The Analysis On Operational Mechanisms Of Tiered Health Care System

ObjectiveTo review and integrate the theories and practices of tiered health care system both in China and abroad; and understand the operational mechanisms and effects of the tiered health care system in Xiamen; and summary the experiences worthy of popularizing and the applicable conditions of the tiered health care system in Xiamen, to provide references for the establishment and improvement of the tiered health care system in other regions.Contents:1. Review the concepts, connotations and relevant theories of the tiered health care system, to build a theoretical analysis framework for the tiered health care system.2. According to the theoretical analysis framework, analyze the institutional background, policies and measures, operational mechanisms and effects, and discuss current problems, possible causes and corresponding countermeasures of the tiered health care system in Xiamen.3. Summary the useful experiences in the process of implementing the tiered health care system in Xiamen, and analyze the prerequisites and the range can be extended, providing references for other regions to establish and improve the tiered health care system.Methods:1. Literature reviewBy searching the databases, the concepts, connotations, theories and practices of the tiered health care system both in China and abroad were reviewed, to lay the foundation for the case study design.2. Expert adviceBy consulting experts in the fields of health policy and health economics and officials of the health administrative departments, demonstrate the accuracy and reliability of the design, analysis and conclusions of the study.3. Case studieThrough case study on Xiamen, emphatically analyze the operational mechanisms of the tiered health care system.(1) Data source:① Document survey:collect related files, archives, summaries, report materials, research reports, statistics, media coverages and other data and information of the tiered health care system in Xiamen.② Key informant interviews:carry out in-depth interviews and focus group interview with relevant persons in charge of the Health and Family Planning Commission, Finance sector, Health care insurance sector and the Development and Reform Commission of Xiamen, as well as the responsible persons, medical staffs and patient representatives of the community health service centers and hospitals.(2) Analytical methods① System dynamics:Use the system dynamic causality diagram to analyze the influences of the institutional mechanisms of the tiered health care system on the policy objectives② The Stakeholder Analysis:Based on the Stakeholder Theory, analyze the interest demands and policy influence of the relevant subjects in the tiered health care system.Results:1. According to the System Dynamics analysis:(1) powerful decision-making and coordination mechanisms are necessary to ensure all policies and measures being promoted synergistically; (2) effective accountability and assessment mechanisms are the basic guarantee to urge the health care institutions to carry out the tiered health care system persistently and normatively; (3) the scale and methods of health fiscal input are of great significance in making different level health care institutions return to their own functional orientation in the tiered health care system; (4) medical insurance payment and different reimbursement ratio play a regulatory and guiding role in the behavior strategy of both the supply and demand sides; (5) medical personnel salary level, pay structure and performance assessment mode form the most direct incentives and constraints on doctors’attitude and behavior in participating the tiered health care; (6) medical service price level, price relation and formation mechanism play a leverage effect in ensuring the other financing and payment measures’effects in the tiered health care system.2. According to the Stakeholder analysis:(1) health sector and health insurance sector are the major driving forces of tiered health care and play an irreplaceable role; (2) coordination of financial sector and development and reform sector (price sector) is the essential condition to promote tiered health care smoothly; (3) managers and health workers of primary health care institutions are important motivating factors for tiered health care, while the premise is to reform the relevant systems and mechanisms; (4) managers and health workers of hospitals may be the key obstacles to tiered health care, because of which they are more likely to lose benefit, but the degree of resistance from the both sides are different; (5) residents and patients are ultimate beneficiaries of tiered health care, but they can also be the obstructive factors if the policy doesn’t work well or the propaganda and guidance is not effective; (6) selectively participating in part of the service link, medical device makers are expected to be the positive power to promote the tiered health care system.Conclusion:With the chronic disease prevention and control as an entry point, through the "three doctor management" service delivery model, adopting appropriate governance and regulatory mechanisms, financing and payment mechanisms and corresponding measures, Xiamen introduced a progressive "soft" policy to guide all stakeholders’behaviors to build the tiered health care system, and has achieved good phased results. As a reference, ascertaining the fundamental objective of the system, developing a reasonable reform program, taking an appropriate implementation path, applying advanced technology are all useful experiences for other regions. But the issue of the sustainability of existing policies, the hysteresis of the personnel system reform and the "depression effect" and "island effect" should also be paid particular attention for other regions, and they should be fully aware that both the strong economic strength and relatively adequate health resources, and a long time exploration and accumulation in the field of social governance, supporting and paving the way for the tiered health care system. Only when taking into account these factors and conditions, based on local conditions, can the experiences of the implementation of tiered health care system in Xiamen be better applied to the exploratory practice in various regions.Recommendations:1. Recommendations for the improvement of the Xiamen tiered health care system(1) Focus on building a long-term mechanism with internal motivation for the tiered health care system(2) Gradually break the "unit system" barriers of the physician team services(3) To explore and establish a wisdom medical service pattern of "integration of the medical treatment, pension and nursing"2. Reflections and suggestions for the establishment and improvement of the tiered health care system in other region(1) Being patient-centered and demand-driven, improve the service delivery model for the tiered health care system(2) Transform the governance concepts, optimize the policy tools, and straighten out the core institutional mechanisms of the tiered health care system(3) With talents as the core, with information as the link, strengthen the support system of the tiered health care system...