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1. Comparative Study of Payment Systems for General Practitioners in Four Countries
ZHAO Minjie, Ayan MAO, WANG Kun, MENG Yueli, YAN Xiaoling, QIU Wuqi
Chinese General Practice    2022, 25 (31): 3850-3856.   DOI: 10.12114/j.issn.1007-9572.2022.0158
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As main health service providers in primary care, general practitioners (GPs) undertake the responsibility of gatekeepers for residents' health. Vigorously training GPs will contribute to the transformation of the healthcare delivery model, and the addressing of the issue related to difficult and high cost of getting medical treatment in China. However, the number of qualified GPs is insufficient in China, and low income is a major factor associated with the willingness of medical students to work as a GP. How to take actions to recruit, retain and appropriately employ GPs in primary care is a problem that needs to be addressed urgently in the development of China's primary care workforce. To provide evidence for the improvement of China's payment system for GPs, we collected the information related to the payment for GPs in the United Kingdom, the United States, Australia, and China by reviewing relevant studies and relevant official websites of the four countries, and performed an inter-county comparative analysis of the information in terms of income source, income level, payment methods, payment composition, and performance appraisal. We found that the four countries have the following aspects in common: all of them own a payment system for GPs and an assessment system for service quality and effectiveness of GPs, adopt a mixed payment method for GPs, and use financial incentives to promote GPs to improve the quality of their performance. In addition, the United States and China have explored methods to decentralize the management of medical insurance funds, so that the primary healthcare institutions can independently redistribute the surplus funds which has improved the proactivity of GPs at work. And Australia has set up the "coefficient of difference" and scholarships/subsidies for GPs, and carried out free trainings for improving the service capacities of GPs working in remote areas, to increase the attractiveness of working as a GP.

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2. Research Progress and Prospects of Incentive Mechanisms for General Practitioners in China and Abroad
PAN Xuanda, YU Xiaosong, SHAN Haiyan
Chinese General Practice    2023, 26 (01): 14-20.   DOI: 10.12114/j.issn.1007-9572.2022.0762
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General practitioners are the gatekeepers when it comes to residents' healthcare. This means that the quality and quantity of their services will play a key role in improving basic medical services. The most appropriate incentive mechanism for general practitioners can improve their ability, minimize the desire to leave, and promote the stability of teams. Currently, China lacks a comprehensive and flawless practice system, and the exploration of incentives for general practitioners is still in its infancy, and there is a lack of a complete and effective practice system. This study highlights the critical importance of incentives and incentive mechanisms. It summarizes the experience of the United Kingdom, Australia, the United States, Shenzhen, Xiamen, and Shanghai with relatively mature incentive mechanisms in China and abroad. Additionally, to summarise the current problems that still exist in the incentive mechanism for general practitioners in China (single incentive approach, lack of career attraction due to the lack of obvious incentive effect, poor science of incentives leads to uneven allocation across regions, different incentive policies across regions and slow implementation) . As part of this strategy, together with the strategy of "Healthy China", innovative ideas are put forward in terms of enrolling general practice in national key clinical specialty, establishing authoritative professional academic institutions and regulatory institutions, developing a unified performance appraisal system, improving the diversified material and non-material incentive mechanisms, improving the competition and punishment mechanisms by means of information, and forming an efficient general practitioner service teams. In order to provide new research methods for investigating the incentive system of primary general practitioners in China.

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3.

Development of an Incentive Model for General Practitioners in Fengxian District of Shanghai Based on Herzberg's Motivation-hygiene Theory

PAN Danying, GU Chunmei, CAO Weiyi, PENG Yan, TANG Yan, JIN Jiahui, WENG Zhixian, ZHANG Jie
Chinese General Practice    2022, 25 (07): 837-845.   DOI: 10.12114/j.issn.1007-9572.2021.00.343
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Background

In view of the shortage of general practitioners (GPs) and limited community healthcare resources, it is urgently necessary for community health institutions to find accurate and scientific incentive methods to retain GPs and help them to realize their full potential, as well as promote the development of both community health institutions and GPs, thereby benefiting the health promotion of community residents.

Objective

To develop an incentive model for GPs to test the performance and effectiveness of current incentives for GPs, so as to put forward suggestions to improve the mechanisms of employing and retaining GPs.

Methods

In August 2019, we recruited 204 GPs from 11 community health centers (CHCs) in Shanghai's Fengxian District using stratified random sampling to attend an online survey using a questionnaire named General Practitioners' Perception and Evaluation of Incentive Measures developed based on our previous research results and Herzberg's motivation-hygiene theory. Then from August to September 2019, we invited directors responsible for medical care or public health issues, and medical quality control department heads from the above-mentioned 11 CHCs to attend an online survey using a questionnaire named Workload for General Practitioners in Community Health Centers of Fengxian District developed by usbased on a literature review. Then under the guidance of Herzberg's motivation-hygiene theory, we constructed a structural equation to develop an incentive model for GPs within Fengxian District with representative incentive policies, systems and initiatives related to GPs selected from the survey results as latent independent variables to measure GPs' (responders') perception and assessment of incentives, and with willingness to work, service radius, and workload of GPs as dependent variables.

Results

The average scores for the implementation of incentive measures, and its associated influence on GPs' work status assessed by the 204 GPs were (0.77±0.14) , and (0.73±0.19) , respectively. The assessment score for implementation of incentive measures for GPs differed significantly by personal health condition and administrative position in the respondents (P<0.05) . The assessment score for the influence of implementing incentive measures on GPs' work status differed significantly by personal health condition in the respondents (P<0.05) . Spearman correlation analysis showed that GPs' work status was associated with the implementation of 25 incentive measures (one incentive measure at the subdistrict level was not included for analysis) (P<0.05) . The top three most highly correlated incentive measures were performance distribution (rs=0.652) , performance-based salary calculation (rs=0.621) , and wages and benefits (rs=0.614) . Partial correlation analysis indicated that, after controlling for variables such as the regional policy environment, the street and town government, and the work unit, the assessment score for implementation of either regional, or subdistrict or institutional incentive measures for GPs, was positively correlated with the assessment score for the influence of implementation of incentive measures for GPs on GPs' work status (r=0.381, 0.387, 0.528, P<0.001) . Theaverage assessment score for willingness to work by the respondents was (0.76±0.18) points. Theassessment scores of willingness to work by the respondents differed significantly by work unit (P<0.05) . Structural equation modeling revealed that the implementation of policy incentive measures influenced GPs' workload via GPs' willingness to work. Specifically, the implementation of policy incentive measures increased GPs' willingness to work (w1=0.43) , while GPs' willingness to work decreased with the increase of weighted workload (w2=-0.156) .

Conclusion

The GPs in Fengxian District showed higher level of willingness to work, namely, relatively high job stability, but they had not been incentivized by policy incentives to be competitive in obtaining improved performance, indicating that although policy incentives have produced partial effects on incentivizing GPs, the effects are still unsatisfactory. In the long run, it is necessary to consider whether there will be changes in GPs' retention status due to the lack of work initiative. For GPs, besides a guarantee of stable income, incentives to get more by doing more are also needed, which may be achieved by increasing the incentive authority and proportion of community health institutions when the total amount of incentives is limited.

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4. Practice and Effect of "First-class Financial Supply,Second-class Performance Management" Plan in Primary Health Care Institutions 
ZHANG Lifang,QIN Jiangmei,ZHANG Yanchun,LIN Chunmei,MENG Yeqing,TAO Mengyuan
Chinese General Practice    2020, 23 (1): 1-6.   DOI: 10.12114/j.issn.1007-9572.2020.00.093
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"First-class Financial Supply,Second-class Performance Management" Plan in public welfare is the key content of the current comprehensive reform in primary health care.Guangdong Province took the lead in implementing this plan and has received certain achievements.Therefore,its reform experience has been popularized as the typical demonstration nationwide.But there are differences in the actual situation of different regions,problems and reform priorities in pushing forward this reform plan are also various.Based on the 2019 Typical Cases of Comprehensive Reform in Primary Health Care and field investigation,this paper summarized and analyzed the specific measures in the implementation of "First-class Financial Supply,Second-class Performance Management" Plan in public welfare in Guangdong Province(especially Yingde City and Shaoguan City),Hainan Province(especially Lingshui County and Wuzhishan City),and Heze City of Shandong Province.The achievements of each region in improving service ability and stimulating operational workload of primary health care institutions,and improving the attractiveness to and satisfaction of patients were briefly described.Although different regions are faced with various problems and reform priorities,the vigorous promotion of the government,the close cooperation between departments,and the initiative of primary health care institutions are all important factors in advancing the "First-class Financial Supply,Second-class Performance Management" Plan.
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5. Job Characteristics Model-based Study of the Intrinsic Incentive Mechanism for Primary Health Workers
ZHAO Shichao, PING Jing, ZHU Hong, JI Wanting, WANG Yuyan, WANG Ying
Chinese General Practice    2023, 26 (25): 3118-3126.   DOI: 10.12114/j.issn.1007-9572.2022.0642
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Background

The incentivation for primary health workers is vital for the realization of two goals of the new healthcare reform in China, namely strengthening primary healthcare and achieving hierarchical diagnosis and treatment. Most previous studies put more emphasis on extrinsic incentive measures and their effect on job outcomes, ignoring the intrinsic motivation effect of job itself.

Objective

To perform an analysis of the job characteristics of primary health workers using the framework of Job Characteristics Model, assess their intrinsic motivation effect on job outcomes of these workers, and compare the strength of impact of the five dimensions of job characteristics and income and other extrinsic motivators on job outcomes, and put forward policy recommendations for improving work motivation and performance of primary health workers.

Methods

A survey using a self-developed questionnaire was conducted with primary health workers who were on duty on the day of the survey selected from a multistage sample of healthcare settings (including 18 community health centers and 20 township health centers) in three cities of Shandong Province from February to June 2021. Then, from those who effectively completed the survey, 167 cases were selected using convenience sampling to attend semi-structured interviews to understand their views of the characteristics of job as a primary health worker. Pearson correlation was used to analyze the correlations of the five dimensions of job characteristics and extrinsic motivators with autonomous motivation, performance, burnout, and turnover intention. Hierarchical multiple linear regression was used to analyze the strength of impact of the five dimensions of job characteristics and extrinsic motivators on job outcomes. Thematic analysis was used to analyze the interview data.

Results

A total of 870 cases who handed in effective questionnaires were included for analysis. Among the five dimensions of job characteristics, respondents scored highest and lowest on skill variety (4.09±0.71) and task identity (3.18±1.04) , respectively, and their scores on task significance, feedback from job and autonomy were (3.91±0.76) (3.46±0.83) and (3.43±0.79) , respectively. Pearson correlation analysis showed that the level of each of the five dimensions of job characteristics had a positive correlation with autonomous motivation and performance (P<0.05) , and had a significant negative correlation with burnout and turnover intention (P<0.05) . Hierarchical multiple linear regression revealed that the five dimensions of job characteristics had significant impacts on job outcomes, specifically, autonomous motivation (R2=18.8%) , performance (R2=11.3%) , job burnout (R2=16.5%) and turnover intention (R2=21.9%) , whose explanatory power was stronger than that of five extrinsic motivators (The R2 values of the five extrinsic motivators' contributions to the four job outcomes were 1.7%, 3.4%, 5.8%, and 11.8%, respectively) . The interview results reflected the problems of task fragmentation, limited autonomy and insufficient feedback from job.

Conclusion

In primary health workers, the intrinsic motivation effect of job characteristics outweighs the extrinsic motivation effect in terms of explanatory power for job outcomes. And there is a gap between actual and theoretical job characteristics. Attention should be paid to the intrinsic motivation effect of job itself. Some measures should be taken, such as increasing training opportunities and quality, reducing work-related burden of these workers and empowering them, increasing resource investment and reducing policy constraints, improving the performance management system, to reshape job perceptions to improve work motivation and performance of primary health workers.

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6. Recent Developments in Performance Assessment Policies and Practices in Primary Healthcare in China 
QIN Jiangmei,WANG Fang,LIN Chunmei,ZHANG Yanchun,ZHANG Lifang
Chinese General Practice    2021, 24 (16): 1989-1994.   DOI: 10.12114/j.issn.1007-9572.2021.00.194
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Using common performance assessment theories and methods,we systematically reviewed the performance assessment policies in primary healthcare published between 2009 and 2020,and summarized typical local practices,experiences as well as problems during the period in China. In this period,the policies on performance assessment in primary healthcare are consistent in essence but have been improved successively,such as the Guiding Opinions on the Implementation of Performance Assessment in Healthcare(No. 98〔2010〕of Department of Personnel of the Ministry of Health),Guiding Opinions on Strengthening the Performance Assessment in Public Healthcare Institutions(No. 94〔2015〕of Department of Personnel of the Ministry of Health),and Guiding Opinions on Strengthening the Performance Assessment in Primary Healthcare(Trial Version)(No. 9〔2020〕 of Department of Primary Health of the National Health Commission),the latter one strengthens the applicability of the assessment,and focuses more on economic operation and informatization. Considering the local innovative practices,typical experiences and problems,we put forward four recommendations on the basis of review of available evidence and our own experience of participating in the drafting of these policies:(1)Modifying the performance assessment system for primary healthcare at the regional level to be a version with clear normal reference value for each indicator and detailed scoring methods.(2)The normal reference values for indicators and scoring methods should be simulated with historical data,and modified continuously.(3)Determining the indicators assessed at the regional level,enhancing the tiered assessment,and highlighting the application of performance assessment results.(4)Using technologies to directly grasp quantitative data from the information platform to reduce the burden of assessing performance of primary healthcare institutions. We expect these recommendations will assist local primary healthcare institutions in implementing and improving performance assessment.
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7. Development of a Contracted Service Performance Assessment System for China's Family Doctors 
SUN Caixia,SI Sijun,JIANG Feng,LIU Tingfang
Chinese General Practice    2021, 24 (34): 4378-4385.   DOI: 10.12114/j.issn.1007-9572.2021.00.249
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Background The implementation of contracted family doctor services is one of the tasks to achieve successful reform of the pharmaceutical and healthcare system in China. Currently,although the services are available nationwide,healthcare workers for delivering such services have not been fully incentivized by existing performance assessment systems,so it is essential to develop a set of more scientific and effective performance assessment system. Objective To develop a system for assessing the performance of China's family doctors in the delivery of contracted services,promoting the domestic development of the services. Methods Through reviewing relevant policy documents,literature,and sophisticated evaluation tools,we developed an item pool for the initial version of the contracted service performance assessment system for China's family doctors. Then from March to May in 2020,we selected 30 experienced experts from relevant fields,and invited them to attend a two-round Delphi survey using a self-developed Delphi Expert Consultation Form. After that,we calculated the authoritative coefficient and other indicators,and according to the consultation results,we revised the initial version of the system to a final one. Results Either the first or second round of survey achieved a 100.0% response rate,with a 100.0% positive coefficient of experts. Furthermore,the authoritative coefficient(Cr) of experts for both rounds of the survey ranged from 0.850 to 1.000,with an average value of 0.913. All of that reached the acceptable standard. In terms of the value of the first-,second-,and third-level indices of the system,the Kendall's concordance coefficients in the first round of survey were 0.144(P<0.05),0.254(P<0.01),and 0.268(P<0.01),respectively,and those in the second round of survey were 0.158,0.354,and 0.495(all P<0.01),respectively,suggesting that the experts' opinions gradually reached a consensus,and the evaluation results were stable and reliable. The final system includes three first-level indices,10 second-level indices,and 59 third-level indices involving the quality of service structure,service delivery process and service outcome. Conclusion The consulted experts were highly motivated with high degree of authority. And they obtained a consensus on the indices of the system after two rounds of survey,indicating that our system is reliable.
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8. Incentive Mechanism for the Delivery of Family Doctor Services:a Case Study of Xiamen's Practice for Promoting the Specialty Physician-general Practitioner-health Manager Management 
LYU Yun,JING Rize,WANG Demeng,FANG Hai
Chinese General Practice    2021, 24 (16): 1995-2002.   DOI: 10.12114/j.issn.1007-9572.2021.00.191
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To develop an integrated healthcare system,Fujian's Xiamen has made many efforts,for example,it has produced a featured healthcare delivery model,that is,providing hypertension and diabetes patients with tertiary care specialty physician-primary care general practitioner-health manager management. While enhancing the efficiency and quality of the management with low cost,Xiamen improves the incentive mechanism for family doctors. By establishing and implementing systems for financing for carrying out family doctor services,distributing the service fee,and appraising and assessing performance as well as non-financial incentive mechanisms,Xiamen has improved the income and working enthusiasm of primary healthcare workers,and the quality and contracting rate of family doctor services as well as patient-doctor communications,manifesting the initial effectiveness of using innovative systems to facilitate the implementation of key actions of "patients are willing to visit primary care,primary care workers are capable of providing care for patients,and tertiary hospitals are willing to transfer patients to primary hospitals" to achieve tiered diagnosis and treatment.
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9. 社区卫生服务机构岗位聘用制与绩效工资制的实施情况及激励作用研究
王泳仪1,徐玲2,张明吉1,3,王伟1,贺蕾2,严非1*
Chinese General Practice    2017, 20 (7): 768-772.   DOI: 10.3969/j.issn.1007-9572.2017.07.002
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目的  了解我国四省市社区卫生服务机构岗位聘用制与绩效工资制的实施情况及其对社区卫生人员的激励作用。方法  本研究采用多阶段抽样方法。采用立意抽样,在东部地区选取山东省、上海市,在中部地区选取安徽省,在西部地区选取陕西省;在3个省各抽取省会所在市和1个社区卫生服务发展较好的地级市;在每个市(包括上海市)各抽取1个区,共7个区。采用分层抽样,在每个区依据社区卫生服务机构举办主体类型和人员规模分层抽样,每层最多抽取3家社区卫生服务机构,共抽取61家社区卫生服务机构。采用整群抽样,在每家社区卫生服务机构选取调查当日所有在岗的社区卫生人员共713例作为本研究对象,并从中抽取社区卫生人员6例作为访谈对象。自行编制调查问卷,问卷主要内容为:社区卫生人员的基本情况;岗位聘用制的实施情况;绩效工资制的实施情况。于2013年8-9月,采用自填式调查问卷进行调查。共发放问卷713份,回收有效问卷656份,问卷的有效回收率为92.0%。在进行问卷调查同时,开展深度访谈,访谈内容为对岗位聘用制和绩效工资制的评价。结果  61家社区卫生服务机构中,有27家公有制举办主体、18家私有制举办主体的社区卫生服务机构实施了岗位聘用制。实施岗位聘用制的45家社区卫生服务机构中,编外社区卫生人员年收入占编内人员年收入的比例为(82.9±16.6)%;未实施岗位聘用制的16家社区卫生服务机构中,编外社区卫生人员年收入占编内人员年收入的比例为(53.0±17.4)%,两者间差异有统计学意义(P<0.05)。34家公有制举办主体的社区卫生服务机构中,有24家实施了绩效工资制。64.7%(180/278)的社区卫生服务中心人员、85.1%(63/74)的社区卫生服务站人员认为绩效考核有激励作用。42.1%(153/363)的社区卫生人员认为该机构的收入分配公平性较好。结论  岗位聘用制和绩效工资制对保障社区卫生人员的收入公平性、提高积极性起到一定作用;但是要打破编制的限制、解除编制与福利的联系、建立科学的绩效工资制度,还需要进一步探索。建议探索完善岗位聘用制,增加收入渠道,保证社区卫生人员收入,合理设置绩效工资比例,充分发挥绩效工资的引导作用。
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10. The Enlightenment of Value-based Pay for Performance Program in California on Improving the Performance Evaluation System and Incentive Mechanism of General Practitioners in China 
WANG Simin,XU Wei,CUI Zidan,SHI Qionghua
Chinese General Practice    2019, 22 (13): 1522-1527.   DOI: 10.12114/j.issn.1007-9572.2019.00.215
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A well-run incentive mechanism and performance evaluation system are key to improve the general practitioner system in China.This study thoroughly analyzed value-based pay for performance program(VBPFP) in California,with emphasis on its performance measures and incentive mechanism and compared it with that in China.On the basis of the comparative analysis,we found that the performance evaluation goals of VBPFP program was specific,which required general practitioners to pay equal attention to the quality and cost of patient care.The performance measures were mainly centered on the prevention and treatment of chronic diseases.The hybrid medical insurance payment methods were adopted to maximize the enthusiasm of general practitioners.Therefore,we put forward suggestions that our performance assessment should add indicators of chronic disease prevention and health management and that we should establish a hybrid payment method links to the medical insurance for general practitioners.In addition,timely disclosure of general practitioners' performance appraisal results and open recognition and reward for general practitioners with outstanding performance are also important to stimulate their enthusiasm at work.
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11. Research on Motivate Mechanism of Family Doctors Based on Two-factor Theory 
LIAN Lu,ZOU Murong,HU Dan,CHEN Jiaying
Chinese General Practice    2019, 22 (28): 3501-3504.   DOI: 10.12114/j.issn.1007-9572.2019.00.371
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Background The key to improving the team building of family doctors is to improve their work enthusiasm and the scientific and reasonable motivate mechanism is the key to improving their work enthusiasm.Objective To analyze the influencing factors of family doctor team members' work enthusiasm in contracted service's and make recommendations for improving the motivate mechanism for family doctors.Methods From July to September in 2017,287 family doctor team members of 11 community health service centers in Pukou District of Nanjing were surveyed by questionnaire,and eight leaders of community health service centers eight leaders of family doctor team,and four government health administrators were surveyed by structured interview.Guided by the two-factor theory,this paper analyzed the influencing factors of family doctor team members' work enthusiasm from two aspects of hygiene and motivation.Results 276 valid questionnaires were collected,the effective recovery was 96.2%.Main drive factors affecting the enthusiasm of family doctor team members were the policy and institutional design and remuneration levels in terms of hygiene,along with sense of achievement and personal development in terms of motivation.Conclusion A sound and standardized management system and salary system should be established to increase the sense of achievement for family doctor team members.It is necessary to establish a career development platform and improve the incentive mechanism,so as to enhance the work enthusiasm of family doctors.
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12. Incentive Factors of Family Physician Team Members in Different Positions 
FENG Huangyufei,JING Rize,WANG Jiahao,FANG Hai
Chinese General Practice    2021, 24 (4): 400-406.   DOI: 10.12114/j.issn.1007-9572.2021.00.089
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Background To improve the subjective initiatives of family physician team members,it is necessary to establish an effective incentive mechanism. Different incentive factors may have different effects on these team members. Objective To compare the level of satisfaction with and preference of incentives in family physician team members in different positions,providing a basis for further improving and refining the incentive mechanism for the team. Methods Using a questionnaire designed by research group,a survey on demographics,basic characteristics of the working environment,the incentive mechanism,and the preference for incentive factors was conducted in all 676 incumbent family physician team members(consisting of family physicians,nurses and public health workers) from 27 community health centers in Xiamen,Hangzhou,Shanghai,and Beijing from July to September 2019,Chi-square test or analysis of variance was used for comparing the demographics and preferred incentives among the members in different positions. Results A total of 676(96.6%) cases who handed in responsive questionnaires were finally included. There were significant differences in the proportion of family doctor special fund and contracted service fee in the monthly income and total income of family doctor team members in different positions(P<0.001),and the proportion of clinical medical workers was higher than that of nursing and public health workers(P<0.016 7). There were significant differences in the evaluation of the matching degree between income and work value of family doctors among different positions of family doctors(P<0.05);the proportion of public health workers who thought that the matching degree of income and work value was higher than that of nursing workers(P<0.016 7). There was no significant difference in the satisfaction of family doctor team members in different positions(P=0.204). There were significant differences in the participation of family doctor team members in different positions(P<0.05);the proportion of clinical medical workers participating in staged refresher training was higher than that of nursing and public health workers(P<0.016 7). The proportion of clinical medical workers participating in relevant professional courses training was higher than that of nursing workers(P<0.016 7). There was no significant difference between the promotion of family doctor team members and the promotion of professional title among different positions(P>0.05).  The majority of family physician team members believed that personal income and welfare were the most important motivators,including 95.6%(387/405) of family physicians,95.7%(180/188) of nurses and 98.8%(82/83) of public health workers. Training opportunities,social recognition and respect,title promotion opportunities ranked the second,third and fourth,respectively. The fifth incentive factor was unit management for family physicians,workload for nurses,and working conditions for public health workers. Conclusion The incentive mechanism varies for family physician team members in different positions. Members engaged in clinical medicine have higher levels of income,welfare and training than those engaged in nursing and public health. Moreover,different family physician team members have different preferences for incentive factors. We should continue to optimize the salary structure of family physician team members,increase family physicians' income and contract service fee,and improve financial incentives;strengthen training,and improve the service capacity at primary health care institutions;protect the rights and interests of medical personnel,and raise their social recognition.
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13. Theoretical Study on the Impact of Incentive Mechanism on Physicians' Practice Behaviors during the Implementation of Contracted Family Doctor System in China 
JING Rize,FANG Hai
Chinese General Practice    2021, 24 (4): 387-391.   DOI: 10.12114/j.issn.1007-9572.2021.00.087
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Background Promoting the delivery of contracted family doctor services is an important way to change the traditional delivery pattern of China's primary health services,and an important task for deepening the reform of the pharmaceutical and healthcare system,and a cornerstone of achieving the Healthy China 2030 goals. Reasonable incentive mechanism may significantly ensure that family doctors take initiative at work. However,there are no theoretical analyses of the impact of the current incentive mechanism,especially the changed health insurance reimbursement methods,on practice behaviors of family physicians. Objective To build up a theoretical framework and a model of family physicians' practice behaviors under the implementation of family doctor system using the principal-agent theory in China. Methods The principal-agent theory was used to develop a model for analyzing the practice behaviors of family physicians under different health insurance payment methods for family physicians,especially when fee-for-service(FFS) and capitation payments coexist. Results If the FFS payment system is used,the moral hazard will be inevitable,and family physicians have no incentive to suppress patients' additional needs. If the capitation payment system is used,the total utility or benefit of family physicians will increase,but the utility obtained from patients' health will decrease. The global budget shall be implemented under the premise that the quantity and quality of health services are reasonably designed,otherwise family physicians will have the motivation to treat patients selectively so as to increase their benefits. The income of Chinese family physicians mainly comes from the medical earnings obtained in FFS and the contracted service fee obtained by capitation. Increasing the proportion of contracted service fee can improve the quality of care provided by family physicians. However,the increase in income may not necessarily have a positive effect on the health care quality,since the earnings obtained in FFS account for a large portion of the income. Conclusion The payment system of family physicians in primary health institutions in China is suggested to be gradually transformed to payment by capitation. At present,family physicians can be encouraged to provide medical services of higher quality by enlarging the proportion of family physicians' contracted service fee in total income.
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14. Financial Incentive Policies for General Practitioners in the UK and Its Inspiration to China
LIU Yong-jun,LIU Na,ZHANG Qi,WANG Zhao,GU Ying-li,LI Zi-yang
Chinese General Practice    2018, 21 (25): 3033-3037.   DOI: 10.12114/j.issn.1007-9572.2018.25.002
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In the UK,the general practitioner system was established rather early,and financial incentive policies for general practitioners(GPs) are relatively well-developed,both of them are important guarantees for the efficient and economic operation of the NHS.In contrast,in China,the development and implementation of the performance appraisal system for GPs are still in the initial phrase,so advanced lessons from abroad should be learned.In order to provide a reference for domestic development of the performance appraisal system for GPs,we systematically introduced the major contents of the financial incentive policies for GPs in the UK,including payment method,structural model,implementation effectiveness,and so on,and proposed suggestions such as developing the authoritative and efficient management and service system for GPs,building the regional comprehensive general practice information network based on the local conditions,improving the wage and welfare levels of GPs as well as enhancing the government investment in general practice.
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15. Effect of Standardized Workload Used in Comprehensive Performance Management in Community Health Institutions: a Practice-based Analysis 
LIN Jixiang,GU Jinghua,WANG Tianying,HUANG Shuxian,JIAO Lulu,GAO Jun,JIANG Wenzhen,ZHANG Wenyu,MA Junling,YANG Huilan,SHEN Yongmei,KANG Jie,CHEN Biao,ZHOU Jingyu,ZHANG Lina,GUO Haiying,et al
Chinese General Practice    2021, 24 (25): 3210-3220.   DOI: 10.12114/j.issn.1007-9572.2021.00.183
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Background Standardized workload is a tool that can be used by community health institutions to accurately measure the manpower consumption in delivering a service. The parameters and variables used in the calculation of standardized workload may involve all aspects of the development of such institutions. Therefore,this tool is highly applicable. However,there is a lack of research on guiding the practical use of it in the operation and comprehensive assessment of community health institutions. Objective To comprehensively and systematically analyze the application of standardized workload in staff performance management by Beicai Community Health Center,providing evidence for organizing the services of a health institution,and for using standardized workload to measure the workload of newly developed services,and to build a relationship between different business departments. Methods A real-world research design was used. The measurement of standardized workload by Beicai Community Health Center was discussed in terms of themes(n=4) and steps(n=6). Results The actual operation process,applied principles and formulas for measuring the performance of all employees and for pricing new services were summarized. Conclusion The experience of Beicai Community Health Center analyzed in detail may be directly used by other community health institutions to guide the measurement of standardized workload,including the pricing of newly developed services,performance assessment for workers in different departments,and so on,which may help to maintain the unity of operation strategies of the institution.
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16. Reform progress and development strategy of general practitioners training and incentive mechanisms in China
QIN Jiangmei,LI Sisi,LIN Chunmei
Chinese General Practice    2020, 23 (19): 2351-2358.   DOI: 10.12114/j.issn.1007-9572.2020.00.379
Abstract567)      PDF(pc) (1209KB)(1007)    Save
To understand the current status and implementation progress of the Opinions on Reforming and Improving the General Practitioners Training and Incentive Mechanisms(〔2018〕 No.3 issued by General Office of the State Council of the People's Republic of China),this paper systematically reviews the documents issued by provinces(autonomous regions and municipalities) in 2018 and typical cases reported in 2019 in China,and analyzes the results of field research in Shanghai,Guangdong,Anhui,Shandong,Hainan,Shaanxi and other provinces(autonomous regions and municipalities) using the relevant data of general practitioners(GPs) in the 2013—2016 China Health and Family Planning Statistical Yearbook and 2018—2019 China Health Statistics Year book.As of December 2018,provinces(autonomous regions and municipalities) in China have issued implementation opinions or plans for GPs,and some of them have made innovations and breakthroughs in policies such as the training of GPs,reforming and improving the salary system for GPs,and expanding the career development of GPs.In 2018,the number of GPs per 10 000 population in China reached 2.22,and 40.6%(13/32) of the provinces(autonomous regions and municipalities) reached the goal of two qualified GPs per 10 000 population in 2020 ahead of schedule.The GP registration rate increased from 33.9% in 2012 to 50.8% in 2018.From the aspect of GP training,the three-stage organic training system for GP college education,GP postgraduate education,and GP continuing education has been further improved in some areas in the past two years.From the aspect of salary system reform,the performance salary of primary health care institutions is approved according to the salary level of public county(district) hospitals,and GP allowance is established internally,and more than 70% of the fee from contracted family doctor service is used for internal distribution in service teams in representative areas.The salary of GPs has been raised.From the aspect of appointment management,some representative regions improve the establishment of a turnover pool system and implement "employed by county and work in township" policy for GPs who have passed the standardized training of resident physicians and practice in rural areas,and give priority to the authorized strength and position to GPs.At the same time,drawing on the experience of representative regions,this article proposes relevant policy recommendations for the weaknesses of GP training and incentive mechanisms,with a view to providing suggestions for the further improvement of the GP system.
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17. 选择性激励下的社区医生签约积极性均衡点研究
贾清萍*,肖森保
Chinese General Practice    2017, 20 (4): 394-398.   DOI: 10.3969/j.issn.1007-9572.2017.04.004
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社区医疗契约服务是一种新型医疗改革制度,是未来医改的方向,政府目标是要在2017年实现家庭医生签约服务覆盖率达到30%以上,而实现该目标的关键是如何调动社区医生的签约积极性,因此,社区医生签约积极性均衡点研究具有重要意义。本文创新性地采用集体行动逻辑下的选择性激励理论分析,探讨一个既能调动社区医生签约积极性,又能平衡其与政府及社区居民之间关系的均衡点,并从社区医生的角度获得了调动社区医生签约积极性的均衡点,认为该均衡点既要考虑社区医生的付出成本与收益间的平衡,也要顾及政府及社区居民对社区医生的贡献索取容忍度。
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18. The Application of Equivalent Method for Cost Accounting and Performance Management in Community Healthcare Institutions
ZHAO Liying, WANG Wei, LI Yuan, LOU Cuidi, CHENG Wei
Chinese General Practice    2023, 26 (13): 1627-1633.   DOI: 10.12114/j.issn.1007-9572.2022.0422
Abstract555)   HTML9)    PDF(pc) (1716KB)(318)    Save
Background

During the promotion of category-based management for community healthcare institutions (class 1 institutions obtain the financial security, and class 2 institutions implement a performance management system), how to appropriately determine the security level and scientifically evaluate the performance is a difficulty to tackle for health administrative departments.

Objective

To assess the operational efficiency of community healthcare institutions with the data envelopment analysis (DEA) using the information of costs of these institutions calculated using the equivalent method, then attempt to develop an input and management model of integrating cost accounting and performance management for these institutions, providing a theoretical basis for accurate and scientific input of various resources into the community through cost measurement with equivalent method, and a data basis for performance assessment in communities with different characteristics through efficiency evaluation.

Methods

The real data (financial status and staffing) of 14 community healthcare institutions during 2019 to 2020 were collected from their financial reports, hospital information system, maternal and child healthcare information system, chronic disease management information system, as well as focus group interviews. The equivalent method was used to calculate the total costs of medical services and public health services. The super-efficiency DEA was used to evaluate and analyze the operational efficiency of the 14 sample institutions.

Results

(1) The average cost of one equivalent service (a general medical outpatient service lasting for 15 minutes was defined as one standard service equivalent unit) was 67.64 yuan in 2019 and 69.80 yuan in 2020 for the 14 institutions. The average cost of one equivalent essential medical service was higher than that of one equivalent public health service in both 2019 (167.14 yuan vs 18.86 yuan) and 2020 (215.43 yuan vs 19.78 yuan). The institutions demonstrated significant differences in the average cost of one equivalent essential medical service and the average cost of one equivalent public health service. (2) Each institution had its own peculiar characteristics. For example, S1 institution mainly provided essential medical services, and had higher total equivalent essential medical services and efficiency than other institutions, while S9 institution focused on providing public health services, and had the highest efficiency in delivering public health services. (3) In 2020, the 14 institutions provided 134 800 equivalent COVID-19-related services, with a cost of 1.037 8 million yuan. (4) In 2019 and 2020, only two institutions were relatively overall efficient, and ≥50.0% institutions were pure technically efficient. The institutions with overall operational inefficiency were mainly caused by scale inefficiency primarily due to increasing returns to scale.

Conclusion

The equivalent method provides a relatively unified "scale" to standardize the service efficiency of different types of community healthcare institutions, provides support for health administrative departments implementing category-based compensation for the institutions, benefiting the featured and high-level development of community healthcare institutions. Either institutions delivering essential medical services or those delivering public health services, mainly present increasing returns to scale, suggesting that the efficiency of these institutions can be improved by increasing the human/financial/material input into the institutions and providing precise compensation for them.

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19. Demands and Strategies Analysis of Family Doctors' Performance Evaluation in the Delivery of Contracted Services in China 
ZHANG Yanchun,LIU Zhihua,QIN Jiangmei,LIN Chunmei,ZHANG Lifang
Chinese General Practice    2019, 22 (10): 1133-1138.   DOI: 10.12114/j.issn.1007-9572.2019.10.002
Abstract554)      PDF(pc) (1044KB)(1041)    Save
Background As the implementation of contracted family doctor services is well developing,new service delivery models are forming,it is necessary to develop a national performance evaluation system for family doctors in the delivery of such services.Objective To investigate the status of family doctors' performance evaluation in the delivery of contracted services,and the awareness levels of the contents and indicators in the evaluation system for family doctors' performance in the delivery of such services,and implementation of incentives among the government health administrators and mangers of primary health care facilities,and to put forward solutions to existing problems.Methods This questionnaire survey was conducted at the national training sessions of supportive policies for contracted family doctor services held in Jinan,Zhengzhou and Changsha(provincial capitals of Shandong,Henan and Hunan Provinces) and Chongqing(a province-level municipality) during June to July 2017 by the China National Health Development Research Centre.The final participants were 591 trainees,including all the administrative workers(227 cases) from 32 provincial health administrative departments and 114 prefectural/municipal health administrative departments,and a convenience sample of managers(364 cases) from primary care facilities in Jinan,Zhengzhou,Changsha and Chongqing.A self-developed questionnaire was used,which consists of basic demographic data,awareness level of the setting of evaluation indicators for family doctors' performance and incentives for the implementation of contracted family doctor services.The survey achieved a response rate of 95.3%(591/620).Results In terms of quantitative assessment indicators that should be included,population coverage,key population coverage,rural poverty-stricken population coverage,and coverage of special population receiving family-planning services were proposed by 70.1%(414/591),92.0%(544/591),70.1%(414/591) and 68.4%(404/591) of the respondents,respectively.Moreover,target population's satisfaction rate,completion rate of contractual service package,and eligibility rate of electronic health records of the contracted residents were put forward by 92.4%(546/591),81.6%(482/591),and 72.6%(429/591) of the respondents,respectively.What's more,rate of initial consultation in primary care,rate of visiting the contracted family doctor for medical services,referral rate of the appointed patients were recommended by 85.4%(505/591),78.3%(463/591),and 66.2%(391/591)of the respondents,respectively.As for incentive system,290(49.1%) of the respondents reported that the contracted services were delivered with a fee in their region/ facility.Among them,78.3%(227/290) reported that the service fee was used to incentivize the family doctor team,and 39.0%(113/290)reported that that the service fee was included in the total performance-related pay.The funding source for the fee was reported to come from fiscal subsidies 〔27.6%(80/290)〕,medical insurance programs 〔31.4%(91/290)〕,essential public health service funding〔80.3%(232/290)〕,and out-of-pocket money of the residents receiving contracted services〔30.0%(87/290)〕.Conclusion Most of the health administrators and managerial workers of primary care thought that quantitative and qualitative indicators should be considered as the essential part of the system for assessing the performance of family doctors in delivering contracted services.Initial consultation in primary care should be promoted and be listed as an assessment indicator as well.Furthermore,in order to incentivize the family doctors and increase their enthusiasm for work by additional bonus payments,the funding sources for the fee for contracted services should be ensured.
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20. Construction of a Performance Evaluation System for Elderly Care Institutions Delivering Integrated Medical and Nursing Care 
XIAO Xiaohua,HUANG Zhuomin,WU Yafei,YAN Mengqi,LI Bei
Chinese General Practice    2019, 22 (26): 3233-3237.   DOI: 10.12114/j.issn.1007-9572.2019.00.153
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Background At present,it is difficult to ensure the quality of services of elderly care institutions delivering integrated medical and nursing care in China,partly due to the imperfect performance evaluation mechanism for such institutions.But correct evaluation results are directly related to the quality of elderly care and the development of such institutions,so it is necessary to construct a sound performance evaluation system for such institutions.Objective To construct and verify a scientific and rational performance evaluation system for elderly care institutions delivering integrated medical and nursing care.Methods From August to November 2018,we conducted two rounds of telephone-based or face-to-face consultations using Delphi technique in experts with 10 years of research experience in social welfare industry management,elderly care institutions management,geriatric disease management,health administration,health management teaching,and clinical medicine and with an associate professor or professor title.We used analytic hierarchy process and analysis of membership function to determine the 3 dimensions(input,outcome and outcomes)and indicator weights of the performance evaluation system for elderly care institutions delivering integrated medical and nursing care.We tested the reliability the system using Cronbach's alpha coefficient.Results The degree of familiarity(Cs)of the experts' authority in the two rounds of consultation was 0.679 and 0.768,respectively.The selection basis(Ca)was 0.614 and 0.657,respectively,and the authoritative coefficient(Cr)was 0.646 and 0.713,respectively.The Kendall's W of the two rounds of expert consultation was 0.394 and 0.426,respectively,showing a significant difference(χ2=481.049,504.768,P<0.001).In accordance with the consultation results,we revised and improved the initial system,and established a performance evaluation system for elderly care institutions delivering integrated medical and nursing care finally,which consists of 3 first-level dimensions,and 8 second-level dimensions,and 49 third-level indicators,and assigned weight to each indicator.The weights for 3 first-level domains were 0.216 3,0.576 2,0.207 5,respectively,and the combined weights CR were all <0.10.The reliability test results showed that the Cronbach's alpha coefficients of each dimension and the total Cronbach's alpha coefficients were all>0.800.Conclusion Our system was proved to have high reliability and validity,which can provide scientific and feasible supports for decision-making by related departments.
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21. Impact of Pay-for-performance Program for Family Physicians on Medical Expenses of Type 2 Diabetics 
ZOU Xin, HAN Yarong, GUAN Shenyi, TANG Zemin, QIU Min, ZHANG Shuqin, WU Xuming, GAO Yuexia
Chinese General Practice    2021, 24 (13): 1644-1649.   DOI: 10.12114/j.issn.1007-9572.2020.00.043
Abstract546)      PDF(pc) (963KB)(583)    Save

Background A diabetes pay-for-performance(P4P) program has been implemented in Haimen District since January 2018,to incentivize family physicians to improve the quality of family physician care for type 2 diabetics.Objective To investigate the impact of P4P program for family physicians on type 2 diabetics' blood glucose control,medication compliance,health service utilization and medical expenses. Methods From March to June 2019,we selected type 2 diabetics from the name list of confirmed type 2 diabetics receiving the management from village health clinics(one was extracted every 10 cases) in Nantongli Tongzhou and Haimen Districts,including 496 with care delivered by family physicians incentivized by the P4P program(incentive group),and 589 with care delivered by family physicians without the program as an incentive(control group),and surveyed them using a questionnaire for collecting their information involving demographics,healthcare utilization,medical expenses,fasting blood glucose and medication compliance. Negative binomial regression,Logistic regression and OLS regression were used to analyze the influencing factors of annual outpatient visits,annual inpatient service utilization and medical costs. Results There were statistically significant differences between the two groups in terms of the distribution of education level and mean number of coexisted chronic diseases,and annual household income(P<0.05). The incentive group had statistically lower mean fasting blood glucose level,less mean number of annual outpatient visits,lower annual inpatient service utilization rate and lower mean annual total medical costs than the control group(P<0.05). The incentive group also showed statistically higher medication compliance(P<0.05). After adjustment for demographic characteristics and fasting blood glucose,multivariate regression analysis found that compared with the control group,the incentive group demonstrated a reduction of 34.6% in mean annual outpatient visits(IRR=0.654,P<0.05),an increase of 54.96%(eb-1=0.549 6,P<0.05) in mean annual medication cost,and a decrease of 34.43%(eb-1=-0.344 3,P<0.05) in mean annual total medical costs. Further age-based subgroup analysis found that compared with the patients aged <60 and >70 in the control group,the number of outpatient visits of the same age patients in the incentive group decreased by 63.2%(IRR=0.368,P<0.05) and 54.2%(IRR=0.458,P<0.05) respectively;compared with the patients aged >70 in the control group,the utilization rate of inpatient services of the patients aged >70 in the incentive group decreased by 48.0%(OR=0.520,P<0.05). Conclusion The diabetes P4P program for family physicians may partially contribute to reducing the outpatient care utilization in type 2 diabetics,and reducing the annual inpatient service utilization rate and annual total medical costs in over 70-year-old type 2 diabetics.

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22. Conceptual Framework Model of Performance Evaluation of Family Doctors' Contracted Services 
HUANG Jinling,CONG Ziwei,YANG Yang,ZENG Zhirong
Chinese General Practice    2019, 22 (13): 1516-1521.   DOI: 10.12114/j.issn.1007-9572.2019.00.127
Abstract533)      PDF(pc) (1217KB)(864)    Save
On the basis of a comparative analysis of common international frameworks for healthcare performance evaluation,we developed clear ideas for establishing a family doctors' performance appraisal framework in the delivery of contracted services in China,determined its contents,and divided it into five subscales(structure,input,process,output,outcomes)using content analysis.Moreover,output and outcomes of family doctor services were distinguished from the demand-supply perspective.Our framework can provide guidance for the establishment of a scientific family doctors' performance management mechanism in the delivery of contracted services.
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23. Performance Evaluation Indicators Screening for the Vertical and Compact Medical Consortium 
WANG Manli,FANG Haiqing,TAO Hongbing
Chinese General Practice    2020, 23 (28): 3533-3539.   DOI: 10.12114/j.issn.1007-9572.2019.00.724
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Background The vertical and compact medical consortium is an important form of the integration of medical institutions in China,whose performance evaluation is directly related to its sound development. Hence,it is necessary to construct a sound performance evaluation system for this type of medical consortium. Objective To establish a framework for the performance evaluation of the vertical and compact medical consortium,to provide a reference for the construction and performance management of medical consortiums in China. Methods We conducted this study from August 2017 to October 2018. On the basis of analyzing related literature and semi-structured interview results,we developed the initial version of vertical and compact medical consortiums performance evaluation system(VCMCPES),and revised it in accordance with results of two rounds of Delphi consultation with 16 experts. We used the Kendall's W to assess the agreement among experts. Results The expert response rate of two rounds of consultation was 100.0%,the anthority coefficient of two-round of Delphi consultation was 0.73,the coordination coefficients for the two-round of Delphi consultation were 0.30,0.51(P<0.01),respectively,meeting the requirements of Kendall's W test. Finally,a framework of VCMCPES was developed,which consisted of six first-level indicators including accessibility of health services,quantity of health services,quality of health services,efficiency of health services,effect of health services and affordability of health services and 24 second-level indicators. Conclusion The response level,authority coefficient and coordination coefficient of the experts involved in the consultation are high. And the reliability and specificity of the included indicators are good. To optimize the system,expert consultations should be carried out,and the indicators should be verified further.
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24. Competence-based Incentive Payment Mechanism for General Practitioners in a Family Doctor Team 
LI Hao,LI Jinlin,ZHU Jingrong
Chinese General Practice    2020, 23 (1): 19-24.   DOI: 10.12114/j.issn.1007-9572.2019.00.630
Abstract519)      PDF(pc) (1073KB)(929)    Save
The development of a competence-based incentive payment mechanism for general practitioners(GPs) is beneficial to the increase of GPs' initiative in delivering contracted family doctor services.We firstly calculated the competency-based marginal cost for GPs by use of combination weighting algorithm,then developed a proactive incentive payment mechanism by competence level using the principal-agent theory,namely,according to their own competence,GPs actively choose the level of performance and performance-related pay listed in the incentive payment mechanism for GPs designed by the government department,by which a win-win situation can be achieved for the government department and GPs.By use of this mechanism,equal pay for equal work regardless of the levels of performance may be changed,and the pay may be closely associated with performance of GPs,realizing incentive cooperation between the government department and GPs.
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25. Incentive Policies for Allocating High-quality Health Resources to Primary Healthcare Institutions: an Analysis from the Perspective on Policy Tools 
ZHANG Jiarui,ZHANG Shu'e,YIN Dong,FAN Lihua,HUANG Ying,ZHAI Chuncheng,SHI Lei,SUN Tao
Chinese General Practice    2019, 22 (34): 4190-4196.   DOI: 10.12114/j.issn.1007-9572.2019.00.446
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Background Incentives for quality health resources to sink depend on government policies.Policy tools are designed and appropriately selected by the government to drive a series of health sector reforms,so interpreting these tools can best reflect the healthcare reform process.Objective To explore the characteristics and blind spots of 30 policy documents issued by the central government and the provinces and cities focused on model medical reform,so as to provide a good guide for the effective subsidence of quality health resources.Methods Using content analysis,from three dimensions of policy classification framework,core competitiveness of medical institutions and policy targets,we selected and interpreted 30 policies incentivizing the allocation of high-quality health resources to primary care issued by the central government,and the provincial and municipal governments of the focus demonstration provinces and cities during the ten years from January 2009 to December 2018 as research objects.With "quality health resources sinking and incentive policy analysis" as the key words,the paper searched through the government portal website,Chinese reform information database and other channels,and analyzed based on the policy classification framework,the core competitiveness of medical institutions and the target of policy action.Results Among the 150 text units,environmental policy tools were more widely used,accounting for 61.3%(92/150),supply policy tools 24.7%(37/150),and demand policy tools were less used,accounting for only 14.0%(21/150).Among environmental policy tools,institutional mechanisms are more frequently used than other tools,accounting for 22.8%(21/92) and 21.7%(20/92),respectively.Among the supply-oriented policy tools,the application frequency of training assistance and information platform is relatively high,accounting for 32.4%(12/37) and 27.0%(10/37),respectively.Among the demand policy tools,the traditional medicine service policy tools only account for 14.3%(3/21) of the demand policy tools.In addition,in the dual dimension,the policy items were mostly focused on diagnosis and treatment(60.0%),followed by preventive screening(33.3%),and the least involved rehabilitation and health care stage(6.7%).Conclusion We found some core problems existing in the policies,such as the overuse of mandatory environmental policy tools,insufficient effectiveness of supply policy tools in meeting the public health needs,weak interactions between the environmental policy tools,and lack of functionally optimized complementarity between the policy tools.To further incentivize the allocation of high-quality health resources to primary care in China,we put forward the following suggestions:appropriately weakening or reducing the use frequency of mandatory environmental policy tools,increasing the use frequency of supply and demand policy tools,exploration of the optimal combination of policy tools,and appropriately using policy tools according to the specific time and local conditions.
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26.
Literature Analysis of Performance Appraisal of Basic Medical Institutions in China
蒋易芬,蒲川,张力
Chinese General Practice    2016, 19 (25): 3020-3023.   DOI: 10.3969/j.issn.1007-9572.2016.25.005
Abstract509)      PDF(pc) (553KB)(455)    Save
 Objective  To understand the research status of performance appraisal of basic medical institutions in China,and to provide references for establishing perfect performance appraisal system of basic medical institutions.
 Methods  Related literatures of performance appraisal of basic medical institutions(including community health service center/station,health clinics in towns and townships and village clinics) were included through the searching of Chinese National Knowledge Infrastructure.Literature information extraction table was made by the author to collect basic characteristics of literatures,including research time,research sources,research objects,research categories,research areas and research funds sources.On the basis of further literature screening,related contents of performance appraisal including index types,methods of establishing appraisal system,appraisal cycle,appraisal modes and dimensions were collected.Descriptive analysis was made through applying SPSS 19.0 statistical software.
 Results  According to the literature search strategies,518 literatures were obtained,and finally 92 were included in accordance with inclusion and exclusion criteria.Studies on performance appraisal of basic medical institutions in China started in 2006,54(58.7%) literatures were included from 2012 to 2014;the number of literatures with research source of scientific research institutions and community health service center/station was 28(30.4%) and 19(20.7%) respectively;while the number of literatures with research objects of health clinics in towns and townships and community health service center/station was 42(45.6%) and 39(42.4%);the number of literatures with research categories of current status analysis and index system construction were both 23(25.0%);the number of literatures with research areas of eastern region and western region was 50(54.3%) and 18(19.6%) respectively;27(29.4%) had funding supports.21 were retrieved by further screening,of which 15(71.4%) literatures′ type of performance appraisal index was mainly based on service quantity and service proportion;considering methods of establishing evaluation system,13(61.9%) adopted Delphi method and 11(52.4%) used literature analysis method;in terms of appraisal cycle of institutions,half-year and annual cycle literature numbers were both 3(14.3%);12(57.1%) applied the appraisal manner of superior examination and self-inspection;and 8(38.1%) literatures took appraisal dimension of functions.
 Conclusion  Basic medical institutions in China starts relatively late on studies of performance appraisal,and presents the following shortages:lack of the participation of township health institutions and health administration institutions,relatively less usage of quantitative methods,relatively single appraisal modes and dimensions,and lack of long period appraisal.The exploration of performance distribution and influence factors needs to be strengthened.
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27.
 Pay-for-performance in UK and the United States and Its Implications for Performance Appraisal of Community Health Service Institutions in China
张力,蒲川,成秋娴,李仪,蒋易芬
Chinese General Practice    2016, 19 (25): 3014-3019.   DOI: 10.3969/j.issn.1007-9572.2016.25.004
Abstract494)      PDF(pc) (552KB)(684)    Save

 Establish scientific and efficient performance appraisal system can improve service quality of community health service institutions and regulate service behaviors.This paper summarizes the implementation of pay-for-performance(P4P) in UK and the United States and current situation and problems of performance appraisal in Chinas community health service institutions,and puts forward the implications of P4P in UK and the United States for our country,hoping to provide references for the formulation,implementation and feedback of performance appraisal in Chinas community health service institutions.

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28. 北京市朝阳区社区卫生服务机构绩效考核改革效果研究
杨非衡,倪娜娜,朱磊,杨桦,高运生,何欢,孙思伟,刘宝花
Chinese General Practice    2016, 19 (04): 386-391.   DOI: 10.3969/j.issn.1007-9572.2016.04.005
Abstract486)      PDF(pc) (682KB)(480)    Save
目的  评价北京市朝阳区社区卫生服务机构绩效考核改革的效果。方法  本研究资料来源于2012、2013年北京市朝阳区社区卫生服务管理中心对辖区内29家社区卫生服务机构两年的绩效考核数据,通过对考核指标数据的统计分析来评价绩效考核改革效果。绩效考核指标包括基本医疗工作量、公共卫生工作量、公共卫生工作量在总工作量中的比重、综合K值、医药比、次均门诊费用、人均绩效工资。结果  2012、2013年的基本医疗工作量分别为673 756(761 165)、1 110 182(803 117),公共卫生工作量分别为178 324(72 167)、322 636(133 418),公共卫生工作量在总工作量中的比重分别为19.78(10.38)%、22.91(13.94)%,医药比分别为0.104(0.031)、0.135(0.059),每月人均绩效工资分别为3 992(1 940)、2 925(735)元,差异均有统计学意义(P<0.05);综合K值分别为8 385(982)、8 338(647),次均门诊费用分别为164.5(56.1)、180.3(38.5)元,差异均无统计学意义(P>0.05)。2012年和2013年的人均基本医疗工作量、医药比、次均门诊费用均与人均绩效工资呈正相关(P<0.05);2012年和2013年的公共卫生工作量在总工作量中的比重、2012年综合K值与人均绩效工资呈负相关(P<0.05)。结论  朝阳区2013年的绩效考核改革取得了一定成效,基本医疗和公共卫生工作量上升,工作重心向公共卫生服务转移,遏制了医药费用过快增长,增强了社区卫生服务机构的公益性;但工作质量和效率未得到显著提高,人均绩效工资各机构间差异减小,改革方案有待进一步完善。
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29. Value of Principle of Selective Excitation Technique and Diffusion Tensor Imaging in the Evaluation of Unilateral Lumbosacral Nerve Root Entrapment Caused by Lumbar Disc Herniation 
LI Li-yan1*,GUO Yun-zhi1,HAN Xiao-mei1,CHU Li-juan1,MA Yun-tao1,ZHOU Shun-ke2
Chinese General Practice    2018, 21 (15): 1827-1831.   DOI: 10.3969/j.issn.1007-9572.2017.00.239
Abstract482)      PDF(pc) (1195KB)(616)    Save
Objective To explore the clinical value of magnetic resonance(MR) principle of selective excitation technique(PROSET) and diffusion tensor imaging(DTI) technique in evaluating L4-S1 unilateral lumbosacral nerve root compression caused by lumbar disc herniation(LDH) locationally and quantitatively.Methods We enrolled 20 cases of unilateral nerve root compression within L4-S1 innervation area due to LDH diagnosed clinically and treated in Jilin City People's Hospital in 2015.MR PROSET and DTI were performed for localizing the three regions of interest(ROI) respectively at preganglionic nerve root sheath out of dural sac,the ganglion and the anterior branch of the postganglionic nerve expenditure at the external orifice of the intervertebral foramen,and measuring fractional anisotropy(FA) and apparent diffusion coefficient(ADC) value.Meanwhile,diffusion tensor tractography(DTT) was also applied to observe the bilateral L4-S1 nerve roots.Results There were totally 25 herniated discs among the 20 LDH patients(28 unilateral nerve root compression),including 22 lateral side types(22 unilateral nerve root compression) and 3 intraforaminal types(6 unilateral nerve root compression).The features of PROSET of each type of LDH:the intraforaminal type showed that the nucleus pulposus pushed the ipsilateral epistatic nerve root outward and upward,and pushed the inferior nerve root inward slightly,while nucleus pulposus only pushed the ipsilateral inferior nerve root inward and backward in lateral side type of LDH.DTT of lumbosacral nerve plexus showed that tract sparsity,narrowing and abrupt break of compressed side nerve root were displayed in all the cases.On the same level of L4-S1 nerve roots,ADC value was significantly higher in the compressed side compared to the normal side nerve root(P<0.05);the FA value was significantly lower in the compressed side compared to the normal side nerve root(P<0.05).On the same nerve root,the difference among the three levels was statistically significant(P<0.05).Conclusion PROSET,DTI and FT could be used to evaluate the lumbosacral nerve root compression syndrome and locationally and quantitatively assess compressed nerve roots in patients with LDH.
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30. Construction of Incentive Mechanism for Family Doctor Contracted Services Based on Comprehensive Incentive Model 
WANG Meinan,ZHAO Panpan,WANG Yiting,LIN Zhenping,QIAN Dongfu
Chinese General Practice    2020, 23 (12): 1523-1528.   DOI: 10.12114/j.issn.1007-9572.2019.00.813
Abstract481)      PDF(pc) (1168KB)(1246)    Save
IThis paper sorts out the incentive mechanism of family doctor contracted services at home and abroad,analyzes the problems existing in the incentive mechanism of domestic family doctor contracted services,and finds that the incentive mechanism is insufficient in theoretical research.On the basis of comprehensively analyzing the comprehensive incentive model,this paper constructs a family doctor contacted service incentive model based on comprehensive incentive model.It is proposed a combination of material incentives and spiritual incentives,internal incentives and external incentives,positive incentives and negative incentives,individual incentives and team incentives,and the improvement of supporting measures and other incentive strategies.
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31. Construction of Incentive Salary Model Based on Family Doctor Services System 
GUI Xiao-hai1,WANG Hong-bo,LIU Hui,YANG Yu-feng
Chinese General Practice    2018, 21 (25): 3038-3043.   DOI: 10.12114/j.issn.1007-9572.2018.25.003
Abstract476)      PDF(pc) (1720KB)(1115)    Save
Objective To explore the model of incentive system for physicians under the family doctor services system and its influencing factors,so as to provide support for medical reform and the implementation of family doctor services system.Methods Following a literature search on policies of family doctor services system and salary system for medical staff,the incentive salary model for family doctor services was divided into 3 parts:the balance of medical insurance fund according to the prepaid package,package service fee of chronic diseases such as diabetes and high blood pressure,and traditional medical income paid by inspection items.We then constructed the incentive salary model and analyzed its influencing factors according to doctors' net income function from Handbook of Health Economics.A total of 3 182 residents were selected in the Haidian District Family Doctor Pilot Program to analyze the relationship between the patient's age,illness and medical expenses in October 2016.Results Based on the established incentive salary models,we found that health insurance payment methods,doctor behavior and patient characteristics affected incentive salaries of medical staff.The incentive salary was maximized when the productivity of the doctor reached the maximum,the service subject had minor illness with less medical expenditure.Based on the study in Haidian District,medical expenses rose as the patient ages.A small number of patients with frequent visits and serious illnesses were key determinants of medical insurance control and incentive salary.Conclusion It is necessary to establish a flexible salary model for medical staff that meets the characteristics of the family doctor services system.Combination of payment methods,improvement of medical services quality,information technology,and data-based means can realize patient segmentation and personalized performance assessment to achieve common interests of health insurers,doctors and patients.
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32.
Construction of Performance Appraisal Indicator System of Family Doctors
徐蕾,赵琦,朱敏杰,袁立,王蔷,江萍,徐飚
Chinese General Practice    2016, 19 (25): 3024-3028.   DOI: 10.3969/j.issn.1007-9572.2016.25.006
Abstract462)      PDF(pc) (561KB)(583)    Save

 Objective  To establish performance appraisal indicator system of family doctors to help perfect work patterns and standardized services of family doctors.

 Methods  20 managers (directors,directors in charge of performance appraisal) were selected by purposive sampling method from all of the 10 community health service centers of Changning District as the first-round consultant experts;relevant managers of health and family planning commission,community health management center,public health institutions and community health service centers in Changning District and family doctors of community health service centers in Changning District were selected as the second-round consultant experts with a total number of 40.Performance appraisal indicator system of family doctors was established by Delphi method after two-round expert consultation.

 Results  20 questionnaires were sent out and 19 were recovered in the first-round expert consultation,the valid response rate was 95.0%;40 questionnaires were sent out and 39 were recovered in the second-round expert consultation,the valid response rate was 97.5%.Judgment coefficient of experts was 0.894,coefficient of familiarity degree was 0.905,and coefficient of degree of authority was 0.900.Cooperation index of experts in the first round was 0.21 (χ2=12.11,P>0.05);and cooperation index of experts in the second round was 0.42 (χ2=49.76,P<0.05).After two-round expert consultations,7 first-grade indicators were determined,they were informatization management of data,signing of contract,basic medical services,health management,signing of contract and medical services,satisfaction degree and medical expenses,17 secondary indicators and 29 third-grade indicators.

 Conclusion  The established performance appraisal indicator system of family doctors has certain authority and operability,better covers the key points of the work of family doctors,and can be used as tools of assessing services of family doctors,improving the provision mechanism of services,and perfecting connotation of services in recent period.

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33. Implementation Progress in Performance Appraisal for the Staff of Community Health Institutions in China after New Health Reform 
YUAN Linlin,SHAO Yuchen,REN Lemeng,SUN Xiaojie
Chinese General Practice    2018, 21 (28): 3417-3422.   DOI: 10.12114/j.issn.1007-9572.2018.28.003
Abstract452)      PDF(pc) (1005KB)(623)    Save
A performance appraisal system is to motivate providers to effectively promote the transformation of service model,improve quality and efficiency of healthcare and sustain strong performance,as well as to motivate the enthusiasm of medical staff.This article introduced several performance appraisal systems for the staff in Chinese community health institutions after the new health reform.We also discussed their strengths and limitations.As "health gatekeepers",community health institutions need to upgrade the performance appraisal system to define job functions clearly,choose key performance indicators wisely,provide impactful incentives to key performers,use performance data to improve care,and improve the efficiency of appraisal process with new information technology "Internet+".
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34. 英国与中国全科医疗绩效考核比较研究
王宇1,2,3,张先福1,2,3,吴学谦1,2,3,吴洪涛1,2,3,王春平1,2,3*,吕军2,4
Chinese General Practice    2017, 20 (25): 3067-3071.   DOI: 10.3969/j.issn.1007-9572.2017.25.001
Abstract435)      PDF(pc) (687KB)(804)    Save
我国全科医疗绩效考核制度的发展和实施仍处于初步阶段,而科学稳定的绩效考核体系可以提高家庭医生团队的服务质量和工作效率,目前仍需借鉴国外先进的经验。2004年英国将质量和结果框架(QOF)引入全科诊所付费和质量控制系统,并制定了相应的绩效工资补偿机制。本研究介绍并比较了我国与英国全科医疗绩效考核体系的内容、指标构成和主要补偿机制,并提出我国应建立一套科学统筹的绩效考核机制、鼓励多方参与绩效管理、做好考核结果反馈及完善补偿机制等建议,以期为我国全科医疗绩效考核机制的完善提供参考。
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35. 社区卫生服务中心团队绩效考核方案实施效果研究
肖俐,黄睿,陈博文
Chinese General Practice    2015, 18 (31): 3781-3786.   DOI: 10.3969/j.issn.1007-9572.2015.31.004
Abstract420)      PDF(pc) (607KB)(774)    Save
目的 探讨团队绩效考核方案在社区卫生服务中心中的实施效果。方法 于2013年10月—2014年9月,以成都市武侯区晋阳社区卫生服务中心的6个全科服务团队为研究对象,采用随机数字表法将其平均分为对照组和试验组。对照组采用个人绩效考核方案,试验组采用团队绩效考核方案,开展时间均为12个月。结束后,比较并分析两组的工作量、工作质量、年人均绩效及满意度。结果 (1)2014年试验组门诊数低于对照组,而健康管理、新建基本健康档案及慢性病管理等公共卫生服务的工作量均高于对照组。(2)2013年和2014年,两组基本医疗服务工作质量得分和公共卫生服务工作质量得分比较,差异均无统计学意义(P>0.05)。2014年两组基本医疗服务工作质量得分与2013年比较,差异均有统计学意义(P<0.05)。试验组公共卫生服务工作质量得分与2013年比较,差异有统计学意义(P<0.05);而对照组公共卫生服务工作质量得分与2013年比较,差异无统计学意义(P>0.05)。(3)2013年两组医生年人均绩效和护士年人均绩效比较,差异无统计学意义(P>0.05)。2014年两组医生年人均绩效比较,差异无统计学意义(P>0.05);而护士年人均绩效比较,差异有统计学意义(P<0.05)。2014年对照组医生年人均绩效和护士年人均绩效与2013年比较,差异均无统计学意义(P>0.05);而试验组医生年人均绩效和护士年人均绩效与2013年比较,差异均有统计学意义(P<0.05)。(4)两组医务人员对收入、绩效考核方式激励性、团队协作的满意度比较,差异有统计学意义(P<0.05);而对绩效分配合理性的满意度比较,差异无统计学意义(P>0.05)。两组就诊患者对诊疗计划的解释、医生服务态度、总体的满意度比较,差异有统计学意义(P<0.05);而对倾听及解答疑问、医生诊疗水平、护士护理水平、护士服务态度的满意度比较,差异无统计学意义(P>0.05)。结论 与个人绩效考核方案相比,团队绩效考核方案能更好地提高社区医务人员的工作量和工作质量,尤其是公共卫生服务;可以提高社区医务人员的绩效水平,激励性较好;医务人员和就诊患者的满意度均较高。
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36. 全科医生激励约束机制的国际经验和启示
朱晓丽,黄菊,马晓静,杨顺心
Chinese General Practice    2015, 18 (25): 3001-3005.   DOI: 10.3969/j.issn.1007-9572.2015.25.001
Abstract414)      PDF(pc) (601KB)(1608)    Save
建立完善的激励约束机制是提高全科医生职业吸引力的根本。本文从支付方式、约束机制、对偏远地区激励等方面对部分典型国家和地区全科医生的激励约束机制进行梳理和分析,总结出三个经验:要建立与医保挂钩的混合支付方式;通过完善法律法规、加强行业管理和建立竞争机制等手段约束全科医生的行为;通过经济激励、拓展职业发展前景和培养本地全科医生等手段吸引全科医生到农村或偏远地区工作,为建立我国全科医生激励约束机制提供借鉴。
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37. 卫生人才激励机制改革背景下医务人员离职意愿研究
刘坤1,荆丽梅1*,周徐红2,孙晓明1,3,王俐2,娄继权1,陈层层1,吴娟2
Chinese General Practice    2017, 20 (19): 2338-2341.   DOI: 10.3969/j.issn.1007-9572.2017.19.009
Abstract401)      PDF(pc) (676KB)(704)    Save
目的  探讨卫生人才激励机制改革背景下医务人员的离职意愿。方法  于2015年6月15-30日,在享受《关于加强浦东新区农村卫生人才队伍建设的实施意见》(“卫生八条”)政策的A(偏远农村12家)、B(一般农村11家)、C(城郊结合9家)3类共32家社区卫生服务中心,选取所有与政策实施相关的医务人员3 800例。采用自行设计的问卷对纳入医务人员进行调查,主要内容包括医务人员的基本信息、离职意向、离职原因及离职去向。结果  共回收有效问卷3 295份(A类1 020份、B类1 206份、C类1 069份),问卷有效回收率为86.7%。3 285例医务人员填写了离职意愿,其中520例有离职意向,意向离职率为15.8%。不同地区、岗位医务人员的意向离职率比较,差异有统计学意义(P<0.05);不同性别、学历、职称医务人员的意向离职率比较,差异无统计学意义(P>0.05)。离职原因排在前4位的分别为其他工资待遇(57.1%,297/520)、工作压力(50.0%,260/520)、“卫生八条”奖励待遇(39.4%,205/520)、发展空间(19.6%,102/520)。离职去向排在前4位的分别为离开卫生行业(43.7%,227/520)、其他卫生事业单位(20.0%,104/520)、二/三级医院或专科医院(18.5%,96/520)、“卫生八条”奖励待遇更高的偏远地区(18.3%,95/520)。结论  卫生人才激励机制改革政策实施以来,医务人员的意向离职率较低,激励政策起到了正向引导医务人员向偏远地区流动的作用,其他工资待遇和“卫生八条”奖励待遇均是影响离职意愿的重要因素,近半数有离职意向的医务人员想离开卫生行业。
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38. 医事服务费试点对医生薪酬及工作的影响研究
王冰玉,张文晓,郭泽华,刘大锦,谢铮,崔涛,简伟研,王志锋
Chinese General Practice    2015, 18 (19): 2325-2328.   DOI: 10.3969/j.issn.1007-9572.2015.19.019
Abstract379)      PDF(pc) (1181KB)(749)    Save
目的  了解医事服务费试点后医生在薪酬和工作方面发生的变化。方法  选择北京市某三级甲等综合医院作为研究现场,该院自2012年9月启动"医药分开"试点。依据滚雪球法确定样本,按照信息饱和原则决定访谈样本量,采用个人深入访谈法,对1名医院中层管理者和14名医护人员进行访谈。访谈核心内容包括医事服务费试点前后院科薪酬分配方式、个人薪酬构成、试点后薪酬增长量;试点前后被访者日常工作内容、工作量方面发生的改变以及对当前薪酬与工作量的匹配程度、对医生劳动价值的体现程度等个人看法。采用MAXQDA10对访谈资料进行编码分析。结果  试点后,医生薪酬构成中增加医事服务费一项,其每月薪酬总数增加,门诊量大、职称高的医生薪酬增加幅度较大。以药物治疗为主的内科诊室门诊量增长明显,以技术治疗为主的外科和口腔科,门诊量变化不大。在其他政策并行推进后,大处方、不合理处方现象得到改善。结论  医事服务费的设立使医生薪酬数量增加,体现医生劳动价值;规范医生诊疗行为的同时,也使不同科室医生的工作量发生改变。
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39. Analysis of the Performance Evaluation of Basic Public Health Service Projects in Chongqing in 2016
PAN Lun1,LING Bin1*,HE Ping1,CHENG Sa-nuo1,HU Bin2,WU Jian-hua3
Chinese General Practice    2018, 21 (13): 1550-1554.   DOI: 10.3969/j.issn.1007-9572.2018.13.008
Abstract373)      PDF(pc) (1054KB)(490)    Save
Objective To understand the performance evaluation of basic public health service projects in 2016 in Chongqing and to provide suggestions for improving the quality of basic public health services.Methods According to the corresponding report(Chongqing Basic Public Health Service Project Performance Appraisal)within the database of the Chongqing Community and Rural Health Association,12 items of public health service performance evaluation data of four functional areas,including the Chongqing urban functional core area + the urban function expansion area,the urban development new area,the ecological conservation area of north Chongqing,and the ecological conservation area of southeast Chongqing,were collected and compared.Results The overall scores of basic public health services in the fourfunctional areas were(0.97±0.02)%,(0.98±0.10)%,(0.88±0.13)%,and (0.83±0.14)%,respectively,which was a statistically significant difference(P<0.05).The scores of the urban functional core area + urban functional expansion area and urban development new area were higher than the ecological conservation area in north Chongqing and the ecological conservation area in southeast Chongqing,and the differences were statistically significant(P<0.05).Of the 12 public health service items,there were significant differences in the following items:health education;residents' health records;vaccinations;health management of children 0–6 years of age;maternal health management;elderly health management;hypertension management;diabetes management;severe mental illness management;infectious diseases/emergency public health management;and traditional Chinese medicine management among the four functional areas(P<0.05).There was no significant difference in health supervision(P>0.05).Conclusion The quality of basic public health services in Chongqing did not reach "equalization", and there were differences in the quality of basic public health services in different functional areas.
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40. 基于服务当量值的社区卫生服务岗位绩效管理的实践探索与效果评价
刘继霞1,欧阳伟2*,肖立新3,杨志云4,常利杰1,赵怡辰1
Chinese General Practice    2017, 20 (22): 2698-2702.   DOI: 10.3969/j.issn.1007-9572.2017.22.004
Abstract353)      PDF(pc) (660KB)(696)    Save
当前国家制订了一系列鼓励性政策大力促进社区卫生服务机构的发展,其中绩效分配改革尤为重要。南苑社区卫生服务中心以"唯同岗位可比,不同岗位比较岗位系数"为原则,按照工作数量、工作质量、运行效率3个维度展开考核,建立起了基于服务当量值的社区卫生服务岗位绩效管理模式和评价体系。该分配激励模式及岗位绩效管理评价体系解决了考核指标"标准当量值"在不同岗位间不可比的现状,促进了有效资源和绩效的合理分配,调动了社区卫生服务机构人员的工作积极性,并引领了中心整体工作的改善,有利于社区卫生服务中心持续、健康的发展。
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