经济学院知识库

  随着生活水平的不断提高，人们对高质量健康服务的需求日益增长，在“健康中国”的战略目标下，如何建立高质量、高效率、低成本和高可及性的医疗服务体系这一问题越来越受关注。而当前我国医疗资源的配置不尽合理、基层医疗服务能力不足、部分患者无序就医等问题较为突出，实施分级诊疗政策已经成为国家深化医药卫生体制改革，促进基本医疗服务均等化的重要举措。为建立基层首诊、双向转诊、急慢分治、上下联动的就医格局，全国各地都在不断探索分级诊疗模式，但其实施效果并不明显。

  实现分级诊疗政策的关键在于如何正确引导患者到基层医疗机构就诊。由于我国患者就医选择的“自由”性和医患之间存在信息不对称的情况，患者只能通过医院等级去做选择。此时，关键是看患者更看重医疗价格还是医疗质量，这主要取决于居民对价格的敏感度和患病的严重程度。鉴于此，文章对分级诊疗政策下患者就医行为选择的原因做了更近一步的划分。

  文章基于2012年、2014年、2016年和2018年的中国家庭追踪调查数据（CFPS），利用面板回归模型从就医成本和患者选择两个方面评估分级诊疗政策的实施效果，以及对城乡患者和疾病较为严重患者的异质性进行了分析。实证结果表明：分级诊疗政策对引导患者到基层医疗机构就诊和降低居民就医成本的效果均不显著。收入对患者就医选择的影响具有显著的城乡差异，医疗服务价格相比于医疗服务质量，居民更看重的是后者。但农村居民收入的变化对其就医选择的影响比城镇居民要大，且对医疗服务价格更敏感，医保政策对农村居民的引导作用更大。特别是当患者疾病较为严重时，更印证了这一结果，居民在能负担起的情况下，都会选择去高质量的医院就诊，此时分级诊疗政策是失效的。因此，为推进分级诊疗政策的顺利进行，必须加强基层医疗机构的建设，提高其医疗服务能力和质量，制定针对城乡的差异化医保报销政策，对疾病较为严重的患者不再实施分级诊疗政策的限制。

  With the continuous improvement of living standards, people's demand for high-quality health services is growing. Under the strategic goal of "Healthy China", the problem of how to establish a medical service system with high quality, high efficiency, low cost and high accessibility is getting more and more attention. At present, China's medical resources allocation is unreasonable, the basic medical service capacity is insufficient, some patients disorderly medical treatment and other problems are more prominent, the implementation of hierarchical diagnosis and treatment policy has become an important measure to deepen the reform of the medical and health system, promote the equalization of basic medical services. In order to establish a medical treatment pattern of primary treatment, two-way referral, treatment of urgent and slow, and linkage between upper and lower levels, the hierarchical diagnosis and treatment mode is being explored all over the country, but its implementation effect is not obvious.

  The key to the implementation of the hierarchical diagnosis and treatment policy is how to guide patients to the primary medical institutions.Due to the "freedom" of patients' choice of medical treatment in China and the information asymmetry between doctors and patients, patients can only make the choice through the grade of the hospital.At this point, the key is to see whether the patients value the price or the quality of medical treatment more, which mainly depends on the residents' sensitivity to the price and the severity of the disease.In view of this, this paper further classifies the reasons for patients' choice of medical behavior under the hierarchical diagnosis and treatment policy.

  Based on the China Family Panel Studies (CFPS) data from 2012, 2014, 2016 and 2018, this study used the panel regression model to evaluate the implementation effect of the hierarchical diagnosis and treatment policy in terms of the cost of treatment and patient selection, and analyzed the heterogeneity between urban and rural patients and patients with more severe disease.The empirical results show that the hierarchical diagnosis and treatment policy has no significant effect on guiding patients to primary medical institutions and reducing residents' medical costs. The impact of income on patients' medical treatment choice is significantly different between urban and rural areas, and residents value the latter more than the medical service quality. However, the change of rural residents' income has a greater impact on their choice of medical treatment than that of urban residents, and is more sensitive to the price of medical service, and medical insurance policy has a greater guiding effect on rural residents. Especially when the patient's disease is more serious, this result is more confirmed. As long as urban residents can afford it, they will choose to go to high-quality hospitals. At this time, the hierarchical diagnosis and treatment policy is ineffective. Therefore, in order to promote the smooth implementation of the hierarchical diagnosis and treatment policy, it is necessary to strengthen the construction of primary medical institutions, improve their medical service capacity and quality, formulate differentiated medical insurance reimbursement policies for urban and rural areas, and no longer implement the hierarchical diagnosis and treatment policy restrictions for urban patients with more serious diseases.