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

Implementation Status of the "1+1+1" Type of Contracted Family Doctor Services in Shanghai:a Qualitative Study

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。

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.