本文選題：醫(yī)聯(lián)體 + 醫(yī)療資源整合�。� 參考：《山東大學(xué)》2017年博士論文

【摘要】：世界衛(wèi)生組織指出,衛(wèi)生服務(wù)整合是提升衛(wèi)生系統(tǒng)的重要途徑之一。在我國,衛(wèi)生服務(wù)的整合主要是醫(yī)療機(jī)構(gòu)之間的整合,表現(xiàn)為不同層級(jí)的醫(yī)療機(jī)構(gòu),以資產(chǎn)或技術(shù)等要素為紐帶,從橫、縱兩種方向,通過協(xié)作、兼并、重組等不同的方式建立起來的衛(wèi)生服務(wù)提供和管理的聯(lián)合體。2013年,隨著"醫(yī)聯(lián)體"這一概念的正式提出,我國開始了醫(yī)療資源整合的新一輪探索。"醫(yī)聯(lián)體"的界定,"醫(yī)聯(lián)體"的優(yōu)勢(shì)和問題,"醫(yī)聯(lián)體"未來應(yīng)如何發(fā)展等成為了學(xué)者們關(guān)注的問題。一、研究目的1.梳理我國"醫(yī)聯(lián)體"的理論基礎(chǔ)。主要包括:總結(jié)醫(yī)療資源整合的相關(guān)理論、對(duì)比醫(yī)療資源整合在國內(nèi)外發(fā)展的異同、界定"醫(yī)聯(lián)體"的概念、分析"醫(yī)聯(lián)體"的典型案例等,為實(shí)證研究和結(jié)論與建議奠定基礎(chǔ)。2.對(duì)代表性的"醫(yī)聯(lián)體"展開實(shí)證研究。分別以廣度和深度為側(cè)重,展開兩個(gè)實(shí)證研究。通過實(shí)證研究,分析不同模式"醫(yī)聯(lián)體"在建設(shè)中的共性問題以及基層醫(yī)療機(jī)構(gòu)在"醫(yī)聯(lián)體"中的優(yōu)勢(shì)及問題。3.在理論基礎(chǔ)上結(jié)合實(shí)證研究的結(jié)果,得出結(jié)論并提出政策建議。根據(jù)SWOT分析法的相關(guān)理論,從當(dāng)前我國"醫(yī)聯(lián)體"發(fā)展的優(yōu)勢(shì)(Strengths)、劣勢(shì)(Weakness)、機(jī)會(huì)(Opportunities)與挑戰(zhàn)(Threats)四個(gè)方面進(jìn)行總結(jié),并根據(jù)不同的要素組合提出針對(duì)性的政策建議。二、研究方法本研究重視社會(huì)科學(xué)研究方法的科學(xué)性,在質(zhì)性研究與定量研究相結(jié)合的思想指導(dǎo)下,根據(jù)研究的目的與特點(diǎn),確立以質(zhì)性研究為主導(dǎo),定量研究相輔助的思路。本研究在理論基礎(chǔ)的構(gòu)建中,通過文獻(xiàn)復(fù)習(xí)的內(nèi)容分析法,嚴(yán)格按確定研究?jī)?nèi)容、進(jìn)行文獻(xiàn)檢索、確定分析單元、制定分析類目、單元編碼統(tǒng)計(jì)、分析信度檢驗(yàn)的六個(gè)步驟,對(duì)所選的420篇文獻(xiàn)進(jìn)行編碼分析,編碼結(jié)果通過信度檢驗(yàn)。在實(shí)證研究中,依照質(zhì)性研究方法和定量研究方法的要求,借助訪談提綱及問卷,收集訪談資料、數(shù)據(jù)資料及其它材料。對(duì)于質(zhì)性資料,嚴(yán)格按照質(zhì)性研究中的扎根理論研究法對(duì)于資料分析的要求,借助Word和Excel對(duì)資料進(jìn)行一級(jí)編碼、二級(jí)編碼及三級(jí)編碼,最終歸納出模型。在研究的每一個(gè)環(huán)節(jié),注重對(duì)信度和效度的把握,并根據(jù)研究方法的要求,通過文獻(xiàn)資料和定量資料對(duì)一級(jí)編碼的結(jié)果進(jìn)行了檢驗(yàn)。對(duì)于實(shí)證研究中的定量資料,均使用epidata3.1軟件進(jìn)行錄入,并使用SPSS17.0進(jìn)行規(guī)范數(shù)據(jù)分析。在理論基礎(chǔ)上,結(jié)合實(shí)證研究的結(jié)果,根據(jù)SWOT分析法的相關(guān)理論,從當(dāng)前我國"醫(yī)聯(lián)體"發(fā)展的優(yōu)勢(shì)(Strengths)、劣勢(shì)(Weakness)、機(jī)會(huì)(Opportunities)與挑戰(zhàn)(Threats)四個(gè)方面進(jìn)行總結(jié),并根據(jù)不同的要素組合提出針對(duì)性的政策建議。三、研究結(jié)果1梳理了我國"醫(yī)聯(lián)體"的理論基礎(chǔ)(1)總結(jié)并分析了醫(yī)療資源整合的相關(guān)理論與實(shí)踐本研究在文獻(xiàn)復(fù)習(xí)的基礎(chǔ)上,總結(jié)了醫(yī)療資源整合的動(dòng)因和基本要素。并對(duì)國內(nèi)外醫(yī)療資源整合的實(shí)踐進(jìn)行了總結(jié)和對(duì)比分析。醫(yī)療資源整合的動(dòng)因主要包括資源結(jié)構(gòu)性矛盾及政府的政策推動(dòng),市場(chǎng)經(jīng)濟(jì)的發(fā)展與競(jìng)爭(zhēng)壓力的加劇,疾病譜的改變與人們需求的增加等宏觀動(dòng)因,以及醫(yī)療機(jī)構(gòu)之間優(yōu)勢(shì)互補(bǔ)、降低成本提高效率等微觀動(dòng)因。醫(yī)療資源整合的基本要素包括整合紐帶(資產(chǎn)紐帶、非資產(chǎn)紐帶)、整合方式(涉及資產(chǎn)的:資產(chǎn)重組、連鎖經(jīng)營、院辦院管、股份制合作等,不涉及資產(chǎn)的:幫扶協(xié)作、委托代管、新集團(tuán)化等)、治理結(jié)構(gòu)(董事會(huì)(理事會(huì))模式、管委會(huì)模式等)、成員構(gòu)成、合作內(nèi)容等。對(duì)于醫(yī)療資源整合的探索,在上世紀(jì)6、70年代就在美國展開,并在20世紀(jì)90年代開始了以兼并和重組等方式進(jìn)行的醫(yī)療集團(tuán)的建設(shè),英國和德國也采取了類似的舉措。國外學(xué)者通過對(duì)醫(yī)療資源整合的研究發(fā)現(xiàn),醫(yī)療資源整合降低了管理成本并促進(jìn)了醫(yī)療機(jī)構(gòu)間技術(shù)的交流,醫(yī)院之間在協(xié)作診療的過程中提升了治療效果,但整合也帶來了醫(yī)療費(fèi)用上漲、規(guī)模不經(jīng)濟(jì)、保險(xiǎn)更加昂貴等問題。我國的醫(yī)療資源整合從上世紀(jì)80年代開始,到現(xiàn)在為止大致經(jīng)歷了四個(gè)階段,20世紀(jì)80年代處于萌芽階段,僅形成了醫(yī)院之間聯(lián)合的雛形;20世紀(jì)90年代處于興起階段,一些早期的醫(yī)療集團(tuán),已經(jīng)開始通過托管、共建等方式建立起來;21世紀(jì)初處于快速發(fā)展階段,在國家政策的支持下,各類的醫(yī)院集團(tuán)開始在全國各地涌現(xiàn);2013年,"醫(yī)聯(lián)體"的概念正式提出,各地紛紛進(jìn)入了探索這種新型醫(yī)院集團(tuán)的新階段。本研究從社會(huì)、整合模式、整合參與者、患者、實(shí)踐過程等五個(gè)角度,對(duì)中外的醫(yī)療資源整合進(jìn)行了對(duì)比。發(fā)現(xiàn)西方國家的醫(yī)療資源整合偏向于以控制醫(yī)療費(fèi)用為主,并出現(xiàn)了醫(yī)院與醫(yī)療保險(xiǎn)公司進(jìn)行整合的實(shí)踐,而中國的醫(yī)療資源整合更多的以緩解"看病難、看病貴"為主。中西方的醫(yī)療資源整合都存在資產(chǎn)整合與非資產(chǎn)整合并存的現(xiàn)象,并且呈現(xiàn)出從最初以應(yīng)對(duì)市場(chǎng)競(jìng)爭(zhēng),實(shí)現(xiàn)互利共贏為目的向?qū)用襁M(jìn)行全面健康管理為目標(biāo)轉(zhuǎn)變的趨勢(shì),而且發(fā)展中遇到了經(jīng)驗(yàn)不足、組織變革、文化沖突等共性問題。(2)界定了 "醫(yī)聯(lián)體"的概念并進(jìn)行了典型案例分析"醫(yī)聯(lián)體"是醫(yī)療聯(lián)合體的簡(jiǎn)稱。目前對(duì)于"醫(yī)聯(lián)體"并沒有一個(gè)統(tǒng)一的概念。本研究認(rèn)為:"醫(yī)聯(lián)體"的概念隨著其不斷發(fā)展而處于變化和豐富的過程中。就目前而言,應(yīng)主要包括以下幾個(gè)方面:定義:"醫(yī)聯(lián)體"應(yīng)當(dāng)是不同層級(jí)醫(yī)療機(jī)構(gòu)組成的,以醫(yī)療資源整合為目的的衛(wèi)生服務(wù)提供和居民健康管理的統(tǒng)一體。目的:通過不同層級(jí)醫(yī)療機(jī)構(gòu)間的聯(lián)合,將優(yōu)質(zhì)資源下沉到基層,提升基層醫(yī)療機(jī)構(gòu)的實(shí)力,并借助上下級(jí)醫(yī)療機(jī)構(gòu)之間的密切聯(lián)系,促進(jìn)雙向轉(zhuǎn)診的實(shí)現(xiàn)。內(nèi)涵:"醫(yī)聯(lián)體"是新型的醫(yī)院集團(tuán),它與醫(yī)院集團(tuán)同為醫(yī)療機(jī)構(gòu)之間的整合,但更強(qiáng)調(diào)上下級(jí)醫(yī)療機(jī)構(gòu)之間,特別是大醫(yī)院與基層之間的結(jié)合。因此"整合至少包含兩個(gè)層級(jí)的醫(yī)療機(jī)構(gòu)"應(yīng)當(dāng)是判斷"醫(yī)聯(lián)體"的標(biāo)志。外延:"醫(yī)聯(lián)體"的發(fā)展方向是健康責(zé)任體,旨在對(duì)居民進(jìn)行全面的健康管理。在對(duì)"醫(yī)聯(lián)體"的概念進(jìn)行界定的基礎(chǔ)上,本研究主要選取了比較有特點(diǎn)的安徽省馬鞍山市市立醫(yī)療集團(tuán)(管辦分開、法人實(shí)體的醫(yī)療集團(tuán)的代表),江蘇鎮(zhèn)江康復(fù)醫(yī)療集團(tuán)和江濱醫(yī)療集團(tuán)(同一地域兩家不同類型醫(yī)療集團(tuán)并存的代表),南京鼓樓醫(yī)院集團(tuán)(傳統(tǒng)醫(yī)院集團(tuán)向"醫(yī)聯(lián)體"轉(zhuǎn)型的代表)及北京世紀(jì)壇醫(yī)院醫(yī)療聯(lián)合體(以"新集團(tuán)化"方式整合的"醫(yī)聯(lián)體"的代表)。旨在通過案例的描述和分析,了解不同類型醫(yī)院集團(tuán)的發(fā)展歷程、特點(diǎn)、優(yōu)勢(shì)與弊端等。2.對(duì)代表性的"醫(yī)聯(lián)體"進(jìn)行了實(shí)證研究(1)山東省"醫(yī)聯(lián)體"建設(shè)情況分析該研究是本研究的實(shí)證研究之一。旨在從類型的廣度上對(duì)"醫(yī)聯(lián)體"進(jìn)行深入的了解,并以省際范圍為單位,概括地域內(nèi)不同類型"醫(yī)聯(lián)體"所存在的共性問題。該研究在對(duì)山東省社會(huì)經(jīng)濟(jì)及衛(wèi)生事業(yè)發(fā)展情況和山東省"醫(yī)聯(lián)體"建設(shè)的相關(guān)政策進(jìn)行簡(jiǎn)要回顧的基礎(chǔ)上,通過訪談和收集相關(guān)資料的方式,收集山東省醫(yī)療資源整合的總體情況及五家代表性的"醫(yī)聯(lián)體":山東省立醫(yī)院集團(tuán)、山東大學(xué)齊魯醫(yī)院醫(yī)療聯(lián)合體、滕-山醫(yī)療聯(lián)合體、"高康"醫(yī)療集團(tuán)和"密康"醫(yī)療集團(tuán)的相關(guān)資料,對(duì)上述"醫(yī)聯(lián)體"的發(fā)展現(xiàn)狀進(jìn)行了分析。最后,通過扎根理論研究方法,構(gòu)建出山東省"醫(yī)聯(lián)體"建設(shè)存在問題的SMPM模型(體制型障礙(Obstacles of System)機(jī)制型障礙(Obstacles of Mechanism)、政策型障礙(Obstacles of Policy)、管理型障礙(Obstacles of Management)。分析結(jié)果顯示:體制型障礙是其它障礙的根源,主要包括:基層資源匱乏和整合不觸動(dòng)原有體制。機(jī)制型障礙和政策型障礙相互影響,機(jī)制型障礙包括:醫(yī)護(hù)人員心態(tài)不平衡、缺乏聯(lián)合主動(dòng)性、付出和回報(bào)不對(duì)等等。政策型障礙包括:醫(yī)保未起到激勵(lì)作用、雙向轉(zhuǎn)診落實(shí)缺乏制度保證、缺乏管理和評(píng)價(jià)制度等。在上述三種障礙下產(chǎn)生管理型障礙,包括:信息化建設(shè)困難、患者信任危機(jī)、機(jī)構(gòu)間文化沖突、對(duì)健康管理缺乏重視、統(tǒng)一管理困難、服務(wù)同質(zhì)化難實(shí)現(xiàn)等。(2)深圳市南山區(qū)"醫(yī)聯(lián)體"改革研究該研究是本研究的另一個(gè)實(shí)證研究,著眼于從研究的深度出發(fā),把"醫(yī)聯(lián)體"中基層醫(yī)療機(jī)構(gòu)這一重要成員在聯(lián)合體中的發(fā)展情況及遇到的問題作為深入挖掘的重點(diǎn)。通過對(duì)深圳市南山區(qū)三家具有代表性的"醫(yī)聯(lián)體"進(jìn)行實(shí)地調(diào)研,對(duì)以資產(chǎn)為紐帶的"3+1"及"2+1"模式的"醫(yī)聯(lián)體"進(jìn)行深入剖析。通過對(duì)定量資料的收集和處理,對(duì)三家"醫(yī)聯(lián)體"的資源配置與利用情況(包括基礎(chǔ)設(shè)施建設(shè)、經(jīng)營狀況、人力資源因素、技術(shù)支持因素)和社區(qū)衛(wèi)生服務(wù)提供及患者需求滿足情況(包括基本醫(yī)療服務(wù)、公共衛(wèi)生服務(wù)、雙向轉(zhuǎn)診及社區(qū)首診的開展情況、后勤保障與集中送檢和患者滿意度)進(jìn)行了定量的分析。并通過扎根理論研究方法,分別構(gòu)建出南山區(qū)"醫(yī)聯(lián)體"特點(diǎn)及優(yōu)勢(shì)的SPFR模型及南山區(qū)"醫(yī)聯(lián)體"存在問題的3M模型。從制度(System)、人事(Personnel)、財(cái)務(wù)(Financial)、和資源共享(Resources Sharing)四個(gè)層面分析了南山區(qū)"醫(yī)聯(lián)體"的特點(diǎn)和優(yōu)勢(shì)。從宏觀(Macro)、中觀(Medium)、微觀(Micro)三個(gè)層面分析了南山區(qū)"醫(yī)聯(lián)體"存在的問題。最后,本研究根據(jù)深圳市南山區(qū)"醫(yī)聯(lián)體"的發(fā)展特點(diǎn),結(jié)合當(dāng)?shù)鼐唧w情況,在醫(yī)療資源整合的視角下,提出并命名了"一體兩制"(即在不改變社康中心與核心醫(yī)院隸屬關(guān)系的基礎(chǔ)上加強(qiáng)一體化管理)的改革方案,主要包括:(1)社康中心全額事業(yè)單位轉(zhuǎn)變,減輕對(duì)核心醫(yī)院的經(jīng)濟(jì)依賴;(2)設(shè)立社康中心獨(dú)立賬戶,落實(shí)收支兩條線制度;(3)鼓勵(lì)"醫(yī)聯(lián)體"與社區(qū)居民簽約,實(shí)行醫(yī)保預(yù)付制;(4)實(shí)行兩級(jí)考核機(jī)制,注重基層醫(yī)療機(jī)構(gòu)的職能落實(shí);(5)細(xì)化雙向轉(zhuǎn)診標(biāo)準(zhǔn),明確"醫(yī)聯(lián)體"內(nèi)各級(jí)機(jī)構(gòu)責(zé)任;(6)完善信息平臺(tái)建設(shè),加強(qiáng)"醫(yī)聯(lián)體"內(nèi)信息溝通等六項(xiàng)內(nèi)容。四、結(jié)論與政策建議本研究在理論基礎(chǔ)上,結(jié)合實(shí)證研究的結(jié)果,根據(jù)SWOT分析法的相關(guān)理論,從當(dāng)前我國"醫(yī)聯(lián)體"發(fā)展的優(yōu)勢(shì)(Strengths)、劣勢(shì)(Weakness)、機(jī)會(huì)(Opportunities)與挑戰(zhàn)(Threats)四個(gè)方面進(jìn)行f總結(jié)。優(yōu)勢(shì)主要包括:帶動(dòng)成員機(jī)構(gòu)的發(fā)展和資源配置與利用更加合理;劣勢(shì)主要包括:產(chǎn)權(quán)障礙、治理結(jié)構(gòu)和管理機(jī)制不健全及對(duì)基層成員的重視不足;機(jī)會(huì)主要包括:"醫(yī)聯(lián)體"的建設(shè)得到政策的倡導(dǎo)與支持和相關(guān)改革正在新醫(yī)改中逐步推進(jìn);挑戰(zhàn)主要包括:政府主導(dǎo)未能與市場(chǎng)緊密結(jié)合和配套制度建設(shè)任重道遠(yuǎn)。并在此基礎(chǔ)上,針對(duì)不同的要素組合,提出了四個(gè)建議:(1)OS開拓型建議——加強(qiáng)對(duì)基層能力的建設(shè):旨在針對(duì)目前"醫(yī)聯(lián)體"的建設(shè)中對(duì)基層醫(yī)療機(jī)構(gòu)重視不足的問題,建議發(fā)揮"醫(yī)聯(lián)體"促進(jìn)優(yōu)質(zhì)資源下沉的自有優(yōu)勢(shì),在建設(shè)中重點(diǎn)加強(qiáng)對(duì)基層醫(yī)療機(jī)構(gòu)能力的建設(shè),成為重構(gòu)我國就診秩序的重要途徑,通過重視基層機(jī)構(gòu)公共衛(wèi)生職能的落實(shí),使"醫(yī)聯(lián)體"逐漸向區(qū)域健康管理體轉(zhuǎn)變。(2)TS抗?fàn)幮徒ㄗh——以利益為紐帶向緊密聯(lián)合推進(jìn):針對(duì)目前"醫(yī)聯(lián)體"中各成員機(jī)構(gòu)產(chǎn)權(quán)不一致等問題帶來的障礙,建議在"醫(yī)聯(lián)體"的建設(shè)中,發(fā)揮資源共享等優(yōu)勢(shì),各成員單位首先以利益為紐帶,求同存異,并建議有關(guān)部門盡快完善相應(yīng)制度。(3)OW爭(zhēng)取型建議——在制度變革中打破整合障礙:目前,去行政化改革、法人治理結(jié)構(gòu)建設(shè)、全科隊(duì)伍建設(shè)等政策的逐步推進(jìn)為"醫(yī)聯(lián)體"打破成員間的產(chǎn)權(quán)障礙創(chuàng)造了有利條件,當(dāng)這些政策在醫(yī)院中逐步成熟,就可以借鑒到"醫(yī)聯(lián)體"當(dāng)中,為"醫(yī)聯(lián)體"法人治理結(jié)構(gòu)和管理制度的建設(shè)創(chuàng)造條件。(4)TW保守型建議——以目的為導(dǎo)向創(chuàng)新整合形式:當(dāng)外部環(huán)境與內(nèi)部條件都處于不利因素時(shí),建議從"醫(yī)聯(lián)體"促進(jìn)資源下沉的核心內(nèi)涵出發(fā),因地制宜,創(chuàng)新醫(yī)療資源整合形式。
[Abstract]:The WHO points out that the integration of health services is one of the important ways to improve the health system. In our country, the integration of health services is mainly the integration of medical institutions. It is manifested by different levels of medical institutions, with assets or technology as the link, from the two directions of horizontal and vertical, through cooperation, merger, reorganization and other different ways. The united body of health service provided and managed in.2013, with the formal proposal of the concept of "Medical Union", China has begun a new round of exploration of the integration of medical resources. The definition of Medical Union, the advantages and problems of "medical couplet", the future of "Medical Union", and so on, have become the concerns of the scholars. First, the 1. combs of the research purpose The theoretical basis of medical couplet in China includes: summarizing the related theories of medical resources integration, comparing the similarities and differences of medical resources integration at home and abroad, defining the concept of "medical couplet", analyzing the typical cases of "Medical Union", and laying the foundation for the empirical research and conclusion and suggestions on the representative "medical couplet" to carry out an empirical study. Two empirical studies are carried out with the emphasis on breadth and depth respectively. Through empirical research, the common problems in the construction of "medical couplet" in different modes and the advantages and problems of basic medical institutions in "medical couplet" are analyzed, and.3. is combined with the results of empirical research on the basis of theory. The conclusion is drawn up and the policy recommendations are put forward. According to the SWOT analysis method, Related theories are summarized from the four aspects of the advantages (Strengths), inferiority (Weakness), opportunity (Opportunities) and challenge (Threats) in the current development of "Medical Union" in China, and put forward pertinent policy suggestions according to the combination of different elements. Two, the research method this study attaches importance to the scientific research method of social science, in qualitative research and determination. Under the guidance of the combination of quantitative research, according to the purpose and characteristics of the study, the idea of qualitative research as the dominant and quantitative research is established. In the construction of the theoretical basis, the research is based on the content analysis method of literature review, strictly according to the content of the study, the retrieval of the literature, the determination of the analysis unit, the formulation of the analysis category and the unit compilation. Code statistics, analysis of the six steps of reliability test, the selected 420 documents are encoded and analyzed. The results of the code are tested by reliability. In the empirical study, the interview outline and the questionnaire are used to collect the interview data, data and other materials in accordance with the requirements of qualitative research and quantitative research methods. In the qualitative research, the grounded theory study method for data analysis, using Word and Excel for the first level coding, two level coding and three level coding, finally summed up the model. In every link of the study, it pays attention to the confidence and validity of the data, and according to the requirements of the research method, through the literature and quantitative data to the first level The results of the coding are tested. For the quantitative data in the empirical study, the epidata3.1 software is used for input and SPSS17.0 is used to analyze the data. On the basis of the theory and the results of the empirical study, according to the relevant theories of the SWOT analysis, the advantages of the development of the "Medical Union" in China (Strengths) and the disadvantage (Weakness) are in accordance with the relevant theories of the analysis. The four aspects of opportunity (Opportunities) and challenge (Threats) are summarized, and the pertinent policy suggestions are put forward according to the combination of different elements. Three, research results 1 have combed the theoretical basis of "Medical Union" in China (1) summarize and analyze the related theory and practice of medical resources integration, and summarize medical treatment based on literature review. The reasons and basic elements of the integration of resources are summarized and analyzed. The reasons for the integration of medical resources include the structural contradiction of resources and the promotion of the government policy, the development of the market economy and the intensification of the competition pressure, the change of the disease spectrum and the increase of the people's demand, etc. The basic elements of medical resources integration include integration bonds (asset bonds, non asset ties) and integration methods (assets: assets reorganization, chain management, hospital management, joint stock cooperation and so on, which do not involve assets: assistance cooperation, entrustment management, new collection. The exploration of the integration of medical resources was launched in the United States in the 6,70 years of the last century, and the construction of medical groups, such as merger and reorganization, was started in 1990s, and the UK and Germany have also taken a similar approach. Through the study of the integration of medical resources, foreign scholars have found that the integration of medical resources has reduced the cost of management and promoted the exchange of technology between medical institutions. In the process of cooperative diagnosis and treatment, the hospital improved the effect of treatment, but the integration also brought about the rise of medical expenses, the uneconomical scale and the more expensive insurance. The integration of medical resources began in the 80s of last century. Up to now, it has roughly experienced four stages. In 1980s, it was in the embryonic stage. It only formed the embryonic form of the union between hospitals; in 1990s it was in the rise stage, and some early medical groups have been established by trusteeship and co construction. At the beginning of twenty-first Century, it was at the beginning of twenty-first Century. In the rapid development stage, with the support of national policy, all kinds of hospital groups began to emerge all over the country. In 2013, the concept of "Medical Union" was formally put forward, and the new stage of exploring the new hospital group was entered. This study was from five angles of society, integration model, integration of participants, patients, practice process and so on. The integration of medical resources is compared. It is found that the integration of medical resources in western countries is biased towards the control of medical costs, and the integration of hospitals and Health Insurance Company has appeared, and the integration of medical resources in China is more to alleviate the difficulty of seeing the disease, and the medical resources integration in China and Western countries all have the integration of assets and the integration of assets. The phenomenon of non asset integration coexists, and presents a tendency to change from the initial response to the market competition and the realization of mutual benefit and win-win for the overall health management of the residents. In addition, there are common problems such as lack of experience, organizational change, cultural conflict and so on. (2) the concept of "Medical Union" is defined and a typical case has been carried out. "Medical couplet" is the abbreviation of Medical Union. At present, there is no unified concept of "Medical Union". This study holds that the concept of "medical couplet" is in a changing and rich process with its continuous development. At present, it should mainly include the following aspects: "Medical Union" should be a different level of medical institutions. A unified body of health services and health management for the integration of medical resources. Objective: to sink high quality resources down to the grass-roots level through the combination of different levels of medical institutions, to enhance the strength of grass-roots medical institutions, and to promote the realization of two-way referral by means of close links between the upper and lower medical institutions. "Medical Union" is a new type of hospital group. It is the integration between the hospital group and the hospital group, but it emphasizes the combination of the upper and lower medical institutions, especially the large hospitals and the grass-roots. Therefore, the "integration of at least two levels of medical institutions" should be the symbol of judging the "Medical Union". On the basis of the definition of the concept of "medical couplet", this study mainly selected the relatively characteristic Ma'anshan municipal medical group in Anhui province (separate management office, representative of medical group of legal entity), Jiangsu Zhenjiang rehabilitation medical group and Jiang Bin medical group (the same one) The representative of the two different types of medical groups in the region, the representative of the Nanjing Gulou Hospital group (traditional hospital group to the "Medical Union") and the representative of the Medical Federation ("medical couplet" integrated by the "new collectivization"). The purpose is to understand the development calendar of the different types of hospital groups through the description and analysis of the cases. .2. has carried out an empirical study on the representative "medical couplet" (1) analysis of the construction of "Medical Union" in Shandong Province, which is one of the empirical studies of this study. The purpose of this study is to make a thorough understanding of the "medical couplet" from the breadth of the type and to generalize the different types of "medical couplet" in the region with the inter provincial scope as the unit. On the basis of a brief review of the development of social and health undertakings in Shandong and the relevant policies of "medical couplet" in Shandong Province, the study collects the overall situation of the integration of medical resources in Shandong province and the five representative "medical couplet" through interviews and collection of relevant information: Shangdong Province-owned Hospital The group, the Medical Union of Qilu Hospital of Shandong University, Tengshan Medical Union, Gao Kang medical group and Mi Kang medical group, analyzed the development status of the "medical couplet". Finally, the SMPM model of the problems in the construction of "Medical Union" in the eastern province was constructed by the method of grounded theory (Obst Acles of System) mechanism type disorder (Obstacles of Mechanism), policy barrier (Obstacles of Policy), management barrier (Obstacles of Management). The analysis results show that institutional barriers are the root of other obstacles, mainly including the lack of basic resources and the absence of integration into the original system. The interaction between the mechanism type barrier and the policy type barrier The mechanism type obstacles include: the imbalance of mental health, the lack of joint initiative, the lack of pay and return, etc. policy barriers include: the medical insurance is not motivated, the two-way referral is not guaranteed, the management and evaluation system is lacking. Management barriers are created under the above three obstacles, including the difficulty of information construction, Patient trust crisis, inter agency cultural conflict, lack of attention to health management, unified management difficulties, and homogeneity of service difficult to realize. (2) the study on the reform of "Medical Union" in Nanshan District, Shenzhen, is another empirical study of this study, focusing on the development of the research, and the important members of the basic medical institutions in the "medical couplet" The development and problems encountered in the complex are the key points. Through the field investigation of three representative "medical couplet" in Nanshan District, Shenzhen, the "medical couplet" of "3+1" and "2+1" model with assets as a link is deeply analyzed. The resources of the "medical couplet" are collected and processed through the collection and treatment of the quantitative data. Location and utilization (including infrastructure construction, operating conditions, human resources, technical support factors) and community health service delivery and patient needs satisfaction (including basic medical services, public health services, two-way referral and community first consultation, logistics and centralized inspection and patient satisfaction) were quantified The SPFR model of the characteristics and advantages of Nanshan District "Medical Union" and the 3M model of the existence of "Medical Union" in Nanshan District are constructed by the method of grounded theory. The characteristics and advantages of the "medical couplet" in Nanshan District are analyzed from four aspects of system (System), personnel (Personnel), Finance (Financial), and resource sharing (Resources Sharing). From three aspects of macro (Macro), Medium, and microcosmic (Micro), this paper analyzes the problems existing in the "medical couplet" in Nanshan District. Finally, according to the characteristics of the development of the "Medical Union" in Nanshan District, Shenzhen, combining with the specific local conditions, the "one and two systems" are proposed and named under the visual angle of the integration of medical resources. The reform plan of strengthening the integrated management on the basis of the relationship of the heart hospital, mainly includes: (1) the transformation of the full institution of the social health center to reduce the economic dependence on the core hospital; (2) to establish an independent account of the social health center and to implement the two line system of revenue and expenditure; (3) encourage the "Medical Union" to contract with the community residents and carry out the medical insurance prepayment system; (4) two The assessment mechanism focuses on the implementation of the functions of primary medical institutions; (5) refine the standard of two-way referral and clarify the responsibilities of all levels of medical institutions; (6)
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2017
【分類號(hào)】：R197.1

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