Research On The Mechanism Of Integrated Payment On Continuity Of Care Within The County

[Purpose]The purpose of this research is to analyze the mechanism of integrated payment on continuious service within the county.Construct the core stakeholder analysis framework and implementation model of county-wide continuious service,clarify the connotation and design of integrated payment,explore the role target,path and mode of integrated payment in the process of realizing continuious service,and put forward the implementation strategy of integrated payment,so as to provide theoretical support for medical insurance payment to promote the construction of national hierarchical diagnosis and treatment system.[Methods](1)Literature research.This study has searched domestic and foreign literatures about continuity of care and medical insurance payment,understood the key variables of continuity service and medical insurance payment and the hot spots of their correlation research,as well as the connotation and framework of stakeholder theory and behavior theory,thus to provide theoretical basis and literature support for this study.(2)On-site intervention and investigation.This study is based on the intervention experiment in two counties of Xinyang City,Henan Province.The on-site intervention has completed the formulation and implementation of continuous clinical pathway,and integrated payment design and communication.Relevant investigations have been carried out in the two counties.(3)Expert consultation and semi-structured interview.Through expert consultation,stakeholders were identified and classified,and the target of integrated payment was determined;semi-structured interviews with core stakeholders were conducted,and qualitative analysis of interview records was conducted using Nvivo 12.0 to sort out the path of continuous service realization and the path of integrated payment function.(4)Data processing and analyzing methods.Re-admission data screening and propensity score matching were carried out on the medical insurance inpatient database,and the continuity of inpatient service between counties and townships was analyzed by paired sample T test.The questionnaire of doctors and patients were analyzed by multiple ordered logistic regression to determine the influencing factors of continuity service.(5)System fundamental model analysis and flow rate basic tree-entry modeling method.In order to construct an integrated payment mechanism model,the causal cycle diagram and dynamic feedback modeling in system dynamics were used to study the role link and path of integrated payment in the process of functioning on continuous service.[Results](1)The stakeholders of continuious service within the county were identified and classified.The core stakeholders include health department managers(policy implementation),health insurance department managers(fund management),patients and family members(quality and costs),managers of medical institutions at county and township levels(benefit and development),clinical department directors and doctors(income and medical risk),totally 9 categories.They have consistent interest demands and conflicts of interest,which interact with each other and act together on the realization of continuous services.(2)The results of service ability analysis showed that although most township healthcare centers have the ability to diagnose and treat common diseases,a certain proportion of diseases still occur in county hospitals,and there exists much room to optimize the visiting structure within the county through continuous services;the result of re-admission analysis showed that,whether county hospitals or township healthcare centers,they often do not consider the situation of pre-admission patients.The service continuity between counties and townships was poor.(3)Based on the analysis of the influencing factors of continuity service from different stakeholder perspectives,19 key elements of continuity service were identified.Using Nvivo to code and analyze the interview data,we found that the policy effect,value orientation and economic effect at the social level mainly affected the organization operation,organization management,internal relationship,inter-agency relationship and doctor-patient relationship at the relationship level,and that the factors at the organization level and the relationship level interacted with each other and act on the continuous service provision at the individual level.The comparative analysis of ideal situation and reality situation showed that the lack of economic effect of medical insurance at the social level leads to the blockage of the path to realization at other levels.(4)The results of the evaluation of the effect of integrated payment showed that the integrated payment can satisfy the interests of policy makers,improve the economic benefits of county hospitals,increase the income of township healthcare centers and reduce patients’ self-payment costs.(Take cerebral infarction in Xi County as an example,after implementing the integrated payment,county hospitals can obtain 181.34 million yuan of "incentive compensation",and the more capable township healthcare centers can earn more 339.54 million yuan,the general township healthcare centers can increase income by 2319,000 yuan,patients’ self-paid expenses decreased by 174.91 million yuan,and per capita decreased by 737.39 yuan.)(5)The integrated payment mechanism model for continuous services was constructed.Integrative payment can not directly affect continuous services,but promote the realization of continuous services through the positive impact of policy implementation,institutional benefits,institutional collaboration,leadership on continuous service support and patient self-payment.Among them,institutional benefits,leadership support,institutional collaboration and patient compliance were the most important variables,while bed utilization pressure,incorporation of continuous services into performance appraisal,and patient compliance were the most direct variables affecting the continuity of service provided by doctors.[Conclusions ]Conclusions: In the current medical service system,due to the lack of the guiding role of medical insurance payment,the realization paths at all levels are broken,and the continuity of medical services between county and township level is low.Integrative payment can effectively promote the realization of continuous services: at the social level,it can play the role of economic effect,policy effect and value orientation;at the organizational level,it can improve the economic benefits of institutions and leadership support for continuous services,thereby reducing the pressure of bed use and improving the degree of continuous services into performance appraisal;influence service provision through the above effects on income of doctors at the individual level.At the relationship level,it helps to break down the interest barrier between county level and township level medical institutions,mprove interagency collaboration,gradually build trust through multiple communication and cooperation;and integrated payment effectively reduces patients’ self-payment costs,thereby improving compliance.Suggestions: When carrying out integrated payment within the county,we should make full use of the current policy environment,implement it step by step according to the actual situation,guarantee the interests of both suppliers and consumers,and pay attention to the improvement of costbenefit consciousness of the leaders of medical institutions,as well as the corresponding adjustment of internal management,so as to realize the virtuous circle of medical treatment and medical insurance.[Innovation and Deficiency]Innovation: Based on the multi-level theory integration model and stakeholder theory,the key elements of county continuity service realization were determined from multi-angle and multi-level,and the influencing mechanism between the realization paths and factors was sorted out,which is the extension of service integration and institutional collaboration exploration,and also provided specific guidance scheme for county continuity service development.Innovatively,the concept and design of integrated payment which considering multi-interests was put forward.And its functioning targets and their relationship were clarified.The function mechanism of integrated payment on continuity service was expounded through system dynamics flow chart.It is an extension of medical insurance payment theory research,highlights the role of medical insurance in the construction of medical service system,and puts forward the implementation strategy of integrated payment.Deficiencies: Although the research elaborated the function mechanism of integrated payment,it is difficult to verify the mechanism because of the lack of practice of integrated payment and continuous service.Although the survey coverd all the direct participants,it is still difficult to completely avoid the impact of subjective judgment.Based on the intervention experiments conducted in two counties of Henan Province in the central region,whether the results of the study are equally suitable for the eastern and western regions remains to be further verified.