混合预付制对县域医疗服务体系整合的影响及作用机制研究：典型案例比较

The Chinese healthcare system has been facing mixed problems of fragmented administrative management and discontinuous care delivery, which hampered the efficiency of the delivery system and resulted in a rapid medical expenditure increase, especially in higher-level hospitals in rural area. The integrated care system has been proved to be effective in solving the fragmentation problem, and become a reliable strategy in health system reform worldwide. However, from the available experiences of the Chinese system integration reforms, such as Medical Alliance and Cooperative Care Delivery, most of them have not shown the effects as expected to. An essential part that was missing among these integration strategies was the shared incentives mechanism among multi-institutional collaborations, which might largely contribute to the failure of the policy implementation. ..In previous studies conducted by the applicant, the blending prospective payment system was proved to be significantly effective in building the integrated health system. Therefore, in this study, the applicant will continue to testify the marginal effect of blending prospective payment system on health system integration, with trusty evidence from an empirical study design. This will be a case study, including 2 typical cases (rural counties) and 1 control case. To avoid selection bias, we will mainly use the Propensity Score Matching to select and match the hospitalization cases from the claims dataset (5 years and above) in each sampled area, to compare the effects on visits structure and hospitalization fee with Segmented Time Series Regression Model and Difference-in-differences Model. And then, we will enroll representative patients sample in each area, to simulate their hospitalization choices after the introduction of Blending Prospective Payment System through the Discrete Choice Experiment; with a combined consideration of hospitalization rate and disease burden, we will predict the future expenditure in rural healthcare system using the Markov Analytical Decision Model. ..The impact will be evaluated mainly through the following aspects: patient choice, cooperative care delivery, synergetic management, policy consistency, hospitalization structure and medical expenditure. The final step of this study is to create an analytical framework of rural health system integration with blending prospective payment reform to support evidence-based decision making in future healthcare system integration reforms.

整合服务体系被证明是解决卫生系统内部体系割裂、管理碎片化和服务不连续问题的有效方式，然而在目前国内医联体等整合式改革中，由于未能很好解决整合激励机制设计问题，导致成效并不显著。混合预付制的医保支付方式，在前期研究中被证明能显著促进体系整合。本研究拟通过案例比较的方法，进一步系统地论证混合预付制对体系整合的影响。研究选择典型案例与空白案例进行对比，利用倾向得分法抽取案例地区改革前后病例进行匹配，通过间断时间序列和双重差分模型比较预付制产生的影响。同时选取一定患者样本，借助离散选择试验，模拟混合预付制对患者就医选择的改变；在马尔科夫决策分析模型中纳入上述数据，预测改革对县域医疗服务利用的长期影响。评估指标包括：患者流向、服务协作水平、管理协同性、政策整合性、住院结构、费用水平。最后，借助全面影响评估和变革模型，梳理支付方式的作用机制，构建县域服务体系整合模型，为分级诊疗等改革设计提供参考依据。

本研究自2017年1月至今，已完成理论研究、文献梳理、数据收集与部分分析/发表工作。理论构建部分，从协作激励、服务质量、费用控制、患者分流四个维度对不同支付方式对服务体系整合的影响进行了比较分析，在按项目付费、按人头付费、按病种付费（含DRGs）、总额预付和集团总额预付五种方式中肯定了集团总额预付对整合具有最优效果。文献研究部分，通过系统综述和文献计量分析，对单病种付费、DRGs、总额预付和医联体支付模式四种支付方式在我国运行的效果进行了回顾总结，得到“医疗机构内部将实现由单病种向DRGs结合临床路径转变、医疗联合组织中将实现集团打包支付模式”的初步结论。实证研究部分，一方面通过观察某县域医疗联合体在机构整合、供方协作方面的整合措施实施情况，判断该“医联体”的失败，并结合调查及访谈分析其失败原因，认为医联体是个自组织，可持续运转的关键在于整合的利益激励机制。另一方面借鉴美国责任医疗组织（Accountable Care Organization, ACO）的理念，设计并实施了一项县域准实验，探索了我国整合服务改革中基于绩效的集团总额预付（Performance-Based Global Budget Payment, PBGB）的模式，并论证了PBGB在降低住院率及住院费用、提高服务连续性、促进双向转诊方面相对于常规诊疗组具有显著性优势。下一步研究计划为：分析5个典型县域医疗整合实践效果，并系统评价支付方式对整合的效果。.上述研究结果已经形成了21篇学术性文章，其中5篇收录于SCI/SSCI，最高影响因子5.48，16篇收录于北大中文核心期刊。另有8篇以会议摘要形式被收录于SCI/SSCI期刊中。此外，培养博士后及省社科优青一名，硕士研究生9名，本科生6名。项目相关成果获第八届钱学森城市学金奖提名奖及南京市医改办政策采纳应用。

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