研究背景 公立医院改革实质上为“医改难题”探索出“中国式解决办法”。不仅要解决当前公众和社会呼吁关注强烈的“看病难、看病贵”的问题，更重要的在于，它是对医疗、医药、医保“三医联动”的顶层设计和深入推进，是在社会主义市场经济条件下，所进行的一场涉及医疗卫生服务体系再造、健康干预模式转变和政府公共服务模式创新的深层次改革。数量庞大、地域分散、服务人群众多的县级医院，是解决医改重心下沉和分级诊疗问题的关键。全面推进县级公立医院综合改革，提高县级医院医疗卫生服务能力和群众县域内就诊率，最终实现“大病不出县”的改革目标，关系着新医改的成败。 山东是我国第二个人口大省，全省常住人口9733万，辖17个市，140个县(市、区)，地区之间差异明显，某种程度上山东是中国的缩影。为全面了解山东省县级公立医院综合改革进展情况及总体成效，本研究受山东省卫生与计划生育委员会委托，作为第三方，进行了对山东省县级公立医院综合改革进展情况和效果评估研究的课题。评估研究对象为第一、二批试点县的l84家县级公立医院，其中：第一批试点72家医院，第二批试点112家医院；综合医院97家，中医医院65家，专科医院22家。评估采用定性与定量相结合、填报数据与实地调研互为补充的方法进行，共实地调研34个县，通过函调回收173份试点医院调查问卷、自制问卷调查1114名医务人员和931名居民。研究目的和意义 县级公立医院综合改革是一项重大民生工程。从项目管理评估角度说，把县级公立医院改革效果研究作为一个科研项目，系统地收集项目活动、特征及产出结果方面的信息，在项目结束后用来评估项目的作用，证实项目的价值，进而综合判断项目实施效果，提高县级医院医疗服务水平和科学管理水平。县级公立医院综合改革还是一项涉及面广、系统性强的重大民生政策。从公共政策分析角度看，改革涉及利益调整和分配，是政策变迁的过程，也是公立医院系统耦合和制度治理的过程。通过公立医院对改革进程和效果的评估研究，分析政策的可行性和可推广性，为进一步深化改革提出相关建议和配套措施，为医改政策与政府决策提供参考借鉴。 研究的具体目的包括： (1)对山东省县级公立医院综合改革进程情况和总体效果进行评估，做出全面、真实、客观的第三方调研分析； (2)充实县级公立医院综合改革的数据资料和研究成果； (3)总结山东省县级公立医院综合改革成功做法和经验，通过赋分排名的方式，树立先进和典型，为公立医院改革提供范式借鉴； (4)通过赋分指标的量化分析，对参与试点改革的县级公立医院进行综合等级排序，总结县级公立医院的改革成效；分析医务人员和群众对县级公立医院改革的满意度； (5)结合赋分指标和非赋分指标，分析影响县级公立医院改革成效的关键因素，指出改革现阶段面临的困难和问题；分析讨论县级公立医院综合改革存在问题和困境，提出相关政策建议。 研究方法 本研究采用定性与定量相结合、监测数据与实地调研互为补充的方法进行评估，力求科学、客观地反映山东省县级公立医院改革的实际情况。评估指标分为两类：一类是赋分指标，一类是非赋分指标。赋分指标按照县级公立医院综合改革评估指标体系中的评分方法进行，用来反映县级公立医院自身的改革推进及成效；非赋分指标，用来分析影响县级公立医院综合改革成效的主要因素。 根据不同的研究目的，分别采用文献复习法、个案分析法、深度访谈法、专题小组讨论法、指标评分法等研究方法。本研究将收集的问卷按照地区和医院进行统一编码，采用Epidata进行统一录入。在录入前对录入员进行统一培训，明确各数据的变量名称和相关注意事项。并指定专人，采用抽查的方式，对录入结果与原始数据进行对比，以确保录入的准确性。数据录入完成后，对数据库进行逻辑分析，对发现的异常值和逻辑问题及时予以更正。本研究主要采用Excel 2007和SPSS v21.0进行统计分析，统计分析方法主要为描述性分析。应用Excel主要进行作图操作，应用SPSS统计相关评述和构成比情况。 主要研究结果 1.理论研究 梳理公立医院改革效果评估的理论系统分析框架，回答公立医院改革政策变迁和完善问题，为公立医院改革提供理论支撑，是本研究的出发点和逻辑基础。借鉴多种理论中的重要概念，对公立医院改革过程进行整合性解读。本研究重点基于六个方面整合的可能性，构建县级公立医院综合改革效果评估的理论分析框架：(1)公立医院改革的根本遵循；(2)公立医院改革的经济学考量；(3)公立医院改革的“政策窗口期”；(4)公立医院改革的系统耦合；(5)公立医院改革的制度治理：(6)公立医院改革的效果评估。 本研究总体设计的定位是：以对县级公立医院综合改革进程和效果评估研究为“目张”，通过“问题倒逼”来指向政策过程理论研究角度的“纲举”，对政策产生、制定、执行情况进行分析和研究。进而对公立医院改革宏观上做政策理论研究探讨，对公立医院改革进程和效果进行实践上的定量分析评估，定量分析为定性分析提供必要铺垫和验证，而定性分析又对定量分析做出具体界定和升华。 2.山东省县级公立医院综合改革的进展成效评估 (1)破除以药养医机制。试点医院按照改革的要求落实了取消药品加成政策，调整了医疗服务价格，主要涉及诊疗费、手术费、护理费、床位费、中医服务费、大型设备检查费和高值医用耗材费用。2015年各试点医院因为取消药品加成减少的收入总额为30.4l亿元，各级财政针对医院取消药品加成的补助共计5.97亿元，占到药品减少收入的l9.6％；医院通过调整医疗服务价格增加的收入为13.68亿元，占到药品减少收入的45.0％。 (2)医保支付制度改革。在填报数据的172家医院中，有l41家(82.0％)医保支付方式进行了改革，有102家(59.3％)建立了医院和医保经办机构谈判协商和风险分担机制，有80家(46.5％)建立了医疗服务价格与医保支付政策动态调整衔接机制，有151家(87.8％)将调整的医疗服务价格纳入医保支付范围。 (3)人事分配制度改革。83.1％的医院在人员聘用和岗位管理方面采用了竞聘上岗制度，同时采用竞聘上岗、合同管理、按需设岗、按岗聘用四项制度的有98家医院(57.0％)。绝大多数医院在收入分配上都能向临床一线倾斜，但幅度不大。医院职工收入主要由固定工资和绩效工资两部分构成，月均固定工资3165.1元(占月收入的62.2％)，月均绩效工资1920.8元(占月收入的37.8％)。正式编制人员占53.4％，聘用制人员占46.5％。其中聘用制人员中医生占20.9％，护士占59.6％。聘用制与在编人员收入的主要差距在其固定工资水平较低，在编职工月均固定工资为4322.2元，而聘用制职工月均固定工资为1661.6元。 (4)药品供应保障机制改革。91.8％的试点医院实施了省级药品集中采购， 78．8％的医院能保证已经挂网的高值医用耗材采取网上集中采购，基本药物和常用药物占药品收入比例超过80％的共有73家。90.0％的医院能保证低价药品优先配备使用，但经常出现以低价药品为主的部分药品涨价较多、不挂网或长期缺货的情况。 (5)政府责任落实情况。调查发现，很多医院财政补助都是政府打包拨付，没有具体分列项目，医院也不清楚具体的分项费用。整体来看，基本建设补助在2014年之后呈现大幅度增加，大型设备、学科建设、离退休人员经费投入在2013年大幅度增加之后逐年下降，政策性亏损、基本公共卫生投入呈逐年上升趋势。截止到2015年底，试点医院的总负债额为261.97亿元，总体负债率达到45.4％。 36.6％的医疗机构债务纳入到县级政府债务平台管理。 3．山东省县级公立医院综合改革改革的总体效果评估 (1)医药费用变化情况。门诊次均医药费用呈小幅增长趋势，2012年为178.6元，2015年191.8元；门诊次均药费变化幅度不大，2012年为79.3元， 2015年81.0元。住院病人人均医药费用呈增长趋势，2012年为4509.8元，2015年5442.4元；住院病人人均药费呈下降趋势，2012年为2172.0元，2015年1863.9元。 (2)医院收支结构变化情况 药品收入占医疗收入的比例持续下降，从2012年的47.4％下降到2015年的36.6％。检查检验收入占医疗收入的比例呈上升趋势，从2012年的20.2％上升到2015年的23.9％。卫生材料收入占医疗收入的比例逐年上涨，2012年为6.4％， 2015年8.7％。挂号、诊察、床位、治疗、收入和护理收入总和占医疗收入的比例呈现上升趋势，2012年24.9％，2015年27.5％。人员支出占业务支出的比例逐年上升，从2012年的30.1％升至2015年的35.4％。管理费用支出占业务支出的比例持续下降，从2012年的l5.3％降至2015年12.7％。 (3)医院运行效率情况。县级综合医院和中医院平均住院日呈逐年下降趋势，从2012年的8．29天降至2015年的8.04天。病床使用率总体呈下降趋势，从2012年的91.6％降至2015年的82.9％。医院百元固定资产医疗收入(不含药品收入)整体呈上升趋势，从2012年的78.0元升至2015年的90.4元。 (4)医保基金支付。职工医保住院实际报销比例由2012年的73.3％提高至2015年的74.7％；城镇居民医保住院实际报销比例由2012年的52.7％提高至2014年的55.9％；农村居民医保住院实际报销比例由2012年的50.6％提高至2014年的51.3％。我省2015年将城镇居民医保与新农合合并为城乡居民医保，合并后的城乡居民医保住院实际报销比例为51.9(2015年)。存在医保基金欠费的医院数量逐年增加。2015年共有83家县级医院存在医保基金欠费，欠费额度超过10亿元，欠费总额度占83家医院医保收入的l0％。 (5)医务人员满意度和群众就医满意度。通过问卷调查发现，34.8％的医护人员对县级公立医院改革总体表示“满意”。医护人员对技术培训和医院管理的满意度比较高，对收入情况、薪酬公平性、个人工作压力和个人工作时间满意度，改革前后虽然也有所上升，但满意度总体偏低。问卷调查发现，群众对医院的整体满意度和就医方便程度满意度较高，满意率达到90％以上。对医疗报销满意度和就医费用满意度较低，就医费用满意率为64.2％。69.5％的群众认为与三年前相比，“看病难、看病贵”现象有所缓解。 政策建议 1．政府责任落实。在深化公立医院改革的攻坚阶段，建议省、市、县三级建立医改工作联系点制度，省市医改领导小组主要成员单位分片包干，督促县级政府各相关职能部门对县级公立医院改革的组织保障和责任落实，真正形成上下联动、多部门合作的工作推进机制，共同促进县级公立医院改革和发展。各级政府应明确财政集中资源、集中力量加大医改投入，落实六项政府责任，以投入换机制，强化公共医疗卫生的公益性。敦促县级政府主导化解历史债务，对于经济欠发达地区，上级政府应适度予以倾斜，也可探索推进PPP模式改革，积极化解医院历史债务。 2．三医联动。逐步归拢人社、卫计、物价、民政等职能部门所涉及的医保职能，解决管理碎片化，发挥组合优势，提高运行效率。成立专业化、去行政化的医保基金第三方经办机构，对医保资金进行科学管理和精算，同时加强对医院的监管力度，确保医保资金全部用在患者身上，不拖欠医院的医保费用，向社会公开医保资金的走向和使用情况。推广威海市医保部门与商业保险合作保障居民健康的模式。强化短缺药品供应保障和预警，建立部门会商联动机制，完善短缺药品信息报送制度。建立药品出厂价格信息可追溯机制。在全省范围内推行“两票制”。建议试点引进药业公司托管医院药房，将药房从医院剥离。 3．人事分配制度。加快推进县级公立医院编制备案制，编外人员备案管理，将岗位设置与身份脱钩，编内和备案管理人员同岗同酬，形成灵活的用人机制。对医生护士层面的薪酬支付，建议充分考虑到医务人员的职业特点，在全省范围内制定政策，上调医院绩效工资上限，使医务人员收入可以高出其他事业单位同类人员50％以上。在医院有结余的前提下，放宽医院结余分配自主权，搞活内部分配，使绩效进一步向业务骨干倾斜。 4．医院管理制度。政府切实履行办医职能，组建县级公立医院管理委员会，落实县级公立医院经营管理自主权。全面推开县级公立医院法人治理结构，根据《山东省公立医院法人治理结构建设实施方案》，制定可以落地实施的针对县级公立医院法人治理结构的具体实施意见。 5．调整医疗服务价格。按照“腾空间、调结构、保衔接”的步骤，进一步理顺医疗服务价格，分步实施，逐步到位。医疗服务价格调整时，不能仅针对取消药品加成部分调整价格。进一步提高护理费、床位费等服务项目价格，尽快将中医服务项目价格调整到位，促进中医医院的发展。对于药品加成财政补偿比例高的医院，如果不调整医疗服务价格，要确保财政投入的可持续性。 6.控制过度医疗。制订医疗机构医疗费用增长控制目标清单，建立县级公立医院医疗费用监测体系，严格控制医疗费用的不合理增长。药占比高的医院进一步通过指标分解、处方点评、与绩效挂钩、排名通报等措施控制药占比，达到30％的目标。医院在质量控制中实行多种疾病不输液“负面清单”，进一步降低医院门诊输液率；实行剖宫产手术指征“正面清单”，进一步降低助产机构剖宫产率。规范医疗服务行为，将同级同类定点医疗机构住院“次均三费”(药品费、检查费、材料费)结构和涨幅变化等数据，定期进行对比分析、排名通报。 7．推进分级诊疗实施。制定政策让上级公立医院减少或停止提供不符合其功能定位的医疗服务。建议探索除儿童医院外，全省二级以上医院全面停止门诊患者静脉输液等政策，将最基本的门诊医疗服务分流下去。实行服务价格和医保报销明显差异化，大幅度降低县域外就诊医保报销比例。以县医院为龙头，实施县乡村医疗服务资源纵向一体化，强化转诊服务与技术帮扶。鼓励二级以上医院医生多点执业，开展全科医生团队个性化签约服务，建立居民健康和医保基金“双守门人”制度。统一卫计部门基本药物目录和人社部门基本医疗保险药物目录，完善基层医疗卫生机构用药目录，加强二级以上医院与基层卫生机构用药衔接，将基层医疗卫生机构使用的高血压、糖尿病等慢性病医保目录用药纳入门诊慢性病报销范围，引导慢性病和恢复期病人到基层医疗卫生机构就诊。创新与不足 1.创新点。(1)截至目前，本研究为山东省内规模最大的县级公立医院改革评估研究，综合运用了定量评估和定性分析方法，数据样本量大，覆盖范围广，数据质量可信。(2)本研究评价指标体系来自于全国县级公立医院综合改革评估指标体系，研究工具较为可信。(3)本研究内容较为丰富，梳理了山东省县级公立医院改革的具体文件、报告和做法，分析了山东省县级公立医院改革进展情况、对改革相关指标从医院运行、医院医保相关数据和群众、医疗人员满意度几个方面对改革效果进行了评价。 2.不足之处。本研究的评估工作实施于2016年，相关数据时间为2012-2015年，因第二批县级公立医院工作启动时间较晚，因此，在进行效果评估时，由于部分指标变化具有滞后性，县级公立医院改革所影响的部分指标结果可能会被低估，需要在未来的研究中进一步进行分析。 关键词 县级公立医院改革；进展评估；效果评估；山东省

Research background The reform of public hospitals is essentially to find out a "Chinese style solution" for the "medical reform". It should not only solve the problem that “it is difficult and expensive for people to see a doctor”, which is strongly focused on by the public and society. More importantly, it is the top-level design and in-depth promotion of the health reform in medical treatment, medicine and medical insurance, and a deep reform involving reconstruction of medical and health service system, change of health intervention model and the innovation of governmental public service models under the condition of socialist market economy. The county hospitals with large quantity, scattered areas and large population of services are the key to solving the problem of core subsidence and graded diagnosis and treatment in medical reform. We should promote the comprehensive reform of the county public hospitals in an all-round way, and improve the medical service capacity of county hospitals and the visiting rate of the masses within the county, and finally realize the reform objective that “People don’t need to go out of the county for serious illness”, which is closely related to the success or failure of the new medical reform. Shandong is China's second most populous province with the permanent resident population of 97.33 million, and it has jurisdiction over 17 cities and 140 counties (cities, districts). It has obvious differences between the regions, so Shandong is an epitome of China to a certain extent. For a comprehensive understanding of the progress and overall effectiveness of the comprehensive reform in county public hospitals in Shandong, this study is entrusted by Health and Family Planning Commission of Shandong Province to evaluate the progress and effect of the comprehensive reform of the county public hospitals in Shandong as the third party. The object of evaluation and study is 184 county public hospitals in the first and second batch of pilot counties, including 72 hospitals in the first batch of pilots and 112 hospitals in the second batch of pilots, 97 general hospitals, 65 hospitals of traditional Chinese medicine and 22 special hospitals. The evaluation adopts qualitative and quantitative methods, and data reporting and field investigation methods to complement each other. It investigated 34 counties on the spot, and recovered 173 questionnaires of pilot hospitals in the investigation conducted by correspondence and investigated 1,114 medical staff and 931 residents through self-made questionnaires. Research purpose and significance The comprehensive reform of county public hospitals is a major livelihood project. From the perspective of evaluation of project management, we take the research on the reform effects of county public hospitals as a scientific research project, systematically collect information in project activities, characteristics and the output to assess the role of the project at the end of the project and confirm the value of the project, and then conduct comprehensive judgment of the project implementation effect, improve the medical service and scientific management of county hospitals. The comprehensive reform of county public hospitals is a major livelihood policy involving a wide range and a strong system. From the point of view of public policy analysis, the reform involves the adjustment and distribution of interests, which is the process of policy change, as well as the process of system coupling and institutional governance in public hospitals. Research on the comprehensive reform progress and effect evaluation of county public hospitals, and analyzing the feasibility and popularization of the policy can put forward relevant suggestions and supporting measures for further deepening the reform, and provide reference for the policy of medical reform and government decision-making. The specific purposes of the study include: 1) To evaluate the progress and overall effect of the comprehensive reform in county public hospitals in Shandong, and conduct a comprehensive, authentic and objective survey and analysis as the third party. 2) To enrich the data and research results of the comprehensive reform of county public hospitals. 3) To summarize the successful practice and experience of comprehensive reform of county public hospitals in Shandong and set up advanced and typical models by means of score ranking, thereby providing paradigm reference for the reform of public hospitals. 4) To conduct the quantitative analysis of scoring indexes, and make comprehensive ranking of the county public hospital to participate in the pilot reform, and summarize the reform effect of county public hospitals, as well as analyze the satisfaction of medical staff and the masses with the reform of county public hospitals. 5) To analyze the key factors affecting the reform effect of county public hospitals based on scoring indexes and non-scoring indexes, and point out the difficulties and problems at the current stage of the reform, as well as to analyze and discuss problems and difficulties in the comprehensive reform of county public hospitals and put forward relevant policy suggestions. Research methods This study adopts qualitative and quantitative methods, and data monitoring and field investigation methods to complement each other for evaluation, and tries to scientifically and objectively reflect the actual situation of the reform of county public hospitals in Shandong. The evaluation indexes can be divided into two categories. One is the scoring index, which is carried out according to the scoring method in the evaluation index system of the comprehensive reform in county public hospitals so as to reflect the reform promotion and effectiveness of county public hospitals. The other is the non-scoring index, to analyze the main factors that affect the effectiveness of the comprehensive reform in county public hospitals. According to different research purposes, this paper adopts literature review, case analysis, depth interview, thematic group discussion, index scoring and other research methods. This study conducts unified coding on the collected questionnaires according to the region and the hospital and designates special personnel for unified entry through Epidata. Before entry, unified training is conducted on the data entry staff to define the name of each variable and related matters needing attention. Furthermore, special personnel are designated to compare the entry results and initial data through a selective examination to ensure the accuracy of entry. After the data entry is completed, the database is logically analyzed, and the abnormal values and logical problems are corrected in a timely manner. In this study, Excel 2007 and SPSS v21.0 are used for statistical analysis, and statistical analysis methods are mainly descriptive analysis. Excel is mainly used for plotting operations, and SPSS is used to count relevant reviews and composition ratios. Key findings 1. Theoretical research The starting point and logical foundation of the study is to comb the analysis framework for the theory of the effect evaluation of public hospital reform, answer questions in the policy change and improvement of public hospital reform and provide theoretical support for the reform of public hospitals. Using the important concepts of various theories for reference, the paper interprets the reform process of public hospitals in an integrated way. This research focuses on the possibility of integrating six aspects, and constructs the theoretical analysis framework for the effect evaluation of the comprehensive reform in county public hospitals. The six aspects for integration are as follows: 1) Fundamental compliance of public hospital reform 2) Economic considerations on the public hospital reform 3) Policy “window phase” of the public hospital reform 4) Systematic coupling of public hospital reform 5) Institutional governance of public hospital reform 6) Evaluation of the effect of public hospital reform The overall design of this study is to take the study on progress and effect evaluation of the comprehensive reform in county public hospitals as the outline, and point out the key link in the theoretical research of the policy process through forced question, so as to analyze and study the creation, formulation and implementation of the policy, and then to discuss the policy of the public hospital reform in a macroscopic view and make quantitative analysis and evaluation in practice on the process and effect of the reform of public hospitals. Quantitative analysis provides the necessary foreshadowing and verification for qualitative analysis, and qualitative analysis makes specific definition and sublimation of quantitative analysis. 2. Progress evaluation of comprehensive reform of county public hospitals in Shandong 1)It should abolish the mechanism of supporting the doctor with medicine. According to the requirements of the reform, the pilot hospitals cancel the drug markup policy, and adjust the price of medical services, mainly involving medical fee, operation fee, nursing fees, bed charges, TCM service charges, large equipment inspection fee and costs of high-value medical consumables. In 2015, the total income of the pilot hospitals was reduced by 3.041 billion Yuan due to the abolition of the drug markup, and the total amount of financial subsidies for the abolition of the drug markup was 597 million Yuan, accounting for 19.6% of the reduced income of drugs. By adjusting the price of medical services, the hospital increased its income by 1.368 billion Yuan, accounting for 45% of the reduced income of drugs. 2) It is the reform of medical insurance payment system. In the 172 hospitals which filled in the data, 141 hospitals (82%) reformed the mode of medical insurance payment, 102 hospitals (59.3%) established the negotiation and risk sharing mechanism between the hospitals and medical insurance agencies, and 80 hospitals (46.5%) established the cohesion mechanism between the dynamic adjustment of the price of medical services and medical insurance payment policy, and 151 hospitals (87.8%) brought the adjusted price of medical services into the coverage of medical insurance payment. 3) It is the reform of personnel distribution system. 83.1% of the hospitals adopted the system of competition for employment in the personnel recruitment and post management, and 98 hospitals (57.0%) adopted four systems, namely, competition for employment, contract management, setting up posts according to needs and employment according to posts. The vast majority of hospitals are inclined to the front-line clinical staff in income distribution, but not much. The income of hospital staff is mainly composed of regular wages and performance pay, and the average monthly regular wage is 3,165.1 Yuan (62.2% of monthly income), and the monthly average performance pay is 1,920.8 Yuan (37.8% of the monthly income). The formally authorized personnel accounts for 53.4% and the contract staff accounts for 46.5%, in which doctors account for 20.9% and nurses account for 59.6%. The main difference in income between the contract staff and permanent staff is that the contract staff has low regular wages, while the average monthly regular pay is 4,322.2 Yuan for permanent staff, and that is only 1,661.6 Yuan for contract staff. 4) It is the reform of the guarantee mechanism for drug supply. 91.8% of the pilot hospitals implement the centralized drug purchasing at provincial level, 78.8% of the hospitals can guarantee high-value medical consumables which have been put on the network adopt online centralized purchasing, and there are 73 hospitals in which the income of basic drugs and common drugs account for more than 80% of the total drug revenue. 90% of the hospitals can guarantee the priorities to low-priced drugs, but there will be often such conditions that low-priced drugs are on the rise, or the drugs are not put on the network or the drugs are in short supply for a long time. 5) It is the implementation of governmental responsibility. The survey found that financial subsidies in many hospitals are appropriated by the government in package, while there are no specific items and hospitals are not clear about the specific fees of the items. Overall, the infrastructure subsidies have increased significantly after 2014, the funds in large equipment, discipline construction, and retired personnel have declined year by year after the substantial increase in 2013, and policy-related losses and funds in basic public health have increased year by year. By the end of 2015, total liabilities of pilot hospitals were 26.197 billion Yuan, and total liability ratio reached 45.4%. 36.6% of the medical institution debt has been included in the county-level government debt platform for management. 3.Overall effect evaluation of comprehensive reform of county public hospitals in Shandong 1) Changes in medical expenses The average medical expenses for outpatient services showed a slight growth trend, which were 178.6 Yuan in 2012 and 191.8 Yuan in 2015. There was little change in average outpatient drug expenses, which were 79.3 Yuan in 2012 and 81 Yuan in 2015. The medical expenses per inpatient showed an increasing trend, which were 4,509.8 Yuan in 2012 and 5,442.4 Yuan in 2015. The drug expenses per inpatient showed a downward trend, which were 2,172.0 Yuan in 2012 and 1,863.9 Yuan in 2015. 2) Changes in balance of payment structure in hospitals The proportion of drug income to medical income continued to decline, from 47.4% in 2012 to 36.6% in 2015. The proportion of inspection income to medical income was on the rise, from 20.2% in 2012 to 23.9% in 2015. The proportion of health material revenue in medical income increased year by year, from 6.4% in 2012 to 8.7% in 2015. There was an increasing trend in the proportion of the total of registration, examination, bed, treatment and nursing to the medical income, from 24.9% in 2012 to 27.5% in 2015. The proportion of personnel expenditure to business expenditure increased year by year, from 30.1% in 2012 to 35.4% in 2015. The proportion of management expenses to the business expenditure continued to decline, from 15.3% in 2012 to 12.7% in 2015. 3) Operational efficiency of hospitals The average length of stay in the county general hospitals and the traditional Chinese medicine hospitals decreased year by year, from 8.29 days in 2012 to 8.04 days in 2015. The overall utilization rate of beds decreased, from 91.6% in 2012 to 82.9% in 2015. The medical income of 100-Yuan fixed assets in hospitals (excluding drug income) showed an upward trend, from 78.0 in 2012 to 90.4 in 2015. 4) Medical insurance fund payment The actual proportion of reimbursement for employee hospitalization in medical insurance increased from 73.3% in 2012 to 74.7% in 2015. The actual proportion of reimbursement for urban residents’ hospitalization in medical insurance increased from 52.7% in 2012 to 55.9% in 2014. The actual proportion of reimbursement for rural residents’ hospitalization in medical insurance increased from 50.6% in 2012 to 51.3% in 2014. In 2015, the urban residents' medical insurance and the new rural cooperative medical scheme were merged into urban and rural residents' medical insurance, and the actual reimbursement rate of hospitalization of urban and rural residents in medical insurance was 51.9% in 2015. There are an increasing number of hospitals with arrears of medical insurance funds year by year. In 2015, there were 83 county-level hospitals with arrears of medical insurance funds, the amount of arrears was more than 1 billion Yuan, and the total amount of arrears accounted for 10% of the total medical insurance income in 83 hospitals. 5) Satisfaction of medical staff and satisfaction of the masses with medical treatment Through the questionnaire survey, we found that 34.8% of the medical staff was satisfied with the overall reform of county public hospitals. Doctors and nurses are more satisfied with technical training and hospital management. Medical staff has increased their satisfaction with the income, pay equity, personal work pressure and personal working time compared to that before the reform, but the overall satisfaction is low. Through the questionnaire survey, we found that the masses have high satisfaction with the hospital as a whole and the convenience of medical treatment, and the satisfaction rate was above 90%. The satisfaction rate of medical reimbursement and medical expenses was lower, and the satisfaction rate of medical expenses was 64.2%. 69.5% of the masses believe that compared with three years ago, it has relieved the phenomenon that “ it is difficult and expensive for people to see a doctor” . Policy suggestions 1. Implementation of governmental responsibility In the crucial stage of deepening the reform of public hospitals, we suggested that the governments at the provincial, municipal and county levels should establish the contact system for medical reform, the main member units of the provincial and municipal leading groups in medical reform should divide up the work and assign a part to each group and supervise the relevant functional departments of county governments to guarantee the organization of the reform for county public hospitals and implement the responsibilities, and really form a promotion mechanism in the linkage from top to bottom and cooperation with multiple departments, so as to promote the reform and the development of county public hospitals. Governments at all levels should make it clear that the finance departments should concentrate the resources and efforts to increase investment in medical reform, implement the six governmental responsibilities, and exchange the input for the mechanism to strengthen the public welfare of public health care. The county government should be urged to take the lead in resolving the historical debts. Governments of higher levels should be appropriately tilted to the less developed areas, but also explore the promotion of PPP mode reform, and actively defuse the historical debts of the hospitals. 2. Joint reform of medical treatment, medication and medical assurance We should gradually put together the functions of medical insurance in functional departments, including the departments of human resources and social security, health and family planning commissions, price bureaus and civil administration departments, solve the fragmentation of the management, play a combination of advantages, and improve operational efficiency. Meanwhile, we should establish the professional third-party agencies of de-administration of medical insurance funds for scientific management and actuarial of medical insurance funds, while strengthening the supervision of the hospital, to ensure that all the medical insurance funds are spent on patients, the agencies don’t default on the medical insurance charges of hospitals and make the direction and use of medical insurance funds known to the public. It should promote the cooperative mode of medical insurance departments and commercial insurance to ensure the health of residents in Weihai, strengthen the supply and early warning of drug shortage, establish a linkage mechanism for consultation between departments, and improve the reporting system for shortage of drugs. We should establish the traceability mechanism for the ex factory price of drugs, implement the "two votes system" in the province, and recommend the introduction of the entrustment of pharmaceutical companies to hospital pharmacies so as to remove the pharmacies from hospitals. 3. Personnel distribution system County public hospitals should accelerate the preparation of the filing system, conduct filing management of off-staff workers, separate the positions from identities, and allow the in-staff and filing management personnel to enjoy the same pay at the same post, to form a flexible employment mechanism. In terms of the salary payment of doctors and nurses, we propose to give full consideration to the occupational characteristics of medical personnel, formulate policy in the province, and raise the upper limit of performance pay, so that the income of medical staff will be more than 50% higher than that of similar personnel in other institutions. Under the premise that the hospital has the balance, we should relax restrictions on the hospital’s right to distribute its own balance, and invigorate the internal distribution, and further incline the performance to the backbone of the business. 4. Hospital management system The government should earnestly carry out the functions of medical management, and establish the management committee of county public hospitals, and implement the management autonomy of county public hospitals, as well as fully develop the corporate governance structure for county public hospitals, and formulate the specific implementation opinions for the corporate governance structure of county public hospitals in accordance with “ Implementation plan of corporate governance structure of public hospitals in Shandong Province". 5. Adjustment of the prices of medical service In accordance with the steps of “Clearing space, adjusting structure and maintaining links”, we should further straighten out the price of medical services and implement it step by step. When the price of medical service is adjust, we cannot only adjust the price in the abolition of drug markup, further increase the prices of service items, including nursing fees and bed charges, and adjust the prices of service items in traditional Chinese medicine in place as soon as possible, so as to promote the development of traditional Chinese medicine hospitals. For hospitals with high proportion of financial compensation for drug markup, if the price of medical service is not adjusted, the sustainability of financial input should be ensured. 6. Control of overtreatment We should formulate a list of control objectives for the growth of medical expenses for medical institutions, establish a monitoring system for medical expenses in county public hospitals, and strictly control the unreasonable growth of medical expenses. Hospitals with high proportion of drugs should further control the drug proportion through the index decomposition, prescription reviews, and performance link, ranking report and other measures, reaching the target of 30%. Hospitals should implement the “negative list” of various diseases without infusion in quality control to further reduce the infusion rate in hospital outpatient department, implement the “positive list” of the indications in cesarean section to further reduce the rate of cesarean section in midwifery institutions, standardize the medical service, and make regular comparative analysis and ranking report on the structure and changes in increase of the average fees per time (drug charges, inspection fees and material fees) for hospitalization in similar designated medical institutions at the same level. 7. Promotion of the implementation of the hierarchical medical system We should formulate policies to allow higher public hospitals to reduce or stop providing medical services that do not meet their functional orientation. It is suggested that besides the children's hospitals, the hospitals at the second level or above in the province should stop the venous transfusion of out-patients, distribute the basic medical services, and implement the obvious differentiation of service prices and medical insurance reimbursement, and greatly reduce the proportion of medical insurance reimbursement outside the county. Taking county hospital as the leader, we should implement the vertical integration of medical service resources in the county and rural areas, strengthen the referral service and technical assistance, encourage doctors in hospitals at the second level or above to practice at multiple sites, develop personalized signing services for the general practitioner team, and establish a "double gatekeeper" system for resident health and medical insurance funds. Moreover, we should unify the essential drug list of health and family planning departments and the drug list of basic medical insurance of human resources and social security departments, improve the drug list of primary-level medical and health care institutions, and strengthen the link between hospitals at the second level or above and primary health institutions, and bring the drug list for medical insurance of hypertension, diabetes mellitus and other chronic diseases in primary-level medical and health care institutions into the coverage of the chronic diseases in outpatient reimbursement, and guide the patients in chronic diseases and in recovery to primary-level medical and health care institutions for medical treatment. Innovation and insufficiency 1. Innovations 1) So far, this study is the largest evaluation study on the reform of county public hospitals in Shandong, and uses the quantitative evaluation and qualitative analysis, and the data involves a large number of samples covering a wide range so that the quality of data is credible. 2) The evaluation index system in this study comes from the national evaluation index system of the comprehensive reform in county public hospitals, and the research tool is credible. 3) This study contains rich contents, combs specific documents, reports and practices of reform in county public hospitals in Shandong, and analyzes the progress of reform in county public hospitals in Shandong, and evaluates the reform effect from the relevant indexes, including the hospital operation, related data to the medical insurance of hospitals, and the satisfaction of the masses and medical personnel. 2. Insufficiencies The evaluation of this study was carried out in 2016, and the related data was from 2012 to 2015. As the reform practice on the second batch of county public hospitals started late, some indexes change with hysteresis in effect evaluation, and some of the indexes affected by the reform of county public hospitals may be underestimated and need to be further analyzed in future studies. Key words Comprehensive reform of county public hospitals; Progress evaluation; Effect evaluation; Shandong province