A complete analysis of the pilot plan for the launch of urban public hospital reform
Among the new medical reforms, the highly valuable "boot" has finally been implemented.
On May 17, the "Guiding Opinions of the General Office of the State Council on the Pilot Comprehensive Reform of Urban Public Hospitals" (hereinafter referred to as the "Opinions") was officially announced.
The "Opinions" make comprehensive arrangements for the most difficult part of my country's medical reform - the reform of public hospitals, especially the reform of urban public hospitals. The full text is more than 9,000 words and contains 30 articles, covering many key issues in the reform of public hospitals such as management systems, operating mechanisms, payment methods, personnel compensation, hierarchical diagnosis and treatment, etc.
The "Opinions" clarify the reform goals for 2017. This means that this "Opinion" will play a vital role in guiding the reform of urban public hospitals in my country in the next three years. In view of this, the 21st Century Business Herald "New Health" conducted a comprehensive analysis and interpretation of the "Opinions" based on the opinions of relevant experts.
1. Overall requirements: three "basics"
In the overall requirements section, the "Opinions" put forward basic principles, basic goals and basic paths.
Goals for 2017: The comprehensive reform pilot of urban public hospitals has been fully launched, a modern hospital management system has been initially established, the capabilities of the medical service system have been significantly improved, the medical order has been improved, and the number of general outpatient visits in urban tertiary hospitals has The proportion of total visits to medical and health institutions has been significantly reduced; the unreasonable increase in medical expenses has been effectively controlled, and the increase in total health expenses has been coordinated with the increase in the region's GDP; the burden of medical expenses has been significantly reduced, and overall personal health expenditures account for the total health expenses The proportion dropped to less than 30%.
Interpretation:
In the classification guiding principles section, the "Opinions" innovatively proposed that "based on reality, for different regions, different levels, and different types of public hospitals, in the medical insurance payment Implement differentiated reform policies in aspects such as price adjustment, performance evaluation, etc.”
Dean Liu Yuanli of the School of Public Health at Peking Union Medical College analyzed that, “In view of the differences between different types of hospitals and different regions, classified guidance must be followed if any reform measures are to be effectively implemented in China. Basic principles. For example: Although they are all public hospitals, due to their unique 'externalities' (ie, social influence), infectious diseases hospitals should receive more financial support from the government than general general hospitals. In addition, public hospitals should receive more financial support from the government than general hospitals. The restructuring will not be rolled out across the board, but it will first be implemented in areas with relatively sufficient public hospital resources. "
What is particularly noteworthy is that in the basic target part, the goal of medical expense control is the increase in total health expenses. In line with the growth of the region’s GDP.
Previously, research by the Collaborative Innovation Center for Health Risk Early Warning and Governance led by Fudan University showed that from 1991 to 2013, the average annual growth rate of my country’s per capita medical expenses was 17.49%, which was significantly higher than the GDP growth rate during the same period. The growth rate has brought about a series of serious problems.
"Significance" rarely explicitly states that the growth of total health expenditure services must be coordinated with the GDP growth of the region. This means that total health expenditure control will become one of the regulatory goals of regional governments in the future.
2. The reform of public hospital operation, management, and compensation mechanisms
1. The medical level of the management system: Who will perform the medical functions?
《 The Opinions proposed that: Each pilot city can establish a management committee led by responsible government officials and composed of relevant government departments, some deputies to the National People's Congress, members of the Chinese People's Political Consultative Conference, and other stakeholders to perform the government's medical functions and be responsible for the development planning and charter of public hospitals. Formulation, implementation of major projects, financial investment, operation supervision, performance appraisal, etc., and clarify the office organization to undertake the daily work of the Management Committee.
Interpretation:
In terms of the medical system, the separation of political affairs and management and management are still the basic contents. In the previous stage of health care reform, how to implement the separation of management and administration received the most attention and debate. Various places have also made different attempts in this regard, such as the Shenkang Center in Shanghai and the Hospital Authority in Beijing. After the early accumulation, the "Opinions" proposed a clear approach to the form of medical operation: forming a management committee and listing six responsibilities that this medical institution must bear.
In this regard, Liu Yuanli analyzed that, "The separation of management and office is the first step to change the old administrative management model and move towards a modern hospital management system. The modern hospital management system has two propositions: one is governance Another structural change is the improvement of governance capabilities. The former is reflected at the macro level by the establishment of a management committee led by the government as an investor and participated by major stakeholders. This structure is theoretically more representative and more effective than pure administrative management. Reflect public opinion. The micro level of modern hospital management system is the establishment of a corporate governance structure characterized by independent operation. After these new governance structures are established at the macro and micro levels, the improvement of governance capabilities becomes the key. To effectively perform their functions and how the hospital director can become an excellent modern hospital manager requires a lot of education and training work."
2. The hospital level of the management system: "One is lenient and the other is strict. "Two Paths"
The "Opinions" propose: Improve the corporate governance structure and governance mechanism of public hospitals, and implement the autonomy of public hospitals in personnel management, internal distribution, operation management, etc. Take effective forms to establish internal decision-making and control mechanisms in public hospitals. Strengthen refined management of public hospitals. Improve the multi-party supervision mechanism.
Interpretation:
The "Opinions" adopt two directions of "one lenient and one strict" in the reform of the management system at the hospital level. The “broad” level is to implement the autonomy of public hospitals, including personnel, distribution, operations, etc. Only by fully giving public hospitals autonomy can they truly establish a corporate governance structure, effectively participate in market competition, and ultimately form a modern hospital management system.
Whether it is at the medical level or in implementing the autonomy of public hospitals, the "Opinions" are trying to change the original administrative-heavy management system to make it more flexible and efficient. But while being "lenient", the "Opinions" also put forward quite a few requirements in terms of "strictness".
These "strict" requirements include the selection, assessment, and accountability of deans, as well as the assessment and evaluation of hospitals. In particular, the "Opinions" describe the multi-party supervision mechanism in great detail.
This multi-party regulatory mechanism includes industry management, audit supervision and information disclosure by the health and family planning administrative departments, self-discipline, supervision and professional ethics construction by industry associations, as well as social supervision including evaluation by third-party agencies. What is particularly noteworthy is that in terms of information disclosure, the "Opinions" clearly lists information such as financial status, performance appraisal, quality and safety, price and medical expenses. Will the disclosure of prices and medical expenses also help control costs?
3. Breaking down the operating mechanism of using drugs to supplement medical treatment
The "Opinions" propose that: all public hospitals in the pilot cities Promote the separation of medicines, actively explore various effective ways to reform the mechanism of using medicines to supplement medical treatment, and cancel the addition of medicines (except for traditional Chinese medicine preparations). Change public hospital compensation from three channels: service charges, drug markup income and government subsidies to two channels: service charges and government subsidies. Establish a scientific and reasonable compensation mechanism by adjusting medical service prices, increasing government investment, reforming payment methods, and reducing hospital operating costs.
Interpretation:
Reforming the mechanism of using drugs to supplement medical care is still a breakthrough for public hospitals to build a new operating mechanism. The general idea is to reduce the proportion of drugs, materials, etc. in hospital income, while increasing the proportion of technical labor income in business income. The "Opinions" also put forward clear goals, striving to reduce the overall proportion of medicines (excluding traditional Chinese medicine pieces) in pilot cities' public hospitals to about 30% by 2017; and the health materials consumed in one hundred yuan of medical income (excluding drug income) to fall to 20%. Yuan or less.
Recently, Feng Guosheng, director of the Beijing Municipal Hospital Authority, revealed in an interview with the media that as of the end of February, the proportion of medicines for outpatient medical insurance patients in Beijing’s five pilot hospitals had dropped from 70% in the past to the current 58.8%. In these large pilot hospitals in Beijing with relatively strict management, the proportion of medicines after the reform is still not low. It can be seen that the goal of 30% in three years is still quite arduous.
4. "Reducing" and "straightening out" the operating mechanism
The "Opinions" propose: reduce the cost of drugs and medical consumables. High-value medical consumables must be purchased through provincial centralized procurement platforms. Pilot cities should formulate and introduce public hospital medical service price reform plans.
Interpretation:
In terms of reducing the cost of medicines and consumables, the "Opinions" highlight the importance of centralized procurement.
Whether it is medicines or high-value consumables, the "Opinions" sternly pointed out that centralized procurement should be implemented.
However, in terms of improving the current distorted price system and reflecting the value of medical personnel’s services, straightening out the prices of medical services is more important for future public hospital reforms. The "Opinions" clearly stated that pilot cities should formulate and introduce public hospital medical service price reform plans.
5. Government investment in the operating mechanism: What responsibilities does the finance bear?
The "Opinions" propose that governments at all levels should implement the basic construction and equipment purchase of public hospitals in line with regional health plans, Investments include the development of key disciplines, talent training, retired personnel expenses and policy loss subsidies that comply with national regulations. Reform the financial subsidy method and strengthen the linkage between financial subsidy and the performance appraisal results of public hospitals. Improve the government purchasing service mechanism.
Interpretation:
As a public hospital run by the government, how much responsibility should the government bear? What responsibilities should it bear? The "Opinions" lists six items that belong to the government's investment, and of course Including other aspects of funding guarantees to further clarify the boundaries of government investment responsibilities.
It should also be noted that the "Opinions" propose that the inspection price of large-scale equipment purchased by government investment in public hospitals shall be based on the cost after deducting depreciation; for loans or fund-raising purchases that comply with planning and relevant policy provisions, Large-scale equipment will be repurchased by the government at a price after deducting depreciation. If the repurchase is difficult, the inspection price will be reduced within the time limit. This means that local government fiscal expenditures must "pay" for large equipment in public hospitals.
What is more important is the reform of financial compensation methods. Previously, financial compensation to public hospitals was mainly based on the number of staff and the number of beds, but the "Opinions" proposed that future financial compensation will be linked to performance appraisal results.
6. Reform of the personnel compensation system: filing system
The "Opinions" propose: within the existing local establishment, the total establishment of public hospitals should be reasonably determined and the establishment of public hospitals should be innovated. Management methods, gradually implement the preparation and filing system, and establish a dynamic adjustment mechanism. In terms of job setting, income distribution, professional title evaluation, management and use, etc., overall consideration will be given to the treatment of personnel inside and outside the establishment, and the reform of the pension insurance system will be promoted in accordance with national regulations.
Interpretation:
Since the reform of the personnel compensation system in public hospitals involves the overall pattern of the reform of national institutions, there has been little breakthrough before. However, the "Opinions" this time proposed a number of specific measures for staffing reform, including staffing and filing systems, dynamic adjustment mechanisms, overall consideration of internal and external personnel, and the implementation of employment systems and job management systems.
The issue of remuneration of medical staff has been a matter of concern in the industry for a long time. This time, the "Opinions" put forward several reference factors on how to determine the salary of medical personnel, including the long training cycle in the medical industry, high occupational risks, high technical difficulties, and heavy responsibilities.
In this regard, Liu Yuanli said, “Although a personnel compensation system that conforms to the characteristics of the medical industry has been proposed, which department (whether it is the human resources and social security department or the health department), based on what standards, and through what process will establish this system. The system will directly affect the realization of this goal. I am more optimistic about the change of the staffing system to the 'recording system', because the development of public hospitals cannot be separated from a more flexible personnel compensation system, and the 'staffing' system has always affected the modern hospital management system. "One of the biggest obstacles to the establishment of basic medical insurance." 3. Medical insurance fee control is "approaching" , establish a composite payment method such as payment based on disease type, payment based on capitation, payment based on service unit, etc., and gradually reduce payment based on project. Encourage the implementation of payment based on diagnosis-related groups (DRGs). The reform of medical insurance payment methods should cover all public hospitals in the region and gradually cover all medical services.
Accelerate the establishment of an open and equal negotiation mechanism and risk-sharing mechanism between various medical insurance agencies and designated medical institutions. Gradually extend the supervision of medical insurance services by medical institutions to the supervision of the medical service behavior of medical personnel.
Interpretation:
Previously, project-based payment was considered to have played a role in promoting "big examinations and big prescriptions". Reforming the medical insurance payment method has almost become a priority for all parties in the industry. ***knowledge.
At the same time, judging from the reform trend of public hospitals, the role of medical insurance in supervising and restricting medical behavior is receiving more and more attention, and the key to this attention is to be able to effectively control the excessively rising medical expenses and control medical costs. Moreover, in the future, this kind of supervision will not only be for medical institutions, but also for medical personnel. In other words, the role of medical insurance supervision and restriction will become increasingly refined.
IV. Reconstruction of the medical service system
1. Coordinated development of the reconstruction system
The "Opinions" propose: Optimize the planning and layout of urban public hospitals. Strictly control the bed size, construction standards and large-scale medical equipment of public hospitals. For public hospitals that exceed scale standards, comprehensive measures must be taken to gradually reduce the number of beds. Control the scale of special-needs services in public hospitals so that the proportion of special-needs services provided does not exceed 10% of all medical services.
Interpretation:
The "Opinions" still continue the past idea of ??controlling the scale of public hospitals, but make it clear that special services should not exceed 10% of all medical services. Previously, there had been great controversy over whether public hospitals could provide special services. The "Opinions" also responded from another perspective, yes, but not more than 10%. This means that “franchising” and other approaches proposed in some versions of local medical reform will become the channels for the development of public hospitals.
2. Restructure the hierarchical diagnosis and treatment system
The "Opinions" propose:
Gradually increase the number of urban public hospitals making appointments through primary medical health institutions and general practitioners. And referral service numbers, higher-level hospitals provide priority admissions, priority examinations, priority hospitalization and other services to patients who have been scheduled or referred by primary care and general practitioners. Ultimately, the proportion of appointment referrals in public hospital outpatient visits should be increased to more than 20%, and the number of general outpatient visits in tertiary hospitals should be reduced.
Interpretation:
Hierarchical diagnosis and treatment is a very good vision. The "Opinions" gave a hard target of 20%, which is undoubtedly the driving force to promote the implementation of hierarchical diagnosis and treatment (12.05, -1.34, -10.01%).
The current ideas for promoting hierarchical diagnosis and treatment are mainly from two perspectives: one is to improve the protection of grassroots medical treatment, including the sinking of high-quality medical resources, convenient and fast referral channels, and a higher medical insurance reimbursement ratio; the other is to improve the protection of grassroots medical treatment; One is to increase the cost of medical treatment in large hospitals, including reducing the number of visits to general outpatient clinics in large hospitals. For those who do not follow the referral procedures, the medical insurance payment ratio will be reduced or no payment will be made according to regulations.
3. Reconstructing the medical informatization system
The "Opinions" propose that by the end of the year, all public hospitals above the second level and more than 80% of primary medical and health institutions in the administrative region will be implemented Connect with regional platforms. Comprehensively implement the health and medical information action plan to benefit the people.
Strengthen the construction of telemedicine systems, strengthen remote consultation, education and other service functions, and promote the sharing of high-quality medical resources. By the end of the year, all pilot cities have basically completed the construction of informatization standards for all second-level and above hospitals, and 60% of primary medical and health institutions have established telemedicine information systems with higher-level hospitals.
Interpretation:
Medical informatization has high hopes in expanding the scope of high-quality medical resources, improving patients’ medical experience, and strengthening residents’ health management. The regional medical and health information platform proposed in the "Opinions" aims to gradually achieve business synergy between residents' basic health information and public health, medical services, medical security, drug management, comprehensive management and other application systems. Moreover, the "Opinions" have put forward quite clear timetables in terms of information platform construction, hospital information standard construction and telemedicine. This provides considerable imagination for the development of medical informatization.