农村三级医疗服务网络中的纵向医疗服务链现状及发展对策研究
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摘要
农村医疗服务提供体系是农村居民获得优质医疗服务的保障，但研究显示，我国农村医疗服务在整体上存在着明显的缺陷，这种缺陷不仅仅表现为农村各级医疗卫生机构的“要素”问题（卫生人力资源匮乏、医疗质量低劣、医疗服务效率低等），更表现为要素之间的“衔接”不畅（医疗卫生机构之间协同缺失，医疗信息“孤岛化”等）。当单一医疗机构无法满足患者全部医疗服务需求时，两个或两个以上医疗机构协同提供医疗服务便成为必然之势。因此，仅仅关注农村单一医疗机构服务问题，而不重视多机构协同提供服务的整条服务链问题，则无法真正系统性提高农村医疗服务水平。
1.研究目的
本研究突破单一医疗机构的研究禁锢，聚焦于多机构医疗服务的提供与利用。从系统性角度，将供应链理论运用到医疗服务领域，并且从外部环境、患者流和信息流等多维度对中国农村纵向医疗服务链现状进行解析，最终提炼出有利于改善中国农村纵向医疗服务链的政策建议。
2.资料来源与研究方法
本研究的资料主要来源于3个渠道：（1）文献法。收集来的文献资料用于相关理论研究。（2）现场调查。在全国31个省市自治区选择4个调研点进行实地研究：①门诊及住院患者问卷调查——用于患者流研究（患者日常首诊机构选择、特定疾病周期内就诊流向、特定时间段内就诊流向），以及利用方角度的信息流分析；②医务人员问卷调查——用于供方的信息流分析；③深度访谈——用于环境及政策因素的推演。（3）医疗保险数据。选择重庆黔江城乡居民合作医疗保险中住院补偿信息做典型调研——用于分析患者流中住院患者特定疾病周期内的多机构住院情况。
本研究采用定性与定量研究相结合的方式进行研究。（1）利用归纳总结等定性研究方法，进行理论梳理和政策推演。（2）采用书目信息共现挖掘系统（Bibliographic Item Co-Occurrence Mining System, BICOMS）和SPSS中的系统聚类法，对文献进行系统性和定量化研究。（3）利用SPSS和EXCEL对问卷资料和医疗保险数据进行描述性分析和统计学检验，如利用卡方检验对概率分布差异进行统计学检验，用二分类logistic回归模型对患者半年内就诊密度、分散程度及就诊顺序的影响因素进行分析，用无序多分类的logistic回归分别对患者当次就诊流向和患者病历资料携带情况的影响因素进行分析。
3.主要研究结果
医疗服务链相关理论方面。本研究在供应链理论的基础上，结合医疗服务自身的特殊性，对医疗服务链的概念、模型、性质特征及内在价值等进行了系统化梳理。认为医疗服务不同于一般产品，不仅强调供应，也同样强调服务利用；既要关注多机构协同提供医疗服务，也要规范患者流，具有典型的“链流合一”的特征。
中国农村纵向医疗服务供应链方面。研究发现，中国农村纵向医疗服务供应链尚未成形。首先，纵向医疗服务供应链各节点缺乏协同提供医疗服务的动力。从外部环境来说，医疗保险未对医疗服务供应链的形成起到应有的约束和激励作用；从内生动力来说，各医疗机构缺乏协同提供医疗服务的动力，依然更加关注自身利益最大化。其次，从约束理论来看，纵向医疗服务供应链中的“短板”效应普遍存在且地区差异显著。再次，纵向医疗服务供应链中可供选择的“合作伙伴”资源不充分。
患者流方面。患者首诊状况较为理想，但分级就诊状况极度不佳（县医院就诊患者中有67.65%的患者直接就诊于县医院），无序患者流造成了373.57亿元浪费。此外，研究梳理出了特定疾病周期内多机构住院患者的疾病特征：住院级别由“低到高”和由“高到低”的共性疾病主要有急慢性胃肠炎、恶性肿瘤、脑血管病、宫颈炎及腹膜炎；住院级别由“低到高”的特异性疾病是支气管炎（或扩张）、冠心病心绞痛、胆结石症和胆囊炎、肺炎等；住院级别由“高到低”的特异性疾病是骨折、颅内和体内损伤，从而为基层医疗机构诊疗能力改进指明了重点领域。
信息流方面。研究发现，机构间缺乏医疗信息共享的媒介与机制。硬件上，区域医疗信息共享平台及机制尚未建立；软件上，高级别医疗机构医生对低级别医疗机构的信任度不理想。此外，以患者为主要的医疗信息传递媒介缺乏合理性。
4.讨论与建议
在理论研究和实证研究的基础上，本研究认为可从以下三方面入手，改进农村纵向医疗服务链：
从外部环境入手，培育构建农村纵向医疗服务供应链的土壤。第一，以医疗保险为把手，推动农村医疗服务提供体系的改革。第二，采取多重措施并举，增加“合作伙伴”资源。一方面提高乡村两级医疗机构的诊疗能力：从重点疾病入手，提高诊疗和康复服务的能力；变单机构临床路径为多机构临床路径，并逐步推广到整合的服务路径。另一方面是对社会资本进行改造和整合。第三，鼓励医疗机构以多种形式构建医疗服务供应链，如实体整合和虚拟整合等。
三步走战略，规范患者流。第一步，借力公共卫生服务项目，逐步为农村居民配备家庭医生。第二步，完善家庭医生功能，拓宽家庭医生职责。第三步，在医保激励和约束双重作用下，构建首诊及双向转诊机制等，实现分级诊疗。
打破信息孤岛效应，畅通信息流。改变现有的信息传递媒介及机制，构建区域信息共享平台，实现纵向医疗服务供应链中信息共享。可建立区域医学检验中心，提高检查结果的公信力，提高诊疗及检查结果互认。
5.研究创新与价值
理论上，本研究对供应链理论在医疗领域的运用进行了推进，衍生出医疗服务链理论。既往对供应链理论的研究多集中于产品及产品化服务，而本研究聚焦于具有高度专业性的“纯医疗服务”。提出了医疗服务链“链流合一”的思想，即既注重协同提供医疗服务，也注重规范患者流。实证上，既往对医疗服务提供和利用的研究，多集中于单个医疗机构内部，很少有研究从系统性的视角，对多机构提供的医疗服务以及患者对多机构医疗服务利用进行剖析。本研究不仅理清了农村地区患者多机构医疗服务利用情况（患者人口学特征、疾病特征、分级就诊情、无序患者流带来的资源浪费程度等），也揭示了影响多机构协同提供医疗服务的障碍以及影响患者分级就诊的因素。
6.研究局限与不足
第一，本研究对供应链理论在医疗服务领域进行了探索，虽然衍生出了医疗服务链理论，但仍可对节点之间的协调机制、合作伙伴的选择等内容进行深入研究。第二，虽然提出了医疗保险支付方式改革的设想，但未对医疗保险如何作用于纵向医疗服务链才能有效推动医疗机构协同提供医疗服务以及如何进行制度设计才能规范患者流做出细致解析，给后期研究留下了极大的空间。第三，各节点的功能定位及节点目标，以及整合的服务路径构建也是今后可做进一步探索的领域。
Rural health care delivery system to some extent determines the quality ofmedical services. Apparent defects have been demonstrated by researches. It not onlyturns out that the grass-roots health care services system’s ability of supplyingmedical services is poor because of the lack of health human resource as well as thelow efficiency and effectiveness of medical services, but also turns out that the ruralhealth care delivery system is highly fragmented for the lack of coordination andcommunication between organizations. Nowadays, a single medical institution can nolonger meet the demand of patients; what’s more, the coordination and continuity ofcare are needed. Therefore, the core mission to improve medical services in ruralareas is to emphasize the coordination in the medical service supply chain rather thanto focus on the quality of a certain medical institution.
1. Objectives
This dissertation focused on the coordination in the longitudinal medical servicechain rather than the medical service provision and utilization in a single medicalinstitution. Based on the theory of supply chain, this dissertation described the presentstatus of longitudinal medical service chain in rural China from the point of externalinstitutional environment, patient flow and information flow. And then put forwardstrategies of improving longitudinal medical service chain in rural China.
2. Methods
The data of this dissertation came from three channels.(1) Literature research. Literatures were used to do some theoretical research.(2) Field survey.4countieswere selected to investigations: a) Out-patients and in-patients questionnaire surveyswere conducted to analyze the patient flow such as daily first medical institutionselection, patient flows in the certain disease period and in the specific time period,and information from the patients’ perspective. b) Medical personnel questionnairesurveys were employed to do the analysis of information flow from the providers’point of view. c) In-depth interview were used to analyze the external policyenvironment.(3) Medical insurance data were employed to explore demographiccharacteristics and disease attributes of inpatients that had the experience of usingmedical services supplied by more than one institution.
Qualitative and quantitative methods were both used. Qualitative methods wereused to do some theoretical researches and quantitative methods were employed toanalyze questionnaires and insurance data. In this dissertation, hierarchical clusteringmethod was used to select survey site. The statistical analysis was employed todescribe the patient flow and information flow and some demographic characteristics,what’s more, chi-square statistical tests were used for the test of the probabilitydistribution difference, binary logistic regression model was used for the analysis ofthe density, dispersion and sequence of medical institutions’ visits, and multinomialLogistic regressions were employed for the influencing factors of patient flow in thecertain disease period and patients’carrying of medical records.
3. Results
Based on the theory of supply chain and combined with particularity of medicalservice, this dissertation explored the concept and model of medical service chain, aswell as the nature characteristics and intrinsic value of it. Because of the difference ofservice and products, medical service chain emphasizes not only provision but alsoutilization, which means regularizing patient flow as well as improving coordinationbetween medical institutions should be paid attention.
Longitudinal medical service supply chain was demonstrated unformed bythis research. The reasons were as follows. Firstly, there was no driving force formedical institutions to coordinate with each other. Medical insurance failed to play the promoting and regulating role. Secondly, on the basis of theory of constraints, casteffect was ubiquity and there were remarkable differences between different regions.Thirdly, there were not enough available medical service providers in the rural areas.
Patient flow in rural Chain was unreasonable for the reason thathierarchical visits were poor.67.65%patients went to county hospitals directlywithout referrals, causing a waste of37.36billion Yuan. Besides, the disease attributesof in-patients who had the experience of hospitalizing in different medical institutionsin the same disease period were found as follows: the same diseases for in-patientswho changed the medical institutions from low level to high level or from high to lowlevel were acute or chronic gastroenteritis, malignant tumor, cerebrovascular disease,cervicitis and peritonitis; the distinct diseases for in-patients who changed medicalinstitutions from low to high level were bronchitis (or expand), coronary heart diseaseangina pectoris, gallstone and cholecystitis, pneumonia and so on so forth; and thedistinct diseases for in-patients who changed medical institutions from high to lowlevel were fracture, intracranial injury and internal injuries.
Information flow in rural China was obstructed. For one thing, no medicalinformation sharing mechanism and media existed. Regional medical informationsharing platform and the mechanism had not yet been established. Worse still, doctorsin high level medical institutions had a low degree of trust for the outcomesengendered by low level medical institutions. For another, taking patients as the mainmedical information transfer was lack of rationality.
4. Discussions
Based on the theoretical and empirical researches, this dissertation brought uppolicy suggestions from three perspectives.
Firstly, develop a proper environment for longitudinal medical service chainin rural China. Promote health care delivery system reform through changingmedical insurance policy. And improve the ability of diagnosis and treatment ofvillage clinics and township medical institutions as well as change clinical pathway tointegrated care pathway to increase the available medical service providers in thelongitudinal medical service chain. Besides, encourage medical institutions to do some coordination and cooperation in a variety of forms like vertical integration andvirtual integration.
Secondly, develop the three-step development strategies to regulate thepatient flow. The first step is to equip patients suffering from chronic diseases withfamily doctors. The second step is to improve the function of family doctor andbroaden their responsibilities. The third step is to implement hierarchical visits, thefirst-visit system and the referral system under the dual incentive and constraint effectof insurance.
Thirdly, break the information island effect and smooth information flow.Construct the regional information sharing platform to smooth information sharing inthe longitudinal medical service chain. Regional medical inspection center should beset up to improve the credibility of examination results and the mutual recognition oftest results.
5. Innovations
Theoretically, the theory of supply chain has been promoted and the theory ofmedical service chain has been raised by this dissertation. The research perspective ofsupply chain has been changed from products and commercialization service to thehighly professional “pure medical service”. And consider that not only thecoordination of care but also how to regulate patient flow should be paid attention.Empirically, previous researches focused on the medical service provision andutilization in a single medical institution and ignored medical service delivery bymultiple levels of institutions. This dissertation analyzed utilization of medicalservices provided by multiple levels of institutions, including patients’ demographiccharacteristics, disease attributes, hierarchical visits and the waste caused bydisordered patient flow. What’s more, the obstacles and the influential factors oflongitudinal medical service chain were revealed.
6. Limitations
Firstly, though the theory of medical service chain was explored by this research,how to build the coordination mechanism and how to select medical institutions toestablish longitudinal medical service chain have not been solved. Secondly, though the idea of medical insurance payment reform was put forward, the detailed strategiesof encouraging medical institutions to establish medical service supply chain andregulating patient flow remains to be worked out. Thirdly, goals and functions ofdifferent medical institutions in the longitudinal medical service chain and theintegrated care pathway need to be designed.
1.研究目的
本研究突破单一医疗机构的研究禁锢，聚焦于多机构医疗服务的提供与利用。从系统性角度，将供应链理论运用到医疗服务领域，并且从外部环境、患者流和信息流等多维度对中国农村纵向医疗服务链现状进行解析，最终提炼出有利于改善中国农村纵向医疗服务链的政策建议。
2.资料来源与研究方法
本研究的资料主要来源于3个渠道：（1）文献法。收集来的文献资料用于相关理论研究。（2）现场调查。在全国31个省市自治区选择4个调研点进行实地研究：①门诊及住院患者问卷调查——用于患者流研究（患者日常首诊机构选择、特定疾病周期内就诊流向、特定时间段内就诊流向），以及利用方角度的信息流分析；②医务人员问卷调查——用于供方的信息流分析；③深度访谈——用于环境及政策因素的推演。（3）医疗保险数据。选择重庆黔江城乡居民合作医疗保险中住院补偿信息做典型调研——用于分析患者流中住院患者特定疾病周期内的多机构住院情况。
本研究采用定性与定量研究相结合的方式进行研究。（1）利用归纳总结等定性研究方法，进行理论梳理和政策推演。（2）采用书目信息共现挖掘系统（Bibliographic Item Co-Occurrence Mining System, BICOMS）和SPSS中的系统聚类法，对文献进行系统性和定量化研究。（3）利用SPSS和EXCEL对问卷资料和医疗保险数据进行描述性分析和统计学检验，如利用卡方检验对概率分布差异进行统计学检验，用二分类logistic回归模型对患者半年内就诊密度、分散程度及就诊顺序的影响因素进行分析，用无序多分类的logistic回归分别对患者当次就诊流向和患者病历资料携带情况的影响因素进行分析。
3.主要研究结果
医疗服务链相关理论方面。本研究在供应链理论的基础上，结合医疗服务自身的特殊性，对医疗服务链的概念、模型、性质特征及内在价值等进行了系统化梳理。认为医疗服务不同于一般产品，不仅强调供应，也同样强调服务利用；既要关注多机构协同提供医疗服务，也要规范患者流，具有典型的“链流合一”的特征。
中国农村纵向医疗服务供应链方面。研究发现，中国农村纵向医疗服务供应链尚未成形。首先，纵向医疗服务供应链各节点缺乏协同提供医疗服务的动力。从外部环境来说，医疗保险未对医疗服务供应链的形成起到应有的约束和激励作用；从内生动力来说，各医疗机构缺乏协同提供医疗服务的动力，依然更加关注自身利益最大化。其次，从约束理论来看，纵向医疗服务供应链中的“短板”效应普遍存在且地区差异显著。再次，纵向医疗服务供应链中可供选择的“合作伙伴”资源不充分。
患者流方面。患者首诊状况较为理想，但分级就诊状况极度不佳（县医院就诊患者中有67.65%的患者直接就诊于县医院），无序患者流造成了373.57亿元浪费。此外，研究梳理出了特定疾病周期内多机构住院患者的疾病特征：住院级别由“低到高”和由“高到低”的共性疾病主要有急慢性胃肠炎、恶性肿瘤、脑血管病、宫颈炎及腹膜炎；住院级别由“低到高”的特异性疾病是支气管炎（或扩张）、冠心病心绞痛、胆结石症和胆囊炎、肺炎等；住院级别由“高到低”的特异性疾病是骨折、颅内和体内损伤，从而为基层医疗机构诊疗能力改进指明了重点领域。
信息流方面。研究发现，机构间缺乏医疗信息共享的媒介与机制。硬件上，区域医疗信息共享平台及机制尚未建立；软件上，高级别医疗机构医生对低级别医疗机构的信任度不理想。此外，以患者为主要的医疗信息传递媒介缺乏合理性。
4.讨论与建议
在理论研究和实证研究的基础上，本研究认为可从以下三方面入手，改进农村纵向医疗服务链：
从外部环境入手，培育构建农村纵向医疗服务供应链的土壤。第一，以医疗保险为把手，推动农村医疗服务提供体系的改革。第二，采取多重措施并举，增加“合作伙伴”资源。一方面提高乡村两级医疗机构的诊疗能力：从重点疾病入手，提高诊疗和康复服务的能力；变单机构临床路径为多机构临床路径，并逐步推广到整合的服务路径。另一方面是对社会资本进行改造和整合。第三，鼓励医疗机构以多种形式构建医疗服务供应链，如实体整合和虚拟整合等。
三步走战略，规范患者流。第一步，借力公共卫生服务项目，逐步为农村居民配备家庭医生。第二步，完善家庭医生功能，拓宽家庭医生职责。第三步，在医保激励和约束双重作用下，构建首诊及双向转诊机制等，实现分级诊疗。
打破信息孤岛效应，畅通信息流。改变现有的信息传递媒介及机制，构建区域信息共享平台，实现纵向医疗服务供应链中信息共享。可建立区域医学检验中心，提高检查结果的公信力，提高诊疗及检查结果互认。
5.研究创新与价值
理论上，本研究对供应链理论在医疗领域的运用进行了推进，衍生出医疗服务链理论。既往对供应链理论的研究多集中于产品及产品化服务，而本研究聚焦于具有高度专业性的“纯医疗服务”。提出了医疗服务链“链流合一”的思想，即既注重协同提供医疗服务，也注重规范患者流。实证上，既往对医疗服务提供和利用的研究，多集中于单个医疗机构内部，很少有研究从系统性的视角，对多机构提供的医疗服务以及患者对多机构医疗服务利用进行剖析。本研究不仅理清了农村地区患者多机构医疗服务利用情况（患者人口学特征、疾病特征、分级就诊情、无序患者流带来的资源浪费程度等），也揭示了影响多机构协同提供医疗服务的障碍以及影响患者分级就诊的因素。
6.研究局限与不足
第一，本研究对供应链理论在医疗服务领域进行了探索，虽然衍生出了医疗服务链理论，但仍可对节点之间的协调机制、合作伙伴的选择等内容进行深入研究。第二，虽然提出了医疗保险支付方式改革的设想，但未对医疗保险如何作用于纵向医疗服务链才能有效推动医疗机构协同提供医疗服务以及如何进行制度设计才能规范患者流做出细致解析，给后期研究留下了极大的空间。第三，各节点的功能定位及节点目标，以及整合的服务路径构建也是今后可做进一步探索的领域。
Rural health care delivery system to some extent determines the quality ofmedical services. Apparent defects have been demonstrated by researches. It not onlyturns out that the grass-roots health care services system’s ability of supplyingmedical services is poor because of the lack of health human resource as well as thelow efficiency and effectiveness of medical services, but also turns out that the ruralhealth care delivery system is highly fragmented for the lack of coordination andcommunication between organizations. Nowadays, a single medical institution can nolonger meet the demand of patients; what’s more, the coordination and continuity ofcare are needed. Therefore, the core mission to improve medical services in ruralareas is to emphasize the coordination in the medical service supply chain rather thanto focus on the quality of a certain medical institution.
1. Objectives
This dissertation focused on the coordination in the longitudinal medical servicechain rather than the medical service provision and utilization in a single medicalinstitution. Based on the theory of supply chain, this dissertation described the presentstatus of longitudinal medical service chain in rural China from the point of externalinstitutional environment, patient flow and information flow. And then put forwardstrategies of improving longitudinal medical service chain in rural China.
2. Methods
The data of this dissertation came from three channels.(1) Literature research. Literatures were used to do some theoretical research.(2) Field survey.4countieswere selected to investigations: a) Out-patients and in-patients questionnaire surveyswere conducted to analyze the patient flow such as daily first medical institutionselection, patient flows in the certain disease period and in the specific time period,and information from the patients’ perspective. b) Medical personnel questionnairesurveys were employed to do the analysis of information flow from the providers’point of view. c) In-depth interview were used to analyze the external policyenvironment.(3) Medical insurance data were employed to explore demographiccharacteristics and disease attributes of inpatients that had the experience of usingmedical services supplied by more than one institution.
Qualitative and quantitative methods were both used. Qualitative methods wereused to do some theoretical researches and quantitative methods were employed toanalyze questionnaires and insurance data. In this dissertation, hierarchical clusteringmethod was used to select survey site. The statistical analysis was employed todescribe the patient flow and information flow and some demographic characteristics,what’s more, chi-square statistical tests were used for the test of the probabilitydistribution difference, binary logistic regression model was used for the analysis ofthe density, dispersion and sequence of medical institutions’ visits, and multinomialLogistic regressions were employed for the influencing factors of patient flow in thecertain disease period and patients’carrying of medical records.
3. Results
Based on the theory of supply chain and combined with particularity of medicalservice, this dissertation explored the concept and model of medical service chain, aswell as the nature characteristics and intrinsic value of it. Because of the difference ofservice and products, medical service chain emphasizes not only provision but alsoutilization, which means regularizing patient flow as well as improving coordinationbetween medical institutions should be paid attention.
Longitudinal medical service supply chain was demonstrated unformed bythis research. The reasons were as follows. Firstly, there was no driving force formedical institutions to coordinate with each other. Medical insurance failed to play the promoting and regulating role. Secondly, on the basis of theory of constraints, casteffect was ubiquity and there were remarkable differences between different regions.Thirdly, there were not enough available medical service providers in the rural areas.
Patient flow in rural Chain was unreasonable for the reason thathierarchical visits were poor.67.65%patients went to county hospitals directlywithout referrals, causing a waste of37.36billion Yuan. Besides, the disease attributesof in-patients who had the experience of hospitalizing in different medical institutionsin the same disease period were found as follows: the same diseases for in-patientswho changed the medical institutions from low level to high level or from high to lowlevel were acute or chronic gastroenteritis, malignant tumor, cerebrovascular disease,cervicitis and peritonitis; the distinct diseases for in-patients who changed medicalinstitutions from low to high level were bronchitis (or expand), coronary heart diseaseangina pectoris, gallstone and cholecystitis, pneumonia and so on so forth; and thedistinct diseases for in-patients who changed medical institutions from high to lowlevel were fracture, intracranial injury and internal injuries.
Information flow in rural China was obstructed. For one thing, no medicalinformation sharing mechanism and media existed. Regional medical informationsharing platform and the mechanism had not yet been established. Worse still, doctorsin high level medical institutions had a low degree of trust for the outcomesengendered by low level medical institutions. For another, taking patients as the mainmedical information transfer was lack of rationality.
4. Discussions
Based on the theoretical and empirical researches, this dissertation brought uppolicy suggestions from three perspectives.
Firstly, develop a proper environment for longitudinal medical service chainin rural China. Promote health care delivery system reform through changingmedical insurance policy. And improve the ability of diagnosis and treatment ofvillage clinics and township medical institutions as well as change clinical pathway tointegrated care pathway to increase the available medical service providers in thelongitudinal medical service chain. Besides, encourage medical institutions to do some coordination and cooperation in a variety of forms like vertical integration andvirtual integration.
Secondly, develop the three-step development strategies to regulate thepatient flow. The first step is to equip patients suffering from chronic diseases withfamily doctors. The second step is to improve the function of family doctor andbroaden their responsibilities. The third step is to implement hierarchical visits, thefirst-visit system and the referral system under the dual incentive and constraint effectof insurance.
Thirdly, break the information island effect and smooth information flow.Construct the regional information sharing platform to smooth information sharing inthe longitudinal medical service chain. Regional medical inspection center should beset up to improve the credibility of examination results and the mutual recognition oftest results.
5. Innovations
Theoretically, the theory of supply chain has been promoted and the theory ofmedical service chain has been raised by this dissertation. The research perspective ofsupply chain has been changed from products and commercialization service to thehighly professional “pure medical service”. And consider that not only thecoordination of care but also how to regulate patient flow should be paid attention.Empirically, previous researches focused on the medical service provision andutilization in a single medical institution and ignored medical service delivery bymultiple levels of institutions. This dissertation analyzed utilization of medicalservices provided by multiple levels of institutions, including patients’ demographiccharacteristics, disease attributes, hierarchical visits and the waste caused bydisordered patient flow. What’s more, the obstacles and the influential factors oflongitudinal medical service chain were revealed.
6. Limitations
Firstly, though the theory of medical service chain was explored by this research,how to build the coordination mechanism and how to select medical institutions toestablish longitudinal medical service chain have not been solved. Secondly, though the idea of medical insurance payment reform was put forward, the detailed strategiesof encouraging medical institutions to establish medical service supply chain andregulating patient flow remains to be worked out. Thirdly, goals and functions ofdifferent medical institutions in the longitudinal medical service chain and theintegrated care pathway need to be designed.
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