| ObjectivesTo study the status of county medical community reform in the target area,and evaluate the impact of county medical community reform on the quality of health services.Meanwhile,strategies to improve the health services quality under the mode of county medical community were proposed.MethodsThe data of this study were from the monthly report of health statistics from 2016to 2019.The L District of Lincang City,Yunnan Province was selected as the target area,and all public medical institutions were the main research objects.Firstly,through literature research,policy research and key informant interviews,the status of county medical community reform was studied;Next,the specific impact of the county medical community reform on the quality of health services was evaluated using the ITS analysis;Finally,the SWOT analysis was used to propose strategies for improving the quality of health services under the county medical community model.Results1.Status of county medical community reform:In terms of governance mechanism,the target area realized the transformation from"direct governance"to"industry governance"with the reform of"decentralization,management and service"as the key point.In terms of organization and management,the"six unified"management of the medical community has been implemented through the"one office,nine departments"organization form.In terms of service provision,the resource allocation was optimized through the"four line branch".In terms of fundraising and payment,the target area is actively exploring a payment model that combines packaged prepayment of medical insurance funds and Diagnosis Related Groups.2.Changes in the quality of health services before and after the reform of the county medical community:（1）Structure dimension:In terms of health personnel allocation,the proportion of doctors and registered nurses,and medical care ratios in district medical institutions have changed from increasing to decreasing,increased more slowly,and changed from stable to increasing respectively（β3=-0.076,P=0.002;β3=-0.155,P=0.009;β3=0.001,P<0.001）;the proportion of doctors in township health centers has changed from decreasing to increasing（β3=0.639,P=0.021）.In terms of investment in medical facilities,the actual number of beds in township health centers have increased faster,and the actual total bed days open and actual total bed days occupied in township health centers all changed from stable to increasing respectively（β3=5.456,P<0.001;β3=197.885,P<0.001;β3=138.869,P<0.001）.（2）Process dimension:In terms of basic medical and health services,only the change in the number of discharged patients in district medical institutions has changed from stable to decreasing（β3=-48.973,P=0.003）.In terms of basic public health services,only the cumulative number of people filing health records showed a slower increase（β3=-925.944,P=0.029）.In terms of income and expenditure structure,only the total medical income and proportion of drugs in township health centers have increased slowly and changed from stable to decreasing respectively（β3=-7.084,P=0.016;β3=-0.642,P=0.017）.In terms of information system construction,the number of remote electrocardiograms and centralized readings have all changed from stable to increasing,but the growth rate of the number of remote consultation has slowed down（β3=22.150,P<0.001;β3=25.777,P<0.001;β3=-1.335,P<0.001）.In terms of two-way referrals,the number of up referral,down referral and actual down referral have all changed from stable to increasing（β3=36.525,P<0.001;β3=28.406,P<0.001;β3=32.430,P<0.001）.（3）Outcome dimension:In terms of the health service efficiency,only the average length of hospitalization of dischargers in township hospitals has changed from decreasing to increasing（β3=0.159,P<0.001）.In terms of medical expenses and satisfaction of patients,the average outpatient expenses in district level medical institutions have changed from increasing to decreasing（β3=-11.038,P=0.001）,and the average hospitalization expenses in township health centers have changed from stable to increasing（β3=32.747,P=0.016）.After the reform,patient satisfaction increased significantly faster than before the reform（β3=0.379,P=0.014）.In terms of doctor’s business burden and income,the number of patients per doctor per day and inpatient beds per doctor per day in district medical institutions has showed accelerated increase and changed from increasing to decreasing,respectively（β3=0.037,P=0.016;β3=0.007,P=0.035）,and the number of patients per doctor per day in township health centers has changed from stable to increasing（β3=-0.518,P=0.002）.3.Strategies for improving the quality of health services:Pioneering strategies include carrying out the reform of medical insurance payment mode and strengthen the overall view of"playing chess together"in the whole district;promoting the coordinated development of basic public health and basic medical care through the construction of chronic disease health management center;improving the three-level telemedicine network to facilitate grassroots elderly patients;and taking advantage of health policies to promote the continuous sinking of medical resources.Striving strategies include obtaining financial investment to build a regional medical information platform;carrying out special specialty construction to improve the level of primary health services;standardizing the two-way referral process to promote the utilization of primary health resources;taking the chronic disease pilot center as an opportunity to strengthen the basic public health services.Resistance strategies include using the three-level network of telemedicine to improve medical service capabilities;increasing the regional consultation rate to increase the total medical income,and appropriately increasing the income of medical staff to enhance their work enthusiasm;rationally arranging doctors for two-way flexible flow to reduce district medical staff workload.Conservative strategies include building a regional medical information platform to strengthen supervision of basic public health services,and improving the overall health service level of the medical community;standardizing the two-way referral process to maximize the use of medical resources and reduce operating costs.ConclusionsAfter the implementation of the county medical community reform in the target area,in terms of structural quality,the distribution of human resources has been further optimized,but the medical care ratio was still low;the investment in medical facilities has increased significantly,but the use of health resources in township health centers was insufficient;the two-way flow of personnel was continuously enhanced,and the health resources were further sinking.In terms of process quality,the total amount of basic medical services has steadily increased,but basic public health services have weakened;the overall income and expenditure have increased,and the drug occupation ratio has basically reached the standard;information construction has achieved initial results,and the telemedicine three-level network architecture has been completed;the two-way referral system has been initially formed,but the problem of"up transfer is easy and down transfer is difficult"was prominent.In terms of outcome quality,the bed utilization rate was polarized,and the average hospitalization days of patients in township health centers has been slightly extended;patient’s medical expenses have increased or decreased,and their satisfaction continued to increase;medical staff’s income has not increased,and district-level medical staffs had a heavy workload. |
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