Chen Hao: Promoting medical reform is by no means alone

What should be the path to public hospital reform? What can you do if you break this deep water area with medicine? How to get back the doctor's value? Shouldn't the big hospital expand on the brakes? How can grassroots reform avoid unsustainable? During the two sessions of this year, a series of focus topics on medical reform caused special attention on behalf of the members. The views were clear and the confrontation was fierce. It was rare before. In the face of these hot issues, Chen Wei, who has the dual status of a member of the National Committee of the Chinese People's Political Consultative Conference and the Minister of Health, made an exclusive interview and expressed his opinions in a candid manner.

Medicare is also the government's investment in public hospitals, and it is a more important investment method. However, the level of basic medical insurance is still relatively low. Public hospitals also undertake tasks such as public health services and support for grass-roots organizations and need compensation. Investment in suppliers will help implement the government's regional health plan and regulate the behavior of public hospitals to fully reflect public welfare. To sum up, it is "development, public health depends on the government, diagnosis and treatment, operation depends on medical insurance."

This year's National Health Work Conference proposed to eliminate the mechanism of medicine supplementation. The chief concern of the dean is to cancel the drug addition policy and the government's financial compensation can be put in place.

Chen Hao said that such concerns are not unreasonable, but they must also see various factors conducive to reform: the Party Central Committee and the State Council attach great importance to it, the people's eager expectation, and the material basis for more than 30 years of reform and opening up has accumulated over the past three years. The good momentum and basic experience formed in the medical reform, the awareness of the party committees and governments in various places about the medical reform are constantly improving. When the Ministry of Health chose to cancel the 300-county pilot, the most important condition to be considered was whether the local government attached great importance to and seriously studied the reform of public hospitals and had a good working basis.

Specific to the government's support for public hospitals, Chen Hao believes that direct government funding is actually a small head, which currently accounts for about 10%. Everyone should see that medical insurance is also the government's investment in public hospitals, and it is a more important investment method.

Chen Hao said that the government allocated funds directly to hospitals to provide free or low-cost hospital services to the people. This is a model adopted by the former Soviet Union’s health system and the British national health insurance system. However, the international mainstream has become increasingly mainstream. The mode of financing, that is, government finance or the government's organization of social resources through legislation to the demand side, the establishment of a medical insurance system, and these funds also eventually flowed to the hospital, in fact, the government transfer payments to public hospitals. One of the benefits of this is that the hospital must obtain compensation from medical insurance by providing quality and quantity of services, thereby avoiding “raising lazy people” and “big pots.” Second, in most countries, the health administrative department can also manage medical insurance. Effectively control hospital behavior. At present, China's basic medical security system financing model also draws on this path.

Regarding “government funding only accounts for 10% of hospital expenditures, and the remaining 90% depend on the hospital’s own efforts in the market”, Chen Hao believes that this statement is actually wrong. With the continuous increase in the level of medical insurance financing, medical insurance expenditure has become the main source of income for public hospitals. For example, in most county hospitals, about 50% of the income comes from the New Rural Cooperatives. So when we look at the government's investment in public hospitals, we must count two accounts. One is direct appropriation, and the other is transfer payment obtained from Medicare.

Chen Hao said that the level of basic medical insurance is still relatively low. At the same time, public hospitals also perform tasks other than basic medical care, such as public health services, teaching, scientific research, and supporting grass-roots organizations. Therefore, it is not enough to supplement the demand side, and the supplier also To make up. More importantly, the input to the supplier is also conducive to the implementation of the government's regional health planning and standardization of public hospitals in order to fully reflect public welfare. Therefore, the financial appropriation must be increased, and the basic facilities of the public hospitals, large-scale equipment and equipment, salaries of retirees, and public health tasks borne by the hospital must be fully assumed in accordance with the spirit of the Central Medical Reform Document. The funds needed for the daily operation of the hospital should be It is mainly obtained from medical insurance. To sum up, it is "development, public health depends on the government, diagnosis and treatment, operation depends on medical insurance." In addition to the “Twelfth Five-Year Plan” period, except that the county-level general hospitals are to be basically completed as dimethyl hospitals, the state and local governments will also build a group of national, provincial, and municipal-level regional medical centers according to the planning and standards. This kind of investment pattern of “need to be required and suitable for provision” is a feature of the public hospital fundraising compensation mechanism established in the medical reform. By the end of the “Twelfth Five-Year Plan” period, the level of funding for basic medical insurance for new rural cooperative medical and urban residents in China may reach more than 450 yuan, and these are the potential revenues of hospitals. He hopes that the president of the hospital and the majority of medical personnel can realize from the hospital's income growth rate that the government's investment in public hospitals has been greatly improved in recent years.

The key to breaking through the medicine-remedy mechanism is to rationalize the price of medical services. It can be negotiated between the development and reform department and the health department. The principle is not to increase the burden on the public. At the same time, it is necessary to introduce advanced payment systems and achieve full coverage without leaving blank space to avoid situations in which "there are policies and countermeasures."

One of the key steps in breaking through the mechanism of drug supplementation is to rationalize the prices of medical services and provide reasonable compensation for the work of medical personnel. However, this is the difficulty faced by many regions.

Chen Xi said that the new rural cooperative medical system is responsible for the management of the new rural cooperative medical system and is also the main source of income for county hospitals. This is one of the reasons why county hospitals are selected as a breakthrough point for reform, because the health department can use the power of medical insurance to control it. To promote the return of its public welfare. With the increase in the level of funding for the new rural cooperative medical system, it is necessary to consider how to use the increase in government investment and do a good job in county hospital reform.

The 15% drug addition is counted in the hospital's income, and the addition policy encourages hospitals to use more drugs and expensive drugs. The health department is in charge of the new rural cooperative medical system, but the latter is also very embarrassingly reimbursed for the high drug prices and 15% bonus. In the face of such embarrassment, Chen Hao said: Why can't we use medical insurance to reform medicines to make up for them? Whether we can not reimburse the bonuses, we can raise the cost of care rationally, raise the cost of surgery, raise the cost of treatment, and set up the medical service fee, and then use the medical insurance more. Land reimbursement for the value of medical and technical services?

As for how to adjust the price of medical services that have long deviated seriously from the value, Chen Xi believes that the development and reform departments can negotiate with the health authorities. For example, the province's price department can specify which prices can be raised and the extent to which it can be increased. The principle is not to increase the burden of medical treatment for the masses, and it is at the most equal to the situation before the reforms were made with drugs. Chen Hao said that the practice in Zhejiang Province is very good. After the price adjustment, the increased costs are mainly paid by the medical insurance fund. This not only does not increase the burden on the people, but also reduces their medical expenses. Since it is required that the reimbursement rate for the new rural cooperative medical system this year be improved by 5 percentage points, why not let this increase force in the direction favorable to the reform? Actually, we can also do this very wisely. It is to further reform the payment system while eliminating the addition of drugs. Otherwise, we will still pay according to the project, which will lead to "there are policies and countermeasures," and you cancel the use of drugs. To make up for medical problems, I will start a "major inspection." Therefore, it is imperative to introduce advanced payment systems, including pay-by-disease, pay-by-head, and pay-per-service, and that these advanced payment methods must be fully covered and not left blank. After accumulating basic data for two or three years, we can also design a more reasonable system of total advance payment, such as paying 70% of the hospital in the beginning of the year, and then pay in installments. If the hospital has balance at the end of year settlement, it will be rewarded; if it is overspending, it is Unreasonable overspending will reduce the amount of prepayment in the next year.

Dividing medicine into medicine is no more "individual". Only when we have the courage to reform ourselves first can we gain the understanding of the people and all sectors of society in order to get the support of our brotherly departments. The total amount of hospital revenue will remain unchanged. If the purchase price of medicines is pressed down, the increased balance of the hospital can be used for further development, support research and teaching, and improve the treatment of medical personnel.

Just cancelling 15% of drug additions did not really trigger the interest chain in the pharmaceutical circulation field. Under the premise of ensuring that the burden of medical care for the masses is not increased, the prices of medical technology services can only be adjusted slightly. This will have very limited incentives for medical personnel.

Chen Hao believes that the elimination of 15% of drug additions is only the first step to abolish the roadmap for the reform of medicines and medicines, and first let public hospitals get rid of dependence on drug income. In the past, even if the hospital knew that the drug price was unreasonable, it would be happy to see it. However, after the abolition of the additive policy, the behavior of the hospital will immediately change. The hospital will control the cost and will be happy to see that the drug price is low. Of course, the premise is to recognize that the total revenue of the hospital is reasonable, but the structure is unreasonable. Next, we can join hands with the relevant departments to re-administer the intermediate links of drugs, because this will not affect the hospital's income. The hospital's total income remains unchanged. If the purchase price of drugs is pressed down, the hospital's balance will increase. What does the extra money do? For investment and redevelopment, establish a talent fund, support research and teaching, and improve the treatment of medical personnel. It is to squeeze out these waters from the intermediate links and turn them into upright hospital revenues for medical personnel to obtain with dignity.

Chen Hao said that there are indeed some people in the intermediate links who have entered the pockets of medical personnel and become gray income. If major cases are detected, the perpetrators will be ruined and the organizations will be back names. This is why we must get rid of this malady, and we must hurry to change it because it arouses strong dissatisfaction among the masses, causing a strong distortion in the relationship between doctors and patients, and seriously corrupting our ranks. The elimination of the use of medicine to make up for medical treatment is in no way an obstacle to medical personnel, but is fundamentally protecting the team.

Why do a small number of medical staff accept gray income without thinking too much? Chen Hao believes that apart from the declining medical ethics construction, a potential factor is that the income of medical personnel in our country is indeed low, and a small number of medical personnel have gone astray due to psychological imbalances and unsustainable temptations. "Actually, not many countries have relatively low medical personnel's relative income." There is an argument that the income of basic-level doctors should be linked to the average level of public institutions, that is, to the income of primary and secondary school teachers in the compulsory education stage. Chen Hao said that it is difficult to understand the simple comparison of medical personnel's income because the long training period, high labor intensity, and high occupational risk of qualified medical workers are all obvious reasons. However, in our country until now there is a relevant understanding. The problem has not yet been completely resolved.

However, Chen Yu believes that the black hole of gray income must first be blocked. Otherwise, the society cannot understand that the relevant departments will also have concerns about increasing investment. This is why the Ministry of Health shouted out the most “removing medicine to supplement medicine” at the beginning of this year. Strong tone. This is by no means an "individual", because only if we dare to reform ourselves first, can we get the understanding of the people and all sectors of society and we can get the support of our brotherly departments.

There are still some top-level designs for public hospital reforms, that is, first-to-last difficulties, first-priority grassroots centers, and first-country rural cities. Our country is very large and the situation is different everywhere. Finding a "one size fits all" model is more difficult. We do not advocate detaching from the health administrative department to engage in medical asset management institutions that only maintain and increase their value, because public hospitals are a subsystem of the health system and their responsibilities are very heavy and cannot be completely separated from the general health system.

"The lack of top-level design in public hospital reforms" seems to have become the consensus of many reformers and experts. The depiction of the reform in the medical reform program is always relatively macro. As for how to implement it, all parts of the country are still “crossing the river by feeling the stones”. Take the separation of this reform from the management office, it was concluded that there are six kinds of practice models. However, there is no exact statement as to which model is good.

Chen Hao said that our country is very large and the situation is different everywhere. Finding a "one size fits all" model is more difficult. The separation of public hospitals and public health offices now referred to means that government decisions and supervision should be separated from the implementation of public hospitals as government-sponsored public institutions in terms of basic medical services. In a sense, it is the separation of government affairs.

Chen Hao said that there are indeed different ways of operating the separation of management and management. For example, Beijing has learned the experience of the Hong Kong Medical Management Bureau and set up a hospital authority under the Bureau of Health. It is also a bureau-level organization. For public hospitals, there is a special agency to manage the management of assets, and it is a fine, scientific micro-management, so the dean are welcome. Some cities do not come forward with health bureaus. Instead, they are led by the deputy mayor in charge of the establishment of a public hospital management committee and set up offices in the health bureau. This is similar. The Shen Kang Group in Shanghai is a separate agency outside the health system. However, it is coordinated by the city leaders in charge of health. The chairman of the board of directors is the Director of the Department of Health. Representatives from the development, finance, and health care sectors are invited to this. On the management platform, the public hospitals under its management are meticulously managed and the government's investment policies for public hospitals are vigorously implemented.

Chen Hao said that he does not advocate detaching from the administrative department of health to engage in medical assets management institutions that only maintain and increase their value, because public hospitals are an important carrier for the provision of basic public health services as a public product, a subsystem of the health system, and their responsibilities are very important. It is necessary to cure diseases as well as prevent diseases. We must support grass-roots units and establish a relationship of referral to and from the grass-roots level. We must cultivate talents for the entire system. If they are pulled out of business to make them completely out of the general health system, they do not need to think for the grassroots, there is no incentive to divert the patients, only to take into account their own maximization of economic interests, which is not in line with the medical reform "guarantee the basic, strong grassroots, The basic spirit of building a mechanism. In the final analysis, the attributes of public hospitals are public-welfare institutions, not enterprises, so they cannot be separated horizontally and independently from the government's general health system. Instead, they should be vertically separated.

Chen Hao said that at present, 17 public hospitals are in an orderly manner in reforming the country's connection with the pilot cities. Which of these methods is more practical and practical, so that everyone can give it a try, and now no conclusions are drawn. However, we believe that a department that specializes in managing public hospitals is still necessary in big cities, but it is not necessary at the county level. As to whether the management department is located under the health sector, or under the government and the office is located in the health sector, we can look at the pilot results again. As long as the reform aims are achieved, some autonomous practices are allowed. After all, our country is so big and has a population of more than 1.3 billion people. Why is it necessary to solve problems in a one-size-fits-all manner? Of course, there are still some top-level designs, that is, the first to be difficult, the first to be the grassroots, and the first to the rural. This is in line with the basic laws of reform. In particular, it should be pointed out that county-level hospitals are responsible for the medical and medical tasks of 900 million Chinese people, especially farmers. In the past three years, public financial investment has been large, and the cost of reforms has been relatively low. Public hospitals must first be reformed in county-level hospitals. Achieving 90 percent of residents' medical care without going to the county is also conducive to optimizing the rational distribution of medical resources in both urban and rural areas.

Public hospitals cannot be over-marketized. If it is only followed by the market, it will follow its wealth and become an institution serving a few rich people. The allocation of public hospital resources should follow the needs of the people.

This year's government work report proposes to “promote the reform of public hospitals, separate medicines, separate management and management, and eliminate the mechanism for remedy of medicines” to clarify the tasks of public hospital reform. Some members believe that the current reform design of public hospitals has not yet touched the core, and government policy alone cannot always solve the problem fundamentally. The reform of public hospitals should be based on a more open approach to reform and gradually enter the “government-led, health-care reforms that follow the laws of the market”.

Chen Hao said that he does not think that the only way out for the reform of public hospitals is marketization, and public hospitals cannot engage in excessive marketization. Although the market mechanisms conducive to improving efficiency can still be used for reference. However, an important reason for the unfavorable relationship between doctors and patients is that there are problems with institutional arrangements and medical expenses have risen too quickly. Most people have no health insurance at one time. Medical expenses for a major illness often cause family bankruptcy. If we turn a blind eye to these situations, we still say that if we want to liberalize the market mechanism and ignore the establishment of a basic medical and health system, it will only make the relationship between doctors and patients worse and worse. In the end, the groups of doctors will lose the trust of the people. This has happened in some Latin American countries.

Chen Hao said that if it is only followed by the market, the trend of development of large hospitals or high-quality medical resources must be concentrated in big cities, and it is concentrated in the central area of ​​the city. It will not take the initiative to go to the urban and rural areas, not to In the outskirts of the county, it will follow the wealth and become a service for a few wealthy people. Chen Hao believes that the allocation of public hospital resources should follow the needs of the people. If we want to mobilize the enthusiasm for income generation, then there is no system that is more "effective" than using medicines to supplement medicine. But what is the final result? It will make this team completely corrupt. This is not desirable. This is a dispute of principle. Chen Hao said that on this issue, he will not waver in keeping with his position.

The first step in the reform of public hospitals is to strengthen regional health planning. The Ministry of Health is studying the timely expansion of large-scale expansion of public hospitals without government approval and inconsistent with regional health plans, leaving more room for the development of medical services for social capital.

A CPPCC member pointed out that the uncontrolled expansion of large public hospitals has now become a very common phenomenon, which constitutes a "siphon" for social medical resources and places outstanding doctors, large numbers of patients, and medical insurance funds in one place. Not conducive to the healthy development of the regional health system. Is it not the time to expand the brakes for large hospitals?

Chen Hao said that the deep-seated reason for this situation is that, first of all, public finances have been seriously deficient in public hospitals. In the early days of reform, public hospitals needed to improve the medical environment, purchase equipment and equipment, carry out basic construction, and even need to raise funds from workers. If public finances have very little investment in public hospitals, the development of public hospitals will rely on their own lending to banks and raising funds for workers. The government will also lose control of the allocation of medical resources. "If you want to get it, you must give it first." If you want to obtain the command authority for the development of public hospitals and obtain the macro-control power for the allocation of medical resources, the government must implement the responsibility of investing in public hospitals. At this time, it can order public hospitals. It is not allowed to expand at will, but according to the government's plan. (Next to the third edition) (Continued from the first edition)

Chen Yu said that the problem is that even if the government's investment increases, the self-inflation and self-expansion of big hospitals have already formed. Therefore, after the government has put its responsibility for public hospitals into place, it can be constrained by administrative means, economic means, and legal means. For example, the person who violates the regulations and causes adverse consequences will be replaced by the person in charge; for example, the bank will be notified that no government loan will be allowed to public hospitals without government approval.

Chen Xi emphasized that the reform of public hospitals is first of all to strengthen regional health planning, that is, the government must take responsibility for the holding and macro-control of public hospitals and regain their power. Urban public hospitals can no longer be disorderly, because this will inevitably lead to competition for patients and medical insurance resources with county-level hospitals, community health service centers, and township health centers. According to the analysis of experts, at present, about 80% of outpatients in most major hospitals do not need to go to the big hospital for the first visit. This actually wastes medical resources. The big hospitals must do well what they should do. The big hospitals should do the work to solve the difficult problems of diagnosis and treatment, cultivate talents, and engage in medical scientific research. The big hospitals should be handed over to and support grassroots medical institutions. .

Chen Hao said that last year, the number of beds per thousand people in China has reached 3.8, and if the number of beds per thousand people reaches 4, then the hospitalization resources can basically meet the existing needs. It is estimated that the wards currently under construction around the completion of this goal It has already been reached. He disclosed that the Ministry of Health is studying the timely expansion of public hospitals without government approval and inconsistent with the scale expansion of the regional health plan. In the future, it is necessary to leave more room for the development of medical services for social capital.

When people have relatively large opinions on an industry, they often have opinions on the relevant policies and institutional arrangements of the industry. We hate red packets and kickbacks, but when this happens to a certain amount, we must look for the reasons from the system. Moral cultivation alone is not enough. My country

The vast majority of the 8.6 million medical personnel are good. This cannot be denied.

On March 5th, during an interview, Zhong Nanshan, the National People's Congress’s deputy, publicly criticized some medical personnel who “had not even the basic moral bottom line”. For a time, there was a lot of online follow-ups, and there were many people on top of him and few people stepped on him. The person at the top of him magnified his words and said that “the current level of professional ethics of doctors is not high” and it has also received many positive responses. Why is an obviously untenable conclusion that can cause such strong resonance in the crowd?

Chen Hao said that not long ago Peking University and the Ministry of Health Statistics and Information Center jointly completed a public opinion survey. He noticed that everyone's satisfaction with doctors and nurses was 94.6% and 93.5%, respectively, but nearly half of them did not pay for medical expenses. satisfaction. In the end, when the masses have relatively large opinions on an industry, I think that such opinions often exceed the opinions of specific practitioners, but are opinions on the industry-related policies and institutional arrangements. This is why we must change medicine to make up for medicine. It can cause people to lose confidence in the entire industry. Some patients see the prescription prescribed by a doctor. First of all, they think that there will be no trickery or overly-medicine drugs. This is a fault in the system. We hate red packets and kickbacks, but conversely, when this phenomenon occurs in a certain amount, we must look for reasons from the system. It is not enough to rely solely on moral cultivation.

Chen Hao said that Mr. Zhong Nanshan's remarks only targeted a small group of medical personnel. The vast majority of China's 8.6 million medical personnel are good. This point cannot be denied. The team of white soldiers always pulls out when the country and the people need it. They win the game and trust it. The total cost of medical care in China is very low. On average, there are only more than 200 US dollars per person, but we use this to account for only about 3% of the total cost of medical care in the world, and maintain the health of 20% of the world's population. The average life expectancy is nearly 74%. year old. Why is there such a low cost? This is not because our medical equipment is not advanced enough, but because the average income of doctors and nurses in our country is very low. Compared with our international counterparts, we should not say that developed countries are much less than the income of many developing country counterparts.

The "Anhui model" should be fully affirmed as a whole. It has opened the prelude to comprehensive reforms at the grassroots level. The main position of primary health care service organizations is to undertake public health services and common diseases. This year we will launch the 2012 edition of the Essential Drug List to meet the basic drugs for the prevention and treatment of diseases at all levels of medical and health institutions.

In 2009, Anhui Province took the lead in introducing the basic drug system implementation plan in the country, and as a core, it initiated comprehensive reforms at the grass-roots level. The "Anhui Model" was once considered to be "a new way for the nation's medical reform" and "worthy of learning from other provinces (regions, cities) across the country", but just last September, Anhui Province issued a "new 30" "There have been many adjustments to the previous reform model. Does this mean that the "Anhui model" cannot go down?

Chen Hao said that the "Anhui model" should be fully affirmed as a whole, and it opened the prelude to comprehensive reform at the grassroots level. The reform involves the reform of the hospital management system, personnel system, distribution system, and security system, which has fundamentally changed the situation in which the grassroots medical team has not standardized management over the years. After the reform, the hospital's hospitalization expenses, outpatient expenses, and drug costs all decreased significantly, and the masses benefited from the reform.

However, he believes that the “Anhui Model” has encountered two major problems. First, although 307 basic medicines can basically meet the needs of most township hospitals in the central and western regions, they are not enough in the central township hospitals and diseases are everywhere. The spectrum and medication habits are also not consistent, so it is an inevitable choice to adapt appropriately to local conditions. Second, after the reform, the average income of grass-roots workers has increased, but due to the problem of partial proportion of basic salaries and performance-based salaries in performance-based salaries, the income of a few technical backbones The decline in some of the grassroots institutions has affected their enthusiasm. These issues are not unique to Anhui, but the comprehensive reforms at the grassroots level in Anhui Province started early, encountered and identified new situations too early, and the “new 30” was immediately effective after it was launched, and basically solved the problems well.

Chen Hao said that he just got a latest statistical data. After three years of medical reform, the service volume of community health service centers and village clinics has been increasing year by year. In fact, only township hospitals have fewer patients in 2011 than they did in 2010. 8 million, only a drop of 1 percentage point. We must not forget that the primary position of primary health care service providers is not to make money by selling drugs, but to assume public health services and common medical treatment. Of course, public health services were also undertaken before, but it was relatively small. Now that basic public health service items have been increased to 41 items in 10 categories, building health records for only 50% of residents is an extremely important project. Therefore, the workload of the primary health care service has not decreased but it has been very hard.

Chen Hao said that this year the 2012 edition of the Essential Drugs Catalogue will be launched and will be appropriately adjusted according to needs and abilities to meet the basic requirements for the prevention and treatment of diseases by medical and health institutions at all levels. For the shortage of drugs will explore fixed-point production, unified pricing, unified recruitment, unified distribution and other measures. For a relatively high degree of market price recognition, we can consider uniform pricing; and for a small amount of special types of shortage of special varieties, the state must be designated production. Essential medicines are medicines provided by the country to all citizens with a guarantee of credit. They must be supplied in sufficient quantity and cannot be interrupted. If it is interrupted, it is the responsibility of the relevant government departments is not in place.

In the end, Chen Hao stated that human health needs are always improving, and the development of medical science and technology is so fast. However, the resources for social payment of medical and health services are always limited. Therefore, the improvement of the system is an eternal proposition. Any reform is necessary. It is necessary to look at the effect, but also to see the cost, medical reform can not be an exception, in this sense, "I am afraid that medical reform will never end."