基于两部模型的家庭医生签约对社区居民医疗费用影响的实证分析

An empirical analysis of the impact of family physician contract service on the medical expenses of community residents based on a Two-part model

目的:分析家庭医生签约对于社区居民自付医疗费用的影响,探讨签约对缓解居民医疗费用负担的成效。方法:2019年7—9月在厦门、杭州、上海、北京分别选择两个社区卫生服务中心所在街道的居民,根据调研时最新的家庭医生签约率,采用多阶段整群随机抽样的方法获取样本1508人。医疗费用以基层医疗卫生机构次均就诊费用、次均住院费用以及年医疗总费用(均为自付)为指标,采用两部模型分析家庭医生签约对医疗费用的影响。结果:签约家庭医生的社区居民相较于未签约居民医疗服务利用率(尤其是基层医疗机构服务利用率)显著提高,但是没有显著影响次均就诊费用和年医疗总费用;降低了住院服务利用率,并且次均住院费用减少了673元。结论:家庭医生可以促使基层首诊、分级诊疗格局的形成,但是其作为医疗费用守门人的职责还需进一步加强。这需要进一步提升基层医疗机构和家庭医生服务能力,加强团队间的协作,完善与上级医疗机构或者专科医生的合作机制,突出医疗保险的杠杆作用。

Objectives:To analyze the influence of family physician contract service on the out-of-pocket medical expenses of community residents,so as to explore the efficacy of using family physician contract service to reduce the financial burden in healthcare.Methods:this study selected two community healthcare centers respectively in Xiamen,Hangzhou,Shanghai and Beijing.Based on the newest signing rate of family physician contracts of residents in these communities,data were collected from 1,508 residents from July to September 2019 using a multi-stage whole-population random sampling method.Medical expenses(all out-of-pocket)were calculated based on the average expense per primary care visit,the average expense per hospitalization,and the total annual medical expenses in fundamental medical facilities.A two-part model was then used to analyze how family physician contract service impacted the medical expenses.Results:Compared with residents without a contracted family physician,residents with contracted family physicians had a significantly higher likelihood of utilizing medical services,especially from primary medical facilities.However,their average medical expenses per primary care visit and total annual medical expenses were not significantly affected.The likelihood of utilizing inpatient services in these residents was significantly decreased,and the average out-of-pocket expense per hospitalization was also decreased by about 673 CNY.Conclusion:Family physician contract services could facilitate the development of the“first diagnosis in primary care followed by graded diagnosis and treatment”mechanism in China.However,the“gatekeeping”responsibility in medical payments needs to be further strengthened.This requires primary medical facilities and family physicians to enhance their service capability,strengthen team collaboration and improve their cooperation mechanisms with higher-level medical institutions and specialists,and also calls for the better utilization of the leverage effect of health insurance.