分级诊疗与全科诊所:中国医疗供给侧改革的关键

Hierarchical Diagnosis and Treatment and General Practice Clinics: Key of China's Health Supply-side Reform

现行我国医疗服务体系提升效率和质量的关键在于推进分级诊疗。从资源配置角度看,阻碍分级诊疗的最大制度性障碍包括两个方面:第一,公立医院过度主导医疗资源配置和垄断大而全服务的供给;第二,公立医院医务人员的定位是"单位人",而非能够在全社会有效流动的人力资本。本文从我国卫生体系供给侧出发,比较分析了过去5年医院和基层医疗机构的发展,并从国际视角,讨论了我国实现分级诊疗的基础和路径。本文认为,供给侧医改应当成为"十三五"期间的工作重点,要实现分级诊疗,必须回归现代医学的基本定位:普通门诊和全科服务在医生诊所,住院、急诊等专科服务在医院。因此,建议彻底理顺全科与专科服务、诊所与住院服务的相辅相成关系,全面解放医生为"社会人",支持和完善医生开办全科诊所的准入、医保等各种条件,使全科与专科、诊所与医院真正成为我国医生全面发展的自主执业选项。与此同时,医院为中心的资源配置模式必须转型,逐渐减少直到最后取消其一般门诊服务,从而更好集中于住院和急诊等专科服务的供给。

Hierarchical diagnosis and treatment model is the key to improving both efficiency and quality of the medical service system in China. From the perspective of resource allocation,there are two major institutional hurdles to the development of hierarchical diagnosis and treatment. First,public hospitals are the center of resources allocation,and thus monopolize the supply of full range of medical services. Second,medical practitioners are treated as ＂ the asset＂ of public hospitals,rather than the effective flowing human capitals around the society. From the perspective of supply- side reform of our health system,this paper comparatively analyzes the development of the hospitals and primary care institutions in the past five years,and discusses the theoretical basis and practical approaches of achieving hierarchical diagnosis and treatment in China from an international perspective. The paper suggests that the supply- side health reform should be the major task during the ＂ 13 th Five Year Plan＂ period,and returning to the basic location of modern medicine in order to achieve the hierarchical diagnosis and treatment：general outpatient clinics and general services in clinics, specialized services as hospitalization and emergency treatment in hospitals. Therefore,the paper suggests that strengthen out the complementary relations between general services and specialized services and between clinics treatment and hospitalization thoroughly, liberate doctors to be ＂ social person ＂, support and improve the various conditions such as admission and medical insurance of doctors in starting a general clinics,and thus make general and special practice, clinics and hospitals really become the comprehensive and professional options for doctors in China. In the meantime,transform the hospital- centered resources allocation model, reduce gradually and finally cancel its general outpatient services,so as to better concentrate on the supply of specialized services as hospitalization and emergency treatment.