上海分級診療醫(yī)療制度改革英文版

Introductorytheory：InSeptember2015,thestatecouncilgeneralofficeissuedbythegeneralofficeofthestatecouncilonpromotingtheconstructionofthegradingsystemofguidance",thedeploymentofquickeningconstructionofthegradingsystem,putforwardto2020,thehierarchicaldiagnosismodelgraduallyformed,theclassificationsystemofbasicestablishmentconformstothenationalconditionsofthetarget.Planforthenationalhealthservicesystem(2015-2020)"and"healthprogramforChina's2030alsoclearlyputforwardthatestablishingandperfectingtheclassificationdiagnosismodel,graduallyrealizethefirstoptionatthegrass-rootslevel,two-wayreferral,slowpartition,theclassificationsystemofupperandlowerlinkage,repositioningfunctionofmedicalinstitutionsatalllevels,theintegrationofregionalmedicalresourcesandimproveefficiency,forthemassestoprovideefficientandorderly,continuous,homogeneityofmedicalservices,toachievereasonablemedicaltreatmentorder.Thus,pushingforwardtheconstructionofthegradingsystemistheurgentneedtodeepenthereform,isalsodeepenthemedicalandhealthservicesupplyside,theimportantmeasuresforstructuralreformistheonlywaytoestablishabasicmedicalandhealthcaresystem.AlltheseindicatethatChina'smedicalreformhasenteredaneweraofreform,especiallyinShanghaiandotherplaces.Butintermsofthedomesticmedicalconditions,hasnotfundamentallysolvetheproblemof"difficultyandhighcostofthedoctor",bighospitalsareoverwhelmed,andthestatusofthesmallclinicemptyoftenappear.Inmyopinion,thehierarchicalmedicalsystemisconducivetorationalutilizationofmedicalresources,savingmedicalexpensesandguidingpatientstoseekmedicaltreatmentinanorderlymanner.Onthisbasis,thispaperwillbebasedonthehierarchicaldiagnosissysteminChina,discussesthegradingsystemintheimplementationofthestatusquo,problemsandcauses,andthefutureprospectandreflection,andtheclassificationsystemofthepracticeandthecomparativeanalysisinourcountry,andthentoputforwardsomeSuggestionsonthedevelopmentofhierarchicaldiagnosissysteminChina.

Abriefdescriptionofthehierarchicalmedicalsystem

1.1problemssolvedbythereform

ShanghaiisthemostdevelopedcityinChina,medicalandhealthcaresystemisrelativelyperfect,butstillfacesmanyproblems:betweenthedistrictsandcounties,allkindsofmedicalsecuritysystemsecuritylevelthereisagapbetween;Thedistributionofmedicalresourcesisincompatiblewithpopulationdistributionandstructuralchange.Thefunctionalorientationofmedicalinstitutionsatalllevelshasnotbeeneffectivelyimplementedandascientificandreasonablemedicalorderhasnotyetbeenformed.Thedrugpurchasingandmarketingsystemandpricemanagementsystemarenotperfect.Especiallytheproblemof"difficultandexpensivemedicaltreatment"hasalwaysbeenthefocusofmedicalreform.Shanghaiisthefirstonthebasisoffamilydoctors,ahierarchicaldiagnosisandreformofcity,throughthereformoftheclassificationdiagnosisandtreatment,theShanghaimunicipalgovernmenttocanform"slightillnessinthecommunity,inthehospital,rehabilitationbacktothecommunity"theorderlysituation,realizethe"centerofgravitydown,thereachmark"thestructureofhealthmanagement.Ithinkgradingdiagnosisandtreatmentistopointtoinordertoimprovetheefficiency,costsavings,accordingtothediseaseofthelightandheavy,slow,quickclassification,accordingtothefunctionorientationofmedicalinstitutions,differentlevelsofmedicalinstitutionstoundertakedifferenttypesofdiseaseoratdifferentstagesofdiseasetreatment,throughcommunityfirst,two-wayreferralsystemtorealizetheseriousillnessinhospital,ailmentleaveorderlygrassrootsmedicalorder,andultimatelyachievemaximizetheuseofmedicalresources.

Accordingtopatients'conditiongradingdiagnosisandtreatment,andaccordingtotheseverityclassificationandtreatmentofthedisease,itsessenceisakindofmedicalserviceandhealthcareresourcesinthedomesticorganiccombinationofdivisionoflaborandcooperation,isagoodshowtheworkingstateofhealth,isalsoakindoforganicforhospitalmedicaldoctorservicessuchasresourceuseandreasonableconfiguration,alsoreflectedthefineonthenationaldiseasemanagementinourcountry.

1.2.Whatevidenceshowsthatthishasbecomeaproblem?

Inthe2014Shanghaihealthgazette,theproportionofgrassrootsservicesisstilldecreasingyearbyyear,andthenumberofpatientsisstillconcentratedingrade3andgrade2hospitals,presentinganinvertedtrianglemodel.Patientshavepoormedicalexperience,third-levelhospitalsareovercrowded,waitingtimeislong,andbasicinstitutionsarescarce,resultinginmedicaldisputesandincreaseddoctor-patientconflicts.Comparedwiththepreviousplannedeconomyperiod,thecityhasestablishedathree-leveldiagnosisandtreatmentsystemcomposedofcity,districtandstreetclinics.Inruralareas,athree-levelnetworkofcountyhospitals,townshiphealthcentersandvillagehealthclinicshasbeenestablished.Barefootdoctors,asthegatekeepersofvillagers,provideprimarymedicalcareservices.Incontrast,afterthereformandopeningup,duetotheintroductionofmarketmechanismandgovernmentderegulation,thedistributionofmedicalresources"nabla",oftherapidexpansionofthelargehospitalhasstrongextrusioneffectonthegrassrootsmedicalinstitutions,brokethepatternofplannedeconomyperiodtoestablishtheclassificationofdiagnosisandtreatment.IthasformedthecurrentmedicalsituationinChina,especiallyinShanghai,whichisalsothedirectcauseoftheexistingproblems.

1.3whataretheactualreformmeasures?

1.3.1implementthefamilydoctorsystem

(1)providehealthmanagementservicestosignupoffamilies,(2)setupthemechanismoffamilydoctorfirst,openastronglineofreferralchannels,(3)(4)graduallyachievesignedacontractwitheachfamilytoestablishservicerelationship,(5)tooptimizethefamilydoctorserviceteam,(6)adjustmentandgiveplaytotheroleofcommunityhealthservicecenterplatform,(7)applicationofinformatizationtechnologyfully,(8)withthefamilydoctorsystemstepbysteptocarryoutthehealthexpenditureofformacompletesetofpaymentreform,(9)throughavarietyofwaystoenrichfamilydoctors,tolaunchallkindsofcommunity(10)issuitablefortalentcultivation,(11)tostrengthentheassessmentandmanagementofthefamilydoctor,(12)improvetheincentivemechanismforfamilydoctors

1.3.2implement1+1+1contract

Thatis,onthebasisofvoluntarycontractwithfamilydoctors,residentswillchooseonedistrictandonemunicipalhospitaltosignthecontract.Asasupportingpublicitymeasuretopromotethehierarchicalmedicalsystem

1.3.3strengthenthesupportofsecondaryandtertiaryhospitals

Strengthenstheserviceability,reducethechargestandard,takecomprehensivemeasures,suchasreimbursementratioincreaseleadgeneralpracticesinktograss-roots,graduallyachievecommunityfirst,medicalandtwo-wayreferral,perfectthereasonableclassificationdiagnosismodel,communitydoctorsandresidentscontractservicerelationship.Shanghaiisproposed:by2020,twolevel3graduallyformedfirstoptionatthegrass-rootslevel,two-wayreferral,acuteslowpartition,thefluctuationofhierarchicaldiagnosismodel,basicestablishmentconformstothenationalconditionsofthegradingsystem".

1.4whyisthereformexpectedtosolvethisproblem?

1.4.1governmentsupport

Firstofall,thegovernmenthasincreaseditsinvestmentingrassrootsmedicalinstitutions,andthegovernmentattachesgreatimportancetoShanghai'smedicalcare.Beforethesecond,intheaspectofreferraltoalackofunifiedstandardoftheoldstate,andprovisionsforreferralupjusttoreferralrate,standardandregulationstrictlytothedownwardreferral,deepresolvetheinterceptpatients,toomuchtotakeupthemedicalresources.Thereafter,moreover,thegovernmentaskedthehierarchicaldiagnosticmatchingwithhealthpolicy,submitanexpenseaccountthanthegapbetweendifferentlevelsofmedicalinstitutions,theuseoftheroleofpricelevertogetpatientstothehospitalformedicaltreatment,referraltostartinglinenotrepeat,reducetheburdenofthepatients.Finally,thegovernmentestablishedthe"gatekeeper"system,patientscanchoosetheirownmedicalinstitutions,thereisnomandatoryprimarycare.

1.4.2medicalinstitutions

First,thestrengtheningofthebasictechnicalabilityofmedicalinstitutions,andoneisbecausethehardwareresourcessuchasequipmentpurchaseandselfdevelopment,2itisbecauseoftheincreaseinthelevelofcompensationatthegrass-rootslevel,causedthehighlevelsofmedicaltechnicians,alsocontributedtotheincreaseinthenumberofselfcultivationofmedicalstaff.Second,locationclear,thepublichospitalinobtainingthevestedinterestsatthesametimethereissocialresponsibilityandcorporateconscience,isabsolutelynotallowedtoexistbighospitalsandgrassrootsmedicalinstitutions"grab"thepatient.Third,thecollaborationbetweenthemedicalinstitutionsatalllevelstostrengthentheconnection,setupnewinformationsharingnetworkplatform,coupletofthemedicalmodelisbecomingmoreandmorecompactstructure,bighospitalsofgrassrootsmedicalinstitutionscounterpartsupportandmanagementstrengthening,etc.

1.4.3patientlevel

Atpresent,thebasicmedicalinstitutionsarerelativelybackwardinfacilities,fewexperts,relativelypoorenvironment,andpatientsdonothaveenoughconfidenceinthem.Soaspeople'slivingstandardscontinuetoimproveandincreasetotherequirementoflifeandhealthandsafety,thehealthcarereformcanmakebighospitalstoprovidehigh-qualitymedicalservicesandorganicuseofbasic-levelhospitalstoprovidethebasisofmedicalservices.Inordertoavoidmedicalrisks,acceleratethespeedofmedicaltreatmentandtreatmentandimprovethemedicalefficiency,patientsshouldacceptthemeasuresofgradeddiagnosisandtreatment.Insteadofblindlypursuingbighospitalsandhigh-levelmedicalteamsandexperts.

1.5whatarethecurrentimpacts?

"Chinahealthstatisticsyearbook","2015Chinafeedhealthandfamilyplanningstatisticsfrom2005to2014innearly10yearsofrelevantdata,bystudyingthedifferentlevelsofmedicalinstitutionsserviceconditiontoanalyzetheclassificationsystemoftheimplementationofthestatusquo.From2005to2014,thenumberofprimarymedicalinstitutionsincreasedby8.0%,whilethenumberofhospitalsincreasedby38.3%,muchfasterthanthatofprimarymedicalinstitutions.In2014,thegrassrootsmedicalinstitutionsofoutpatientservicesproportionfellto63.3%from57.4%,reflectingthefunctionofhighlevelrapidexpansioninthenumberofmedicalinstitutions,medicalandhealthserviceresourcesmorefocusedupwards,exacerbatedby"nabla"phenomenoninmedicalresourcesallocation.Intermsoftheprovisionofmedicalservices,thenumberoftotalmedicalpersonnelinprimarymedicalinstitutionsincreasedby68.3percent,whilethenumberoftotalmedicalpersonnelinhospitalsincreasedby114.4percent,significantlyfasterthanthatofprimarymedicalinstitutions.Whenyoulookatthehospitalizationdata,thenumberofpeopleadmittedtoprimarycarefacilitieshasincreased1.44timesoverdecades,whilethenumberofpeopleadmittedtohospitalshasincreased2.01times.In2014,hospitalsprovided75.2%ofhospitalstays,comparedwith20%atgrassrootsmedicalinstitutions.Fromtheabovedatacanbeanalyzed,withtherapidincreaseofmedicalservicedemandmoreandmorepatientstothehospital,thegradingsystemstressedthefirstoptionatthegrass-rootslevel,two-wayreferralhasnotcome,butthefurtherdevelopmentofreverse.

1.6whatshouldbedonenext?

1.6.1establishahierarchicalmedicalandhealthservicesystem

ReferenceforBritain'sexistingthree-levelmedicalsystem,andcombiningthecurrentsituationofhealthcareinChinaespeciallyinShanghai,Ithinkweshouldestablishacleardivisionofresponsibilitiesofthree-levelmedicalservicenetwork,isdividedintothefamilydoctorcaresystem,community,andthesecondarymedicalsystemandadvancedmedicalcaresystem.Asthegatekeepertothehealthoftheresidents,familydoctorsareresponsibleforthetreatmentofmostcommondiseasesandthemanagementofchronicdiseases,aswellastheregularexaminationofpatients.Communityandsecondlinehealthcaresystemisprovidedbygeneralclinicandgeneralclinicsandsecond-tierhospitalsgenerallybygeneralpractitioners,practicenursesandsoon,thecommunityclinicismostlyprivate,second-tierhospitalisgivenprioritytowithpublichospitals,providethemostcommonsymptomsandtreatmentofmostofthepatientsandhealthmeasures,medicalequipmentandmedicalservices.Three-levelmedicalserviceprovidedbytheseniorhospital,responsiblefortheseverecases,thetreatmentofpatientswithintractablediseasesandemergency,donotsetgeneraloutpatienthospital,onlyaspecialistoutpatientandinpatientservices,receptionofthepatientisusuallygpreferral.Treatmentofcomplicatedanddifficultdiseasesandmajordiseases.

1.6.2generalpractitionertrainingsystem

Generalpractitioners,knownasthegatekeepersofhealth,aremainlyresponsibleforthetreatmentofcommondiseases,chronicdiseasemanagement,rehabilitation,diseasepreventionandhealthcareandotherbasicmedicalservices.Chinahasnotestablishedarealtrainingsystemforgeneralpractitioners,andthenumberofgeneralpractitionersisrelativelysmall.Intermsofthetrainingsystem,medicalstudentsfirstneedtoobtainamedicalundergraduatedegree,thenreceivetwoyearsofbasictrainingandrotateindifferentdepartments.Afterthecompletionofbasictraining,threeyearsofprofessionaltrainingprogramsforgeneralpractitioners,includingcomprehensivetrainingandgeneralprofessionaltraining,willberequired.Medicalstudentsmustfirstcompletecomprehensivetrainingandbecertifiedbeforetheycanparticipateinprofessionaltraining.Intheprofessionaltraining,medicalstudentsmustpassthetheoreticalexaminationandmedicalskillexaminationbeforetheycanfinallyobtainthecertificateofgeneralpractitionerqualificationcertification.

1.6.3firstconsultationandreferralsystem

Chinesecommunityfirstoptionandtwo-wayreferralsysteminthepilotstage,becauseofashortageofgrassrootsmedicalinstitutionsserviceability,lackofunifiedclearreferralcriteriaandeffectiveincentiveandconstraintmechanism,thecommunityfirstoptionisonlyequivalenttotheoutpatientmedicalinstitutions,communityreservationcommunitygeneralpractitionersforpatientstoturnonthediagnosisandtreatmentofbasicdon'tunderstand,existsthephenomenonofturntoturnonthedifficult.TheestablishmentofafullyfunctioningfirstconsultationandreferralsystemisconducivetosolvingmedicalproblemsinChina,especiallyinShanghai.

1.6.4supportofthemedicalinsurancesystem

Primaryfirstconsultationandreferralrequirethesupportofthemedicalinsurancesystem.IntheUK,inadditiontotheemergencysituation,youmustfirstfindageneralpractitioner,thegpreferraltosuperiortreatmentofmedicalinstitutions,healthcaredoesnotgranttopay,otherwisethehospitalalsonottreated,thepatientfirst,ifnotbythegponlyathisownexpensetotheexpensiveprivatehospitaltreatment.Ontheotherhand,whetherinthefamilydoctor'sreferral,indifferenttypesofnetworkresources,familydoctors,thestartinglineofspecializedsubjectdoctor,co-paymentshaveobviousdifference,thusguidethepatientsfamilydoctorcarewithinthenetwork.InChina,somebasicmedicalinstitutionsisnotincludedinthehealthcaresystem,thereimbursementbetweenthethreelevelsofmedicalinstitutionsthanthegapisnotbig,notenoughtogiveplaytotheroleofpricelever,andthehealthcaresystemisnotthefirstoptionatthegrass-rootslevelandtwo-wayreferraltosetclearlimits.Therefore,itisnecessarytoestablishacompletemedicalsecuritysysteminordertofundamentallysolvetheproblemof"expensiveanddifficultmedicaltreatment".

2.Dealwithforeignrelatedproblemsanddrawlessonsfromdomesticones

Inforeigncountries,theconceptofgradeddiagnosisandtreatmentissimilartothe"gatekeeper"systemandthethree-levelmedicalservicemodel.The"gatekeeper"systemreferstothefirstconsultationbyageneralpractitionerandthetransferofunsolveddiseasestoasuperiormedicalinstitutionorspecialisthospital,suchastheUnitedKingdomandtheUnitedStates.Three-levelmedicalservicemodelisreferstothegrassrootshealthservicecentersforthetreatmentofcommondiseasesandchronicdiseasemanagement,rehabilitation,secondaryhospitalshavegeneraltreatmentofincurablediseases,tertiaryhospitalsundertakecriticallyilltreatmentandteachingandscientificresearchtasks.

Britainhasafirst-consultationsystemforgeneralpractitioners,whichrequirescitizenstosignupforfreemedicalcare.Inadditiontoanemergency,afterfallingillresidentsmustfirstfindagp,generaldiseasecanbetreatedingpthere,ifitisageneralpractitionercannotsolvethesevere,incurablediseases,needtoberecommendedbygpreferral,togettothecomprehensivehospitalforspecialisttreatment.

3.ConclusionsorSuggestions

BycomparingwiththeUK,wecanseethatChina'shierarchicalmedicalsystemstillneedstobeimprovedinmanyaspects.ThispaperproposesseveralcountermeasuresandSuggestionsfromthreerelatedsubjects.Fromthegovernmentlevel,oneistoincreasefinancialinputtothegrassrootsmedicalinstitutions,setupageneralpractitionertrainingsystem,throughtopreparethereformtopromotethedoctormorepracticeandimprovethegrass-rootsmedicalpersonnelsalarytreatment,topromotehigh-qualitymedicalresourcessinking,improvetheserviceabilityofgrass-rootsmedicalinstitutions;Second,weneedtoimplementthecommunityfirstconsultationsystem,explorethefamilydoctorcontractsystem,formulateunifiedreferralstandardsandstrengthensupervision.Third,weneedtoreformthemedicalinsurancesystem,widenthereimbursementratiogapbetweendifferentlevelsofmedicalinstitutions,leveragetheprice,andguidepatientstoseekmedicaltreatmentinanorderlymanner.Fromthelevelofmedicalinstitutions,tobuildthecollaborationmechanismbetweenthevariousmedicalinstitutionsatalllevels,andexplorethecounterpartsupport,coupletofmedicalmodel,andthroughtheinformationplatformconstruction,realizetheresourcesharing,promotetheupperandlower