| [Purpose]Through literature and intelligence analysis,this paper studies the constructing status of hierarchical medical system in Wuhan City, and conducted stakeholder analysis to the construction of hierarchical medical system which was based on the health alliance,based on this kind of method this study probed the key problems in this process. Then, comparative analysis of the construction status of hierarchical medical system before and after the implement of different health alliance, on this basis, selected indicators to overview the construction status of hierarchical medical system that belongs to different health alliance in the year before/during/after the reform and 2012, research and study the effects of different health alliance will cause to hierarchical medical system, perfection the hierarchical medical system mode in health alliance, provide a reference for our country based on the health alliance build hierarchical medical system.[Methods](1) Document analysis: using Chinese database, foreign language database, Google and other academic literature retrieval means to query related journals, books and the other references of the health alliance and hierarchical medical system; and also review relevant documents relating to the national and local health alliance or hierarchical medical system by the relevant government websites. and also review relevant documents for both which relating to the national and local by the relevant government websites. So that analysis the overall status, practice and related research development situation of the impact that produced by health alliance to hierarchical medical system on this basis, and judge the situation of the construction of hierarchical medical system.(2) Stakeholder analysis: This study included core hospitals/member medical institutions of health alliance, health insurance agency and patients, etc., and using Stakeholder analysis divided them into different stakeholders to stakeholder group analysis,explore the interaction of the behavioral characteristics,study the points of interest conflict and corresponding constraints, as well as overall contribution and potential development space in the future to constructing hierarchical medical system that various stakeholder groups will produce.(3) Typical Case Analysis Methods: This study selected three typical health alliance modes in Wuhan: the alliance A which is established by merger, the alliance B which is established by trusteeship and the alliance C which is established by healthcare collaborative, on the basis of carefully analysis of the health alliance run model,evaluate the construction situation of hierarchical medical system in health alliance.(4) Comprehensive Evaluation Method: Based on the general statistical description of survey data, this research used TOPSIS, RSR methods and the combination of both methods to comprehensive evaluate various indicators of hierarchical medical system from four time points: the year before/during/ after implement health alliance and 2012, study the effects that the health alliance will conducted to the construction of hierarchical medical system, find out the year in which the construction of is the best, so that this study can provide data support for the overall health alliance and different effects that different health alliance modes will caused to hierarchical medical system. Provide a theoretical and practical reference for our country in terms of the mode constructing of health alliance and the perfect of hierarchical medical system.[Results](1) By analyzing the construction status of hierarchical medical system, this research found the grassroots first diagnosis has not been established, the medical care habits of residents needs to be improved; size of hospital expanded very quickly, basic services diminished capacity; and the physician order between all levels of hospital is still in the state of disorder. Further SWOT analysis found that the key problems of the constructing of hierarchical medical system in Wuhan is: the allocation of resources between all levels of medical and health institutions was in "inverted pyramid" shape, service capabilities of primary health care institutions are weak, can not assume the task of hierarchical medical system.(2) Using stakeholder analysis method to explore the key questions of hierarchical medical system which based on the health alliance, found that the process of building hierarchical medical system, well inevitably continue to promote the execute of primary first diagnosis and two-way referral, and then led to the reduction of patients in core hospitals of health alliance, thereby affecting the revenue of the hospital. For patients, in the case of the uneven distribution of medical resources, forcing patients conduct first diagnosis in basic hospital, destined will lead to the dissatisfaction of them and will be rejected; two-way referral will also facing difficulties:easy referral to a higher level hospital and difficult referral to a lower level hospital.(3) After the formation of health alliance, the grassroots medical institutions construction situation of the alliance A?the alliance B and the alliance C are getting better; Two-way referral mechanism has been improved, the referrals number has been increased rapidly; and produced the acute and chronic partition as well as upper and lower linkage system. Among these, the outpatient clinics of A hospitals in 2012 was 32.6 times that of the year before the reform, hospital admissions in 2012 was 16.6 times that of the year before the reform; the number of people which referral to a higher level hospital by A hospitals in 2012 was 1.9 times that of the year during the reform, and the number which referral to a lower level hospital by A hospitals in the second half of 2012 was 2.5 times that of the year during the reform. After the reform of health alliance, bed occupancy rate of B community health center increased to 81.4% in 2012 from 64.2% that of the year before the reform. The experts number that down to C hospitals to providing medical service has maintained an upward trend, from the number of 38 in the reform year increased to the number of 200 in 2012, increased 4.3 times.(4) TOPSIS comprehensive evaluation results are consistent with the evaluation results of RSR method: From the pre-reform year to 2012, the scores of iC and RSR of hierarchical medical system in different health alliance are higher and higher: The overall score in 2012 is highest, in the previous year of reform is lowest. Comparative analysis of comprehensive evaluation between hierarchical medical systems in different health alliance found: during the reform year, the scores of iC and RSR is the highest in the alliance A; the scores between the alliance B and the alliance C are similar, and scores of the alliance C is slightly higher than the alliance B. In the year after the reform and 2012, the scores of iC and RSR of the alliance A obviously higher than scores of the alliance B and the alliance C, and the scores in the alliance B higher than the alliance C.[conclusions](1) The formation of health alliance is good for the construction of hierarchical medical system: first of all, the formation of health alliance can strengthen the construction of the grassroots talent team and medical service capabilities, can promote the development of primary health care institutions, lay the foundation for the primary first diagnosis; Secondly, the formation of health alliance can promote the construction of two-way referral. The aim of various medical institutions to construct health alliance is to strengthen mutual cooperation, provide patients with continuity of medical service. Moreover, the formation of health alliance can also promote the construction of acute and chronic partition as well as upper and lower linkage system.(2) Based on the health alliance, in the process of constructing hierarchical medical system has to ensure the interests of the core hospital: the core hospital is the key and the top priority of this process, only by ensuring the core hospital's interests will they has motives to positively format the hierarchical medical system. Therefore, how to ensure the interests of the core hospital in the process of constructing hierarchical medical system based on the health alliance is very critical.(3) In the process of constructing hierarchical medical system based on the health alliance, enhance the basic services ability is the foundation: In the process of constructing hierarchical medical system, only primary health care services really strong can(the government) realize primary first diagnosis, that is why(the government) has to figure out possible methods to improve grassroots service capabilities.[Innovation and the insufficiency]This article innovatively linked the two most popular topic together: health alliance and hierarchical medical system, using SWOT, Stakeholders and other qualitative analysis, probe the key problems of the process of constructing hierarchical medical system based on the health alliance, through quantitative data to analyze, before and after the implement of health alliance, as well as in different health alliance, the construction status of hierarchical medical system, this article also using TOPSIS method to overview the overall health alliance and different effects that different health alliance will cause to hierarchical medical system.However, owing to time constraints, this article hasn't reference enough foreign literature, and don't have enough understood to international research trends. Moreover, by the limit of objective conditions, this study selected only three typical health alliance modes to study, this sampling may have some influence to the conclusions accuracy. |
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