Study On The Two-way Referral Between Urban And Rural Hospitals

With the strong leadership of the Party Central Committee and the State Council since the 18 th CPC National Congress,the medical and health services achieve long-term development.Health care facilities,medical technology and health security has been significantly improved.A sound medical and health services in rural three-tier network has established,greatly improve the medical and health services,equity and efficiency in service delivery to achieve equalization of basic public health services.The national system of basic drugs at the primary level has been fully implemented.The basic medical insurance systems for urban works and residents and a new type of cooperative medical care system in rural areas has been continuously improved and developed.Meanwhile,the total expenditure on health has also increased rapidly.In recent years the growth of total health expenditures was more rapid than the growth of GDP in our county.In addition to the rise of prices,advances in medical technology,the preference for the general hospital is an important reason.From 2009,China has started to deepen the health care system reform,focusing on making community medical institutions the first option in medical treatment,establishing the system of graded diagnoses and treatment and two-way referral,to gradually ease the problem of “proper health care in difficult to get” and “proper health care is expensive”.As the key to the distribution of patients,the revitalization of primary health service institutions,control of rising medical cost and rational allocation of health resource,two-way referral system now gets more and more attention.The issue of two-way referral involves many other problems,such as patients' desires on the two-way referral and influential factors,the allocation of health resources,medical institutions operating mechanism and the cooperation pattern,etc.From 2015,the standardized and normalized two-way referral guideline was issued by the health and family planning commission of several provinces.Through literature analysis and field investigation,it was found that the two-way referral has not been effectively carried out.The main reason is that there are some obstacles in the decision making of pardicipating agents of two-way referral,and it need to bulid the operating mechanism between urban and rural hospitals.So by applying management science methods,this dissertation comprehensively studied the two-way referral system in urban and rural health care service.The main contents are listed as follows:1.Using the date of 2008,2010 and 2013 of medical units selection of patients,it shows that the country hospitals and the hub of township health centers are play the key role.The distance,quality,price,designated hospitals and the trust doctors are the top five important factors to influence patients.Through questionnaire survey and analysis of the status quo,the influence factors for upward referral included restricted medical condition at primary hospitals,rare diseases,acute and critical diseases,first aid treatment,require of patients.The influencing factors for the unwillingness for downward referral include dissatisfaction with medical and technical level at primary hospitals,complicated referral procedure,nonsupport of doctors and hospitals for referral.Therefore,the key problem of two-way referral is that it is easy to referral to a general hospital and difficult to referral to primary hospital.2.The gravity model of medical service demand was derived based on individual utility function and profit object function of medical institutions.According to the research,the main factors influencing the quantity of medical service are disposable income of residents,the cost of medical services and medical distance.The factors of supply side play the key role.Hospital will be able to make up for the cost of medical service through a variety of ways.To increase the accessibility of medical service,it needs to promote the development of primary hospitals.The scale of large hospitals should be limited so as to lead large hospitals to separate low value-adds medical service.3.After analyzing the influencing factors and their relationship,the physician's decision mode was set up based on the decision theory as the instruction.It can be conclude that physician in medical institutions at rural areas tend to reduce medical service after the new medical reformation.Inpatient data form a hospital in Jiujiang were gleaned and analyzed to study on the mean difference of patients with different medical insurance.Economic factors play a key role in diagnosis and treatment decision of doctors.Through the literature analysis,the factors to influence the doctor's decision were studied.They are personal experience,personal ability,hospital software and hardware,patient's condition and so on.Through factor analysis,the model of doctor's decision making was construdted.4.At present,it is generally emphasized to improve the allocation efficiency of medical resources through the reform public hospitals and the competition of medical market.Based on the theory of the asset specificity,the case study was made to compare competitive performance with cooperation performance of hospital to demonstrate the importance of graded diagnoses and two-way referral.Then using the behavioral dynamic model of the health care services chain,it shows the bullwhip effect in health care chain reduce the system performance and the collaboration between the hospital go far towards solving it.5.Two-phase game model is set up by using the game theory to analyzing a two-echelon medical service chain composed of one primary hospital and one general hospital.It shows that the medical group could attract more patients in the primary hospital,but will set the higher medical health price.So it should be careful to promote the organization mode of medical group.Then build a cooperative mechanism based on reputation incentive based on the cooperative game analysis.6.Sets up the model to study the distribution of interests of two-way referral cooperation.Chang-shan of Zhejiang province was selected as a pilot.Suggestions of policies are put forward by analyzing results and measurement results of a pilot.The payment system effects control of medical expenditure and the level of health service.The effect of different medical insurance payment system on two-way referral was studied and some reform proposals were put forward.7.With the impact of mobile internet technology,it is believed that the medical service model will increasingly replace the hospital service model.Then the referral cooperation pattern was studied and mode innovation was analyzed based on innovation system approaches.The individual dynamic mechanism,the system related obstacles,the environment and technical support obstacles in the innovation of referral model are studied to put forward the policy to promote the two-way referral model innovation.This dissertation systematically studied the behavior decision model among patients,doctors and medical institutions during the referral,the referral cooperation pattern and mechanism between urban and rural medical institutions,proposed suggestion for the design of the referral information system.It will play a positive role in operating referral efficiently and is also useful for the research of health reforms.