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Article(id=1240413926878401168, tenantId=1146029695717560320, journalId=1227665162245664772, issueId=1240413921266429979, articleNumber=null, orderNo=null, doi=10.20043/j.cnki.MPM.202503031, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=null, receivedDate=1740844800000, receivedDateStr=2025-03-02, revisedDate=null, revisedDateStr=null, acceptedDate=null, acceptedDateStr=null, onlineDate=1773667325943, onlineDateStr=2026-03-16, pubDate=1754755200000, pubDateStr=2025-08-10, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1773667325943, onlineIssueDateStr=2026-03-16, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1773667325943, creator=13701087609, updateTime=1773667325943, updator=13701087609, issue=Issue{id=1240413921266429979, tenantId=1146029695717560320, journalId=1227665162245664772, year='2025', volume='52', issue='15', pageStart='2689', pageEnd='2880', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=0, createTime=1773667324606, creator=13701087609, updateTime=1773667356299, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1240414054267802325, tenantId=1146029695717560320, journalId=1227665162245664772, issueId=1240413921266429979, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1240414054267802326, tenantId=1146029695717560320, journalId=1227665162245664772, issueId=1240413921266429979, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=2808, endPage=2814, ext={EN=ArticleExt(id=1240413927142642325, articleId=1240413926878401168, tenantId=1146029695717560320, journalId=1227665162245664772, language=EN, title=Cognition of medical staff to the reform of medical insurance payment method in compact county medical community, columnId=1240413923615240265, journalTitle=Modern Preventive Medicine, columnName=Health Policy and Managenment, runingTitle=null, highlight=null, articleAbstract=
Objective

To explore the cognition of medical staff within the tightly-knit county-level medical consortium in Xinyi County, Jiangsu Province regarding the reform of medical insurance payment methods and the influencing factors, and to provide references for deepening the reform of medical insurance payment methods within the medical consortium.

Methods

By using stratified cluster sampling method, a questionnaire survey was conducted among 1 415 medical staff within the medical consortium of Xinyi City from October 2021 to January 2022. The random forest model was employed to screen variables and multivariate logistic regression analysis was conducted to analyze the influencing factors.

Results

Medical staff had a relatively high level of understanding of the medical insurance payment methods of disease-based payment (87.1%) and service-item-based payment (74.3%); they had a relatively high level of recognition of the medical insurance payment methods of disease-based payment (75.1%) and bundled payment based on medical consortium (51.7%). 91.7% of the medical staff were relatively familiar with the reform. The working institutions were township health centers and community health service centers (OR=2.300, 95% CI: 1.205-4.391), and medical staff with senior professional titles or above (OR=4.701, 95% CI: 1.610-13.727) had a relatively high level of understanding of the reform. 81.5% of the medical staff expressed their recognition of the reform. Doctors (OR=2.032, 95% CI: 1.459-2.828), nurses (OR=1.638, 95% CI: 1.073-2.501), medical staff with a master's degree or above (OR=2.399, 95% CI: 1.050-5.480), and medical staff with shorter working years (OR11-15years=0.546, 95% CI: 0.327-0.911; OR16-20years=0.516, 95% CI: 0.285-0.932; OR≥21years=0.443, 95% CI:0.272-0.722) had a relatively high level of recognition of the reform.

Conclusion

The level of awareness and acceptance of new payment methods such as bundled payment for total medical expenses by medical staff within the tightly-knit county-level medical consortium still needs to be improved. It is suggested that measures such as stratified training and the introduction of talent incentive policies for grassroots medical institutions be adopted to enhance the awareness and recognition of medical staff.

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目的

探究江苏省新沂市紧密型县域医共体内医务人员对医保支付方式改革的认知情况及其影响因素，为深化医共体医保支付方式改革提供参考。

方法

采用分层整群抽样法，于2021年10月—2022年1月对新沂市医共体内1 415名医务人员进行问卷调查，运用随机森林模型筛选变量并通过多因素logistic回归分析影响因素。

结果

医务人员对按病种付费（87.1%）、按服务项目付费（74.3%）的医保支付方式认知水平较高；对按病种付费（75.1%）、医共体打包总额付费（51.7%）的医保支付方式认可水平较高。91.7%的医务人员对改革较为了解。工作机构为乡镇卫生院、社区卫生服务中心（OR=2.300，95%CI：1.205～4.391）以及副高及以上职称（OR=4.701，95%CI：1.610～13.727）的医务人员对改革的认知水平较高。81.5%的医务人员对改革表示认可。医生（OR=2.032，95%CI：1.459～2.828）、护士（OR=1.638，95%CI：1.073～2.501）、硕士及以上学历（OR=2.399，95%CI：1.050～5.480）、工龄越短（OR11-15年=0.546，95%CI：0.327～0.911；OR16-20年=0.516，95%CI：0.285～0.932；OR≥21年=0.443，95%CI：0.272～0.722）的医务人员对改革的认可水平较高。

结论

紧密型县域医共体内医务人员对医共体打包总额付费支付方式的认知和认可水平仍有待提高。建议通过分层培训，出台基层医疗机构人才激励政策等措施，提升医务人员认知与认可水平。

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覃朝晖，E-mail:
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沈黄颖（2001—），女，硕士在读，研究方向：医疗保险

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沈黄颖（2001—），女，硕士在读，研究方向：医疗保险

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沈黄颖（2001—），女，硕士在读，研究方向：医疗保险

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Chinese Journal of Health Policy, 2023, 16(7): 10-15.(In Chinese), articleTitle=A study on the influencing factors of total prepayment incentive effect of county medical communities: A clear set qualitative comparative analysis based on 24 cases, refAbstract=null)], funds=[Fund(id=1240424362935899055, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240413926878401168, awardId=2021SJZDA136, language=CN, fundingSource=江苏省高校哲学社会科学研究重大项目(2021SJZDA136), fundOrder=null, country=null), Fund(id=1240424363011396528, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240413926878401168, awardId=KY27011901, language=CN, fundingSource=徐州市卫生健康委员会项目(KY27011901), fundOrder=null, country=null)], companyList=[AuthorCompany(id=1240424356027880071, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240413926878401168, xref=1., ext=[AuthorCompanyExt(id=1240424356040462984, tenantId=1146029695717560320, journalId=1227665162245664772, 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journalId=1227665162245664772, articleId=1240413926878401168, xref=5., ext=[AuthorCompanyExt(id=1240424356556362417, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240413926878401168, companyId=1240424356547973808, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=5.盐城市疾病预防控制中心办公室)])], figs=[ArticleFig(id=1240424361379812221, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240413926878401168, language=EN, label=Figure 1, caption=The gradual random forest out-of-bag data error rate for cognitive conditions, figureFileSmall=PpEb9vg01dFTVLEFx1QDog==, figureFileBig=NqJKQrnJqIcZTggS8m5Dzg==, tableContent=null), ArticleFig(id=1240424361472086914, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240413926878401168, language=CN, label=图1, caption=认知情况的逐步随机森林袋外数据误差率, figureFileSmall=PpEb9vg01dFTVLEFx1QDog==, figureFileBig=NqJKQrnJqIcZTggS8m5Dzg==, tableContent=null), ArticleFig(id=1240424361614693257, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240413926878401168, language=EN, label=Figure 2, caption=The ranking of the importance of variables related to cognitive conditions, figureFileSmall=fYAU+kz2CvyGfzm58lt/Fw==, figureFileBig=Ah7gHp3BZVqUeHDGfM5yKQ==, tableContent=null), ArticleFig(id=1240424361711162254, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240413926878401168, language=CN, label=图2, caption=认知情况的变量重要性排序, figureFileSmall=fYAU+kz2CvyGfzm58lt/Fw==, figureFileBig=Ah7gHp3BZVqUeHDGfM5yKQ==, tableContent=null), ArticleFig(id=1240424361824408467, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240413926878401168, language=EN, label=Figure 3, caption=The gradual random forest out-of-bag data error rate for the recognized situation, figureFileSmall=TYmOhJUIiWZo1LRHSHSCQg==, figureFileBig=FasLa7iXdwciLKxebR5z4w==, tableContent=null), ArticleFig(id=1240424361925071770, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240413926878401168, language=CN, label=图3, caption=认可情况的逐步随机森林袋外数据误差率, figureFileSmall=TYmOhJUIiWZo1LRHSHSCQg==, figureFileBig=FasLa7iXdwciLKxebR5z4w==, tableContent=null), ArticleFig(id=1240424362000569243, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240413926878401168, language=EN, label=Figure 4, caption=The ranking of the importance of variables for the recognition situation, figureFileSmall=i6JaLGyDQBLA3gsvxB3J0w==, figureFileBig=2sB7I2jYUAkk6Dkzf07GPA==, tableContent=null), ArticleFig(id=1240424362071872414, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240413926878401168, language=CN, label=图4, caption=认可情况的变量重要性排序, figureFileSmall=i6JaLGyDQBLA3gsvxB3J0w==, figureFileBig=2sB7I2jYUAkk6Dkzf07GPA==, tableContent=null), ArticleFig(id=1240424362155758497, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240413926878401168, language=EN, label=Table 1, caption=

Basic characteristics of the survey subjects

, figureFileSmall=null, figureFileBig=null, tableContent=
特征人数占比（%）
性别
男37026.1
女1 04573.9
年龄（岁）
<3020314.3
30～3959642.1
40～4935825.3
≥5025818.2
岗位
医生52737.2
护士66647.1
医技人员22215.7
学历
中专及以下18713.2
大专27919.7
本科87661.9
硕士及以上735.2
职称
未定级1097.7
初级69449.0
中级41729.5
副高及以上19513.8
工龄（年）
≤528820.3
6～1031522.3
11～1528119.8
16～201389.8
≥2139327.8
工作机构
村卫生室16311.5
乡镇卫生院、社区卫生服务中心37926.8
新沂市人民医院87361.7
月平均收入（元）
≤5 00063544.9
5 001～8 00059341.9
8 001～12 00015611.0
≥12 001312.2
周工作时长（h/周）
<4015711.1
40～6085160.1
61～8022716.0
≥8118012.7
), ArticleFig(id=1240424362235450275, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240413926878401168, language=CN, label=表1, caption=

调查对象基本特征

, figureFileSmall=null, figureFileBig=null, tableContent=
特征人数占比（%）
性别
男37026.1
女1 04573.9
年龄（岁）
<3020314.3
30～3959642.1
40～4935825.3
≥5025818.2
岗位
医生52737.2
护士66647.1
医技人员22215.7
学历
中专及以下18713.2
大专27919.7
本科87661.9
硕士及以上735.2
职称
未定级1097.7
初级69449.0
中级41729.5
副高及以上19513.8
工龄（年）
≤528820.3
6～1031522.3
11～1528119.8
16～201389.8
≥2139327.8
工作机构
村卫生室16311.5
乡镇卫生院、社区卫生服务中心37926.8
新沂市人民医院87361.7
月平均收入（元）
≤5 00063544.9
5 001～8 00059341.9
8 001～12 00015611.0
≥12 001312.2
周工作时长（h/周）
<4015711.1
40～6085160.1
61～8022716.0
≥8118012.7
), ArticleFig(id=1240424362327724965, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240413926878401168, language=EN, label=Table 2, caption=

Medical staff's cognition and recognition of different medical insurance payment methods ［n（%）］

, figureFileSmall=null, figureFileBig=null, tableContent=
医保支付方式认知认可
了解不了解是其他
医共体打包总额付费650(45.9)765(54.1)732(51.7)683(48.3)
按病种付费1 233(87.1)182(12.9)1 063(75.1)352(24.9)
按服务项目付费1 051(74.3)364(25.7)575(40.6)840(59.4)
按人头付费528(37.3)887(62.7)538(38.0)877(62.0)
按床日付费469(33.1)946(66.9)473(33.4)942(66.6)
), ArticleFig(id=1240424362411611048, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240413926878401168, language=CN, label=表2, caption=

医务人员对不同医保支付方式的认知与认可情况［n（%）］

, figureFileSmall=null, figureFileBig=null, tableContent=
医保支付方式认知认可
了解不了解是其他
医共体打包总额付费650(45.9)765(54.1)732(51.7)683(48.3)
按病种付费1 233(87.1)182(12.9)1 063(75.1)352(24.9)
按服务项目付费1 051(74.3)364(25.7)575(40.6)840(59.4)
按人头付费528(37.3)887(62.7)538(38.0)877(62.0)
按床日付费469(33.1)946(66.9)473(33.4)942(66.6)
), ArticleFig(id=1240424362503885740, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240413926878401168, language=EN, label=Table 3, caption=

Multivariate logistic regression analysis of medical staff's cognition on the reform of medical community's medical insurance payment methodology

, figureFileSmall=null, figureFileBig=null, tableContent=
变量B值Waldχ2值P值OR值(95% CI)
年龄（以<30岁为参照）
30～39岁0.1410.3960.1260.7221.151(0.529～2.503)
40～49岁-0.3920.5590.4910.4840.676(0.226～2.022)
≥50岁-0.6820.6451.1190.2900.506(0.143～1.789)
工龄（以≤5年为参照）
6～10年0.0540.3810.0200.8881.055(0.500～2.227)
11～15年0.7090.4692.2850.1312.032(0.810～5.094)
16～20年0.3610.5930.3700.5431.435(0.448～4.589)
≥21年0.6290.6091.0640.3021.875(0.568～6.191)
职称（以未定级为参照）
初级0.1630.3320.2410.6241.177(0.614～2.258)
中级0.3000.3530.7220.3951.350(0.676～2.699)
副高及以上1.5480.5478.0150.0054.701(1.610～13.727)
工作机构（以村卫生室为参照）
乡镇卫生院、社区卫生服务中心0.8330.3306.3700.0122.300(1.205～4.391)
新沂市人民医院0.6850.3653.5240.0601.984(0.970～4.055)
月平均收入（以≤5 000元为参照）
5 001～8 000元0.1790.2750.4220.5161.196(0.698～2.048)
8 001～12 000元0.4870.4681.0830.2981.627(0.651～4.069)
≥12 001元0.4951.0690.2140.6431.640(0.202～13.323)
常量2.6020.73512.5370.00013.489
), ArticleFig(id=1240424362583577515, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240413926878401168, language=CN, label=表3, caption=

医务人员对医共体医保支付方式改革认知的多因素logistic回归分析

, figureFileSmall=null, figureFileBig=null, tableContent=
变量B值Waldχ2值P值OR值(95% CI)
年龄（以<30岁为参照）
30～39岁0.1410.3960.1260.7221.151(0.529～2.503)
40～49岁-0.3920.5590.4910.4840.676(0.226～2.022)
≥50岁-0.6820.6451.1190.2900.506(0.143～1.789)
工龄（以≤5年为参照）
6～10年0.0540.3810.0200.8881.055(0.500～2.227)
11～15年0.7090.4692.2850.1312.032(0.810～5.094)
16～20年0.3610.5930.3700.5431.435(0.448～4.589)
≥21年0.6290.6091.0640.3021.875(0.568～6.191)
职称（以未定级为参照）
初级0.1630.3320.2410.6241.177(0.614～2.258)
中级0.3000.3530.7220.3951.350(0.676～2.699)
副高及以上1.5480.5478.0150.0054.701(1.610～13.727)
工作机构（以村卫生室为参照）
乡镇卫生院、社区卫生服务中心0.8330.3306.3700.0122.300(1.205～4.391)
新沂市人民医院0.6850.3653.5240.0601.984(0.970～4.055)
月平均收入（以≤5 000元为参照）
5 001～8 000元0.1790.2750.4220.5161.196(0.698～2.048)
8 001～12 000元0.4870.4681.0830.2981.627(0.651～4.069)
≥12 001元0.4951.0690.2140.6431.640(0.202～13.323)
常量2.6020.73512.5370.00013.489
), ArticleFig(id=1240424362667463596, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240413926878401168, language=EN, label=Table 4, caption=

Multivariate logistic regression analysis of medical staff's acceptance of the reform of medical consortium's medical insurance payment method

, figureFileSmall=null, figureFileBig=null, tableContent=
变量B值Waldχ2值P值OR值(95% CI)
岗位（以医技为参照）
医生0.7090.16917.6420.0002.032(1.459～2.828)
护士0.4930.2165.2190.0221.638(1.073～2.501)
学历（以中专及以下为参照）
大专0.3010.2611.3290.2491.351(0.810～2.252)
本科0.1330.2130.3890.5331.142(0.752～1.734)
硕士及以上0.8750.4214.3120.0382.399(1.050～5.480)
工龄（≤5年为参照）
6～10年-0.6870.2557.2410.0070.503(0.305～0.830)
11～15年-0.6050.2625.3570.0210.546(0.327～0.911)
16～20年-0.6620.3024.8090.0280.516(0.285～0.932)
≥21年-0.8130.24810.7090.0010.443(0.272～0.722)
常量1.5290.29227.4590.0004.614
), ArticleFig(id=1240424362759738285, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240413926878401168, language=CN, label=表4, caption=

医务人员对医共体医保支付方式改革认可的多因素logistic回归分析

, figureFileSmall=null, figureFileBig=null, tableContent=
变量B值Waldχ2值P值OR值(95% CI)
岗位（以医技为参照）
医生0.7090.16917.6420.0002.032(1.459～2.828)
护士0.4930.2165.2190.0221.638(1.073～2.501)
学历（以中专及以下为参照）
大专0.3010.2611.3290.2491.351(0.810～2.252)
本科0.1330.2130.3890.5331.142(0.752～1.734)
硕士及以上0.8750.4214.3120.0382.399(1.050～5.480)
工龄（≤5年为参照）
6～10年-0.6870.2557.2410.0070.503(0.305～0.830)
11～15年-0.6050.2625.3570.0210.546(0.327～0.911)
16～20年-0.6620.3024.8090.0280.516(0.285～0.932)
≥21年-0.8130.24810.7090.0010.443(0.272～0.722)
常量1.5290.29227.4590.0004.614
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紧密型县域医共体内医务人员对医保支付方式改革的认知研究
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沈黄颖 1 , 李琦 1 , 徐妍 2 , 郑瑞呢 3 , 陈礼江 4 , 唐静 5 , 覃朝晖 2
现代预防医学 | 卫生政策与管理 2025,52(15): 2808-2814
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现代预防医学 | 卫生政策与管理 2025, 52(15): 2808-2814
紧密型县域医共体内医务人员对医保支付方式改革的认知研究
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沈黄颖1, 李琦1, 徐妍2, 郑瑞呢3, 陈礼江4, 唐静5, 覃朝晖2
作者信息
  • 1.徐州医科大学管理学院，江苏 徐州 221004
  • 2.徐州医科大学第二临床医学院医疗卫生应急救援研究中心，江苏 徐州 221004
  • 3.徐州市卫生健康委员会
  • 4.南平市第一医院
  • 5.盐城市疾病预防控制中心办公室

    • 沈黄颖（2001—），女，硕士在读，研究方向：医疗保险

通讯作者:

覃朝晖，E-mail:
Cognition of medical staff to the reform of medical insurance payment method in compact county medical community
Huang-ying SHEN1, Qi LI1, Yan XU2, Rui-ni ZHENG3, Li-jiang CHEN4, Jing TANG5, Zhao-hui QIN2
Affiliations
  • School of Management, Xuzhou Medical University, Xuzhou, Jiangsu 221004, China
出版时间: 2025-08-10 doi: 10.20043/j.cnki.MPM.202503031
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摘要
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目的

探究江苏省新沂市紧密型县域医共体内医务人员对医保支付方式改革的认知情况及其影响因素，为深化医共体医保支付方式改革提供参考。

方法

采用分层整群抽样法，于2021年10月—2022年1月对新沂市医共体内1 415名医务人员进行问卷调查，运用随机森林模型筛选变量并通过多因素logistic回归分析影响因素。

结果

医务人员对按病种付费（87.1%）、按服务项目付费（74.3%）的医保支付方式认知水平较高；对按病种付费（75.1%）、医共体打包总额付费（51.7%）的医保支付方式认可水平较高。91.7%的医务人员对改革较为了解。工作机构为乡镇卫生院、社区卫生服务中心（OR=2.300，95%CI：1.205～4.391）以及副高及以上职称（OR=4.701，95%CI：1.610～13.727）的医务人员对改革的认知水平较高。81.5%的医务人员对改革表示认可。医生（OR=2.032，95%CI：1.459～2.828）、护士（OR=1.638，95%CI：1.073～2.501）、硕士及以上学历（OR=2.399，95%CI：1.050～5.480）、工龄越短（OR11-15年=0.546，95%CI：0.327～0.911；OR16-20年=0.516，95%CI：0.285～0.932；OR≥21年=0.443，95%CI：0.272～0.722）的医务人员对改革的认可水平较高。

结论

紧密型县域医共体内医务人员对医共体打包总额付费支付方式的认知和认可水平仍有待提高。建议通过分层培训，出台基层医疗机构人才激励政策等措施，提升医务人员认知与认可水平。

紧密型县域医共体  /  医务人员  /  医保支付方式改革  /  认知
Objective

To explore the cognition of medical staff within the tightly-knit county-level medical consortium in Xinyi County, Jiangsu Province regarding the reform of medical insurance payment methods and the influencing factors, and to provide references for deepening the reform of medical insurance payment methods within the medical consortium.

Methods

By using stratified cluster sampling method, a questionnaire survey was conducted among 1 415 medical staff within the medical consortium of Xinyi City from October 2021 to January 2022. The random forest model was employed to screen variables and multivariate logistic regression analysis was conducted to analyze the influencing factors.

Results

Medical staff had a relatively high level of understanding of the medical insurance payment methods of disease-based payment (87.1%) and service-item-based payment (74.3%); they had a relatively high level of recognition of the medical insurance payment methods of disease-based payment (75.1%) and bundled payment based on medical consortium (51.7%). 91.7% of the medical staff were relatively familiar with the reform. The working institutions were township health centers and community health service centers (OR=2.300, 95% CI: 1.205-4.391), and medical staff with senior professional titles or above (OR=4.701, 95% CI: 1.610-13.727) had a relatively high level of understanding of the reform. 81.5% of the medical staff expressed their recognition of the reform. Doctors (OR=2.032, 95% CI: 1.459-2.828), nurses (OR=1.638, 95% CI: 1.073-2.501), medical staff with a master's degree or above (OR=2.399, 95% CI: 1.050-5.480), and medical staff with shorter working years (OR11-15years=0.546, 95% CI: 0.327-0.911; OR16-20years=0.516, 95% CI: 0.285-0.932; OR≥21years=0.443, 95% CI:0.272-0.722) had a relatively high level of recognition of the reform.

Conclusion

The level of awareness and acceptance of new payment methods such as bundled payment for total medical expenses by medical staff within the tightly-knit county-level medical consortium still needs to be improved. It is suggested that measures such as stratified training and the introduction of talent incentive policies for grassroots medical institutions be adopted to enhance the awareness and recognition of medical staff.

Compact county medical community  /  Medical staff  /  Health insurance payment method reform  /  Cognition
沈黄颖, 李琦, 徐妍, 郑瑞呢, 陈礼江, 唐静, 覃朝晖. 紧密型县域医共体内医务人员对医保支付方式改革的认知研究. 现代预防医学, 2025 , 52 (15) : 2808 -2814 . DOI: 10.20043/j.cnki.MPM.202503031
Huang-ying SHEN, Qi LI, Yan XU, Rui-ni ZHENG, Li-jiang CHEN, Jing TANG, Zhao-hui QIN. Cognition of medical staff to the reform of medical insurance payment method in compact county medical community[J]. Modern Preventive Medicine, 2025 , 52 (15) : 2808 -2814 . DOI: 10.20043/j.cnki.MPM.202503031
正文
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建设紧密型县域医共体能有效提高县域内卫生资源配置和利用效率，在医保、医疗、医药协同发展和治理格局下，医保支付方式改革对推动紧密型县域医共体建设作用显著。2017年国务院办公厅印发《关于推进医疗联合体建设和发展指导意见》中提出要开展医疗联合体建设，并将医保总额付费等多种付费方式改革作为医联体建设的重要内容[1]。2021年《“十四五”全民医疗保障规划》中强调要深化医保支付方式改革并完善紧密型医疗联合体医保支付政策[2]。2023年《关于全面推进紧密型县域医疗卫生共同体建设的指导意见》对紧密型县域医共体医保支付方式进一步明确为实行医保基金总额付费，完善结余留用机制，稳步推进县级医院实行按疾病诊断相关分组（DRG）或按病种分值（DIP）付费[3]。在不断推进县域医共体建设过程中，深化医共体医保支付方式改革一直是重点所在。紧密型县域医共体构建以县级医院为龙头、乡镇卫生院为枢纽、村卫生室为基础的一体化管理体系[4]，在此体系中，医保资金是购买医疗卫生服务最主要的支付来源，因此，医保支付在对参与主体利益关系进行协调和再分配方面发挥着关键作用，通过医保资金对医疗机构服务的购买实现协调医共体内不同层级医疗机构间、个人和集体的利益一致[5]。相关研究显示医共体打包总额付费对缓解患者的经济负担、促进医保基金有效使用、推动分级诊疗等均有积极意义[6]。医务人员作为医疗卫生服务的直接提供者，任何一项医保支付制度都要作用于每个医生[7]，其政策效果表现为医务人员供给方式的变化，因此，医务人员对医保支付方式改革的认知与认可将对改革的有效推进有重要影响。目前，已开展关于医务人员对医保支付方式的认知与评价研究[8]，但多聚焦于DRG（按病种）支付方式，而对于县域医共体内医务人员对医保支付方式改革认知的研究较少。本研究以首批国家级紧密型县域医共体建设试点县江苏省新沂市为例，旨在调查该县域医共体内，医务人员对医保支付方式改革的认知与认可情况，分析其影响因素，以期为进一步提高医务人员对医保支付方式改革的认知水平，推进医共体内医保支付方式改革，促进改革政策的有效落地提供参考依据。
1　对象与方法
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1.1　研究对象
研究采用分层整群抽样法，以新沂市人民医院为核心的医共体成员单位为研究对象（涵盖11个社区卫生服务中心、乡镇卫生院及其辖下的115所村卫生室），按照分层原则随机抽取1个社区卫生服务中心，6个乡镇卫生院及其所属的12所村卫生室，于2021年10月—2022年1月进行调查。纳入标准：医生、护士、医技人员，知晓本研究目的并自愿参与（伦理审批号：XZHMUZK-2021057）。排除标准：见习生、实习生、进修及规培人员、职能部门行政人员。本次调查共发放调查问卷1 600份，回收整理后得有效问卷1 415份。
1.2　问卷调查
本研究采用课题组自编问卷，以面对面的方式对研究对象展开问卷调查，经信效度检验问卷的信度和效度良好，Cronbach α值为0.898，KMO值为0.764。调查内容包括：（1）研究对象基本情况，包括年龄、性别、岗位、职称等；（2）县域医共体内医务人员对不同医保支付方式的认知与认可情况。其中，关于支付方式的选择根据相关政策文件[2-3]中提到的支付方式，从中选择与医共体医保支付方式改革较为密切的5种，具体为医共体打包总额付费、按病种付费、按服务项目付费、按人头付费、按床日付费；（3）县域医共体内医务人员对医共体医保支付方式改革的认知与认可情况。本研究对不同医保支付方式认知和认可的测量，依据调查对象对各类医保支付结算规章制度，政策的了解和认可情况。对医保支付方式改革认知和认可的测量，依据调查对象对医共体内所推行的“总额付费，结余留用，合理超支分担”机制的了解及认可情况。
1.3　随机森林模型
随机森林最早是由Leo Breiman在2001年提出的一种基于决策树和Bagging算法相结合的学习算法[9]。随机森林可用来探究各影响因素的重要程度，采用基尼系数指数法，识别显著影响医务人员对医保支付方式改革认知与认可的相关因素，均基尼系数的降低表示所有树的可变分区节点处的平均杂质减少，而值越高，则表示变量的重要程度越高[10-12]。
1.4　统计分析
利用EpiData建立数据库并实施数据录入，分类变量用频数（构成比）表示，运用R4.4.1构建随机森林模型筛选影响因素，使用SPSS 23.0构建logistic回归模型分析关键变量。检验水准α=0.05。
2　结果
收起
2.1　基本特征
本研究共对1 415名医务人员进行调查，其中男性370人(26.1%)，女性1 045人(73.9%)；调查对象平均年龄(39.67±9.15)岁；医生527人(37.2%)，护士666人(47.1%)，医技222人(15.7%)；本科及以上学历949人(67.1%)，初级职称694人(49.0%)等。见表1。
2.2　医务人员对不同医保支付方式的认知与认可情况
医务人员对不同医保支付方式的认知水平从高到低依次为：按病种付费(87.1%)、按服务项目付费(74.3%)、医共体打包总额付费(45.9%)、按人头付费(37.3%)、按床日付费(33.1%)；认可水平从高到低依次为：按病种付费(75.1%)、医共体打包总额付费(51.7%)、按服务项目付费(40.6%)、按人头付费(38.0%)、按床日付费(33.4%)。见表2。
2.3　医务人员对医共体医保支付方式改革认知情况及影响因素分析
2.3.1　认知情况及基于随机森林模型的影响因素排序
1 415名医务人员中，对医共体医保支付方式改革不了解的118人(8.3%)，了解的1 297人(91.7%)。纳入相关变量构建随机森林模型，通过变量筛选发现，当变量数为5时袋外误差估算率最低，见图1。在随机森林模型中，重要性评估排名前五位的变量分别是工龄、年龄、月平均收入、工作机构、职称，见图2。
2.3.2　医务人员对医共体医保支付方式改革认知情况的多因素logistic回归分析
以医务人员是否了解医共体医保支付方式改革为因变量（赋值：不了解=0，了解=1），选取随机森林模型中，重要性评估前五位的变量作为自变量，将其纳入多因素logistic回归模型。结果表明：与村卫生室医务人员相比，乡镇卫生院、社区卫生服务中心的医务人员认知水平较高（OR=2.300，95%CI：1.205～4.391）；与未定级的医务人员相比，副高及以上职称的医务人员认知水平较高（OR=4.701，95%CI：1.610～13.727）。见表3。
2.4　医务人员对医共体医保支付方式改革的认可情况及影响因素分析
2.4.1　认可情况及基于随机森林模型的影响因素排序
在1 415名医务人员中，有1 153人(81.5%)对医共体医保支付方式改革表示认可。纳入相关变量构建随机森林模型，通过变量筛选发现，当变量数为3时袋外误差估算率最低，见图3。在随机森林模型中，变量重要性评估排名前三位的变量分别是岗位、学历、工龄，见图4。
2.4.2　医务人员对医共体医保支付方式改革认可情况的多因素logistic回归分析
以医务人员对医共体医保支付方式改革的认可情况作为因变量（赋值：其他=0，认可=1），选取随机森林模型中，重要性评估前三位的变量作为自变量，将其纳入多因素logistic回归模型。结果表明：与医技人员相比，医生（OR=2.032，95%CI：1.459～2.828）和护士（OR=1.638，95%CI：1.073～2.501）对改革的认可度较高；与学历为中专及以下的相比，硕士及以上学历的医务人员对改革的认可度较高（OR=2.399，95%CI：1.050～5.480）；与工龄≤5年的医务人员相比，工龄越短的医务人员对改革的认可度较高（OR11-15年=0.546，95%CI：0.327～0.911；OR16-20年=0.516，95%CI：0.285～0.932；OR≥21年= 0.443，95%CI：0.272～0.722）。见表4。
3　讨论
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3.1　医务人员对医共体打包总额付费支付方式的认知和认可水平有待提高
本研究调查了医共体内医务人员对按病种付费、医共体打包总额付费、按服务项目付费、按人头付费、按床日付费五种支付方式的认知与认可情况。结果显示，医务人员对医共体打包总额付费的认知水平排在第三位，对其认可度排在第二位。医共体打包总额付费是医共体管理的核心，其目的在整合医疗卫生资源、精细优化费用结构，实现医疗服务的高效管理和成本控制。但调查发现，医务人员对该支付方式的认知和认可水平均不高，建议重视医务人员对医共体打包总额付费的宣传培训，各级医院开展多种形式的培训，将理论学习与临床工作紧密结合，激发医务人员主动学习的内生动力[13]。
3.2　工作机构，职称影响医务人员对医共体医保支付方式改革的认知
研究显示，在乡镇卫生院、社区卫生服务中心工作的医务人员，副高及以上职称的医务人员对改革的认知水平较高。在县域医共体内不同层级医疗机构所承担的功能不同，导致医务人员对改革的认知水平存在差异。高级职称的医务人员通常担任着管理者的角色，需高频参与医共体内政策解读会及跨机构协作等，使得其对改革的认知水平较高。而中级职称及以下的医务人员多聚焦于临床诊疗操作，政策信息获取渠道相对单一，对改革的认知水平相对偏低。建议根据医疗机构的功能定位制定培训内容以缩小认知差距，重点关注中级职称及以下的医务人员，开展分层培训，提升对改革的认知水平。
3.3　岗位、学历、工龄影响医务人员对医共体医保支付方式改革的认可
研究显示，医护人员、硕士及以上学历、工龄越短的医务人员对改革的认可度较高。因各个岗位医务人员的工作职责不同，导致其对改革的认可存在差异；学历背景影响医务人员的专业视野和理论素养，高学历医务人员对改革的认可意愿较高；工龄的长短直接关系到医务人员的工作经验和对医疗体系变化的适应能力，工龄长的医务人员对传统的医保支付方式已形成路径依赖，相较而言年轻的医务人员对改革的认可意愿较高。在基层医疗机构卫生人才队伍中，医务人员数量不足，特别是高素质、高层次、高学历的人才稀缺[14]。基层医疗机构承担着维护居民健康的守门人角色，应加强基层医疗机构人才队伍建设，出台基层医疗机构人才激励政策，完善县域人才一体化统筹配置与引育使用机制[15]。
在县域医共体内，医务人员作为医保支付方式改革政策的最终落脚点，直接决定了政策的实施效果以及患者所接受的医疗服务质量。本调查抽取的江苏新沂紧密型县域医共体在推进医保支付方式改革中，以医保结算为杠杆，通过逐渐影响医务人员对医保支付方式改革的认知发挥优化医生诊疗行为的作用，一方面，促使医务人员在诊疗过程中加强成本控制，规范诊疗行为，注重对医疗资源的合理使用[16]。另一方面，促使基层医疗机构医务人员以疾病预防和健康管理为核心。综上，医务人员作为医疗服务体系建设的核心一环，其认知的改变必然带来行为的改变，提高其对改革的认知水平，对推进医共体医保支付方式改革，优化卫生资源的配置，促进医疗、医保、医药协同发展均具有较大意义。但本研究仍存在一定的局限性，研究样本仅覆盖新沂市一个医共体内的部分医疗机构，目前对医共体内医保支付方式改革国家层面仅出台指导意见，地方存在操作空间，且各县域经济发展水平不同，故各地医共体医保支付方式改革在实践中有所差异。因此，研究结果的的外推性可能会受到影响。
基金
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  • 江苏省高校哲学社会科学研究重大项目(2021SJZDA136)
  • 徐州市卫生健康委员会项目(KY27011901)
文献
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2025年第52卷第15期
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doi: 10.20043/j.cnki.MPM.202503031
  • 接收时间：2025-03-02
  • 首发时间：2026-03-16
  • 出版时间：2025-08-10
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  • 收稿日期：2025-03-02
基金
江苏省高校哲学社会科学研究重大项目(2021SJZDA136)
徐州市卫生健康委员会项目(KY27011901)
作者信息
    1.徐州医科大学管理学院，江苏 徐州 221004
    2.徐州医科大学第二临床医学院医疗卫生应急救援研究中心，江苏 徐州 221004
    3.徐州市卫生健康委员会
    4.南平市第一医院
    5.盐城市疾病预防控制中心办公室

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2种不同金属材料的力学参数
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Number of
genus		 种数
Number of
species		 占总种数比例
Percentage of
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鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
栓菌属 Trametes 5 2.39
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