基于家庭医生制的医保签约管理支付机制评价与改进策略研究

In recent years, the family doctor program has risen progressively and gained extensive attention in our country, but the universal lack of motivation in family doctors remains one of the major concerns. How to effectively play the guiding role of medical insurance to motivate them to provide more valuable services becomes the key problem to be solved. A specific area was chosen as a sample in this study. Multi-disciplinary quantitative and qualitative methods were used to conduct the evaluation and comprehensive analysis on the cooperative reform between family doctor's contract-service and medical insurance payment, including the following several aspects: 1.To expound the fundamental theory of collaborative reform; 2. To develop the performance assessment system on the family doctor program under the contract-service management model of medical insurance. 3. To evaluate the operation effectiveness of the medical insurance payment mechanism for family doctor's contract-services; 4.To identify the determinant factors in people’s permission to the contract-service and service attendance, and to build up a dynamic model; 5.To explore the main problem, reasons and working mechanism under the cooperative reform; 6.To put forward measurement to improve incentive program for the family doctor. The study will be favorable for a breakthrough and innovation of the integration between the family doctor service and the medical insurance payment scheme under a new round of medical reform to enhance the role of the family doctor as the first-stop care provider, and to promote a more comprehensive and holistic health care service, with a strong pioneering and penetrating application prospect.

近年来家庭医生制在我国逐步兴起并受到广泛重视，而家庭医生群体普遍缺乏积极性是该制度推进过程中面临的主要困境之一。如何有效发挥医疗保险的导向作用，激励家庭医生提供更多有价值服务，是当前亟需解决的关键问题。本研究以特定区域为样本，运用多学科理论及定量与定性调查相结合的方法，从多维角度对家庭医生签约服务与医保支付联动改革进行系统评价和综合分析：①阐明二者联动改革的理论基础；②研制医保签约管理模式下的家庭医生制绩效体系；③评价家庭医生签约服务医保支付机制的实施效果；④识别影响签约意愿与服务利用的决定因素，构建激励路径模型；⑤探寻联动改革下存在主要问题的深层次原因与作用机制；⑥提出完善家庭医生补偿激励机制的对策与措施。本课题研究成果将有利于实现新医改背景下家庭医生制与医保支付整合的有效突破与创新，从而更好地发挥家庭医生“守门人”作用，促进形成有序有效医疗卫生服务体系，具有很强的开拓性和广阔应用前景。

家庭医生签约服务作为推进分级诊疗的重要抓手，与医保支付联动改革受协同效应、社会交换和委托代理理论的支撑。通过将一体两翼模型与“结构-过程-结果”框架整合，研制出3个一级指标、10个二级指标和28个三级指标组成的绩效评估体系。政策评价显示，家庭医生组织管理机制逐渐完善，但数量与能力不足；家庭医生收入构成中签约服务费占比提高（一半占比超过20%），但激励效果不够显著（76.8%认为无作用）；居民签约比例持续上升（32.49%），但签约居民认知程度模糊，有序就医行为尚未形成；家庭医生与专科医生对签约服务的认知改善，但二者合作协同机制尚未建立；签约居民慢病健康管理状况更佳，但并发症干预防治不理想（83.33%下降为53.78%）；签约居民医疗费用都低于未签约居民，但签约后医疗费用先升后降；签约居民对社区卫生服务满意度更高，但呈下滑趋势；家庭医生对协同服务和工作环境满意度低，且整体呈下降趋势。经多因素回归和结构方程模型分析得出：①居民对家庭医生认知与是否签约行为，通过作用于就诊行为选择和慢病服务利用两个中介变量，对医疗费用控制和慢病健康管理产生显著影响。社区首诊行为越强的居民，家庭医生参与下的慢病自我管理服务开展越好，更加有利于提升健康管理效果。②续约依从性强的签约居民更愿意到社区首诊，并显著提升预约就诊和定向转诊比例。签约居民选择社区首诊并非在家庭医生处定点就诊，但如选择家庭医生处定点就诊，通常其预约就诊和定向转诊比例更高。③家庭医生对自身工作的认知度决定了他们的行为取向和服务效果。通过提升家庭医生的收入满意度，能够增强他们的工作稳定性，进而提高签约服务绩效，这表明稳住人才作为中介效应变量是关键。本项目提出需要梳理并解决与联动改革相关的政策矛盾，提升家庭医生签约服务的价值内涵和增强公立医院支持力度，构建竞争机制激活家庭医生签约服务供给的能动性，同时推进签约服务费向真正按人头支付方式转变，以更好地发挥家庭医生“守门人”作用。