关键词: 家庭医生, 签约服务费, 诊疗行为, 两水平方差成分模型

Abstract: Background　In China，the charging for services delivered by the contracted family physician is an important financial incentive for family physicians，this incentive mechanism of income distribution may affect the practice behaviors of family physicians. Objective　To analyze the impact of contracted service fee on family physician's practice behaviors，including the number of visits，the average consulting time per visit and the medical costs of patients，so as to provide evidence for the construction of family physician system in China. Methods　A total of 27 community health centers were selected from Xiamen City，Hangzhou's Yuhang District，Shanghai's Changning District，and Beijing's Xicheng and Fangshan Districts from July to September 2019，from which all incumbent family physicians（n=420） were surveyed by a questionnaire designed by research group consisting of demographic data and basic characteristics of the working environment，incentive mechanism，and perceptions and practice behaviors related to contracted services. The two-level variance component model and multiple linear regression model were used for analysis. Results　The survey obtained a response rate of 96.4%（405/420）.Correspondence analysis found that compared with family physicians whose contracted service fee accounted for less than 10% of total monthly income，there was a 0.84 times decrease in the number of daily referrals（P=0.01），a 32% increase in the total monthly healthcare cost of patients（P=0.01），and a 13% increase in the average cost of per visit（P=0.02） among those with contracted service fee accounting for 10% to 20% of total monthly income，and there was a 1.96 minutes decrease in the average consulting time per visit（P=0.01），and a 36% increase in the total monthly healthcare cost of patients（P=0.02） among those with contracted service fee accounting for 20% to 30% of total monthly income，and there was a 14.68 times increase in the number of daily consultations（P<0.01），a 2.66 minutes decrease in the average consulting time per visit（P<0.01），a 53% increase in the total monthly healthcare cost of patients（P<0.01），and a 22% increase in the average cost per visit（P=0.01） among those with contracted service fee accounting for more than 30% of total monthly income. Conclusion　Increasing the proportion of contracted service fee can increase the service volume of family physicians and reduce the number of daily referrals，which is conducive to improving physicians' work enthusiasm and promoting patients to seek healthcare in primary care and the development of hierarchical diagnosis and treatment. However，the increase in the proportion of contracted service fee may reduce the average consulting time per visit of family physicians，so it is necessary to maintain the balance between quality and the quantity of such services. In addition，it is recommended to further promote the gatekeeping mechanism in which family physicians act as the gatekeeper of medical expenses for patients.

Key words: Family physician, Contract service fee, Treatment behavior, Two-level variance component model