New medical reform: 12 years of exploration, into the "deep water area"

Medical Net, August 17 News In 2009, after years of deliberation, the "Opinions of the CPC Central Committee and the State Council on Deepening the Reform of the Medical and Health System" was released, kicking off a new medical reform
.
The medical field, which was pushed to the market during the wave of reform and opening up, tried to "return" towards public welfare
.
The original intention of the medical reform was simple: to solve the problem of difficult and expensive medical treatment for the common people
.
Subsequently, the fiscal three-year investment of 1,516.
6 billion yuan, the basic medical insurance system covering the whole people, the establishment of the National Medical Insurance Bureau, and the national promotion of the reform of the separation of medicines-in continuous progress, the new medical reform has gone through 12 years
.
The optimization of Chinese health indicators, the reduction in the proportion of out-of-pocket medical treatment, and the convenience of seeking medical advice are the changes brought about by the medical reform
.
The proportion of patients who abandon medical treatment due to financial difficulties has dropped significantly in 10 years
.
However, the questioning and controversy have never stopped
.
The expression "reform has entered the deep water zone" has been mentioned for many years
.
Although local pilot projects have explored well-recognized stock reform paths, they are still weak in progress
.
This year, the key tasks of deepening the health care reform include the promotion of Sanming health care reform in the first article, which states that “all relevant departments in all regions must earnestly strengthen organization and leadership, be brave to act, and dare to touch interests”
.
At present, many provinces such as Beijing, Hunan and Hainan have formulated work plans, proposing to learn from and promote Sanming's experience
.
It is understood that the Secretariat of the Medical Reform Leading Group of the State Council is formulating an evaluation index system and conducting regular evaluations on the progress of various provinces
.

　　Health care reform 12 years the primary hospital "counter-attack"
Not long ago, Chen Jun, director of Beijing Fengtai District Majiapu Community Health Center unexpectedly found that staff appeared a few good initiative from the sinking of the top three public hospital doctors and nurses, the more titles and education team More and more "high and big"
.
If you pay attention to the medical field, you will find this is a rare thing
.
For many years, the grassroots has been the "siphoned" party, and coldness is the norm
.
Doctors pursue better career development and treatment, and love to go to big hospitals.
Residents have a headache.
They would rather crowd people in big hospitals than go to community hospitals in front of their homes
.
Since 2017, the situation has quietly changed
.
With the launch of the comprehensive reform of separation of medicines in Beijing , a series of policies such as expenses, medicines , and registration have been tilted to the grassroots level, and community hospitals have quietly turned upside down
.
Last year, the number of community outpatient visits in Fengtai District surpassed that of second- and third-level hospitals.
Even when the epidemic hit, the outpatient visits of the Majiapu Community Health Service Center reached 450,000
.
The community is beginning to be popular
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Residents in the community often greet Chen Yingjun and say hello, saying that the hospital is getting better and better; the family doctor serves to harmonize the doctor-patient relationship, and the story of a patient serving the doctor for a long time is talked about by everyone
.
Not all community hospitals have experienced such rapid changes, but they can still see the vision of the new medical reform
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When time went back to 2008, medical treatment was not so convenient and economic pressure was not small
.
Every five years, the health department will organize a nationwide health service survey and research
.
In the "2008 China Health Service Survey and Research", 36.
4% of patients chose not to seek medical care after illness.
"Financial difficulties and too expensive medical care" are the most important reasons second only to "self-infection," accounting for 24.
4%
.
Lv Xiaoming, the former deputy director of the Chuzhou Municipal Health Bureau in Anhui Province, still remembers that in the face of high medical expenses, some people "killed and did not want to go out to see a doctor".
"When the ambulance rang, the pigs were raised for nothing; they lived in the hospital once.
"Three years of living for nothing" is a real folk feeling, not an exception
.
At that time, the problems exposed in the field of public health in China included excessive personal burden, unbalanced development of urban and rural and regional medical and health services, irrational allocation of resources, weak public health and rural and community medical and health work, and an imperfect medical security system.
The order of drug production and circulation is not standardized, the hospital management system and operating mechanism are not perfect, the government's health investment is insufficient, and the medical expenses are rising too fast
.
In 2009, the "Opinions of the Central Committee of the Communist Party of China and the State Council on Deepening the Reform of the Medical and Health System" was promulgated, kicking off a new medical reform
.

　　From controversy to sail the new medical reform direction of public service explicitly
talk about the "new" vision and direction of health care reform, not open around the "old" health care reform
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In 2000, a medical reform in Suqian, Jiangsu that "sold out public hospitals" caused a national sensation
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In the past four years, the property rights of 124 local township hospitals and 10 hospitals above the county level have been restructured, making it the only prefecture-level city in the country without public hospitals
.
The historical background of Suqian's "sold-out" medical reform is the health field that was pushed to the market after the reform and opening up
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From the founding of New China to 1978, China established collective and state-owned health service institutions to provide basic health services to most urban residents and farmers.
During that period, the average life expectancy of Chinese residents rose from 35 to 68 years
.
After the reform and opening up, with the introduction of important documents such as the "Report on Several Policy Issues in the Reform of Health Work" in 1985 and the "Several Opinions on Deepening the Reform of the Medical and Health System" in 1992, the concepts of drug addition, independent operation, and self-financing were introduced.
Entering public hospitals, medical services are gradually linked to profitability
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Regarding the medical reform during this period, both affirmed the improvement of the level of health technology and the basic formation of a medical and health service system covering urban and rural areas, but also questioned the fairness and the decline in efficiency.

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In 2005, in the "Evaluation and Recommendations of China's Medical and Health System Reform" by the research group of the State Council Development Research Center, the evaluation of China's medical supply has basically formed a commercial and market-oriented service delivery model, and has become a private consumer product and a medical insurance-covered urban practitioner Less than half, the rural population is only 10%
.
"The fairness of medical services has declined, and the macro-efficiency of health investment has been low.
.
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Since the reform and opening up, China's medical reform has generally been unsuccessful
.
" Since 2003, the industry has set off new medical reforms that should be "market-oriented" or "government-oriented".
Dispute
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In August 2006, the State Council established the Leading and Coordinating Group for Deepening the Reform of the Medical and Health System.
After nearly two and a half years of research, solicitation of opinions, and program adjustments, the "Opinions of the Central Committee of the Communist Party of China and the State Council on Deepening the Reform of the Medical and Health System" were issued in March 2009.
Explain the meaning and direction of the new medical reform with more than ten thousand characters
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The new medical reform plan did not simply choose between the "market" and "government", but it is clear that "the design of the reform plan, the establishment of the health system, and the construction of the service system must follow the principle of public welfare".
The overall goal is Establish and improve the basic medical and health system covering urban and rural residents, and provide the people with safe, effective, convenient, and inexpensive medical and health services
.
"This is a well-written plan.
The guiding ideology, principle and direction are very good, and the direction of public welfare is clear
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However, how to implement it and what kind of system is required requires a long period of realistic exploration.
The documents are compared.
Abstraction and principleization leave a lot of free space for relevant departments and local governments
.
" Said Jiang Yu, Research Institute of Development Research Center of the State Council
.
After that, the new medical reform followed the direction of the "blueprint" and began 12 years of reform and exploration
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　　How to implement the stock reform? Local pilot multi-party pathfinder
new medical reform covers a wealth of content, enough to be dazzling
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The reform contents given in the plan, including the improvement of the four major medical and health systems, and the establishment of a basic medical and health system covering urban and rural residents, have been summarized as "one goal, four pillars and eight pillars
.
" Under each "beam" and "pillar", there are also many articles
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In Jiang Yu's view, many measures of medical reform can be summarized as incremental reform and stock reform
.
The former is to increase the supply of resources, and the latter is to change the operating mechanism of medical institutions and is also the core of medical reform
.
Every few years, the new medical reform will clarify the key tasks of the phases, while advancing towards clear quantitative indicators, while expanding the trials and exploring experience
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Coincidentally, shortly after the start of the new medical reform, many local "answer sheets" were handed in one after another to provide ideas for the implementation of the stock reform
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The first to emerge is the grassroots medical reform in Anhui
.
The grassroots is the focus of the new medical reform in the first few years
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Of the five key tasks given in the "Recent Implementation Plan for the Reform of the Medical and Health System (2009-2011)", three are related to the grassroots level, including the establishment of a national essential medicine system.
Anhui is one of the pilot provinces for this system
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The core of the basic drug system is the zero-markup sales of drugs, which means that medical institutions will lose a large amount of revenue from selling drugs and directly access economic benefits
.
Lv Xiaoming personally experienced the medical reform in Anhui
.
He introduced that at that time, the situation in Anhui and Chuzhou was similar.
The main providers of primary health care were community health service centers, township health centers, village clinics and other institutions.
They were public hospitals in name, but the financial balance allocation was essentially a market.
The privately-run organization "makes its own money and eats its own money
.
" Therefore, there is a lack of interest in basic public health services that do not make money
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Infectious diseases such as hepatitis B are severely prevalent, and a large number of newborns have become carriers of hepatitis B virus; young people are also plagued by chronic diseases, and some died of cerebral infarction at the age of 30 or 40
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The grassroots are motivated to prescribe drugs and perform operations to earn money
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Only a one-person village clinic can prescribe hundreds of thousands of yuan of medicines a year
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The former Anhui Provincial Department of Health conducted a survey of township health centers in southern, central, and northern Anhui, and found that the lowest drug addition was 82%, and the highest was 167%-far more than 15%
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On September 1, 2010, Anhui initiated the comprehensive reform of primary medical and health institutions, and cancelled the drug markup of township health centers
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However, the local area has also implemented a series of supporting policies, including including all township hospitals and community health service institutions in the province into preparation and budget management, with separate revenue and expenditure; lowering the price of drug bidding and purchasing; promoting full competition for employment, and fixed appointments.
Indefinite people in towns and townships and personal assessment and so on
.
Sun Zhigang, a member of the Standing Committee of the Anhui Provincial Party Committee and Vice Governor of Anhui Province, was responsible for the medical reform in Anhui
.
He introduced afterwards that the drug markup rate of primary medical and health institutions varies greatly.
The cancellation of the drug markup for financial compensation makes it difficult to determine a reasonable compensation standard, and it is difficult to operate in practice
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At the same time, only abolishing bonuses does not cut off the interest relationship between medical institutions, medical staff and drug sales, and does not eradicate the benefit-driven mechanism that evolved from the mechanism of supplementing medicine with medicines.
It is difficult to achieve public welfare and reforms are difficult to last
.
Only by systematically promoting comprehensive reforms can the old mechanism be broken and a new one can be established
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In addition to Anhui, other places have also explored various unique medical reform models.
For example, Shenmu County in Shaanxi Province, which is known as "free medical care for all", adopted "overall medical insurance funds, unified reimbursement standards, all people should be covered, and full fiscal The reform of the basic medical insurance system based on subsidies and a series of measures have realized the urban-rural integration of basic medical insurance and the "severe illnesses cannot leave the county
.
" However, the medical reform does not happen overnight, and the deepening of the reform often exposes new contradictions
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For example, regarding the medical reform in Anhui, some people questioned the decline in the enthusiasm of doctors, prevarication of patients, and the inconvenience of medication; after the start of the Shenmu medical reform, medical demand has blown out, and there are problems such as insufficient resources.
Others questioned that the Shenmu medical reform relies on the local wealthy finances and is not of reference significance
.
Policy has been adjusted
.
A few years after the medical reform in Anhui, the “separation of revenue and expenditure” of government-run primary medical institutions was abolished; Shenmu increased its input in medical supply, and at the same time formulated strict supervision measures to strictly control medical expenses
.
Some local pilots have been upgraded to national experience
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In 2012, the then Minister of Health Chen Zhu stated that “Anhui’s achievements in the grassroots comprehensive medical reform are recognized and worthy of national promotion
.
” Jiang Yu introduced the "Opinions on Consolidating and Improving the Essential Medicine System and the New Mechanism for Grassroots Operation" issued by the State Council.
Documents such as "Guiding Opinions on Establishing and Standardizing the Essential Drug Procurement Mechanism of Government-run Primary Medical and Health Institutions" all refer to Anhui's experience
.
The subsequent Sanming medical reform has emerged in the reform of urban public hospitals
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　　Unexpected experience in
Sanming Sanming medical reform began in 2012
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To a certain extent, it is not to answer the question of the new medical reform, but to save oneself by the reality
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On the eve of the health care reform, this industrial city with a small population, a small economy, and a high proportion of retirees had a situation of "getting old before getting rich"
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In 2010, the Sanming Employee Medical Insurance Coordination Fund received more than 140 million yuan and exceeded 200 million yuan in 2011.
The fund owed the city's 22 public hospitals medical expenses 17.
486 million yuan, and the finances were unable to cover the bottom
.
The health care reform was thus initiated
.
The "trader" of Sanming's medical reform was Zhan Jifu, then the deputy mayor of Sanming.
He had worked for Sanming Food and Drug Administration and Fujian Food and Drug Administration for many years and was well versed in the gray interest chain in the medical field
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He introduced the medical chaos before the medical reform in a lecture at Peking University
.
On the supply side, inflated drug prices are common, and a companyThe ex-factory price of aspirin dipyridamole sustained-release tablets is 6 yuan, and through layer-by-layer price increases, it becomes 69.
8 yuan in the hands of patients; ), the same is isosorbide mononitrate, there are more than 40 drugs
.
On the demand side, doctors’ salaries and bonuses are linked to drug revenues, and they have the urge to increase drug revenue; supplementary and nutritious "magic drugs" are wasted
.
Under this profit logic, Sanming's medical expenses increase at an annual rate of 20% , and more than 60% of the medical expenses collected by the hospital are medicine expenses
.
Sanming's medical reform adopted the "three-medicine linkage" of medicine, medical care, and medical insurance, "cutting, blocking, and adjusting at the same time
.
" What is "cutting" is the gray chain of interests in the circulation of drug consumption
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The falsely high prices of medicines and consumables are related to the intermediate links of increasing prices
.
Sanming has adopted the "two-invoice system" to reduce the circulation links and implement volume purchases to squeeze price moisture .
Through the zero-addition policy of drug consumption, the way for hospitals to make profits by selling drugs and doing inspections is blocked
.
The "magic medicine" with inaccurate curative effect and expensive is included in the surveillance and strictly controlled
.
How can the income of the hospital and medical staff be maintained if the project that makes money no longer makes money? The saved financial funds will be compensated to hospitals by adjusting the prices of technical services and reforming the salary system
.
The total salary of the hospital is decoupled from medicines, consumables, inspections, bed income, etc.
, and a target annual salary system for the directors and doctors is implemented
.
According to post-event calculations, according to the median increase of 16% in medical expenses in Fujian Province, by 2020, the Sanming medical reform has saved more than 11 billion yuan in total medical expenses and 12.
4 billion yuan in drug consumption costs, and medical service income of medical institutions will increase.
2.
5 billion yuan
.
On February 23, 2016, the 21st meeting of the Central Deep Reform Group listened to a report on Sanming's medical reform
.
Since 2017, General Secretary Xi Jinping has affirmed the Sanming medical reform many times, and Sanming’s experience has also risen to the top-level plan of the new medical reform, and has been asked to promote it nationwide
.

　　Medical reform into the "deep water zone"
At the overall level, the medical reform is advancing year by year
.
In the first three years, the national financial health expenditure totaled 1,516.
6 billion yuan
.
The number of urban and rural residents participating in the three basic medical insurances exceeded 1.
3 billion, with a coverage rate of over 95%
.
The national essential medicine system has been initially established.
The comprehensive reform of primary medical and health institutions has basically completed the reform task.
Primary medical and health institutions have ended their decades of "medicine supplementation"
.
The reform of county-level public hospitals and the reform of urban public hospitals respectively promoted large-scale pilot projects in 2011 and 2010, and comprehensive reforms were launched in 2015 and 2017
.
In 2018, the National Medical Insurance Bureau, which integrated some of the functions of the Ministry of Human Resources and Social Security, Health, Development and Reform, and Civil Affairs, was established, and carried out a series of tasks such as integrating urban and rural basic medical insurance, implementing national drug purchases, and reforming medical insurance payment methods
.
As time goes by, the connotation of the new medical reform is constantly updated
.
In 2016, the first National Health and Health Conference was held and the "Healthy China" 2030 planning outline was issued, which promoted the transformation from disease treatment as the center to people's health as the center
.
Promote hierarchical diagnosis and treatment and family doctors, and do a good job in disease prevention and health management as the focus
.
At the local level, the Sanming medical reform explored the establishment of a county general hospital and a close medical community; the Beijing medical reform launched a community "long prescription", giving priority to large hospitals in the community
.
These measures are intended to adjust people's medical habits and increase the "popularity" of the grassroots
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　　Looking back on the 12 years of medical reform , what is the effect?
According to the Statistical Bulletin of China's Health Service Development, my country's total health expenditure has risen from 145.
354 billion yuan in 2008 to 7230.
64 billion yuan in 2020 (expected), and the proportion of personal health expenditure has dropped from 40.
4% to 27.
7%.

.
Since the new medical reform, the national health service statistical survey has been updated twice.
In the latest report, the coverage rate of China's basic medical insurance has reached 96.
8%
.
The number of untreated patients fell to 1.
7% in two weeks, and the number of patients who did not receive any treatment due to financial difficulties accounted for 0.
59% of the number of patients in two weeks
.
The availability of medical resources is increasing, and many diseases do not have to go to major hospitals
.
In 2018, 89.
9% of families were able to reach the nearest medical point within 15 minutes, and 87.
1% of residents visited medical institutions in the county
.
However, as the reform enters the "deep water zone", medical reform is also facing resistance
.
Li Ling, director of the Health Development Research Center of Peking University, mentioned in a recent speech that the income-generating mechanism of public hospitals has not yet been broken, and the total medical expenses are growing rapidly
.
Since the medical reform, the financial and medical insurance investment has been huge, but the investment has become bigger and bigger.
Although the proportion of personal health expenditure has dropped significantly, the amount is still rising
.
If the core points are not broken, the medical reform will be difficult to continue
.
"The medical reform has now climbed halfway through the mountain, and the easy-to-change has been completed, and the most dangerous ones have not yet been climbed up
.
" Jiang Yu said that the next step is to transform the operating mechanism of public hospitals to eliminate profit-seeking, otherwise the medical consortium and disease prevention will also Will promote fatigue
.
An interviewee who went to study in Sanming and once served as the director of the health bureau of a county in Hunan Province said that the Sanming model should be promoted, but in the eyes of many people in the industry, the efforts of the party and government in other places and the financial resources invested by the government are not easy to achieve.
This level
.
"Vested interests are deeply rooted.
If you don't do it really, you can't change it
.
" In July this year, the Secretariat of the State Council’s Medical Reform Leading Group and the National Health Commission held a press conference in Sanming City, Fujian Province, and the National Health Commission’s System Reform Director Xu Shuqiang introduced that the goals, paths, and tasks of learning and promoting Sanming’s medical reform experience are clear.
The blocking and difficult points are mainly in four aspects.

.
Including some local party committees (and) governments not paying enough attention to deepening the medical reform and promoting the experience of Sanming medical reform, fear of difficulties in the joint reform of the "three medical", and lack of initiative in reform; the overall price of medical services is low; most public hospitals can lack of disposable income and so on
.

　　What's the next step?
In May of this year, the key tasks of 2021 to deepen the reform of the medical and health system were issued
.
The article proposes to implement the healthy China strategy in depth, promote the experience of Sanming’s medical reform, strengthen the linkage of the reform system, promote the balanced distribution of high-quality medical resources, coordinate the epidemic prevention and control and the construction of the public health system, and continue to focus on the transformation from the treatment of diseases to the people.
Health is the center, and efforts are made to solve the problem of difficult and expensive medical treatment
.
It reads, “All localities and relevant departments must earnestly strengthen their organization and leadership, be brave enough to take responsibility, and dare to touch interests
.
” According to the requirements of the State Council’s Medical Reform Leading Group, many provinces including Beijing, Hebei, Hunan, and Hainan have formulated work plans, mentioning learning from Sanming’s experience
.
According to information from the Department of Restructuring of the National Health Commission, the promotion of Sanming’s experience will also have a clear timetable, road map, and responsible persons
.
The Secretariat of the State Council’s Medical Reform Leading Group is formulating an evaluation index system for promotion, regularly evaluating the progress and effectiveness of each province, and reporting the evaluation results to the local party committees and governments
.
The road to new medical reform will continue
.