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

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

摘要： 背景　中国家庭医生签约服务实施过程中，签约服务费是一项重要的经济激励，这种收入分配的激励机制会影响家庭医生的诊疗行为。目的　分析家庭医生签约服务费的实施对家庭医生诊疗行为，包括服务数量、平均服务时间及接诊患者费用的影响，为家庭医生签约服务制度的完善提供依据。方法　于2019年7—9月在厦门市、杭州市余杭区、上海市长宁区、北京市西城区和房山区共选择27家社区卫生服务中心，采用课题组自行设计的问卷对所有在岗的家庭医生进行普查，共调查家庭医生420人。调查的主要内容包括家庭医生的个人基本情况和工作环境基本特征、激励机制及家庭医生签约相关的认知和行为。运用两水平方差成分模型和多元线性回归模型进行分析。结果　共收回有效问卷405份，有效回收率为96.4%。对应分析结果显示，签约服务费占比 10%~20%的家庭医生组与占比<10%组相比，每日转诊数减少0.84人（P=0.01），接诊患者的月总费用增加32%（P=0.01），次均费用增加13%（P=0.02）。签约服务费占比>20%~30%的家庭医生组与占比<10%组相比，平均接诊时间减少1.96 min（P=0.01），接诊患者的月总费用增加36%（P=0.02）。签约服务费占比>30%的家庭医生组与占比<10%组相比，每日接诊数增加14.68人（P<0.01），平均接诊时间减少2.66 min（P<0.01），接诊患者的月总费用增加53%（P<0.01），次均费用增加22%（P=0.01）。结论　提高签约服务费占收入比例可以提高家庭医生的每日接诊人数，减少每日转诊人数，有利于提升工作积极性，也有利于患者下沉至基层医疗卫生机构和分级诊疗格局的形成；签约服务费占比的提高会减少家庭医生的平均接诊时间，在推行家庭医生签约服务的过程中，要平衡好服务数量和服务质量的关系；要继续推进构建家庭医生作为患者医疗费用“守门人”的机制。

关键词: 家庭医生, 签约服务费, 诊疗行为, 两水平方差成分模型