上海医疗资源纵向整合研究
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摘要
1背景
资源有限,需求无限。有限的医疗卫生资源和人民群众日益增长的医疗卫生服务需求之间,矛盾始终存在。缓解这一矛盾,需要政府的有效规划和管制,需要通过制度设计或直接干预,降低每类医疗卫生服务的单位成本,提高当前医疗卫生资源的利用效率,获得更多的医疗卫生服务产出,更大程度地满足人民群众的医疗卫生服务需求。
达到上述目的,有多种途径和策略可供选择,例如增加政府对卫生的投入、完善医疗保障制度、调整现有的医疗服务价格体系、严格控制药品和检查费用、拉开不同等级医院收费价格和医保补偿比例,等等。但是,由于中国当前的大医院“人满为患”、部分医院“门可罗雀”的资源利用矛盾,以及小医院、农村医院和基层医院缺乏技术力量的现实,中国卫生改革特别提出了资源整合、扩大卫生服务提供、缓解看病难问题的策略,期望通过各类医院的联合、协作提高医疗资源整体利用效率,从而扩大医疗服务供给。
资源整合是在已有资源的基础上,吸收消化外部资源,优化内部资源,并将之重新组合的活动,目的是让有限资源发挥更大的效用,应用在医疗卫生领域,即为医疗资源整合。整合的对象在社会地位或实力规模上有着显著差别,可称之为医疗资源纵向整合,其模式有二,一是机构之问的相互契约或资产融合,促使优质医疗资源输出;二是政策形态的资源调配、转移或归并,例如卫生行政部门号召城市医院派遣医疗力量支持农村县医院或乡镇卫生院的医疗工作。
本次研究,主要关注机构形态的医疗资源纵向整合,通过必要性分析、执行现状描述、执行障碍分析和个案评价,总结医疗资源纵向整合的适宜模式和操作步骤,为优化上海医疗资源配置和利用提供循证建议。
2内容
2.1分析上海医疗资源纵向整合的必要性
(1)分析上海居民就医地理可及性、医生可及性和就医交流充分性,明确上海居民看病难问题的表现:(2)分析上海医疗机构、医疗床位、医务人员、医疗设备、医疗费用的现状,并与直辖市、全国平均水平,以及部分国家和地区进行比较;(3)分析上海医疗机构提供的诊疗服务、门急诊服务、住院服务、手术服务的基本情况,分析医疗机构人力效率、床位使用效率和平均住院天数,并与直辖市、全国平均水平,以及部分国家和地区进行比较。
2.2明确上海医疗资源纵向整合的现实进展和障碍
(1)分析改革开放以来,在全国范围内的医疗资源整合历史和实践经验:(2)分析国内外典型国家和地区医疗资源整合模式、办法和运作效果;(3)总结上海医疗资源纵向整合的模式;(4)分析医疗资源纵向整合的利弊和关键点,分析医疗资源纵向整合存在的问题和障碍。
2.3评价上海医疗资源纵向整合的实施成效和不足
根据专家推荐选择运作情况较好的个案进行评价研究。研究对象是瑞金医院和原卢湾区中心医院。主要针对原卢湾区中心医院在接受瑞金医院托管之后机构诊疗水平的变化和影响力的变化展开研究。同时还进一步分析了该个案成功的前提条件和仍然面临的困难。
2.4提出上海医疗资源纵向整合的模式和策略
针对上海医疗资源纵向整合的障碍、成功个案的前提条件,提出医疗资源纵向整合的政策思路、策略、方案和操作逻辑步骤。
3方法
(1)通过上海市卫生局、上海申康医院发展中心、卫生部等途径收集2003年上海卫生服务调查报告、国家第三次卫生服务调查研究报告、中国卫生统计年鉴,从中获得用于国际比较和国内城市比较的有关卫生服务可及性、医疗资源配置和利用效率的资料数据。
(2)通过文献综述,获得国内外医疗资源整合理论、实践和经验总结的信息材料;通过结构问卷的方式普查上海三级医院资源纵向整合的现况;通过专家咨询明确上海目前医疗资源纵向整合各类模式的利弊、关键点、存在的问题和障碍。
(3)通过1995、1997、1998、1999(实施集团化改革之年)、2001、2003、2005、2007年住院病人病案调查,获得用于资源整合效果个案评价的信息资料。住院病人总体为53377人,通过固定样本量(500或1000)系统抽样获得样本住院病人5500人。其中用于住院病人危重度变化评价的有效样本是4513例,用于住院病人分布变化评价的有效样本量是5124例。
(4)通过专家咨询和焦点小组访谈提出医疗资源纵向整合的蓝图策略和需要的配套政策支持,总计咨询253人次。
统计软件使用SPSS11.5,作图软件使用SPSS11.5和MAPINFO7.0。
4结果
4.1推行医疗资源纵向整合对于优化上海医疗资源配置和利用的潜在作用
4.1.1上海人力、床位配置水平较高,其中,每千人口执业医师3.33人,高于北京(2.28)、天津(2.65)、香港(1.65)、澳门(2.82),也高于日本(2.12)、新加坡(1.55)、英国(2.30)、美国(2.56)和澳大利亚(2.72);每千人口床位5.20张,低于北京(6.41)、台湾(6.03)和日本(14.19),但高于天津(4.18)、香港(4.92)、澳门(2.33)、新加坡(3.33)、英国(4.0)、美国(3.3)和澳大利亚(3.93)。
4.1.2上海医疗资源的利用效率也比较高。上海医生人均每日承担诊疗服务9.1人次,远高于北京(6.8)、天津(5.4)和重庆(5.8);上海医生年人均承担住院服务2.0天,也远高于北京(1.3)、天津(1.4)和重庆(1.2);上海各医院床位使用率达到了93.5%,亦远高于北京(77.3%)、天津(68.1%)和重庆(69.1%)。
4.1.3上海医疗资源整体利用效率在各层次医疗机构差异较大。三级医院床位使用率高达99.43%,二级医院为96.38%,一级医院等只有81.59%;三级医院平均住院天数只有13.55天,但二级医院为16.28天,一级医院达27.41天。
4.1.4实行医疗资源纵向整合,共享各级医院床位资源,可缓解高层次医院住院难、基层医院床位使用率低的矛盾,提高基层医院的技术水平,促使病人到基层医院就医,优化医疗资源配置和利用效率。
4.2上海医疗资源纵向整合主要有四种模式
4.2.1托管。例如中山医院对青浦区中心医院的托管。该模式的优点是不涉及产权变更,操作比较方便,也能够比较顺利实现资源共享和优质医疗资源支援基层的目的。不足之处在于,产权归属不清前提下,大医院的主要目的是掌控医疗市场、缓解大医院运营压力,建设被整合医院的积极性不高。
4.2.2兼并。主要是撤并部分经营状态比较差的公立医疗机构,将其人员、床位编制整合到经营状态较好的公立医疗机构中。例如瑞金医院对原市政医院的兼并,中山医院对原纺三医院的兼并。
4.2.3集团化。主要依托核心医院的特色专科,以学科为纽带,建立或联合成立医院集团。典型案例是上海华山神经外科(集团)医院。这种模式已经成为上海医疗资源纵向整合的主流,一方面缓解了各级医院之间忙闲不均的问题,另一方面也因为资源自由整合的缘故,给区域卫生规划的贯彻落实提出了新的挑战。
4.2.4合作。例如复旦大学附属肿瘤医院和上海建工医院在乳腺癌外科服务上的合作。
上海所有三级医院都通过某种模式与基层医院建立了资源整合联系,以合作和集团化模式多见。
4.3上海医疗资源纵向整合实施效果的个案评价
知情人认为是目前上海医疗资源纵向整合各类模式中,集团化模式效果最好,而且特别指出,瑞金医院对原卢湾区中心医院的整合有其特殊之处,一方面瑞金医院向原卢湾区中心医院派驻院长和业务骨干,有着委托管理的思想,另一方面瑞金医院获得了原卢湾区中心医院一半的资产权,有着资产兼并的做法。有鉴于此,本次研究对瑞金医院整合原卢湾区中心医院的效果进行了个案评价。由于
4.3.1自纵向整合之后,瑞金医院帮助卢湾分院加强学科建设。来自瑞金医院的专家、教授定期开展查房、手术、特色门诊,并指导临床、科研及教学等工作,提高卢湾分院的服务能力和述评,接治住院病人的疑难程度有所上升。卢湾分院肿瘤病人的大幅度增加很好地说明了这一点。1995—1999年间,瑞金医院卢湾分院接治的肿瘤病人数量基本保持在550例左右,此后,肿瘤病人数量迅速上升,2001年翻了1倍,达到1142例,2007年更是达到了3616例,占该医院所有住院病人的32.0%。
4.3.2在纵向整合之后,瑞金医院派遣神经内科和内分泌科专家担任卢湾分院科室主任负责人,在分院新建的神经内科病房和糖尿病强化治疗病房。同时将卢湾分院作为分流病人的重要渠道,大量肿瘤、血液病类型的病人转移到卢湾分院救治。由于卢湾分院技术水平的有限,转移病人大多病情平稳,由此带来纵向整合之后卢湾分院住院病人病情危重程度的下降。1995年的平均危重度分值为71.71,以后下降至1999年的64.96,至2001年达到最高平均为82.21,随后又开始呈现下降趋势,到2007年降低至64.19。单因素方差分析表明:这8个年份的危重度分数均值不全相同(F=11.598,P＜0.01),进一步做两两比较(LSD)发现,除1999、2003和2005年外,其余年份的分值均高于2007年。卢湾分院住院病人危重程度的下降,一方面体现了资源纵向整合之后医院之间合理分工的开始形成,另一方面也说明以往期望资源纵向整合之后好医院带差医院,显著提高差医院技术水平的期望是过高的,在实践过程中核心医院更希望被整合的医院扮演拾遗补缺的角色。
4.3.4纵向资源整合之前,瑞金医院卢湾医院的医疗市场整体在萎缩当中,1995年住院病人为4974人,1998年下降到3751人。自纵向整合开始,住院病人有了大幅度的跃升,2001年增长近1倍,达到了6642人。2007年较2001年又增长了70.1%,达到了11299人。同期,与瑞金医院卢湾分院规模、周边环境比较相似的静安区中心医院,2001年住院病人为7439人,2007年为11222人,增长只有50.9%。由此可以推论,纵向整合有力推动了瑞金医院卢湾分院的发展,扩大了他的业务规模。
4.3.5整合之后市场占有情况变化。2001年到2007年,瑞金医院卢湾分院接纳的卢湾区本地病人增长了30.2%,非卢湾区病人增长了269.1%。瑞金医院对原卢湾区中心医院的纵向整合有助于提升原卢湾区中心医院的辐射力,目前的瑞金医院卢湾分院在上海医疗市场中扮演的角色,已不仅仅是一所区域性医疗服务中心。
4.4上海医疗资源纵向整合面临的问题和障碍
4.4.1宏观层面存在区域市场垄断问题。很多区域内的大医院只有一所或者少数几所,基层医疗机构选择余地小,一开始就会处于不平等地位。整合之后,基层医院的服务费用会与核心医院趋同,有着促使费用更加昂贵的嫌疑。
4.4.2政府层面存在区级政府的积极性问题。两级财政管理下,区级政府负有建设和发展医疗机构的责任。一旦实行纵向整合,基层医疗机构划归核心医院管理,区级政府的投入将难以保证。
4.4.3制度层面存在物价制定、医疗保险结算标准问题。不拉开整合体中各医疗机构的服务价格差异,或是沿用目前不同等级医院基本相似的医疗保险结算标准,仍然很难通过价格杠杆实现双向转诊。
4.4.4卫生行政部门层面存在职能定位问题。被整合医院往往是二级或一级医院,其原上级主管部门往往是区县卫生行政部门。整合之后,被整合医院面临着双重领导,既要服从主体医院的管理,又要听从区县卫生行政部门的指令,两者之间容易出现矛盾。
4.4.5医疗机构层面存在文化冲突问题。整合体各成员医院成长历程不同、经营状况不同,必然带来价值观念、行为准则、运作习惯、工作作风、典礼仪式、管理制度等的差异,冲突不可避免。
4.5可供上海医疗资源纵向整合借鉴的国际经验
4.5.1新加坡的经验表明,在实行医疗资源纵向整合的同时,也要引入竞争机制,防止独家垄断,为此特地设置了两个医疗集团,以推动彼此间的比较竞争。同时还通过一系列的政策来取得类似医疗资源纵向整合的效果,例如“经社区首诊转入大医院者给予10—20%的优惠”。台湾也提供了类似的经验。
4.5.2英国的经验表明,要将医疗资源整合落到实处,所形成的集团首先必须在人事改革、增减床位等问题上有充分的自主权,应当注意在增加医院收入的基础上,增加职工的收入,以充分调动员工的主观能动性。形成的集团应当包含各种层次和类别的医疗机构,使不同需求的病人在集团的相应机构得到服务,减少候诊、等待,减少盲目进入高级医院的次数。形成的集团可以采用直接控股与联盟合作等多种资本运营的方式。
4.5.3美国的经验表明,要有力推动医疗资源纵向整合,必须在改革医保偿付制度,促进高等级医院不得不着力于压缩成本,从而将注意力放到基层医疗机构,并与之形成战略联盟。例如规定大型医院特定病种住院可获得的补偿床日数,病人住院超过天数则需自费,除非他转移到社区服务中心。
4.5.4香港的经验更具借鉴价值。一是统一各项制度。所有医院实行统一行政管理制度,采用同一套的财务管理制度、规章和模式,实行统一的薪酬制度,使用统一的信息平台和数据定义,统一采购医疗设备、药品等医用物资等。二是推行医院分区联网。特定联网区域内医院不重复设置专科,不重复配置大型设备。三是在全民健保前提下,按人口、老年人口、人口流动情况等下拨医院预算资金。
4.6上海医疗资源纵向整合的蓝图和策略建议
在分析上海形势,回顾国内发展,借鉴国际经验,咨询有关专家的基础上,提出了上海医疗资源纵向整合的蓝图和策略。
4.6.1第一类策略是政府主导策略,在政府主导下,以医疗保险为基础,以医疗机构资产属地化管理为前提,统合上海市各级各类公立医疗机构,组建若干医疗集团。医疗集团以三级医院为核心,以若干三级专科医院、二级医院和社区卫生服务中心为延伸,以社区卫生服务站和全科医师团队为基础。
4.6.2第二类策略是市场主导策略,在市场主导下,以三级医院为核心医院,以产权为纽带,兼并二级医院,在本区域或跨区域形成医疗集团,并通过契约与二级医院所在区域社区卫生服务中心合作。
4.6.3第三类策略是行政区域整合策略,以当前财政拨款体制和社会医疗保险为基础,以区县公立医疗机构管办分离为前提,在各区县实行二级医院为核心的纵向医疗集团,推行区县范围的医疗资源纵向整合。
4.6.4第四类策略是政策引导策略,在现有医疗机构管理体制、运行机制基础上,以不改变原有医疗机构产权性质为特征,从机构托管和政策调节的角度,促进医疗资源纵向整合。具体构想是:
4.6.5第五类策略是利益整合策略,以三级医院为主体,通过项目合作的形式,与本区域或跨区域二级医院及若干个社区卫生服务中心进行某一方面的资源整合,达到各自利益目标的实现。
上述医疗资源纵向整合策略需要四项政策支持措施一是统一产权主体;二是调整医保支付方式,由总额预付逐步过渡到按服务量支付、按人口支付;三是改革人事分配制度,实行年薪制,促进医务人员在成员单位之间的顺畅流动;四是明确成员机构的职能,高等级医院主要从事住院和急诊服务,社区卫生服务中心主要从事门诊和预防保健服务。
5创新和不足
5.1创新
5.1.1医疗资源纵向整合是提高医疗资源利用效率、扩大医疗卫生服务提供、解决居民看病难问题的一项重要战略。国外有比较成熟的经验,国内则成功经验不多,仍然处于摸着石头过河的阶段。本次研究分析了上海医疗卫生资源的配置和利用现状,论证了医疗资源纵向整合的必要性。
5.1.2本次研究基于上海医疗资源现状、基于国内实践案例,基于国外成功经验、基于专家的分析判断,提出了上海医疗资源纵向整合的蓝图策略和所需要的政策支持。
5.1.3本次研究的个案是上海第一家开展医疗集团探索的瑞金医院卢湾分院(原名“卢湾区中心医院”),通过个案研究的方式分析了医疗资源纵向整合前后,被整合医院的住院病人地理分布的变化。国内目前还缺乏这类针对住院病人地理分布的研究。
5.2不足
5.2.1 1999年至2007年,发生在三级医院和二级医院之间的上海医疗资源纵向整合共60起。本次研究限于时间,未能对所有60起案例进行逐一分析,只是从中有目的地研究了若干案例,并且针对瑞金医院托管原卢湾区中心医院进行比较详细的评价。研究的广度有所欠缺。
5.2.2针对瑞金医院托管原卢湾区中心医院的效果评价,考虑到门诊病案由病人随身携带,收集整理有困难,故而侧重于住院病人数据的收集、整理和分析,容易造成不能全面反映纵向医疗资源整合对原卢湾区中心医院医疗服务的影响。
1 Background
The health resource is limited while the health needs are unlimited.There are always contradictions between the limited health resources and the increasing needs of the people in medical and health service.In order to alleviate the contradiction,the effective governmental planning and regulations are needed to involve in or directly intervene through regulations to reduce unit cost of each medical and health service, increase the efficiency of the utilization of current medical esource,obtain more output of the medical service and satisfy people's need on medial service in a greater extent.
In order to realize the above goals,there are various means and strategies available,such as increasing governmental inputs in sanitation,perfecting medical insurance system,regulating the current medical service price system,strictly controlling medicine and inspection cost,widening charge price and medical insurance reimbursement proportion,and etc.But due to the contradictions in resource utilization that the big hospitals are crowded by large quantity of patients and the some other hospitals have few patients,and the situation of the small hospital, rural hospital and grassroots hospital,China health reform specially puts great effort on resource integration strategy to expand health service and alleviate the problem of "difficult medical care",hoping to increase overall utility efficiency to expand medical service provision through cooperation between various hospitals.
Resource integration is an activity absorbing external resource,optimizing internal resource and reorganizing based on its existing resources,the aim of which is to make the limited resource exert more efficiency to apply in medical and health field, i.e.medical resource integration.Because integration targets have noticeable differences with regard to different social status and strength,it can be also called medical resource vertical integration which has two patterns;the first is mutual agreement or asset integration to promote premium medical resource output;the second is resource deployment,transfer or merging policy,such as the health administrative department calls on urban hospital to assign medical force to support medical work of the rural hospital or township hospitals.
The study mainly focuses on medical resource vertical integration on institutional level,summarizes suitable mode and operational procedure for medical resource vertical integration and offers suggestion on Shanghai medical resource allocation and utilization through necessity analysis,implementation status quo,and obstacle analysis in implementation as well as case appraisal.
2 Contents
2.1 Analyzing the necessies of medical resource vertical integration in Shanghai
(1)Analyze geographical availability of medical care for Shanghai residents, doctor availability and sufficiency of communication with doctor,make clear manifestation of difficult medical care for Shanghai residents;(2) Analyze status quo of Shanghai medical institution,hospital beds,medical staff,medical equipment and medical expense and compare with the level of other municipality,average level of the country,and the level of some countries and regions;(3) Analyze basic situation of diagnosis service,outpatient and emergency treatment service,surgery service, analyze manpower effectiveness,hospital beds utility efficiency and average inpatient days,and compare with the level of municipality directly under the Central Government,average level of the country,and the level of some countries and regions.
2.2 Making the actual development and obstacle clearly in Shanghai medical resource vertical integration
(1)Analyze historical and practical experience of medical resource integration nationwide since the reform and opening-up;(2) Analyze medical resource integration mode,method and operational effect of typical countries and regions domestically and overseas;(3) Summarize mode of Shanghai medical resource vertical integration;(4) Analyze advantage,disadvantage and key points of medical resource vertical integration,and analyze problems and obstacles existing in medical resource vertical integration.
2.3 Evaluating strengths and weaknesses of medical resource medical integration in Shanghai
Case study is applied based on the case with good operation recommended by experts.Research object is Ruijin Hospital and the former Central Hospital of Luwan District.The research is carried out mainly on medical level change and influence of the former Central Hospital of Luwan District after trusted to Ruijin Hospital, meanwhile,I further analyse precondition of the successful case and existing difficulties.
2.4 Putting forward different mode and strategies for Shanghai medical resource vertical integration
Policy,strategy,plan and operational procedure for medical resource vertical integration are put forward in accordance with obstacle in Shanghai medical resource vertical integration and precondition of successful cases.
3 Methods
(1) Data are collected from 2003 Shanghai health service survey report,the 3~(rd) national health service survey report and yearbook of health in the PRC through Shanghai municipal health bureau,Shanghai Shenkang hospital development center, resource allocation and utility efficiency and are compared with those of overseas and domestic cities.
(2)Obtain information of domestic and overseas medical resource integration theory,practice and experience summary hrough literature;general investigate status quo of resource vertical integration of Shanghai GradeⅢhospital through questionnaire;make clear advantage,disadvantage,key points,existing problems and obstacle in various modes of the current Shanghai medicalresource vertical integration.
(3)Obtain information for resource integration effect evaluation through inpatients medical reports in 1995,1997,1998,1999,2001,2003,2005 and 2007.The total inpatients were 53377,and samples of 5500 inpatients are obtained through systematic sampling with fixed amount((500or 1000),among which,4513 cases are effective samples for inpatients severity change appraisal,5124 cases are effective samples for inpatients distribution change appraisal.
(4)Put forward strategy roadmap and necessary policy support for medical resource vertical integration through expert consultation and interview with professional team,253 people are consulted in total.
Statistic software used is SPSS11.5,drawing software of SPSS11.5 and MAPINFO7.0.
4 Results
4.1 Potential effects of promoting medical resource vertical integration in optimization of Shanghai medical resource allocation and utilization
4.1.1 Manpower and hospital bed allocation in Shanghai are at a high level,there are 3.33 certified doctors per thousand people,which are higher than Beijing(2.28), Tianjin(2.65),HK(1.65),Macau(2.82),Japan(2.12),Singapore(1.55),GB(2.30), USA(2.56) and Australia(2.72);there are 5.20 hospital beds per thousand people, which are lower than Beijing(6.41),Taiwan(6.03) and Japan(14.19) but higher than Tianjin(4.18),HK(4.92),Macau(2.33),Singapore(3.33),UK(4.0),USA(3.3) and Australia(3.93).
4.1.2 Utililization efficiency of Shanghai medical resources is also high.Each Shanghai doctor diagnoses 9.1 people per day,much higher than Beijing(6.8), Tianjin(5.4) and Chongqing(5.8);each Shanghai doctor provides inpatient service for 2.0 days per year,also much higher than Beijing(1.3),Tianjin(1.4) and Chongqing (1.2);Utilization ratio of hospital beds in each Shanghai hospital amounts to 93.5%, also much higher than that of Beijing(77.3%),Tianjin(68.1%) and Chongqing(69.1 %)
4.1.3 Overall utilization efficiency of Shanghai medical resource varies a lot in medical institution of various levels.Hospital bed utilization ratio in GradeⅢ hospital;average hospital days of GradeⅢhospital is only 13.55 days,but 16.28 days in GradeⅢhospital and 27.41 days in GradeⅠhospital.
4.1.4 Implementation of medical resource vertical integration and sharing hospital beds among hospital at various levels can alleviate the problem of difficult hospitalization in high level hospital and low hospital bed utilization ratio in grassroots hospital,improve skills of the grassroots hospital,promote the patients to be hospitalized in grassroots hospital and optimize medical resource allocation and utilization efficiency.
4.2 Four major modes for Shanghai medical resource vertical integration
4.2.1 Trusteeship.Such as Central Hospital of Qingpu District is trusted to Zhongshan Hospital.Such mode does not involve ownership change,therefore is convenient to operate and helpful in realizing resource sharing and premium medical resource supporting the grassroots hospital.While,under the precondition of unclear ownership,main aim of the big hospital is to control medical market and relieve operational pressure,but they are not active in constructing the integrated hospital.
4.2.2 Merge.It is mainly to revoke and merge some government run medical institution with bad operation,integrate its staff and hospital beds to government run medical institution with good operation,such as Ruijin Hospital merges the former Municipal Hospital and Zhongshan Hospital merges the former No.3 Textile Hospital.
4.2.3 Conglomerate.It is to establish or co-establish hospital group based on special section and the academy of the key hospitals.The typical case is Shanghai Huashan Neurosurgery(Group) Hospital.Such mode has been the main stream of Shanghai medical resource vertical integration,on one hand,it alleviates the contradiction that some hospitals are too busy and some others are idle;on the other hand,it raises new challenge for implementation of regional health planning due to free resource integration.
4.2.4 Coopeartion.Such as Tumor Hospital Attached to Fudan University cooperates with Shanghai Jiangong Hospital on mammary cancer.
All the GradeⅢhospitals have established resource integration contract with grassroots hospital through certain mode,among which,cooperation and conglomerate are most common.
4.3 Case appraisal on implementation effect of Shanghai medical resource vertical integration
Insiders think that conglomerate is the best one among various modes of Shanghai medical resource vertical integration,in addition,integration of the former Central Hospital of Luwan District to Ruijin Hospital has special meaning:on the one hand,Ruijin Hospital appoints president and technical backbone to the former Central Hospital of Luwan District,which means mandatory administration;on the other hand, Ruijin Hospital obtains half assets of the former Central Hospital of Luwan District, which means asset acquisition.In view of this,the study makes case appraisal integration effect of the former Central Hospital of Luwan District into Ruijin Hospital.
4.3.1 After vertical integration,Ruijin Hospital helps the former Central Hospital of Luwan District enhance academic construction,experts and professors from Ruijin Hospital regularly carry on ward inspection,surgery,and characteristics diagnosis, guide works as clinic,scientific research and teaching,increase service ability and value of Luwan branch and increase the complexity of inpatients,which is proved by substantial increase of tumor patients in Luwan branch,from 1995 to 1999,tumor patients seek for medical treatment in Ruijin Hospital Luwan branch has been basically maintain at about 550 cases,later,quantity of tumor patients increased rapidly,about one times in 2001,reaching 1142 cases,and 3616 cases in 2007,taking 32.0%of its total inpatients.
4.3.2 After vertical integration,Ruijin Hospital assigns neurological and endocrinological exports to be section head of Luwan branch,builds new neurological wards and diabetes intensive cure ward,and makes Luwan branch as the main channel to redirect patients,large quantity of tumor and hemopathic patients were transferred to Luwan branch for treatment.Due to the limited technique of Luwan branch,the transferred patients were generally in stable condition,which led to inpatients severity reduction in Luwan branch after integration.Average inpatients severity in the year of 1995 was 71.71 and then reduced to 64.96 in 1999,average inpatients severity increased to 82.21 in 2001,and then it is again in a downtrend,reduced to 64.19 in 2007.One-way ANOVA shows that average severity value are not the same in the eight years(F=11.598,P＜0.01),then the least significant difference(LSD) is made which shows that except for the year 1999,2003 and 2005,value in other years are all higher than that in 2007.Reduction of inpatients severity in Luwan branch one the one hand represents formation of rational division between hospital after resource vertical integration,on the other hand,it also represents that people expect too much on the good hospital guiding the inferior ones and remarkably improve skill of the inferior hospitals after resource vertical integration,during practice,the key hospital hopes the integrated hospital to play a complementary role.
4.3.4 Prior to resource vertical integration,overall medical market of Ruijin Hospital Luwan branch is in shrink,there were 4974 inpatients in 1995,and reduced to 3751 in 1998.After the vertical integration,quantity of inpatients reduces and rises rapidly,increasing about one time in 2001,reaching to 6642,inpatients increased by 70.1%in 2007 than that in 2001,reaching to 11299.In the same period,there are 7439 and 11222 in the year of 2001 and 2007(increased by only 50.9%) in Central Hospital of Jingan District which is similar to scale and surrounding environment of Luwan branch,therefore,it can be deduced that vertical integration drives development of Luwan branch and expand its business scale.
4.3.5 Market share change after the integration.From 2001 to 2007,local patients treated by Luwan branch increased by 30.2%,patients not from Luwan district increased by 269.1%.Vertical integration of the former Central Hospital of Luwan District into Ruijin Hospital helps to upgrade radiative force of the former Central Hospital of Luwan District,at present;Luwan branch does not just play a role as regional medical service center in Shanghai medical market.
4.4 Problems and obstacles in Shanghai medical resource vertical integration
4.4.1 In the macro-level,there exists the problem of regional market monopoly. There are only or several big hospitals in the region,grassroots medical institution has little choice and is in unequal position,after integration,service charge of the grassroots hospital will be the same as that of the key hospitals,hence having suspicion of increasing treatment cost.
4.4.2 In the government level,there exists the problem of motivation of the district government.Under the two layer financial management,district government is liable for constructing and developing medical institution.Once the vertical integration is implemented,grassroots medical institution is put under its administration of the key hospital,hence input from the district authority will be difficult to guarantee.
4.4.3 In system level,there exist the problems as pricing and medical insurance settlement standard.If service price difference in each medical institution of the integration is not widen,or follow the medical insurance settlement standard which are similar in hospitals of different level,it will be difficult to realize double treatment transfer through price leverage.
4.4.4 In health administrative department level,there exists the problem of function position.The integrated hospitals are usually GradeⅡor GradeⅠhospitals whose immediate supervisory department are district or county health administrative department.After integration,the integrated hospitals face double leadership,having to obey the management of the main hospital and the direction of the district or county health administrative department,from which the problems are easy to arise.
4.4.5 In medical institution level,there exists the problem of cultural contradiction.Members of the integration have different growth procedure and business condition,therefore there will be difference in value,code of conduct, operational habit,work style,ceremony and management system,and the contradiction is unavoidable.
4.5 International experience which can be learnt by Shanghai medical resource vertical integration
4.5.1 Experience of Singapore shows that competitive mechanism is introduced at the time of implementing medical resource vertical integration to avoid monopoly; as such,two medical groups are set to promote competition between them.Meanwhile, effects similar to that of medical resource vertical integration through serials of policies are attained,such as "10—20%discount for the patients transferred from community hospital to the big hospital",and Taiwan also provides the similar experience.
4.5.2 Experience of the UK shows that in order to actual implement medical resource integration,the established hospital group shall have sufficient autonomous fight in terms of HR reform at first,adding and reducing beds,etc,it shall pay attention to increase income of the staff on the basis that income of the hospital is increased to fully mobilize subjective initiative of the staff.The formed group includes medical institution of various layers and types to make the patients with different needs are served in corresponding institution of the group,and reduce the waiting period and the time indiscriminately seek for medical care in big hospital.The established hospital group may adopt various capital operation methods as direct holding and alliances.
4.5.3 Experience of the USA shows that in order to drive medical resource vertical integration,medical insurance reimbursement system is reformed to promote the high level hospital to reduce cost,hence seek for support from the grassroots medical institution and form strategic alliance with it.For example,reimbursable inpatient days of special disease in large hospital is stipulated,in case the patients exceed the stipulated inpatient days,they shall be charge unless transferred to community service center.
4.5.3 Experience of HK has more reference value.The first is to unify various systems,all the hospitals carry on uniform administrative management system,adopt the same financial management system,rules and modes,carry on uniform salary system,use the uniform information platform and data,uniformly procure medical equipment,medicine and other medical materials.The second is to implement hospital networking,special section within the networking region will not be reset in other hospital,nor reset large equipment.The third is to allocate budge for the hospital as per population,population of the aged and situation of population flow under the precondition of guarantee overall health insurance of the people.
4.6 Roadmap and strategy proposal for Shanghai medical resource vertical integration
The project team puts forward roadmap and strategy for Shanghai medical resource vertical integration based on analysis of Shanghai condition,domestic development overview,referring to international experience and consulting relevant experts.
4.5.1 The first strategy is to lead the integration through policy and promote medical resource vertical integration based on existing medical institution management mechanism and operational mechanism with unchanged former medical institution property as the characteristic and from the perspective of institutional trusteeship and policy regulation.Specific conception is:(1) implement trusteeship or cooperation between GradeⅢand GradeⅡhospital.The district or county health bureau(entrusting party) forms trusteeship relation of "entrusted management——trustee management" between GradeⅡhospital(target hospital) under its administration and GradeⅢhospital(entrusted party),and transfer the operational management right of the target hospital to the entrusted party for reorganization and operation with certain conditions and terms.(2) Issue serials of health and medical insurance policy to adjust benefits distribution structure between hospitals of various level to promote premium medical resource flow to GradeⅠhospital and meanwhile promote the patients seek for more treatment and rehabilitation services in GradeⅠhospital,such as community health service of GradeⅢhospital,traditional Chinese medicine serve the community,famous doctor serve the community,diagnosis expense reduction and exemption policy in grassroots hospital,inpatient days regulation for high level hospital by the medical insurance, and etc.(3) Promote regional hospital group trial crossing asset relation in the place with proper condition.Carry on uniform administrative management,budget,and medical insurance settlement within the group.Under the precondition not changing asset property,further promote the current trusteeship cooperation to close cooperation and truly exert integration effect of the resource.The above targets are easy to be attained with little technical difficulty and are helpful for naturally form regional medical center and community sanitation service center as GradeⅡmedical service system.As for GradeⅡhospital unable to exist and develop by themselves, and whose ownership will not be abandoned by the district or county health bureau, trustee is the best resource integration method,but its disadvantage is its small reform intensity,therefore trustee is not fundamental solution.
4.5.2 The second strategy is to separated integration between administration and operation,build vertical medical group with GradeⅡhospital as the core in each district and county based on the current financial allocation mechanism and social medical insurance,with separate administration and operation of government run medical institution,and promote medical resource vertical integration within the district and the county.Specific conceptions are(1)Promote separation of administration and operation of public run medical institution in the district or the county,set up medical institution administration center dedicatedly responsible for management work as HR,asset,finance,party affair and etc.Business income of the government run medical institution under its administration(including income from medical insurance) is uniformly turned in to medical institution management center, financial allocation to the government run medical institution is also directly turned into medical institution management center.The third party appraisal institution is entrusted to be responsible for appraisal performance of the public run medical institution.(2) Public run medical institution under its administration does not reset special section and large equipment.Resident physician are trained uniformly in GradeⅡhospital;doctors of community health service center are trained in rotation in GradeⅡhospital in a planned way to gradually upgrade medical skill of community health service center.The target does not involve much benefit adjustment,is easy and feasible and is helpful for effective utilization of the medical resource in the region. Its disadvantages are technical advantage of GradeⅢhospital is difficult to be exerted,hence not helpful for premium resource service transfer to inferior hospital. Such mode has little difficulty in policy and can be used as the first procedure of Shanghai medical resource conglomerate integration.
4.5.3 The third strategy is conglomerate integration,divide networking region according to the needs on medical treatment by the region and population,integrate public run medical institution of Shanghai in various levels and kinds based on nationwide medical insurance,and establish several medical group with GradeⅢcomprehensive hospital as the core,with several GradeⅢspecialized hospital,GradeⅡhospital and community health service center as extension and based on community health service station and doctor team within the whole section.Specific conceptions are(1) Medical group possesses administration authority on asset,HR and financial management of the various medical institutions under its administration.The hospitals under its administration carry on uniform administrative management system, financial management system,rules and modes,and the medical staff carries on uniform salary system.(2)GradeⅡhospital,community health service center and healing hospital are equipped within the networking region.Special section and large equipment are not reset within the networking region to realize resource sharing and reduction of operation cost.Work places of the staff within the networking hospital are subject to transfer as work needs.(3)Medical institution within the networking region carries on budget fund system.Medical group obtains budget fund from government financial and social insurance department,allocate budget fund to the networking region each year as per planned budget,and then the networking region allocate budget fund to medical institution.Budget fund allocation is determined by population,aging population,floating population and special service(such as complex special section charge more).Budget fund ensures fundamental medical service for the people.Medical institution may provide non-fundamental medical service for which the patients are charge at their own expense.(4) Medical group carries on uniform and centralized procurement on medical material as medical equipment and medicine.Information platform is set up,all the medical institution and principle office use uniform information platform and data definition,etc.(5) Resident physician within the group are trained uniformly in GradeⅢhospital; doctors of GradeⅡhospital and community health service center are trained in rotation in GradeⅢhospital in a planned way to gradually upgrade medical skill of grassroots medical institution.Achieving the aim is helpful to exert accumulative effect of premium resource,effective utilization of medical resource,strengthen the appeal of grassroots institution on the patients,and then governmental management aim and purpose will be guaranteed.The disadvantage is that regional monopoly is formed and may create weakened service.The difficult point is to break through the former interest pattern,in which government determination is needed.
4.5.4 The forth strategy is policy-induction.Based on the current medical institution's management system and operation mechanism,characterized by unchanging the property fight of original medical institution,from the point of institution trusteeship and policy adjustment,the medical resource vertical integration would be promoted.
4.5.5 The fifth strategy is benefit conformity.The gradeⅢhospital was selected as principal part to be conbined with the gradⅡhospital or some community health service center through the way of project collaboration.
The above medical resource vertical integration strategies need four policy support,the first is the uniform ownership subject;the second is medical insurance settlement method adjustment,transferring from charges total prepaid to payment as per service volume and population;the third is staffing system,carrying on annual salary system to promote smooth flow of medical staff within the member hospitals; the fourth is defining function of member institution,high level hospital mainly engaging in inpatients and emergency service,community service center mainly engaging in outpatient and preventive health service.
5 Innovation and weak points
5.1 Innovation
5.1.1 Medical resource vertical integration is an important strategy to increase utilization efficiency of medical resource,expand medical health service and solve the problem of difficult medical care of the residents.There are mature overseas experience but fewer domestic successful experiences,and medical resource vertical integration is still in exploratory stage.The study analyzes status quo of configuration and utilization of Shanghai medical health resource and argues necessity of medical resource vertical integration.
5.1.2 The study puts forward strategy roadmap and policy support needed for Shanghai medical resource vertical integration based on status quo of Shanghai medical resource,domestic practical case,successful overseas and domestic experience as well as analysis and judgment of expert.
5.1.3 The study analyzes geographic distribution change of inpatients in the integrated hospital before and after medical resource vertical integration.At present, there is a lack of research on inpatients geographic distribution in our country.
5.2 Weak points
5.2.1 There were altogether 60 cases of Shanghai medical resource vertical integration between GradeⅢand GradeⅡhospital from 1999 to 2007.Due to the limited energy and ability of the project team,the study fails to make analysis for all the 60 cases,and only purposefully makes analysis on several cases and makes detailed appraisal on trusteeship relation between Ruijin Hospital and the former Central Hospital of Luwan District,therefore,the study is not wide and detailed enough.
5.2.2 For effect appraisal of trusteeship relation between Ruijin Hospital and the former Central Hospital of Luwan District,considering outpatient medical records are kept by the patients and difficult to be collected,so the study focuses on collection, filing and analysis on inpatient data,which may result in insufficient representation of medical resource integration on medical service of the former Central Hospital of Luwan District.
资源有限,需求无限。有限的医疗卫生资源和人民群众日益增长的医疗卫生服务需求之间,矛盾始终存在。缓解这一矛盾,需要政府的有效规划和管制,需要通过制度设计或直接干预,降低每类医疗卫生服务的单位成本,提高当前医疗卫生资源的利用效率,获得更多的医疗卫生服务产出,更大程度地满足人民群众的医疗卫生服务需求。
达到上述目的,有多种途径和策略可供选择,例如增加政府对卫生的投入、完善医疗保障制度、调整现有的医疗服务价格体系、严格控制药品和检查费用、拉开不同等级医院收费价格和医保补偿比例,等等。但是,由于中国当前的大医院“人满为患”、部分医院“门可罗雀”的资源利用矛盾,以及小医院、农村医院和基层医院缺乏技术力量的现实,中国卫生改革特别提出了资源整合、扩大卫生服务提供、缓解看病难问题的策略,期望通过各类医院的联合、协作提高医疗资源整体利用效率,从而扩大医疗服务供给。
资源整合是在已有资源的基础上,吸收消化外部资源,优化内部资源,并将之重新组合的活动,目的是让有限资源发挥更大的效用,应用在医疗卫生领域,即为医疗资源整合。整合的对象在社会地位或实力规模上有着显著差别,可称之为医疗资源纵向整合,其模式有二,一是机构之问的相互契约或资产融合,促使优质医疗资源输出;二是政策形态的资源调配、转移或归并,例如卫生行政部门号召城市医院派遣医疗力量支持农村县医院或乡镇卫生院的医疗工作。
本次研究,主要关注机构形态的医疗资源纵向整合,通过必要性分析、执行现状描述、执行障碍分析和个案评价,总结医疗资源纵向整合的适宜模式和操作步骤,为优化上海医疗资源配置和利用提供循证建议。
2内容
2.1分析上海医疗资源纵向整合的必要性
(1)分析上海居民就医地理可及性、医生可及性和就医交流充分性,明确上海居民看病难问题的表现:(2)分析上海医疗机构、医疗床位、医务人员、医疗设备、医疗费用的现状,并与直辖市、全国平均水平,以及部分国家和地区进行比较;(3)分析上海医疗机构提供的诊疗服务、门急诊服务、住院服务、手术服务的基本情况,分析医疗机构人力效率、床位使用效率和平均住院天数,并与直辖市、全国平均水平,以及部分国家和地区进行比较。
2.2明确上海医疗资源纵向整合的现实进展和障碍
(1)分析改革开放以来,在全国范围内的医疗资源整合历史和实践经验:(2)分析国内外典型国家和地区医疗资源整合模式、办法和运作效果;(3)总结上海医疗资源纵向整合的模式;(4)分析医疗资源纵向整合的利弊和关键点,分析医疗资源纵向整合存在的问题和障碍。
2.3评价上海医疗资源纵向整合的实施成效和不足
根据专家推荐选择运作情况较好的个案进行评价研究。研究对象是瑞金医院和原卢湾区中心医院。主要针对原卢湾区中心医院在接受瑞金医院托管之后机构诊疗水平的变化和影响力的变化展开研究。同时还进一步分析了该个案成功的前提条件和仍然面临的困难。
2.4提出上海医疗资源纵向整合的模式和策略
针对上海医疗资源纵向整合的障碍、成功个案的前提条件,提出医疗资源纵向整合的政策思路、策略、方案和操作逻辑步骤。
3方法
(1)通过上海市卫生局、上海申康医院发展中心、卫生部等途径收集2003年上海卫生服务调查报告、国家第三次卫生服务调查研究报告、中国卫生统计年鉴,从中获得用于国际比较和国内城市比较的有关卫生服务可及性、医疗资源配置和利用效率的资料数据。
(2)通过文献综述,获得国内外医疗资源整合理论、实践和经验总结的信息材料;通过结构问卷的方式普查上海三级医院资源纵向整合的现况;通过专家咨询明确上海目前医疗资源纵向整合各类模式的利弊、关键点、存在的问题和障碍。
(3)通过1995、1997、1998、1999(实施集团化改革之年)、2001、2003、2005、2007年住院病人病案调查,获得用于资源整合效果个案评价的信息资料。住院病人总体为53377人,通过固定样本量(500或1000)系统抽样获得样本住院病人5500人。其中用于住院病人危重度变化评价的有效样本是4513例,用于住院病人分布变化评价的有效样本量是5124例。
(4)通过专家咨询和焦点小组访谈提出医疗资源纵向整合的蓝图策略和需要的配套政策支持,总计咨询253人次。
统计软件使用SPSS11.5,作图软件使用SPSS11.5和MAPINFO7.0。
4结果
4.1推行医疗资源纵向整合对于优化上海医疗资源配置和利用的潜在作用
4.1.1上海人力、床位配置水平较高,其中,每千人口执业医师3.33人,高于北京(2.28)、天津(2.65)、香港(1.65)、澳门(2.82),也高于日本(2.12)、新加坡(1.55)、英国(2.30)、美国(2.56)和澳大利亚(2.72);每千人口床位5.20张,低于北京(6.41)、台湾(6.03)和日本(14.19),但高于天津(4.18)、香港(4.92)、澳门(2.33)、新加坡(3.33)、英国(4.0)、美国(3.3)和澳大利亚(3.93)。
4.1.2上海医疗资源的利用效率也比较高。上海医生人均每日承担诊疗服务9.1人次,远高于北京(6.8)、天津(5.4)和重庆(5.8);上海医生年人均承担住院服务2.0天,也远高于北京(1.3)、天津(1.4)和重庆(1.2);上海各医院床位使用率达到了93.5%,亦远高于北京(77.3%)、天津(68.1%)和重庆(69.1%)。
4.1.3上海医疗资源整体利用效率在各层次医疗机构差异较大。三级医院床位使用率高达99.43%,二级医院为96.38%,一级医院等只有81.59%;三级医院平均住院天数只有13.55天,但二级医院为16.28天,一级医院达27.41天。
4.1.4实行医疗资源纵向整合,共享各级医院床位资源,可缓解高层次医院住院难、基层医院床位使用率低的矛盾,提高基层医院的技术水平,促使病人到基层医院就医,优化医疗资源配置和利用效率。
4.2上海医疗资源纵向整合主要有四种模式
4.2.1托管。例如中山医院对青浦区中心医院的托管。该模式的优点是不涉及产权变更,操作比较方便,也能够比较顺利实现资源共享和优质医疗资源支援基层的目的。不足之处在于,产权归属不清前提下,大医院的主要目的是掌控医疗市场、缓解大医院运营压力,建设被整合医院的积极性不高。
4.2.2兼并。主要是撤并部分经营状态比较差的公立医疗机构,将其人员、床位编制整合到经营状态较好的公立医疗机构中。例如瑞金医院对原市政医院的兼并,中山医院对原纺三医院的兼并。
4.2.3集团化。主要依托核心医院的特色专科,以学科为纽带,建立或联合成立医院集团。典型案例是上海华山神经外科(集团)医院。这种模式已经成为上海医疗资源纵向整合的主流,一方面缓解了各级医院之间忙闲不均的问题,另一方面也因为资源自由整合的缘故,给区域卫生规划的贯彻落实提出了新的挑战。
4.2.4合作。例如复旦大学附属肿瘤医院和上海建工医院在乳腺癌外科服务上的合作。
上海所有三级医院都通过某种模式与基层医院建立了资源整合联系,以合作和集团化模式多见。
4.3上海医疗资源纵向整合实施效果的个案评价
知情人认为是目前上海医疗资源纵向整合各类模式中,集团化模式效果最好,而且特别指出,瑞金医院对原卢湾区中心医院的整合有其特殊之处,一方面瑞金医院向原卢湾区中心医院派驻院长和业务骨干,有着委托管理的思想,另一方面瑞金医院获得了原卢湾区中心医院一半的资产权,有着资产兼并的做法。有鉴于此,本次研究对瑞金医院整合原卢湾区中心医院的效果进行了个案评价。由于
4.3.1自纵向整合之后,瑞金医院帮助卢湾分院加强学科建设。来自瑞金医院的专家、教授定期开展查房、手术、特色门诊,并指导临床、科研及教学等工作,提高卢湾分院的服务能力和述评,接治住院病人的疑难程度有所上升。卢湾分院肿瘤病人的大幅度增加很好地说明了这一点。1995—1999年间,瑞金医院卢湾分院接治的肿瘤病人数量基本保持在550例左右,此后,肿瘤病人数量迅速上升,2001年翻了1倍,达到1142例,2007年更是达到了3616例,占该医院所有住院病人的32.0%。
4.3.2在纵向整合之后,瑞金医院派遣神经内科和内分泌科专家担任卢湾分院科室主任负责人,在分院新建的神经内科病房和糖尿病强化治疗病房。同时将卢湾分院作为分流病人的重要渠道,大量肿瘤、血液病类型的病人转移到卢湾分院救治。由于卢湾分院技术水平的有限,转移病人大多病情平稳,由此带来纵向整合之后卢湾分院住院病人病情危重程度的下降。1995年的平均危重度分值为71.71,以后下降至1999年的64.96,至2001年达到最高平均为82.21,随后又开始呈现下降趋势,到2007年降低至64.19。单因素方差分析表明:这8个年份的危重度分数均值不全相同(F=11.598,P＜0.01),进一步做两两比较(LSD)发现,除1999、2003和2005年外,其余年份的分值均高于2007年。卢湾分院住院病人危重程度的下降,一方面体现了资源纵向整合之后医院之间合理分工的开始形成,另一方面也说明以往期望资源纵向整合之后好医院带差医院,显著提高差医院技术水平的期望是过高的,在实践过程中核心医院更希望被整合的医院扮演拾遗补缺的角色。
4.3.4纵向资源整合之前,瑞金医院卢湾医院的医疗市场整体在萎缩当中,1995年住院病人为4974人,1998年下降到3751人。自纵向整合开始,住院病人有了大幅度的跃升,2001年增长近1倍,达到了6642人。2007年较2001年又增长了70.1%,达到了11299人。同期,与瑞金医院卢湾分院规模、周边环境比较相似的静安区中心医院,2001年住院病人为7439人,2007年为11222人,增长只有50.9%。由此可以推论,纵向整合有力推动了瑞金医院卢湾分院的发展,扩大了他的业务规模。
4.3.5整合之后市场占有情况变化。2001年到2007年,瑞金医院卢湾分院接纳的卢湾区本地病人增长了30.2%,非卢湾区病人增长了269.1%。瑞金医院对原卢湾区中心医院的纵向整合有助于提升原卢湾区中心医院的辐射力,目前的瑞金医院卢湾分院在上海医疗市场中扮演的角色,已不仅仅是一所区域性医疗服务中心。
4.4上海医疗资源纵向整合面临的问题和障碍
4.4.1宏观层面存在区域市场垄断问题。很多区域内的大医院只有一所或者少数几所,基层医疗机构选择余地小,一开始就会处于不平等地位。整合之后,基层医院的服务费用会与核心医院趋同,有着促使费用更加昂贵的嫌疑。
4.4.2政府层面存在区级政府的积极性问题。两级财政管理下,区级政府负有建设和发展医疗机构的责任。一旦实行纵向整合,基层医疗机构划归核心医院管理,区级政府的投入将难以保证。
4.4.3制度层面存在物价制定、医疗保险结算标准问题。不拉开整合体中各医疗机构的服务价格差异,或是沿用目前不同等级医院基本相似的医疗保险结算标准,仍然很难通过价格杠杆实现双向转诊。
4.4.4卫生行政部门层面存在职能定位问题。被整合医院往往是二级或一级医院,其原上级主管部门往往是区县卫生行政部门。整合之后,被整合医院面临着双重领导,既要服从主体医院的管理,又要听从区县卫生行政部门的指令,两者之间容易出现矛盾。
4.4.5医疗机构层面存在文化冲突问题。整合体各成员医院成长历程不同、经营状况不同,必然带来价值观念、行为准则、运作习惯、工作作风、典礼仪式、管理制度等的差异,冲突不可避免。
4.5可供上海医疗资源纵向整合借鉴的国际经验
4.5.1新加坡的经验表明,在实行医疗资源纵向整合的同时,也要引入竞争机制,防止独家垄断,为此特地设置了两个医疗集团,以推动彼此间的比较竞争。同时还通过一系列的政策来取得类似医疗资源纵向整合的效果,例如“经社区首诊转入大医院者给予10—20%的优惠”。台湾也提供了类似的经验。
4.5.2英国的经验表明,要将医疗资源整合落到实处,所形成的集团首先必须在人事改革、增减床位等问题上有充分的自主权,应当注意在增加医院收入的基础上,增加职工的收入,以充分调动员工的主观能动性。形成的集团应当包含各种层次和类别的医疗机构,使不同需求的病人在集团的相应机构得到服务,减少候诊、等待,减少盲目进入高级医院的次数。形成的集团可以采用直接控股与联盟合作等多种资本运营的方式。
4.5.3美国的经验表明,要有力推动医疗资源纵向整合,必须在改革医保偿付制度,促进高等级医院不得不着力于压缩成本,从而将注意力放到基层医疗机构,并与之形成战略联盟。例如规定大型医院特定病种住院可获得的补偿床日数,病人住院超过天数则需自费,除非他转移到社区服务中心。
4.5.4香港的经验更具借鉴价值。一是统一各项制度。所有医院实行统一行政管理制度,采用同一套的财务管理制度、规章和模式,实行统一的薪酬制度,使用统一的信息平台和数据定义,统一采购医疗设备、药品等医用物资等。二是推行医院分区联网。特定联网区域内医院不重复设置专科,不重复配置大型设备。三是在全民健保前提下,按人口、老年人口、人口流动情况等下拨医院预算资金。
4.6上海医疗资源纵向整合的蓝图和策略建议
在分析上海形势,回顾国内发展,借鉴国际经验,咨询有关专家的基础上,提出了上海医疗资源纵向整合的蓝图和策略。
4.6.1第一类策略是政府主导策略,在政府主导下,以医疗保险为基础,以医疗机构资产属地化管理为前提,统合上海市各级各类公立医疗机构,组建若干医疗集团。医疗集团以三级医院为核心,以若干三级专科医院、二级医院和社区卫生服务中心为延伸,以社区卫生服务站和全科医师团队为基础。
4.6.2第二类策略是市场主导策略,在市场主导下,以三级医院为核心医院,以产权为纽带,兼并二级医院,在本区域或跨区域形成医疗集团,并通过契约与二级医院所在区域社区卫生服务中心合作。
4.6.3第三类策略是行政区域整合策略,以当前财政拨款体制和社会医疗保险为基础,以区县公立医疗机构管办分离为前提,在各区县实行二级医院为核心的纵向医疗集团,推行区县范围的医疗资源纵向整合。
4.6.4第四类策略是政策引导策略,在现有医疗机构管理体制、运行机制基础上,以不改变原有医疗机构产权性质为特征,从机构托管和政策调节的角度,促进医疗资源纵向整合。具体构想是:
4.6.5第五类策略是利益整合策略,以三级医院为主体,通过项目合作的形式,与本区域或跨区域二级医院及若干个社区卫生服务中心进行某一方面的资源整合,达到各自利益目标的实现。
上述医疗资源纵向整合策略需要四项政策支持措施一是统一产权主体;二是调整医保支付方式,由总额预付逐步过渡到按服务量支付、按人口支付;三是改革人事分配制度,实行年薪制,促进医务人员在成员单位之间的顺畅流动;四是明确成员机构的职能,高等级医院主要从事住院和急诊服务,社区卫生服务中心主要从事门诊和预防保健服务。
5创新和不足
5.1创新
5.1.1医疗资源纵向整合是提高医疗资源利用效率、扩大医疗卫生服务提供、解决居民看病难问题的一项重要战略。国外有比较成熟的经验,国内则成功经验不多,仍然处于摸着石头过河的阶段。本次研究分析了上海医疗卫生资源的配置和利用现状,论证了医疗资源纵向整合的必要性。
5.1.2本次研究基于上海医疗资源现状、基于国内实践案例,基于国外成功经验、基于专家的分析判断,提出了上海医疗资源纵向整合的蓝图策略和所需要的政策支持。
5.1.3本次研究的个案是上海第一家开展医疗集团探索的瑞金医院卢湾分院(原名“卢湾区中心医院”),通过个案研究的方式分析了医疗资源纵向整合前后,被整合医院的住院病人地理分布的变化。国内目前还缺乏这类针对住院病人地理分布的研究。
5.2不足
5.2.1 1999年至2007年,发生在三级医院和二级医院之间的上海医疗资源纵向整合共60起。本次研究限于时间,未能对所有60起案例进行逐一分析,只是从中有目的地研究了若干案例,并且针对瑞金医院托管原卢湾区中心医院进行比较详细的评价。研究的广度有所欠缺。
5.2.2针对瑞金医院托管原卢湾区中心医院的效果评价,考虑到门诊病案由病人随身携带,收集整理有困难,故而侧重于住院病人数据的收集、整理和分析,容易造成不能全面反映纵向医疗资源整合对原卢湾区中心医院医疗服务的影响。
1 Background
The health resource is limited while the health needs are unlimited.There are always contradictions between the limited health resources and the increasing needs of the people in medical and health service.In order to alleviate the contradiction,the effective governmental planning and regulations are needed to involve in or directly intervene through regulations to reduce unit cost of each medical and health service, increase the efficiency of the utilization of current medical esource,obtain more output of the medical service and satisfy people's need on medial service in a greater extent.
In order to realize the above goals,there are various means and strategies available,such as increasing governmental inputs in sanitation,perfecting medical insurance system,regulating the current medical service price system,strictly controlling medicine and inspection cost,widening charge price and medical insurance reimbursement proportion,and etc.But due to the contradictions in resource utilization that the big hospitals are crowded by large quantity of patients and the some other hospitals have few patients,and the situation of the small hospital, rural hospital and grassroots hospital,China health reform specially puts great effort on resource integration strategy to expand health service and alleviate the problem of "difficult medical care",hoping to increase overall utility efficiency to expand medical service provision through cooperation between various hospitals.
Resource integration is an activity absorbing external resource,optimizing internal resource and reorganizing based on its existing resources,the aim of which is to make the limited resource exert more efficiency to apply in medical and health field, i.e.medical resource integration.Because integration targets have noticeable differences with regard to different social status and strength,it can be also called medical resource vertical integration which has two patterns;the first is mutual agreement or asset integration to promote premium medical resource output;the second is resource deployment,transfer or merging policy,such as the health administrative department calls on urban hospital to assign medical force to support medical work of the rural hospital or township hospitals.
The study mainly focuses on medical resource vertical integration on institutional level,summarizes suitable mode and operational procedure for medical resource vertical integration and offers suggestion on Shanghai medical resource allocation and utilization through necessity analysis,implementation status quo,and obstacle analysis in implementation as well as case appraisal.
2 Contents
2.1 Analyzing the necessies of medical resource vertical integration in Shanghai
(1)Analyze geographical availability of medical care for Shanghai residents, doctor availability and sufficiency of communication with doctor,make clear manifestation of difficult medical care for Shanghai residents;(2) Analyze status quo of Shanghai medical institution,hospital beds,medical staff,medical equipment and medical expense and compare with the level of other municipality,average level of the country,and the level of some countries and regions;(3) Analyze basic situation of diagnosis service,outpatient and emergency treatment service,surgery service, analyze manpower effectiveness,hospital beds utility efficiency and average inpatient days,and compare with the level of municipality directly under the Central Government,average level of the country,and the level of some countries and regions.
2.2 Making the actual development and obstacle clearly in Shanghai medical resource vertical integration
(1)Analyze historical and practical experience of medical resource integration nationwide since the reform and opening-up;(2) Analyze medical resource integration mode,method and operational effect of typical countries and regions domestically and overseas;(3) Summarize mode of Shanghai medical resource vertical integration;(4) Analyze advantage,disadvantage and key points of medical resource vertical integration,and analyze problems and obstacles existing in medical resource vertical integration.
2.3 Evaluating strengths and weaknesses of medical resource medical integration in Shanghai
Case study is applied based on the case with good operation recommended by experts.Research object is Ruijin Hospital and the former Central Hospital of Luwan District.The research is carried out mainly on medical level change and influence of the former Central Hospital of Luwan District after trusted to Ruijin Hospital, meanwhile,I further analyse precondition of the successful case and existing difficulties.
2.4 Putting forward different mode and strategies for Shanghai medical resource vertical integration
Policy,strategy,plan and operational procedure for medical resource vertical integration are put forward in accordance with obstacle in Shanghai medical resource vertical integration and precondition of successful cases.
3 Methods
(1) Data are collected from 2003 Shanghai health service survey report,the 3~(rd) national health service survey report and yearbook of health in the PRC through Shanghai municipal health bureau,Shanghai Shenkang hospital development center, resource allocation and utility efficiency and are compared with those of overseas and domestic cities.
(2)Obtain information of domestic and overseas medical resource integration theory,practice and experience summary hrough literature;general investigate status quo of resource vertical integration of Shanghai GradeⅢhospital through questionnaire;make clear advantage,disadvantage,key points,existing problems and obstacle in various modes of the current Shanghai medicalresource vertical integration.
(3)Obtain information for resource integration effect evaluation through inpatients medical reports in 1995,1997,1998,1999,2001,2003,2005 and 2007.The total inpatients were 53377,and samples of 5500 inpatients are obtained through systematic sampling with fixed amount((500or 1000),among which,4513 cases are effective samples for inpatients severity change appraisal,5124 cases are effective samples for inpatients distribution change appraisal.
(4)Put forward strategy roadmap and necessary policy support for medical resource vertical integration through expert consultation and interview with professional team,253 people are consulted in total.
Statistic software used is SPSS11.5,drawing software of SPSS11.5 and MAPINFO7.0.
4 Results
4.1 Potential effects of promoting medical resource vertical integration in optimization of Shanghai medical resource allocation and utilization
4.1.1 Manpower and hospital bed allocation in Shanghai are at a high level,there are 3.33 certified doctors per thousand people,which are higher than Beijing(2.28), Tianjin(2.65),HK(1.65),Macau(2.82),Japan(2.12),Singapore(1.55),GB(2.30), USA(2.56) and Australia(2.72);there are 5.20 hospital beds per thousand people, which are lower than Beijing(6.41),Taiwan(6.03) and Japan(14.19) but higher than Tianjin(4.18),HK(4.92),Macau(2.33),Singapore(3.33),UK(4.0),USA(3.3) and Australia(3.93).
4.1.2 Utililization efficiency of Shanghai medical resources is also high.Each Shanghai doctor diagnoses 9.1 people per day,much higher than Beijing(6.8), Tianjin(5.4) and Chongqing(5.8);each Shanghai doctor provides inpatient service for 2.0 days per year,also much higher than Beijing(1.3),Tianjin(1.4) and Chongqing (1.2);Utilization ratio of hospital beds in each Shanghai hospital amounts to 93.5%, also much higher than that of Beijing(77.3%),Tianjin(68.1%) and Chongqing(69.1 %)
4.1.3 Overall utilization efficiency of Shanghai medical resource varies a lot in medical institution of various levels.Hospital bed utilization ratio in GradeⅢ hospital;average hospital days of GradeⅢhospital is only 13.55 days,but 16.28 days in GradeⅢhospital and 27.41 days in GradeⅠhospital.
4.1.4 Implementation of medical resource vertical integration and sharing hospital beds among hospital at various levels can alleviate the problem of difficult hospitalization in high level hospital and low hospital bed utilization ratio in grassroots hospital,improve skills of the grassroots hospital,promote the patients to be hospitalized in grassroots hospital and optimize medical resource allocation and utilization efficiency.
4.2 Four major modes for Shanghai medical resource vertical integration
4.2.1 Trusteeship.Such as Central Hospital of Qingpu District is trusted to Zhongshan Hospital.Such mode does not involve ownership change,therefore is convenient to operate and helpful in realizing resource sharing and premium medical resource supporting the grassroots hospital.While,under the precondition of unclear ownership,main aim of the big hospital is to control medical market and relieve operational pressure,but they are not active in constructing the integrated hospital.
4.2.2 Merge.It is mainly to revoke and merge some government run medical institution with bad operation,integrate its staff and hospital beds to government run medical institution with good operation,such as Ruijin Hospital merges the former Municipal Hospital and Zhongshan Hospital merges the former No.3 Textile Hospital.
4.2.3 Conglomerate.It is to establish or co-establish hospital group based on special section and the academy of the key hospitals.The typical case is Shanghai Huashan Neurosurgery(Group) Hospital.Such mode has been the main stream of Shanghai medical resource vertical integration,on one hand,it alleviates the contradiction that some hospitals are too busy and some others are idle;on the other hand,it raises new challenge for implementation of regional health planning due to free resource integration.
4.2.4 Coopeartion.Such as Tumor Hospital Attached to Fudan University cooperates with Shanghai Jiangong Hospital on mammary cancer.
All the GradeⅢhospitals have established resource integration contract with grassroots hospital through certain mode,among which,cooperation and conglomerate are most common.
4.3 Case appraisal on implementation effect of Shanghai medical resource vertical integration
Insiders think that conglomerate is the best one among various modes of Shanghai medical resource vertical integration,in addition,integration of the former Central Hospital of Luwan District to Ruijin Hospital has special meaning:on the one hand,Ruijin Hospital appoints president and technical backbone to the former Central Hospital of Luwan District,which means mandatory administration;on the other hand, Ruijin Hospital obtains half assets of the former Central Hospital of Luwan District, which means asset acquisition.In view of this,the study makes case appraisal integration effect of the former Central Hospital of Luwan District into Ruijin Hospital.
4.3.1 After vertical integration,Ruijin Hospital helps the former Central Hospital of Luwan District enhance academic construction,experts and professors from Ruijin Hospital regularly carry on ward inspection,surgery,and characteristics diagnosis, guide works as clinic,scientific research and teaching,increase service ability and value of Luwan branch and increase the complexity of inpatients,which is proved by substantial increase of tumor patients in Luwan branch,from 1995 to 1999,tumor patients seek for medical treatment in Ruijin Hospital Luwan branch has been basically maintain at about 550 cases,later,quantity of tumor patients increased rapidly,about one times in 2001,reaching 1142 cases,and 3616 cases in 2007,taking 32.0%of its total inpatients.
4.3.2 After vertical integration,Ruijin Hospital assigns neurological and endocrinological exports to be section head of Luwan branch,builds new neurological wards and diabetes intensive cure ward,and makes Luwan branch as the main channel to redirect patients,large quantity of tumor and hemopathic patients were transferred to Luwan branch for treatment.Due to the limited technique of Luwan branch,the transferred patients were generally in stable condition,which led to inpatients severity reduction in Luwan branch after integration.Average inpatients severity in the year of 1995 was 71.71 and then reduced to 64.96 in 1999,average inpatients severity increased to 82.21 in 2001,and then it is again in a downtrend,reduced to 64.19 in 2007.One-way ANOVA shows that average severity value are not the same in the eight years(F=11.598,P＜0.01),then the least significant difference(LSD) is made which shows that except for the year 1999,2003 and 2005,value in other years are all higher than that in 2007.Reduction of inpatients severity in Luwan branch one the one hand represents formation of rational division between hospital after resource vertical integration,on the other hand,it also represents that people expect too much on the good hospital guiding the inferior ones and remarkably improve skill of the inferior hospitals after resource vertical integration,during practice,the key hospital hopes the integrated hospital to play a complementary role.
4.3.4 Prior to resource vertical integration,overall medical market of Ruijin Hospital Luwan branch is in shrink,there were 4974 inpatients in 1995,and reduced to 3751 in 1998.After the vertical integration,quantity of inpatients reduces and rises rapidly,increasing about one time in 2001,reaching to 6642,inpatients increased by 70.1%in 2007 than that in 2001,reaching to 11299.In the same period,there are 7439 and 11222 in the year of 2001 and 2007(increased by only 50.9%) in Central Hospital of Jingan District which is similar to scale and surrounding environment of Luwan branch,therefore,it can be deduced that vertical integration drives development of Luwan branch and expand its business scale.
4.3.5 Market share change after the integration.From 2001 to 2007,local patients treated by Luwan branch increased by 30.2%,patients not from Luwan district increased by 269.1%.Vertical integration of the former Central Hospital of Luwan District into Ruijin Hospital helps to upgrade radiative force of the former Central Hospital of Luwan District,at present;Luwan branch does not just play a role as regional medical service center in Shanghai medical market.
4.4 Problems and obstacles in Shanghai medical resource vertical integration
4.4.1 In the macro-level,there exists the problem of regional market monopoly. There are only or several big hospitals in the region,grassroots medical institution has little choice and is in unequal position,after integration,service charge of the grassroots hospital will be the same as that of the key hospitals,hence having suspicion of increasing treatment cost.
4.4.2 In the government level,there exists the problem of motivation of the district government.Under the two layer financial management,district government is liable for constructing and developing medical institution.Once the vertical integration is implemented,grassroots medical institution is put under its administration of the key hospital,hence input from the district authority will be difficult to guarantee.
4.4.3 In system level,there exist the problems as pricing and medical insurance settlement standard.If service price difference in each medical institution of the integration is not widen,or follow the medical insurance settlement standard which are similar in hospitals of different level,it will be difficult to realize double treatment transfer through price leverage.
4.4.4 In health administrative department level,there exists the problem of function position.The integrated hospitals are usually GradeⅡor GradeⅠhospitals whose immediate supervisory department are district or county health administrative department.After integration,the integrated hospitals face double leadership,having to obey the management of the main hospital and the direction of the district or county health administrative department,from which the problems are easy to arise.
4.4.5 In medical institution level,there exists the problem of cultural contradiction.Members of the integration have different growth procedure and business condition,therefore there will be difference in value,code of conduct, operational habit,work style,ceremony and management system,and the contradiction is unavoidable.
4.5 International experience which can be learnt by Shanghai medical resource vertical integration
4.5.1 Experience of Singapore shows that competitive mechanism is introduced at the time of implementing medical resource vertical integration to avoid monopoly; as such,two medical groups are set to promote competition between them.Meanwhile, effects similar to that of medical resource vertical integration through serials of policies are attained,such as "10—20%discount for the patients transferred from community hospital to the big hospital",and Taiwan also provides the similar experience.
4.5.2 Experience of the UK shows that in order to actual implement medical resource integration,the established hospital group shall have sufficient autonomous fight in terms of HR reform at first,adding and reducing beds,etc,it shall pay attention to increase income of the staff on the basis that income of the hospital is increased to fully mobilize subjective initiative of the staff.The formed group includes medical institution of various layers and types to make the patients with different needs are served in corresponding institution of the group,and reduce the waiting period and the time indiscriminately seek for medical care in big hospital.The established hospital group may adopt various capital operation methods as direct holding and alliances.
4.5.3 Experience of the USA shows that in order to drive medical resource vertical integration,medical insurance reimbursement system is reformed to promote the high level hospital to reduce cost,hence seek for support from the grassroots medical institution and form strategic alliance with it.For example,reimbursable inpatient days of special disease in large hospital is stipulated,in case the patients exceed the stipulated inpatient days,they shall be charge unless transferred to community service center.
4.5.3 Experience of HK has more reference value.The first is to unify various systems,all the hospitals carry on uniform administrative management system,adopt the same financial management system,rules and modes,carry on uniform salary system,use the uniform information platform and data,uniformly procure medical equipment,medicine and other medical materials.The second is to implement hospital networking,special section within the networking region will not be reset in other hospital,nor reset large equipment.The third is to allocate budge for the hospital as per population,population of the aged and situation of population flow under the precondition of guarantee overall health insurance of the people.
4.6 Roadmap and strategy proposal for Shanghai medical resource vertical integration
The project team puts forward roadmap and strategy for Shanghai medical resource vertical integration based on analysis of Shanghai condition,domestic development overview,referring to international experience and consulting relevant experts.
4.5.1 The first strategy is to lead the integration through policy and promote medical resource vertical integration based on existing medical institution management mechanism and operational mechanism with unchanged former medical institution property as the characteristic and from the perspective of institutional trusteeship and policy regulation.Specific conception is:(1) implement trusteeship or cooperation between GradeⅢand GradeⅡhospital.The district or county health bureau(entrusting party) forms trusteeship relation of "entrusted management——trustee management" between GradeⅡhospital(target hospital) under its administration and GradeⅢhospital(entrusted party),and transfer the operational management right of the target hospital to the entrusted party for reorganization and operation with certain conditions and terms.(2) Issue serials of health and medical insurance policy to adjust benefits distribution structure between hospitals of various level to promote premium medical resource flow to GradeⅠhospital and meanwhile promote the patients seek for more treatment and rehabilitation services in GradeⅠhospital,such as community health service of GradeⅢhospital,traditional Chinese medicine serve the community,famous doctor serve the community,diagnosis expense reduction and exemption policy in grassroots hospital,inpatient days regulation for high level hospital by the medical insurance, and etc.(3) Promote regional hospital group trial crossing asset relation in the place with proper condition.Carry on uniform administrative management,budget,and medical insurance settlement within the group.Under the precondition not changing asset property,further promote the current trusteeship cooperation to close cooperation and truly exert integration effect of the resource.The above targets are easy to be attained with little technical difficulty and are helpful for naturally form regional medical center and community sanitation service center as GradeⅡmedical service system.As for GradeⅡhospital unable to exist and develop by themselves, and whose ownership will not be abandoned by the district or county health bureau, trustee is the best resource integration method,but its disadvantage is its small reform intensity,therefore trustee is not fundamental solution.
4.5.2 The second strategy is to separated integration between administration and operation,build vertical medical group with GradeⅡhospital as the core in each district and county based on the current financial allocation mechanism and social medical insurance,with separate administration and operation of government run medical institution,and promote medical resource vertical integration within the district and the county.Specific conceptions are(1)Promote separation of administration and operation of public run medical institution in the district or the county,set up medical institution administration center dedicatedly responsible for management work as HR,asset,finance,party affair and etc.Business income of the government run medical institution under its administration(including income from medical insurance) is uniformly turned in to medical institution management center, financial allocation to the government run medical institution is also directly turned into medical institution management center.The third party appraisal institution is entrusted to be responsible for appraisal performance of the public run medical institution.(2) Public run medical institution under its administration does not reset special section and large equipment.Resident physician are trained uniformly in GradeⅡhospital;doctors of community health service center are trained in rotation in GradeⅡhospital in a planned way to gradually upgrade medical skill of community health service center.The target does not involve much benefit adjustment,is easy and feasible and is helpful for effective utilization of the medical resource in the region. Its disadvantages are technical advantage of GradeⅢhospital is difficult to be exerted,hence not helpful for premium resource service transfer to inferior hospital. Such mode has little difficulty in policy and can be used as the first procedure of Shanghai medical resource conglomerate integration.
4.5.3 The third strategy is conglomerate integration,divide networking region according to the needs on medical treatment by the region and population,integrate public run medical institution of Shanghai in various levels and kinds based on nationwide medical insurance,and establish several medical group with GradeⅢcomprehensive hospital as the core,with several GradeⅢspecialized hospital,GradeⅡhospital and community health service center as extension and based on community health service station and doctor team within the whole section.Specific conceptions are(1) Medical group possesses administration authority on asset,HR and financial management of the various medical institutions under its administration.The hospitals under its administration carry on uniform administrative management system, financial management system,rules and modes,and the medical staff carries on uniform salary system.(2)GradeⅡhospital,community health service center and healing hospital are equipped within the networking region.Special section and large equipment are not reset within the networking region to realize resource sharing and reduction of operation cost.Work places of the staff within the networking hospital are subject to transfer as work needs.(3)Medical institution within the networking region carries on budget fund system.Medical group obtains budget fund from government financial and social insurance department,allocate budget fund to the networking region each year as per planned budget,and then the networking region allocate budget fund to medical institution.Budget fund allocation is determined by population,aging population,floating population and special service(such as complex special section charge more).Budget fund ensures fundamental medical service for the people.Medical institution may provide non-fundamental medical service for which the patients are charge at their own expense.(4) Medical group carries on uniform and centralized procurement on medical material as medical equipment and medicine.Information platform is set up,all the medical institution and principle office use uniform information platform and data definition,etc.(5) Resident physician within the group are trained uniformly in GradeⅢhospital; doctors of GradeⅡhospital and community health service center are trained in rotation in GradeⅢhospital in a planned way to gradually upgrade medical skill of grassroots medical institution.Achieving the aim is helpful to exert accumulative effect of premium resource,effective utilization of medical resource,strengthen the appeal of grassroots institution on the patients,and then governmental management aim and purpose will be guaranteed.The disadvantage is that regional monopoly is formed and may create weakened service.The difficult point is to break through the former interest pattern,in which government determination is needed.
4.5.4 The forth strategy is policy-induction.Based on the current medical institution's management system and operation mechanism,characterized by unchanging the property fight of original medical institution,from the point of institution trusteeship and policy adjustment,the medical resource vertical integration would be promoted.
4.5.5 The fifth strategy is benefit conformity.The gradeⅢhospital was selected as principal part to be conbined with the gradⅡhospital or some community health service center through the way of project collaboration.
The above medical resource vertical integration strategies need four policy support,the first is the uniform ownership subject;the second is medical insurance settlement method adjustment,transferring from charges total prepaid to payment as per service volume and population;the third is staffing system,carrying on annual salary system to promote smooth flow of medical staff within the member hospitals; the fourth is defining function of member institution,high level hospital mainly engaging in inpatients and emergency service,community service center mainly engaging in outpatient and preventive health service.
5 Innovation and weak points
5.1 Innovation
5.1.1 Medical resource vertical integration is an important strategy to increase utilization efficiency of medical resource,expand medical health service and solve the problem of difficult medical care of the residents.There are mature overseas experience but fewer domestic successful experiences,and medical resource vertical integration is still in exploratory stage.The study analyzes status quo of configuration and utilization of Shanghai medical health resource and argues necessity of medical resource vertical integration.
5.1.2 The study puts forward strategy roadmap and policy support needed for Shanghai medical resource vertical integration based on status quo of Shanghai medical resource,domestic practical case,successful overseas and domestic experience as well as analysis and judgment of expert.
5.1.3 The study analyzes geographic distribution change of inpatients in the integrated hospital before and after medical resource vertical integration.At present, there is a lack of research on inpatients geographic distribution in our country.
5.2 Weak points
5.2.1 There were altogether 60 cases of Shanghai medical resource vertical integration between GradeⅢand GradeⅡhospital from 1999 to 2007.Due to the limited energy and ability of the project team,the study fails to make analysis for all the 60 cases,and only purposefully makes analysis on several cases and makes detailed appraisal on trusteeship relation between Ruijin Hospital and the former Central Hospital of Luwan District,therefore,the study is not wide and detailed enough.
5.2.2 For effect appraisal of trusteeship relation between Ruijin Hospital and the former Central Hospital of Luwan District,considering outpatient medical records are kept by the patients and difficult to be collected,so the study focuses on collection, filing and analysis on inpatient data,which may result in insufficient representation of medical resource integration on medical service of the former Central Hospital of Luwan District.
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