基于CAS理论的农村医疗服务纵向整合管理模型研究

The fragmentation of the medical service system is becoming a heated issue over countries and areas. The fragmented service delivery and system-inconsistence in China rural medical service system cost Chinese government numerous effort and medical resources in order to better meet the comprehensive and complex needs of the rural residents, and in result worsen the problem of resource utilization effiency and system performance. It is recently frequently proved by many countries' experiences that medical service integration is a key element and useful method solving the above problem, and it is also theoretically proved effective in melting and re-bridge the breakage and gaps in the rural medical service system. The medical service system belongs to the research category "the complex system science", and requires meta-synthesis methods and supportive branch-theories like "nonlinear mechanism", "information feedback mechanism", and "synergy mechanism" which are theoretically firm when applied into the medical service system. In this study we firstly expect to make a thorough systematic literature review on integrated medical service theory and models, and then give our definition about the vertical integration of Chinese rural medical service with the purpose to analyze and predict where it is going nowadays, then move forward to investigate and research the specific integration mechanisms and its functioning environment in which a complete analysis of the 4 working mansions will be included: the supplier, the users, the government and the medical insurance payment authorities. Finally, under the help of the instruction of the Complex Adaptive System Theory and the system dynamic modeling tool, we will establish the Vertical Integration Management Model of the Chinese Rural Medical Service Delivery System. The theory and research method are grounded on the Stakeholders Theory, the SWOT Analysis Tool, the Evolution Game Theory, and the Complex Adaptive System Theory, which four shall be applied when we make analysis of demands, the performance and the relations of the stakeholders in rural medical sercive system and influential factors and mechanisms behind their behaviors, then on this basis , we would form theoretically working service integration mechanisms, such as the positive & negative information feedback passageway, the agency synergy mechanism, the payment incentive mechanism, and the mechanisms of governace and regulation. After studying these above mechanisms, we expect to form a integral complex service system with a uniform vision, a clear stucture and a continously improving performance which is fully funtional when interacting with the rural developing situations.

割裂的医疗卫生服务体系是全球范围内的问题，中国农村医疗是服务提供体系割裂的典型，医疗服务层级之间不连续、不协调的状况加剧了系统失灵，"不整合"的现状成为制约国家卫生体系发挥整体功效的重要原因。整合服务被证明是融合服务体系缝隙、加强服务连续性的有效手段，自21世纪以来成为医疗卫生服务体系理论研究和改革重点，农村医疗服务体系急需进行整合与重塑，以加强纵向服务的连续性、降低农村居民就医难度和家庭经济风险，提高政府财政和医保投入效率。本研究在系统研究国内外医疗服务整合理论与实践的基础上，首先界定整合型医疗服务的概念内涵，通过研制以服务评判为落脚点的医疗服务整合度评价指标对我国医疗服务不整合的现状进行总体分析，整理出服务整合的机制和供方、需方、政府和医保四方面影响因素，最后在明晰利益主体和服务机制相互作用机理基础上，借助CAS理论构建农村医疗服务纵向整合管理模型。

目的： 研究以乡县跨级住院服务为切入点，探索乡县服务纵向整合的机制与管理模型。方法： 基于文献分析建立医疗服务纵向整合的概念模型，实证上调研了我国东中西7个样本县区，问卷调查了1370名县乡两级医生，抽取配对了5个目标病种630套乡县两级住院病历，并对供需政保128人次相关者开展了半结构访谈。结果： （1）纵向服务整合度是指住院患者在两级机构服务过程中，衔接部分服务的契合程度，是基于两级衔接部分服务的经济性、有效性以及连续性三方面综合评价的结果；（2）7个县区2012年乡县跨级住院占再入院的12.6%，不足整个住院总量2%，630名乡县跨级住院患者前期未治愈的患者比重达80.8%，住院时间间隔平均为5.49天，一周内转院的患者中69.5%的患者又在县级医院再次做了X光（CT）/心电图检查；（3）专家认为在全部了解乡镇治疗信息的基础上，接近40%的乡级病历有助于优化县级的诊疗方案，乡县跨级住院中的县级住院费用水平与直接县级住院的费用水平无统计学差异（4047.6 VS 4452.6, P=0.533）；（4）县乡两级医生的组织协作强度得分分别为2.33和2.44，县级医生临床协作强度平均得分高于乡级医生（2.46 VS 2.39，P=0.037）；（5）两级服务整合相关者利益诉求的差异不仅体现在内容上，更多的是体现在对利益诉求的倾向上，即侧重点的不同。结论：（1）当前农村地区跨级住院服务的整合状态几乎处于“0”整合状态，主要表现为跨级结构不合理、跨级有效信息传递不畅、县级医生乡镇信息考量不足；（2）跨级住院服务不整合主要在于制度上各方对跨级住院的关注不足、患者病例信息传递困难，以及县级医生乡镇信息的利用程度不高；（3）两级医生对纵向协作需求较高，但沟通不足，协作意愿没有转化成行为；（4）利益相关者的诉求效益得失在很大程度上影响其对整合政策的行为配合度；（5）整合管理模型的需要关注保障机制与约束机制，同时要正视改革所带来的机会成本与改革成本。