上海市“1+1+1”医疗机构组合签约策略实施现状的质性研究

doi:10.12114/j.issn.1007-9572.2019.00.074

摘要/Abstract

摘要： 背景　上海市为构建分级诊疗体系，与家庭医生制度相结合，2015年3月启动了新一轮社区卫生服务综合改革，推行“1+1+1”医疗机构组合签约策略（“1+1+1”签约）。目的　了解上海市“1+1+1”签约实施状况，分析政策实施中遇到的问题，为进一步推进“1+1+1”签约提供参考建议。方法　2017年7—9月，对上海市6家社区卫生服务中心的医务科长共6人就目前该中心“1+1+1”签约的实施状况，包括开始推行时间、签约率、签约方式、宣传策略、4项主要优惠政策（长处方、延伸处方、预约上级医院号源、转诊）实行状况、家庭医生“1+1+1”签约的服务内容进行数据资料咨询；采用一对一半结构式访谈法对这6家社区卫生服务中心的家庭医生共18人就“1+1+1”签约实施过程中遇到的问题及建议进行访谈。所有数据资料、访谈内容根据主题和内容分析法，进行总结、归纳和分类。结果　截至2017年7月底，6家社区卫生服务中心的平均签约率为9.47%，≥60岁人群的签约率为51.35%，其中4家以门诊签约为主，另外2家以并行开展家庭医生工作室签约及门诊签约为主；6家社区卫生服务中心均采取实行的优惠政策作为签约宣传策略，以居民就诊时宣教及居委协助宣传为主；均已实行长处方、延伸处方政策，5家已实行预约上级医院号源及转诊政策。家庭医生服务内容主要包括基本诊疗、便捷配药、预约及转诊、健康管理、慢性病管理、健康咨询、医疗费用控制。实施过程中主要存在医保药占比（即药品费用与就诊总费用的比值）难控制，预约号源及转诊绿色通道不畅，各项相关配套政策不完善，绩效考核指标不合理，家庭医生工作收入付出不成比例，签而不约等问题。结论　上海市“1+1+1”签约政策陆续在各个社区卫生服务中心实行，在提高签约率、实施各项优惠政策、落实各项服务等各方面都取得了初步成果。建议加大宣传，完善各项相关配套政策，加强上下级医院协作，合理制定考核指标，真正落实签约服务，从而尽快推进“1+1+1”签约实施进程，促进分级诊疗模式的建立。

关键词: 分级诊疗；&ldquo, 1+1+1&rdquo, 签约；家庭医生签约服务；定性研究

Abstract: Background　In order to promote the development of the hierarchical medical system，and its synergic development with family doctor system，Shanghai launched a round comprehensive reform of the community-based health care system in March 2015，and began to facilitate the implementation of "1+1+1" type of contracted family doctor services（"1+1+1" type of contracts）．Objective　To explore the implementation status of the "1+1+1" type of contracts in Shanghai，and put forward suggestions to the existing problems，offering choices for further development of contracted family doctor services delivered by this pattern.Methods　We conducted this study in 6 community health centers（CHCs）in Shanghai from July to September 2017.We carried out semi-structured individual interviews in 6 medical section chiefs（1 from each CHC）for collecting data about the implementation status of the "1+1+1" type of contracts（including long-term prescriptions，extending of prescriptions，making an appointment with the doctor from a higher level hospital，and referrals），and in 18 family doctors from the CHCs for collecting information concerning problems encountered during the implementation of the "1+1+1" type of contracts and corresponding suggestions.Moreover，we obtained the items of the contractual services from the iPAD of the medical section chiefs after getting permission.The electronic data and interview results were summarized，inducted and classified using theme and content analyses.Results　By the end of July 2017，the rate of residents who signed a "1+1+1" type of contract with the CHCs was 9.47%，and in the group aged 60 years or over，this rate was 51.35%.Contracting was mainly conducted in the outpatient departments of all the CHCs，and also in family doctor studios in 2 of the CHCs.In order increase the contracting rate，all the CHCs publicized the preferential policies for such services mainly by informing the residents during their visiting and educating residents with the assistance of the neighborhood committees.Moreover，they wrote long-term prescriptions and extended prescriptions.And in 5 CHCs，residents could make appointments with the doctor from a higher level hospital and could be transferred.The contractual services mainly included essential diagnosis and treatment of diseases，convenient dispensing，appointment and referral，health management，chronic disease management，health counseling，and control of medical expenses.The major problems encountered during the implementation of the "1+1+1" type of contracts were difficult control of the percentage of reimbursed drugs（ratio of cost of reimbursed drugs to the total medical expenses），inefficiencies in making appointments and transferring via the green channel，incomplete supportive policies，inappropriate family doctor performance evaluation indicators，effort-reward imbalance in family doctors，and phenomenon of some contracted residents making no appointments.Conclusion　The "1+1+1" type of contracts have been implemented in various CHCs in Shanghai gradually.And some achievements have been made in increasing the contracting rate，implementation of the preferential policies and services.In order to promote the implementation of such services to facilitate the development of the hierarchical medical system，the publicity of such services should be enhanced，the supportive policies should be improved，the cooperation between higher level and lower level hospitals should be strengthened，and family doctor performance evaluation indicators should be developed reasonably.

Key words: Hierarchical medical system；"1+1+1", signing policy；Contracted family doctor services；Qualitative research

黄翠玲,寿涓,李娅玲,等. 上海市“1+1+1”医疗机构组合签约策略实施现状的质性研究[J]. 中国全科医学, 2019, 22(19): 2308-2313. DOI: 10.12114/j.issn.1007-9572.2019.00.074.
HUANG Cuiling,SHOU Juan,LI Yaling, et al. Implementation Status of the "1+1+1" Type of Contracted Family Doctor Services in Shanghai：a Qualitative Study　[J]. Chinese General Practice, 2019, 22(19): 2308-2313. DOI: 10.12114/j.issn.1007-9572.2019.00.074.

参考文献

［1］国务院办公厅．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］．（2015-09-11）［2018-05-02］．http：//www.gov.cn/zhengce/content/2015-09/11/content_10158.htm.
［2］市政府办公厅印发《关于进一步推进本市社区卫生服务综合改革与发展的指导意见》［EB/OL］．（2015-03-03）［2018-05-02］．http：//www.shdrc.gov.cn/fzgggz/shfz/zcwj/18950.htm.
［3］关于印发《上海市2015年深化医药卫生体制改革工作要点》的通知［EB/OL］．（2015-02-16）［2018-05-02］． http：//www.shdrc.gov.cn/gk/xxgkml/zcwj/zgjjl/16830.htm.
［4］蔡利强，侯进.“1+1+1”组合签约对家庭医生服务效果的影响研究［J］．中国全科医学，2018，21（31）：3814-3817．DOI：10.12114/j.issn.1007-9572.2018.31.007.
CAI L Q，HOU J．Implementation effect of the"1+1+1" type of signing on the development of family doctor services［J］．Chinese General Practice，2018，21（31）：3814-3817．DOI：10.12114/j.issn.1007-9572.2018.31.007.
［5］张晓俊，鲍勇.上海市社区就诊人群“1+1+1”医疗机构组合签约现况及影响因素研究［J］．中华全科医学，2018，16（8）：1227-1230，1382．DOI：10.16766/j.cnki.issn.1674-4152.000337.
ZHANG X J，BAO Y．Current status of "1+1+1" medical institution combination signing project and its influencing factors among the outpatients of community health care center in Shanghai［J］．Chinese Journal of General Practice，2018，16（8）：1227-1230，1382．DOI：10.16766/j.cnki.issn.1674-4152.000337.
［6］叶红梅，温静，郑军华．基于上海市慢性病长处方的利益相关者理论分析［J］．中国医院，2016，20（4）：52-54．DOI：10.3969/j.issn.1671-0592.2016.04.019.
YE H M，WEN J，ZHENG J H．Analysis of chronic disease long prescription in Shanghai based on the stakeholders theory［J］．Chinese Hospitals，2016，20（4）：52-54．DOI：10.3969/j.issn.1671-0592.2016.04.019.
［7］王春辉，曹筱筱，孙颖祎.上海奉贤区某社区延伸处方用药情况分析［J］．中国社区医师，2018，34（20）：11，13．DOI：10.3969/j.issn.1007-614x.2018.20.005.
WANG C H，CAO X X，SUN Y Y．Analysis of extended prescriptions in a community in Fengxian District，Shanghai［J］．Chinese Community Doctors，2018，34（20）：11，13．DOI：10.3969/j.issn.1007-614x.2018.20.005.
［8］国务院医改办．关于印发推进家庭医生签约服务指导意见的通知［EB/OL］．（2016-05-25）［2018-06-06］．http：//www.nhfpc.gov.cn/tigs/s3577/201606/e3e7d2670a8b4163b1fe8e409c7887af.shtml.
［9］崔华欠，方国瑜，杨阳，等．广州市社区居民对分级诊疗模式的知晓和认知情况调查［J］．中国全科医学，2014，17（34）：4123-4126．DOI：10.3969/j.issn.1007-9572.2014.34.027.
CUI H Q，FANG G Y，YANG Y，et al．Investigation on community residents' awareness and cognition of hierarchical diagnosis system in Guangzhou City［J］．Chinese General Practice，2014，17（34）：4123-4126．DOI：10.3969/j.issn.1007-9572.2014.34.027.
［10］赵建功，张向东，王敏，等．北京市西城区家庭医生式服务签约居民续约意愿及影响因素研究［J］．中国全科医学，2015，18（28）：3417-3422．DOI：10.3969/j.issn.1007-9572.2015.28.009.
ZHAO J G，ZHANG X D，WANG M，et al．Residents' willingness for renewing the signing of family doctor service in Xicheng District of Beijing and its influencing factors［J］．Chinese General Practice，2015，18（28）：3417-3422．DOI：10.3969/j.issn.1007-9572.2015.28.009.
［11］赵影，祝友元，潘毅慧，等．社区门诊患者签约家庭医生的意愿及其影响因素研究［J］．中国全科医学，2012，15（10）：1151-1153．DOI：10.3969/j.issn.1007-9572.2012.10.027.
ZHAO Y，ZHU Y Y，PAN Y H，et al．Factors influencing signinging percentage of family physicians among community outpatients［J］．Chinese General Practice，2012，15（10）：1151-1153．DOI：10.3969/j.issn.1007-9572.2012.10.027.
［12］李婷，林其意，黄涛，等．慢性病长处方政策对签约患者医疗质量的短期影响及政策建议［J］．中国全科医学，2017，20（25）：3084-3087．DOI：10.3969/j.issn.1007-9572.2017.25.005.
LI T，LIN Q Y，HUANG T，et al．Short-term effect of chronic disease patients with long-term prescription policy oil the healthcare quality of contracted patients and policy recommendations［J］．Chinese General Practice，2017，20（25）：3084-3087．DOI：10.3969/j.issn.1007-9572.2017.25.005.
［13］毕芳，孙向军，任苒．双向转诊制度实施中的问题与对策［J］．中国初级卫生保健，2011，25（4）：9-12．DOI：10.3969/j.issn.1001-568X.2011.04.004.
BI F，SUN X J，REN R．Problems and counter measures in the implementation of two-way referral system［J］．Chinese Primary Health Care，2011，25（4）：9-12．DOI：10.3969/j.issn.1001-568X.2011.04.004.
［14］蔡利强，侯进，陆新建．香港转诊制度对内地实施分级诊疗的启示［J］．中国全科医学，2017，20（15）：1787-1792，1797．DOI：10.3969/j.issn.1007-9572.2017.15.001.
CAI L Q，HOU J，LU X J．Enlightenment of the implementation of patient referral system in Hong Kong to the carrying out of hierarchical medical system in the mainland of China［J］．Chinese General Practice，2017，20（15）：1787-1792，1797．DOI：10.3969/j.issn.1007-9572.2017.15.001.
［15］刘晓溪，陈玉文，毕开顺．借鉴英国医疗服务体系破解我国实施双向转诊制度难题［J］．中国全科医学，2013，16（25）：2926-2929．DOI：10.3969/j.issn.1007-9572.2013.25.005.
LIU X X，CHEN Y W，BI K S．Resolution of two-way referral problem in China by studying British National Health Service System［J］．Chinese General Practice，2013，16（25）：2926-2929．DOI：10.3969/j.issn.1007-9572.2013.25.005.
［16］高凤娟，王培玉，史宇晖，等．德胜社区家庭医生式服务新模式的效果研究［J］．中国全科医学，2017，20（13）：1563-1567．DOI：10.3969/j.issn.1007-9572.2017.13.008.
GAO F J，WANG P Y，SHI Y H，et al．Effect of the new mode of family doctor service in Desheng Community［J］．Chinese General Practice，2017，20（13）：1563-1567．DOI：10.3969/j.issn.1007-9572.2017.13.008.
［17］袁莎莎，王芳，李陈晨，等．社区卫生服务机构签约服务模式分析［J］．中国卫生政策研究，2015，8（8）：56-62．DOI：10.3969/j.issn.1674-2982.2015.08.011.
YUAN S S，WANG F，LI C C，et al．Analysis on the signinging service model in community health centers［J］．Chinese Journal of Health Policy，2015，8（8）：56-62．DOI：10.3969/j.issn.1674-2982.2015.08.011.
［18］ZHOU H，ZHANG W，ZHANG S，et al．Health providers' perspectives on delivering public health services under the signing service policy in rural China：evidence from Xinjian County［J］．BMC Health Services Research，2015，15：75．DOI：10.1186/s12913-015-0739-x.
［19］徐霞凤，杜兆辉．全科医生助理员参与家庭医生签约制服务的效果评价［J］．中国全科医学，2015，18（28）：3410-3412．DOI：10.3969/j.issn.1007-9572.2015.28.007.
XU X F，DU Z H．Effect evaluation of assistants for general practitioners in family doctor service system［J］．Chinese General Practice，2015，18（28）：3410-3412．DOI：10.3969/j.issn.1007-9572.2015.28.007.

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