我国医联体框架下慢病管理模式设计及效果述评

A Review of the Design and Effect of Chronic Disease Management Model under the Framework of China’s Medical Association

摘要: 目的：通过更新我国医联体框架下的慢病管理模式的效果和经验，启示未来我国慢病管理如何更好应用医联体平台实现分级诊疗以提高健康价值。方法：系统检索知网、万方数据库和政府网站截止2024年12月31日发表的文献和政策资料，立足于整合服务六要素定性我国医联体框架下的慢病管理模式设计，从基础机制、运行优势和推广局限三个方面进行归纳总结。同时结合国内医联体实践中六个方向的措施采纳情况，为模式梳理提供实践证据并分析挖掘共通机制和借鉴之处。结果：医联体框架下的慢病管理模式将个人–社区–上级医疗机构进行串联，慢病管理的结构性变革路径大同小异，医保支付方式和信息化平台的运用是其中的亮点设计。目前，医联体框架下慢病管理模式仍存在机构协作碎片化、专业资源不足和整体信息化建设落后的不足。结论：我国慢病管理模式未来应转化思路，坚持以医联体为平台，在医保引领下的多医协同中持续建设人才队伍，丰富对基层的激励方式，利用数字赋能提高慢病管理的效率和质量。

Abstract: Objective: By updating the effect and experience of the chronic disease management model under the framework of China’s healthcare consortium, we can shed light on how to better apply the healthcare consortium platform to realize hierarchical diagnosis and treatment in order to improve the value of health in China’s chronic disease management in the future. Methods: We systematically searched the literature and policy materials published on CNKI, Wanfang database and government websites until December 31, 2024, and summarized the design of the chronic disease management model under the framework of China’s healthcare consortium based on the six elements of integrated services, and summarized the basic mechanism, operational advantages and limitations of the dissemination of the model in three aspects. Meanwhile, the adoption of the measures in the six directions in the practice of healthcare consortia in China was combined to provide practical evidence for the model and to analyze the common mechanisms and lessons learned. Results: The chronic disease management models under the framework of healthcare consortia link individuals, communities and higher-level healthcare institutions, and the pathways of structural change in chronic disease management are similar, with the payment method of health insurance and the use of information technology platforms being the highlights of the design. At present, the chronic disease management model under the framework of healthcare alliance still has the deficiencies of fragmentation of institutional collaboration, insufficient professional resources, and backwardness of overall informatization construction. Conclusion: China’s chronic disease management model should transform its thinking in the future, adhere to the healthcare consortium as a platform, continue to build the talent team in the multi-medicine synergy under the leadership of health insurance, enrich the incentive methods for the grassroots, and utilize digital empowerment to improve the efficiency and quality of chronic disease management.