我国分级诊疗理论架构、实现路径及评价体系
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摘要
为构建我国分级诊疗理论框架、归纳其实现路径并总结其评价体系,本研究借助WHO卫生系统六模块等理论,结合实际对其进行总结梳理。研究发现,虽然各地各地区分级诊疗推进模式不尽相同,但实现路径殊途同归,都是在结构和过程中通过利益相关者的博弈更有效地配置医疗资源,最终实现首诊制的、整合性的、连续性的、减轻医疗负担的和让群众满意的诊疗服务。建议各地、各地区在综合评估卫生发展状况基础上有计划有步骤地推进分级诊疗,同时以史为鉴、参照国际经验,以弥补自身经验不足。
The aim of the study is to discuss the construction of the theoretical framework of the Tiered Diagnosis and Medical Treatment(TDMT) and to summarize the implementation path and evaluation system of TDMT in China. Relevant theories on TDMT such as six modules for health system recommend by World Health Organization(WHO) were used for references in the study. We found that although the promotion modes of the TDMT vary from place to place, the way to achieve the same goal is to allocate medical resources more effectively through stakeholder games in the structure and process of the TDMT, and ultimately achieve the first-visit, integrated, continual, less burden and more satisfactory health system. It is suggested that all regions should systematically promote the TDMT on the basis of comprehensive assessment of health development, draw lessons from history and refer to international experience so as to make up for the lack of experience.
The aim of the study is to discuss the construction of the theoretical framework of the Tiered Diagnosis and Medical Treatment(TDMT) and to summarize the implementation path and evaluation system of TDMT in China. Relevant theories on TDMT such as six modules for health system recommend by World Health Organization(WHO) were used for references in the study. We found that although the promotion modes of the TDMT vary from place to place, the way to achieve the same goal is to allocate medical resources more effectively through stakeholder games in the structure and process of the TDMT, and ultimately achieve the first-visit, integrated, continual, less burden and more satisfactory health system. It is suggested that all regions should systematically promote the TDMT on the basis of comprehensive assessment of health development, draw lessons from history and refer to international experience so as to make up for the lack of experience.
引文
[1]国务院办公厅.关于推进分级诊疗制度建设的指导意见[EB/OL].(2015-9-11)[2018-10-30].http://www.gov.cn/zhengce/content/2015-09/11/content_10158.htm.
[2]新华社.建设健康中国增进人民福祉--学习贯彻习近平总书记在全国卫生与健康大会重要讲话[EB/OL].(2016-8-20)[2018-10-30]http://news.cctv.com/2016/08/20/ARTIK49foKJd WmMrdd42We2M160820.shtml.
[3]国务院."十三五"深化医药卫生体制改革规划的通知[EB/OL].(2017-1-9)[2018-10-30]http://www.gov.cn/zhengce/content/2015-09/11/content_10158.htm.
[4]胡善联.国际组织对我国医药卫生体制改革监测与评价框架的建议[J].中国卫生政策研究,2010,3(3):4-6.
[5]王清波.分级诊疗制度的运行机制分析--基于厦门市的案例研究[D].北京:协和医学院,2016.
[6]郭伟.我国医疗服务业分级诊疗制度及其有效性研究-以重庆市为例[D].重庆:重庆理工大学,2017.
[7]Donabedian A.Evaluating the quality of medical care[J].The Milbank Quarterly,2010,83(4):691-729.
[8]王欣.我国卫生服务整合的体系背景分析及实施效果评价一基于三省九县(区)实证研究[D].济南:山东大学,2017.
[9]Duane W.Can stakeholder interests be balanced?Jones Graduate School of Management MS-531,Rice University[EB/OL].(1999-06)[2018-10-30].http://www.ruf.rice.edu.
[10]李洋,王辉.利益相关者理论的动态发展与启示[J].现代财经,2004,24(7):32-35.
[11]Sirgy MJ.Measuring corporate performance by building on the stakeholder model of business ethics[J].Journal of Business Ethics,2002,35(3):401-414.
[12]Baker WE,Faulkner RR.Interorganizational networks[M].Qxford:Blackwell,2002:16-30.
[13]Burt RS.Structural holes:The social structure of competition[M].Cambridge:Harvard University Press,1992:15-19.
[14]马霞,甄天民,谷景亮,等.社会网络分析方法在国内医药卫生领域的应用及启示[J].中华医学图书情报杂志,2014,23(10):18-21.
[15]王欣,马慧芬,朱炜明.安徽省卫生服务体系整合结构和有效性研究-以马鞍山市、肥西县和肥东县为例[J].中国卫生政策研究,2015,8(10):5-12.
[16]Petersen T.The economics of organizations:the principal agent relationship[J].Acta Sociological,1993(36):277-293.
[17]刘盾,林玳玳,袁伦渠.美国医疗保障体系的第三方代理机制[J].中国劳动,2009(7):29-31.
[18]World Health Organization.Everybody’business:strengthening health systems to improve health outcomes[R].Geneva:World Health Organization,2007.
[19]郑英,李力,代涛.我国部分地区分级诊疗政策实践的比较分析[J].中国卫生政策研究,2016,9(4):1-8.
[20]Grossman SJ,Hart O.The costs and benefits of ownership:a theory of vertical and later a integration[J].Journal of Political Economy,1986,94(4):691-719.
[21]Hart O,Moore J.Contracts as reference points[J].Quarterly Journal of Economics,2008,123(1):1-48.
[22]倪娟,奥利弗·哈特.对不完全契约理论的贡献--2016年度诺贝尔经济学奖得主学术贡献评介[J].经济学动态,2016(10):98-107.
[23]Wiener N.Cybernetics or control and communication in the animal and the machine[M].New Youk:JohnWilet and Sons Inc.,1948.
[24]谭光明,谢春燕,徐舒曼,等.前馈控制在医疗保健服务质量管理中的作用[J].现代医院,2017,17(9):1266-1268.
[25]陈建先.博弈理论框架:一个理论体系的建构[J].重庆理工大学学报(社会科学),2018,32(1):88-95.
[26]Ajzen I.From intentions to actions:a theory of planned behavior[M].Berlin:Springer-Verlag,1985:11-39.
[27]Decie L,Ryan RM.The‘what’and‘why’of goal pursuits:human needs and the self-determination of behavior[J].Psychological Inquiry,2000(11):227-268.
[28]Gagne M,Decie L.Self-determination theory and work motivation[J].Journal of Organizational Behavior,2005(26):331-362.
[29]刘兴智.项目治理社会网络风险分析方法研究[D]济南:山东大学,2011.
[30]李勇杰.社会医疗保险制度创新的框架研究-基于委托代理理论视角[J].广西社会科学,2009(4):48-51.
[31]冯娟,沈晓,向清.浅析医疗保险三方间的委托代理关系[J].中国卫生事业管理,2009(3):171-173.
[32]聂辉华.对中国深层次改革的思考:不完全契约的视角[J].国际经济评论,2011(1):129-140.
[33]Alchian A,Demsetz H.Production,information costs,and economic organization[J].The American Economic Review,1972,62(5):777-795.
[34]张杰.全国医改示范的“天长样本”--天长市创立新型医疗模式探究[N].滁州日报,2016-12-27(1).
[35]李玲,徐扬,陈秋霖.整合医疗:中国医改的战略选择[J].中国卫生政策研究,2012,5(9):10-16.
[36]Adam T,De Savigny D,Ebrary I,et al.Systems thinking for health systems strengthening[M].Geneva:World Health Organization,2009.
[37]韩优莉,常文虎.区域医疗服务体系纵向整合效应研究-不完全契约理论模型及应用[J].中国行政管理,2017(11):128-134.
[38]孟群.构建“互联网+健康医疗”服务新模式打造分级诊疗就医新秩序[J].中国卫生信息管理杂志,2017,14(2):101.
[39]孟群,尹新.互联网+分级诊疗模式的思考[J].中国卫生信息管理杂志,2016,13(2):111-127.
[40]魏东海,曹晓雯,周其如,等.医养护一体化分级诊疗模式的实践与探索--基于医疗网络平台[J].卫生经济研究,2018(3):51-54.
[41]常朝娣,陈敏.分级诊疗服务信息技术应用探讨[J].中国医院管理,2018,38(4):50-52.
[42]张平,徐兵,甘筱青.市场结构、医疗保险与医疗费用的关系研究[J].管理工程学报,2018(2):53-57.
[43]周良荣,怀银平,喻小倩,等.博弈论视角下的医保定点医疗机构监管分析[J].中国中医药现代远程教育,2016,14(3):34-36.
[44]裴俊巍,曹逸涵,尹西明.博弈论视角下政府采购寻租研究-基于政府采购医疗器械的分析[J].中国政府采购,2015(3):68-73.
[45]刘丽虹,李爱梅.动机的自我决定理论及其在管理领域的应用[J].科技管理研究,2010(15):115-119.
[46]克里斯托福M.以价值为导向的医疗服务[M].吴明,译.1版.北京:北京大学医学出版社,2018:185-186.
[47]贺蕾,姚强,蔡敏,等.医药卫生体制改革效果评估框架及指标体系研究[J].中国卫生信息管理杂,2014,11(55):468-473.
[48]王舒捷.公立医院公益性评价指标体系构建及评价--江苏省级医院为例[D].南京:南京大学,2016.
[49]人民网-人民日报.胡锦涛:为群众提供安全有效方便价廉医疗卫生服务[EB/OL].(2010-5-30)[2018-10-30].http://cpc.people.com.cn/GB/64093/64094/11730881.html.
[50]李仁丰.加快建立新型农村合作医疗[N].中国劳动保障报,2003-02-09(1).
[2]新华社.建设健康中国增进人民福祉--学习贯彻习近平总书记在全国卫生与健康大会重要讲话[EB/OL].(2016-8-20)[2018-10-30]http://news.cctv.com/2016/08/20/ARTIK49foKJd WmMrdd42We2M160820.shtml.
[3]国务院."十三五"深化医药卫生体制改革规划的通知[EB/OL].(2017-1-9)[2018-10-30]http://www.gov.cn/zhengce/content/2015-09/11/content_10158.htm.
[4]胡善联.国际组织对我国医药卫生体制改革监测与评价框架的建议[J].中国卫生政策研究,2010,3(3):4-6.
[5]王清波.分级诊疗制度的运行机制分析--基于厦门市的案例研究[D].北京:协和医学院,2016.
[6]郭伟.我国医疗服务业分级诊疗制度及其有效性研究-以重庆市为例[D].重庆:重庆理工大学,2017.
[7]Donabedian A.Evaluating the quality of medical care[J].The Milbank Quarterly,2010,83(4):691-729.
[8]王欣.我国卫生服务整合的体系背景分析及实施效果评价一基于三省九县(区)实证研究[D].济南:山东大学,2017.
[9]Duane W.Can stakeholder interests be balanced?Jones Graduate School of Management MS-531,Rice University[EB/OL].(1999-06)[2018-10-30].http://www.ruf.rice.edu.
[10]李洋,王辉.利益相关者理论的动态发展与启示[J].现代财经,2004,24(7):32-35.
[11]Sirgy MJ.Measuring corporate performance by building on the stakeholder model of business ethics[J].Journal of Business Ethics,2002,35(3):401-414.
[12]Baker WE,Faulkner RR.Interorganizational networks[M].Qxford:Blackwell,2002:16-30.
[13]Burt RS.Structural holes:The social structure of competition[M].Cambridge:Harvard University Press,1992:15-19.
[14]马霞,甄天民,谷景亮,等.社会网络分析方法在国内医药卫生领域的应用及启示[J].中华医学图书情报杂志,2014,23(10):18-21.
[15]王欣,马慧芬,朱炜明.安徽省卫生服务体系整合结构和有效性研究-以马鞍山市、肥西县和肥东县为例[J].中国卫生政策研究,2015,8(10):5-12.
[16]Petersen T.The economics of organizations:the principal agent relationship[J].Acta Sociological,1993(36):277-293.
[17]刘盾,林玳玳,袁伦渠.美国医疗保障体系的第三方代理机制[J].中国劳动,2009(7):29-31.
[18]World Health Organization.Everybody’business:strengthening health systems to improve health outcomes[R].Geneva:World Health Organization,2007.
[19]郑英,李力,代涛.我国部分地区分级诊疗政策实践的比较分析[J].中国卫生政策研究,2016,9(4):1-8.
[20]Grossman SJ,Hart O.The costs and benefits of ownership:a theory of vertical and later a integration[J].Journal of Political Economy,1986,94(4):691-719.
[21]Hart O,Moore J.Contracts as reference points[J].Quarterly Journal of Economics,2008,123(1):1-48.
[22]倪娟,奥利弗·哈特.对不完全契约理论的贡献--2016年度诺贝尔经济学奖得主学术贡献评介[J].经济学动态,2016(10):98-107.
[23]Wiener N.Cybernetics or control and communication in the animal and the machine[M].New Youk:JohnWilet and Sons Inc.,1948.
[24]谭光明,谢春燕,徐舒曼,等.前馈控制在医疗保健服务质量管理中的作用[J].现代医院,2017,17(9):1266-1268.
[25]陈建先.博弈理论框架:一个理论体系的建构[J].重庆理工大学学报(社会科学),2018,32(1):88-95.
[26]Ajzen I.From intentions to actions:a theory of planned behavior[M].Berlin:Springer-Verlag,1985:11-39.
[27]Decie L,Ryan RM.The‘what’and‘why’of goal pursuits:human needs and the self-determination of behavior[J].Psychological Inquiry,2000(11):227-268.
[28]Gagne M,Decie L.Self-determination theory and work motivation[J].Journal of Organizational Behavior,2005(26):331-362.
[29]刘兴智.项目治理社会网络风险分析方法研究[D]济南:山东大学,2011.
[30]李勇杰.社会医疗保险制度创新的框架研究-基于委托代理理论视角[J].广西社会科学,2009(4):48-51.
[31]冯娟,沈晓,向清.浅析医疗保险三方间的委托代理关系[J].中国卫生事业管理,2009(3):171-173.
[32]聂辉华.对中国深层次改革的思考:不完全契约的视角[J].国际经济评论,2011(1):129-140.
[33]Alchian A,Demsetz H.Production,information costs,and economic organization[J].The American Economic Review,1972,62(5):777-795.
[34]张杰.全国医改示范的“天长样本”--天长市创立新型医疗模式探究[N].滁州日报,2016-12-27(1).
[35]李玲,徐扬,陈秋霖.整合医疗:中国医改的战略选择[J].中国卫生政策研究,2012,5(9):10-16.
[36]Adam T,De Savigny D,Ebrary I,et al.Systems thinking for health systems strengthening[M].Geneva:World Health Organization,2009.
[37]韩优莉,常文虎.区域医疗服务体系纵向整合效应研究-不完全契约理论模型及应用[J].中国行政管理,2017(11):128-134.
[38]孟群.构建“互联网+健康医疗”服务新模式打造分级诊疗就医新秩序[J].中国卫生信息管理杂志,2017,14(2):101.
[39]孟群,尹新.互联网+分级诊疗模式的思考[J].中国卫生信息管理杂志,2016,13(2):111-127.
[40]魏东海,曹晓雯,周其如,等.医养护一体化分级诊疗模式的实践与探索--基于医疗网络平台[J].卫生经济研究,2018(3):51-54.
[41]常朝娣,陈敏.分级诊疗服务信息技术应用探讨[J].中国医院管理,2018,38(4):50-52.
[42]张平,徐兵,甘筱青.市场结构、医疗保险与医疗费用的关系研究[J].管理工程学报,2018(2):53-57.
[43]周良荣,怀银平,喻小倩,等.博弈论视角下的医保定点医疗机构监管分析[J].中国中医药现代远程教育,2016,14(3):34-36.
[44]裴俊巍,曹逸涵,尹西明.博弈论视角下政府采购寻租研究-基于政府采购医疗器械的分析[J].中国政府采购,2015(3):68-73.
[45]刘丽虹,李爱梅.动机的自我决定理论及其在管理领域的应用[J].科技管理研究,2010(15):115-119.
[46]克里斯托福M.以价值为导向的医疗服务[M].吴明,译.1版.北京:北京大学医学出版社,2018:185-186.
[47]贺蕾,姚强,蔡敏,等.医药卫生体制改革效果评估框架及指标体系研究[J].中国卫生信息管理杂,2014,11(55):468-473.
[48]王舒捷.公立医院公益性评价指标体系构建及评价--江苏省级医院为例[D].南京:南京大学,2016.
[49]人民网-人民日报.胡锦涛:为群众提供安全有效方便价廉医疗卫生服务[EB/OL].(2010-5-30)[2018-10-30].http://cpc.people.com.cn/GB/64093/64094/11730881.html.
[50]李仁丰.加快建立新型农村合作医疗[N].中国劳动保障报,2003-02-09(1).
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