medical couplet" integrated by the "new collectivization"). The purpose is to understand the development calendar of the different types of hospital groups through the description and analysis of the cases. .2. has carried out an empirical study on the representative "medical couplet" (1) analysis of the construction of "Medical Union" in Shandong Province, which is one of the empirical studies of this study. The purpose of this study is to make a thorough understanding of the "medical couplet" from the breadth of the type and to generalize the different types of "medical couplet" in the region with the inter provincial scope as the unit. On the basis of a brief review of the development of social and health undertakings in Shandong and the relevant policies of "medical couplet" in Shandong Province, the study collects the overall situation of the integration of medical resources in Shandong province and the five representative "medical couplet" through interviews and collection of relevant information: Shangdong Province-owned Hospital The group, the Medical Union of Qilu Hospital of Shandong University, Tengshan Medical Union, Gao Kang medical group and Mi Kang medical group, analyzed the development status of the "medical couplet". Finally, the SMPM model of the problems in the construction of "Medical Union" in the eastern province was constructed by the method of grounded theory (Obst Acles of System) mechanism type disorder (Obstacles of Mechanism), policy barrier (Obstacles of Policy), management barrier (Obstacles of Management). The analysis results show that institutional barriers are the root of other obstacles, mainly including the lack of basic resources and the absence of integration into the original system. The interaction between the mechanism type barrier and the policy type barrier The mechanism type obstacles include: the imbalance of mental health, the lack of joint initiative, the lack of pay and return, etc. policy barriers include: the medical insurance is not motivated, the two-way referral is not guaranteed, the management and evaluation system is lacking. Management barriers are created under the above three obstacles, including the difficulty of information construction, Patient trust crisis, inter agency cultural conflict, lack of attention to health management, unified management difficulties, and homogeneity of service difficult to realize. (2) the study on the reform of "Medical Union" in Nanshan District, Shenzhen, is another empirical study of this study, focusing on the development of the research, and the important members of the basic medical institutions in the "medical couplet" The development and problems encountered in the complex are the key points. Through the field investigation of three representative "medical couplet" in Nanshan District, Shenzhen, the "medical couplet" of "3+1" and "2+1" model with assets as a link is deeply analyzed. The resources of the "medical couplet" are collected and processed through the collection and treatment of the quantitative data. Location and utilization (including infrastructure construction, operating conditions, human resources, technical support factors) and community health service delivery and patient needs satisfaction (including basic medical services, public health services, two-way referral and community first consultation, logistics and centralized inspection and patient satisfaction) were quantified The SPFR model of the characteristics and advantages of Nanshan District "Medical Union" and the 3M model of the existence of "Medical Union" in Nanshan District are constructed by the method of grounded theory. The characteristics and advantages of the "medical couplet" in Nanshan District are analyzed from four aspects of system (System), personnel (Personnel), Finance (Financial), and resource sharing (Resources Sharing). From three aspects of macro (Macro), Medium, and microcosmic (Micro), this paper analyzes the problems existing in the "medical couplet" in Nanshan District. Finally, according to the characteristics of the development of the "Medical Union" in Nanshan District, Shenzhen, combining with the specific local conditions, the "one and two systems" are proposed and named under the visual angle of the integration of medical resources. The reform plan of strengthening the integrated management on the basis of the relationship of the heart hospital, mainly includes: (1) the transformation of the full institution of the social health center to reduce the economic dependence on the core hospital; (2) to establish an independent account of the social health center and to implement the two line system of revenue and expenditure; (3) encourage the "Medical Union" to contract with the community residents and carry out the medical insurance prepayment system; (4) two The assessment mechanism focuses on the implementation of the functions of primary medical institutions; (5) refine the standard of two-way referral and clarify the responsibilities of all levels of medical institutions; (6)
【学位授予单位】：山东大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R197.1

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