基于卫生政策三角形理论的我国分级诊疗政策执行偏差及对策研究

Study on implementation deviation and countermeasures of hierarchical diagnosis and treatment policy based on health policy triangle theory

分级诊疗在执行过程中出现了家庭医生签约服务的象征式执行、基层医疗机构建设的选择式执行、相关利益部门的规避式执行等偏差表现,导致政策执行效果欠佳。本文以卫生政策三角形理论和公共政策相关执行理论为依据,从政策本身、政策相关者、政策执行过程和政策环境等4个方面进行原因及对策研究。在政策本身方面,存在尚未解决不同等级医疗机构间的利益冲突、双向转诊渠道不通畅等问题,建议应明确不同医疗机构功能设置、完善不同类型疾病转诊渠道;在政策相关者方面,存在患者对基层医疗机构的传统认知、医务人员积极性不高以及相关部门间协同不足等问题,建议调整医务人员薪酬分配机制、增强分级诊疗工作考核比重、设置定期反馈制度等;在政策执行过程方面,主要存在政府监管欠缺的问题,建议领导小组分片包干、加强审查;在政策环境方面,存在配套政策不完善、卫生服务需求价格弹性弱、我国传统就医习惯难以改变、基层信息化建设较弱等原因,可从调整医保政策、探索价格动态调整机制、加大宣传力度、加强基层信息化建设等方面入手。

The deviations expression of symbolic execution of family doctor contract service, selective execution of grass-roots medical institution construction and evasive execution of relevant interest departments in the implementation process of hierarchical diagnosis and treatment policy, which lead to poor implementation effects. Based on health triangle and public policy-related implementation theories, this paper conducts research on causes and countermeasures from four aspects: policy itself, policy stakeholder, implementation process of policy and policy environment. In policy itself, it has unresolved problems such as conflicts of interest in different levels of medical institutions, and unsmooth of two-way referral channels and so on. It is recommended that function setting of different medical institutions should be clarified and two-way referral channel of different type diseases should be perfected. In policy stakeholder, there are problems such as patients’ traditional perceptions to primary care institutions, lack of enthusiasm in medical staffs, lack of synergy among related departments and so on. It is recommended to adjust salary distribution mechanism of medical staffs, enhance assessment proportion of hierarchical diagnosis and treatment work, setting of regular feedback system and so on. In the process of policy implementation, the problem is that lack of government supervision, it is recommended that leading group should be divided up the work and assigned to each individual, strengthen examination. In policy environment, there are reasons such as imperfect supporting policies, weak price elasticity of health service demand, difficulty in changing of traditional medical treatment habits in China, weak information construction in grass-roots. It is recommended to adjust medical insurance policies, explore price dynamic adjustment mechanisms, increase publicity, strengthen grassroots’ information construction and so on.