Study On Two-way Referral Under Basic Medical Insurance System

SignificanceTwo-way referral system was to make that common and frequent diseases can be resolved in the community health service institutions, serious illness and other complex diseases can be resolved in large and medium hospitals or specialist hospitals, to achieve a status of reasonable patient diversion, achieved a status of "small disease in the community, seriously in hospital". The sustainable development of the basic medical insurance was facing population aging and the challenges of chronic diseases, therefore, it is great significance for basic medical insurance combination by two-way referral. Optimize health resources, promote rational diversion of patients; reduce medical costs, save Medicare money is conducive for health care reform; distinct functions from different medical institutions, strengthen medical cooperation; promote the development of community health services, reflected the characteristics of community health services, it is fundamental path for primary hospital move away out of the plight.Methods1. SourceWe collected information from Pub Med, EBSCO, Proquest, ISI Web of Knowledge and other foreign search tools, the CNKI database, VIP information, Wan fang data service platform, and the Ministry of Health Web site, the Ministry of Human Resources and Social Security and Health Statistics Yearbook.December 2009, investigators went to the Guangdong Province, Zhuhai City were selected as field research sites, selected the patients and doctors for a questionnaire survey, and interviews of relevant personnel. 2. Methods2.1 Literature Search and Information AnalysisWe collected various data and literature data about Two-way referral, through document retrieval and data query, on this basis, the purpose of the study with the same number of independent studies were compared and integrated analysis, summarized the main points from different types of documents and data.2.2 Field surveyZhuhai was selected for on-site research locations, selected two general hospitals and two community health service centers attached by two-way referral . we selected two general hospitals and four community health services centers. A random survey in each institution, to collect 157 medical patients and 67 doctors by questionnaires survey.2.3 Key insider interviewInterviewed with managers of health insurance, managers of community health services institutions, managers of general hospitals and doctors, , to understand existing problems of basic medical insurance combined with two-way referral, basic medical insurance effect two-way referral , and the suggestions and comments of solution for the current problems.2.4 Statistical analysisUtilized statistical software SPSS 12.0 and Excel 2003 for data analyzed and processed. Descriptive statistical analysis for basic situation of community health service institutions, status of basic medical insurance combined with two-way referral, factors of two-way referral.2.5 Stakeholder Analysisstakeholders of two-way referral mainly contains general hospitals, community health services institutions, doctors of general hospital , doctors of community, patients, health care sector and the health administrative departments (Government), analysis the interests, available resources and political stance of all stakeholders. ConclusionIt is great significance for basic medical insurance combination by two-way referral. But there are some problems in the basic medical insurance combined with two-way referral. lack of effective communication between health insurance management and health management; lack of effective authority: lack of a unified two-way referral criteria and procedures; basic medical insurance system hasn't reasonable adjusted interests between medical care institution; basic medical insurance didn't guide the patients, lack of constraints on the insured for reference, part of the required community health project was not included in the scope of the basic medical insurance; comprehensive hospitals lacked of driving force and effective control in two-way referral, community health service institutions lacked of capacity; medical concept of patients was migrated.SuggestionImprove the basic medical insurance system, reform medical insurance payment: enlargement the scope of the basic medical insurance to pay community health services, reform medical insurance payment, rationalization economic interests between medical institutions, increase reimbursement between community health services institution and hospital, lower starting pay line; uniform standards and procedures for two-way referral; improve community health service network, improve the ability of community health service; Ground binding in patients with guidance on intensity; to increase communication between relevant departments to promote two-way referral. Innovations and DeficiencyInnovations: In this study, analyzing the current problems of two-way referral by medical insurance, using stakeholders analysis to analyze the ability and resources of stakeholders in two-way referral, analyze important role of basic medical insurance, and puts forward policy proposals to resolve the current difficulties.Deficiency: As time and funding constraints, only Zhuhai city, Guangdong province was selected as on-site investigation, study may be less representative. In the investigation process, the health insurance sector, head of general hospital, charger of community health services and doctors, interview results wasn't fully used. By the operation of two-way referral reasons for such poor conduct investigations, the corresponding policy recommendations, but not specific, not comprehensive.