制度供给视角下的基本医疗体制改革之决策

基本医疗改革的财政投入模式应从单一关注医疗服务供给转向协同关注医疗服务产出，无过错医疗损害救济应纳入国家财政投入的预算体系。面对医疗损害的高发性，以救济为心的医疗侵权责任制度应向以预防中心的制度进行改革。医疗过失诉讼制度对医疗体系有着深刻的负面制约作用。基本医疗改革的决策应从更宏观的视角进行制度供给设计。     

基于供给侧视角的我国分级诊疗相关问题思考

自习近平总书记首次提出供给侧改革以来,“供给侧”作为经济改革新词逐渐在医疗领域也引起热议,继续推行分级诊疗制更有现实必要性。从医疗服务提供者和相关配套措施角度详细分析了我国分级诊疗供给侧存在的问题,并提出逐步剥离医院门诊服务、加大对基层的投入力度和加强不同医疗机构的协作的建议。     

关于我国医疗质量监管体系的探讨

通过文献研究和典型现场调查,对国内外医疗质量监管体系进行比较研究,进而提出我国医疗质量监管体系的框架：以政府为主导,政府授权的专业监管机构、医疗保险机构和社会监督力量共同参与的多元化的监管体系。     

美国医师薪酬支付方式改革的几种模式探析

通过对美国在联邦医疗保险体系中实行的不同薪酬支付方式（按绩效支付、按治疗事件支付、责任性医疗组织、以患者为中心的医疗之家）及美国薪酬体系改革几种模式的介绍，了解各种支付方法改革的目的、形式和具体实施中存在的问题，以期对我国的公立医院薪酬制度改革提供参考。     

试论我国公立医院改革的关键点

提出了我国公立医院改革的关键点是：（1）公立医院应聚焦于病人的价值;（2）构建整合的医疗服务体系,使不同级别的公立医院提供不同环节的医疗服务;（3）使不同级别公立医院的医疗服务价格和医疗保险的共付比例不同,促使病人合理选择医院和医生;（4）改善公立医院内部管理和外部监督。     

从供给侧结构性改革视角看三级医院医疗资源下沉

面对区域医疗资源布局失衡、城乡医疗卫生资源配置不均衡的现状,我国部分地区开始落实推行三级医院医疗资源下沉,通过举例分析浙江、河南、福建医疗资源下沉的不同实践模式,从供给侧视角分析优质医疗资源下沉中存在的困境。建议大力推进供给侧结构改革,增加医疗资源的供给,加大政府财政对医疗资源的投入,并坚持市场机制在资源配置中的决定性作用;鼓励社会资本办医,增加供给的主体;鼓励执业医师多点执业缓解医疗人才供给的不足,促进医疗供给结构调整,促使医疗资源下沉。     

关于公立医院补偿机制改革的思考

从理论上分析了公立医院补偿模式的特点,以及政府卫生投入和医疗服务收费之间的关系;梳理了公立医院补偿机制存在的问题;提出了改革补偿机制的建议,即在政府按照医改要求足额投入,调整医疗服务价格的基础上,改革政府投入机制、医疗服务收入分配机制和医保支付方式,并建立有效的监管和奖惩体系。     

积极推进公立医院改革的关键举措——《“十二五”期间深化医药卫生体制改革规划暨实施方案》评述

《“十二五”期间深化医药卫生体制改革规划暨实施方案》明确积极推进公立医院改革是3个重点突破的领域之一。公立医院作为医疗服务供给的主要单位,其改革的成功与否,最终将直接关系到深化医药卫生体制改革的成败。指出规划更具操作性,在公立医院改革方面具有3个显著特点,并提出在具体实施中要处理好3个关系,即改革优先顺序的关系、职能与资源的关系、基础环境与改革的关系。

     

西部地区县级医疗机构网络医疗供给影响因素研究

目的 了解西部县级医疗机构网络医疗供给意愿和现状,为西部推广网络医疗提供发展策略。方法 对云南省某县县级医疗机构的153名医生进行问卷调查。结果 81.7%的受访医生愿意向患者提供网络医疗服务,15.0%提供过相应服务,质量安全、推广路径、服务能力成为主要的发展瓶颈。结论 目前西部农村地区医生提供网络医疗服务的意愿与实际提供比例差距较大,应制定网络医疗的法律法规、完善诊疗规范和监管体系、加快网络医疗平台建设,规范网络医疗培训。     

深圳市社会办医院发展的PEST嵌入式SWOT分析

多元化办医是推动我国公立医院改革和增加医疗卫生资源供给的有效方式。社会办医院是医疗卫生服务体系不可或缺的重要组成部分,是满足人民群众多层次、多元化医疗服务需求的有效途径。通过对深圳市社会办医院的发展现状进行梳理,利用PEST嵌入式SWOT分析模型总结深圳市社会办医院探索过程中的经验和问题,为今后制定和完善社会办医院的发展规划和政策决策提供支持。     

Creating Partnerships With Government,Communities, and Universities to Achieve Results for Children

In recent years, a strategy of partnership and collaboration between government and communities has started to emerge as policy makers and service providers call for a more responsive system to address the health and well-being of children, youth, and families. The trend toward a comprehensive, holistic strategy is driven in part by concern over the effectiveness of a patchwork system of categorical health and human services designed to solve one problem at a time. At issue also is the movement "devolving" more responsibility for child and family well-being from the state to local governments and the challenge this change represents to communities. This article proposes a comprehensive, community-based strategy for reform of health and human services and examines the approach of one state that may be useful for other states interested in reform.     

Anatomy of health care reform proposals.

The current proliferation of proposals for health care reform makes it difficult to sort out the differences among plans and the likely outcome of different approaches to reform. The current health care system has two basic features. The first, enrollment and eligibility functions, includes how people get into the system and gain coverage for health care services. We describe 4 models, ranging from an individual, voluntary approach to a universal, tax-based model. The second, the provision of health care, includes how physician services are organized, how they are paid for, what mechanisms are in place for quality assurance, and the degree of organization and oversight of the health care system. We describe 7 models of the organization component, including the current fee-for-service system with no national health budget, managed care, salaried providers under a budget, and managed competition with and without a national health budget. These 2 components provide the building blocks for health care plans, presented as a matrix. We also evaluate several reform proposals by how they combine these 2 elements.     

Suicide index reduction in Slovenia: the impact of primary care provision

Background Education of primary care providers about diagnosis and treatment of depression and anxiety is an evidence-based suicide prevention measure.Aim To analyse suicide index, mental health epidemiological data and primary care provision in Slovenian regions and to identify examples of good suicide prevention practices in different Slovenian regions.Methods Analysis of existent epidemiological data on mental health in Slovenia.Results Anxiety and depression are the most common complaints in a representative sample of the Slovene population. The number of suicides in Slovenia had been dropping in the period from 2002 to 2006 and was again slowly rising in 2008. The number of visits to family physicians' practices because of mental health problems is low in comparison to other European countries, which might be attributed also to the high workload of family physicians. Suicide prevention programmes follow the example of the Suicide Prevention Project in the central-east region of Slovenia. This programme is based on education of primary care providers and the general public about recognition and treatment of depression in line with international guidelines.Conclusions The differentiation of causes for suicide reduction needs further research, as well as urgent improvement in the accessibility of primary care teams in Slovenia.     

A regional approach to promoting improved care of multiples.

Live births of multiples in the U.S. rose 35% from 87,700 in 1988 to 118,295 in 1998. This increase presents public health issues due to the elevated health and psychosocial risks that accompany multiple birth. However, health and social service providers and educators are poorly prepared to address the specific needs of the multiple birth population. The Twin Service Network Project therefore developed regional networks of multiple birth training and resources in California to address this problem. Results indicate that these can substantially improve the care available to multiples. The project's integrated package of training and parenting education materials is available to other regions to assist in such efforts.     

Measuring and improving the quality of mental health care: a global perspective

Mental disorders are common worldwide, yet the quality of care for these disorders has not increased to the same extent as that for physical conditions. In this paper, we present a framework for promoting quality measurement as a tool for improving quality of mental health care. We identify key barriers to this effort, including lack of standardized information technology‐based data sources, limited scientific evidence for mental health quality measures, lack of provider training and support, and cultural barriers to integrating mental health care within general health environments. We describe several innovations that are underway worldwide which can mitigate these barriers. Based on these experiences, we offer several recommendations for improving quality of mental health care. Health care payers and providers will need a portfolio of validated measures of patient‐centered outcomes across a spectrum of conditions. Common data elements will have to be developed and embedded within existing electronic health records and other information technology tools. Mental health outcomes will need to be assessed more routinely, and measurement‐based care should become part of the overall culture of the mental health care system. Health care systems will need a valid way to stratify quality measures, in order to address potential gaps among subpopulations and identify groups in most need of quality improvement. Much more attention should be devoted to workforce training in and capacity for quality improvement. The field of mental health quality improvement is a team sport, requiring coordination across different providers, involvement of consumer advocates, and leveraging of resources and incentives from health care payers and systems.     

From “Shrinks” to “Urban Shamans”: Argentine Immigrants’ Therapeutic Eclecticism in New York City

This article examines Argentine immigrants' reliance on informal networks of care that enable their access to a variety of health providers in New York City (NYC). These providers range from health brokers (doctors known on a personal basis) to urban shamans, including folk healers and fortunetellers of various disciplines. A conceptual framework, based on analysis of social capital categories, is proposed for the examination of immigrants' access to valuable health resources, which are based on relationships of reciprocity and trust among parties. Results revealed immigrants' diverse patterns of health-seeking practices, most importantly their reliance on health brokers, epitomized by Argentine and Latino doctors who provide informal health assistance on the basis of sharing immigrants' social fields and ethnic interests. While mental health providers constitute a health resource shared by Argentines' social webs, urban shamans represent a trigger for the activation of women's emotional support webs. Contrary to the familiar assumption that dense and homogenous networks are more beneficial to their members, this article underscores the advantages of heterogeneous and fluid social webs that connect immigrants to a variety of resources, including referrals to diverse health practitioners.     

Gender Differences in patient-provider symptom agreement in reporting respiratory complaints on a questionnaire

Background: Men and women communicate differently, but it is unclear whether this influences health care outcomes.Objective: Because women patients frequently choose women health care providers, we examined whether this preference was affected by communication styles. We focused on communication of disease-specific symptoms, hypothesizing that symptom agreement between women patients and women health care providers would be greater than between other patient-provider gender combinations.Methods: Patients attending outpatient clinics were recruited as part of a study of respiratory illness at 7 university-affiliated sites during 3 consecutive influenza seasons (2000–2003). Individuals aged ≥ 19 years were offered enrollment if they sought care for cold or flu symptoms at a participating study site. Patients were eligible to participate in the study if they reported any 1 of 6 symptoms: cough, runny nose, fever (subjective), muscle aches, sore throat, and/or exhaustion. Using separate questionnaires, patients and their health care providers recorded the patients' respiratory symptoms (as present or absent). Patients recorded their symptoms before visiting their health care provider, and providers recorded patient symptoms after the visit. Symptom agreement was compared using general estimating equations across all gender combinations.Results: A total of 327 patients (220 women, 107 men) and 84 health care providers (37 women, 47 men) participated in the study. Overall symptom agreement for all patient-provider gender combinations was 81.9% (95% CI, 79.6%–84.2%). For each symptom, the observed agreement significantly exceeded the agreement expected by chance alone (P < 0.001 for all symptoms except “no energy,” which was P = 0.023). The male-male pairing of patient and provider was more likely to agree on a symptom than were the other gender combinations, although not statistically significantly more so than the female-female pairing.Conclusions: In this survey of patients with respiratory illness, there was no significant difference in symptom agreement for most symptoms between the male-male and female-female patient-provider combinations. Based on these findings, symptom agreement alone does not explain why women patients select women health care providers.     

Incidence of occupational stress among medical radiographers: A population based zonal survey.

Biomechanical and Psychosocial stresses are capable of destabilizing any health care professional. The current health sector reform in Nigeria, which lays emphasis on service delivery on a background of very few radiographers, may lead to an increase in stress level. This study investigated the incidence of occupational stress among radiographers in southeastern Nigeria. 50 self-completion questionnaires were delivered to radiographers in the southeastern Nigeria. The questionnaires included questions seeking information on the demographic profile of the radiographer, anatomical regions of biomechanical systems/stress and Visual analogue scale (VAS), which rated job satisfaction and anxiety levels. 32 questionnaires were returned and analyzed statistically. Biomechanical stress was observed in all anatomical regions studied. Job satisfaction rating was 61.3% and anxiety level was 45.3%. This study has provided a baseline stress level and prevalence among radiographers with which future studies in view of the on going health sector reform in Nigeria could be compared.     

从北京市DRGs试点看医保费用支付方式改革方向选择

医保费用如何支付一直以来都是整个医保体系建设的关键环节之一,医保费用支付方式如何改革在我国医改探索实践中相对比较敏感。北京市于2011年在医保费用支付方式上率先推出国际上比较先进的DRGs支付方式改革新举措,文章介绍了北京大学第三医院作为试点医院的实践。     

Struggling with Imaginaries of Trauma and Trust: The Refugee Experience in Switzerland

This article discusses some effects of migration politics on asylum seekers and refugees and on the Swiss health services. It is based on multisited ethnographic research that tracked interpretative concepts of the refugee experience. Following a grounded theory approach, it identifies imaginaries of trauma and trust as key categories in the field of transnational migration and health. The psychiatric concept of trauma and a more popularized discourse of traumatic memory are strongly emphasized in all of the investigated field sites: the providers of primary health care and psychosocial services and representatives of social welfare agencies and law-making bodies use this "diagnosis" extensively. This leads refugees to develop tactics of a) identifying with the trauma discourse in order to become "good refugees" and achieve legal status in Switzerland; b) struggling with the ascribed pathologies and suffering from retraumatizing effects of these predominant trauma policies; and c) trying to refuse or subvert them by emphasizing the existence of structural violence in the receiving countries. An analysis of the interactions of health providers and refugees shows that it takes place in an environment of social and economic insecurity and in a shared imaginary of (mis)trust, putting at stake the moral economy of recent migration politics and the refugee experience.