"Medical care integration" is one of the hottest keywords in the field of elderly care. However, the medical service system centered on large public hospitals has become the biggest obstacle to the realization of "healthcare integration". In the six years since the launch of the new health care reform, the government has invested heavily in rebuilding the primary health care system, but the problem of access to health care services has not been effectively solved.
"Making the elderly always run to big hospitals when they are sick is an unbearable burden for them and their families." Yang Yansui, director of the Employment and Social Security Research Center at Tsinghua University, said in an exclusive interview with the First Financial Daily that the accelerated onslaught of population aging is forcing China's public ****health policy to make fundamental adjustments, and that it is necessary to break down systemic barriers to develop community-based medical care and family beds, and to set up a system of family doctors who are trusted by the residents, so that they can truly become the national health resources' "gatekeepers".
Population aging ≠ social aging
First Financial Daily: China is running into an aging society, what do you think the silver wave means for China?
Yang Yansui: Aging is a manifestation of social stability and economic development. Population aging is not equal to social aging, and the key is to be prepared for old age. I prefer to call the economy after population aging the silver economy. Improving the asset structure of the aging population to increase purchasing power and improving the human capital of the working population to increase productivity are the two main engines of the silver economy. As long as the working population has enough labor power and the elderly population has enough purchasing power, the aging society is still a vibrant and dynamic society.
The characteristics of the silver economy reflect three issues: first, the consumption pull of the aging population, which must pay attention to their consumption needs; second, the improvement of the supply mode in response to the demand for senior care services; and third, the attention to the purchasing power of the aging population, which is otherwise an ineffective demand. In the age of the silver economy, these three issues must be well matched.
The "silver economy" is a buyer's market, and consumption has become crucial to economic growth. This is a time when much attention must be paid to improving the asset structure of the elderly population and increasing their purchasing power, a significant portion of which is in health care. Improving the asset structure of the elderly population is a long-term process, requiring public **** policy throughout one's career to promote employment, fair distribution and the allocation of reasonable social security, etc., which is something that needs to be planned for.
Daily: "medical" and "nursing" are the basic needs of the elderly population, "medical and nursing" is also the last one or two years in the field of old age a buzzword, "medical and nursing". What is the current status of the "medical and nursing" combination?
Yang Yansui: The combination of medical care and nursing is just a reference now, and there hasn't been any in-depth study or institutional arrangement. The Beijing Municipal Home Nursing Regulations mentioned "medical care integration", but it only roughly reflects the demand, without mentioning how to supply. Some community medical organizations in Guangzhou, Qingdao and Hangzhou are making some attempts to do so, but they are far from being on a large scale.
The Hongshan Street Medical Service Center in Guangzhou's Huangpu District, one of the city's pilots, has set up a medical service area for chronic diseases in the elderly and provides services such as family doctors, home hospital beds and hospice care, which are popular among the elderly. The cost of seeing a doctor there is only one tenth of that of a large hospital, and it is very popular with the elderly. As it prioritizes services for the elderly in this community, some of them are even willing to move their household accounts to Hongshan Street.
Journal: In your opinion, what are the characteristics of "medical and nursing integration"?
Yang Yansui: From the point of view of the consumption needs of the elderly population, medical and nursing are the basic reflection of the consumption needs of the elderly population, but at different age stages, the elderly have different needs for medical and nursing focus, "medical and nursing" also presents different characteristics.
The first stage is from 60 to 75 years old, which we call the "old age", the elderly still have their own life and entertainment. Few elderly people are willing to go to an institution, and they generally age at home. In this age group, "integrating medical care" is characterized by "replacing medical care with nursing", and "nursing" is the mainstay, as the elderly's expenses are not mainly spent on medication and medical care. At this time only need to strengthen the home nursing community services, in the community medical service center to open chronic disease management is enough.
The second stage is 75 to 90 years old, the elderly ability to take care of themselves as well as organic diseases will come to the fore, this period is called "medical care instead of nursing". Their need for medical care is more important than the basic needs of daily life, and without medical care, they may not be able to continue their lives, and aging in place can be very difficult.
In the stage of "medical care instead of nursing care", it is necessary to develop supporting geriatric wards and home beds in community medical institutions, as well as corresponding nursing and living care, so that they can get convenient and low-priced health care services close to their homes, and so that as few as possible of them have to go to the big hospitals to be hospitalized. Large hospitals have to undergo a lot of tests, the cost is very high, even if only 20% of the burden, many elderly people can not afford to pay, which not only puts a great burden on their children, but also leads to a waste of health insurance funds and medical resources.
Who pays for the "medical care integration"
Daily: "medical care integration" is the concept pursued by the elderly institutions, but compared with the life services, medical services is the short board of the elderly institutions, which makes it impossible to realize the old age at home. The old man even in the nursing institution is difficult to meet the medical needs, what is the reason for this predicament?
Yang Yansui: Most of the elderly institutions must face the problem of "medical care instead of nursing", for the vast majority of the elderly, to go to the institution is a choice of last resort. Even in recent years, the new, very high-grade living facilities of the elderly institutions, customers are mainly elderly, disabled elderly.
The development of senior care institutions is now hampered by the health insurance system. Medicare can only reimburse the costs of medical institutions, not nursing homes, which is tantamount to encouraging all the elderly to live in medical institutions. The fact that Medicare can pay for the costs of rehabilitation institutions has forced many nursing institutions to apply for the establishment of rehabilitation institutions. However, the establishment of rehabilitation institutions are standards, the need to reach a certain number of beds and medical staff, the threshold is very high, many private, social institutions can not meet such standards, can establish a rehabilitation institutions are often large-scale, the cost is very high, the average older people can not afford to pay.
The State Council proposed that as long as enough ten beds can handle small nursing homes, the development of community-based chronic disease areas for the elderly, home hospital beds and end-of-life comfort and other services are very humane, and the elderly can afford such services, but the health insurance can not reimburse the medical costs of these care institutions but restricts their development.
Journal: So how can these institutional and policy barriers be broken down to harmonize health insurance with health care?
Yang Yansui: In the combination of health care, health insurance can only pay for the "medical" part but not the "nursing" part, which is the basic principle. Therefore, the first thing we need to do is to put home hospital beds, community medical institutions for the elderly chronic diseases, end-of-life comfort and other services to establish a scientific service packages, clear what belongs to the medical services, which belongs to the daily nursing services, medical insurance only pay medical services, not pay nursing services.
This requires a very refined and scientific design of the system, the Red Mountain Community Medical Center to try to develop such a service package, according to the need to provide the necessary services for the elderly chronic diseases, to determine the diagnosis and treatment standards of the service, and ultimately to determine the cost of medical services, the health insurance fund in accordance with a certain proportion to pay, but in general is not yet mature, must be carried out more empirical research.
Daily News: What kind of cost-sharing mechanism should be established for "medical care"? What kind of responsibility should the government take in the "medical care combination"?
Yang Yansui: "medical care" has just begun, from the individual, on the one hand, the people themselves to buy, on the other hand, the children can help their parents to buy a part. After the establishment of a service package that distinguishes between "medical" and "nursing", the medical insurance can also bear part of it, and the financial institutions can subsidize the land, beds, taxes, and staff training of the nursing institutions.
Local governments are struggling with the question of whether to "make up for the bricks" or "make up for the heads" of elderly services, which is supposed to follow the law, elderly services should do things according to the timetable for the development of an aging society, which has just entered into an aging society, and which needs a large number of people. When we first enter an ageing society, the elderly population is not yet large, so we need to make up a lot of "bricks and mortar", firstly, to develop gerontological science and technology, improve facilities for the elderly and set up standards for gerontological services, and secondly, to consolidate the system of general practitioners and family doctors. These are the two necessary conditions for entering an aging society and realizing a well-prepared old age.
After the deep aging society, with the increase of the elderly population, it is necessary to "make up for the headcount" as the main focus, the government should subsidize the elderly who do not have enough purchasing power.
China's situation is different from that of the developed countries. Ten years ago, the government did not "make up for the bricks" when it entered the aging society, but now that it is approaching the deep aging society, it is only now that it has begun to make preparations for the aging society, and therefore it has to "make up for the bricks" and "make up for the bricks". Therefore, it is necessary to "make up for the bricks" and "make up for the headcount" at the same time.
The two lines of income and expenditure "strangled" family doctors
Daily: you think that the family doctor is an important condition to be prepared for old age, and now the new health care reform has also implemented the system of general practitioners, the effect is how?
Yang Yansui: We found that a country into the depth of the aging society, there must be familiar with the health of the elderly and the elderly family trust of the family doctor, if the family doctor system is not sound, the elderly life will not have a place to go, "medical care" is also an empty word,
The health care reform over the years, the flaw is that immediately into the depth of the health care reform, the family doctor system is also an empty word.
The shortcoming of the health care reform over the years is that the accessibility of health care resources is still very poor as we are about to enter a profoundly aging society.
Medicine is a service, not a transaction. Medical services are high-cost and need to be well compensated by the state, society, health insurance, and the individual, but the healthcare reform treats healthcare as a transaction, forcing doctors to trade with patients, and public hospitals to take the lead in pursuing the volume of outpatient visits, consumables, equipment, and so on. This distortion of value, so that the public hospitals have formed a huge siphon effect, occupying a variety of resources, the government and a high degree of compromise to the public hospitals, which makes the allocation of our health resources is very bad, whether it is home care, or community care, even high-grade community care, can not attract the doctor's resources.
Family doctors are supposed to be the gatekeepers who look after the "two doors": the client's health record and the country's health resources. In many countries, the family doctor is a service unit system, signing a contract with 2,000 households or less of customers, to give them medical advice and services, with consultation fees, but also enjoy the government and health insurance capitation fee subsidies, they are the best income, the most level, the most trusted and respected by the customer group of doctors.
After the healthcare reform, although we have established a general practitioner system, we only treat them as a low-end duty worker, mainly responsible for guarding health records, the national health resources are not allocated to them, their education level, income level, and authority to use medication are all very low, and the residents' trust in them is very poor, so when the elderly get sick, they still have to crowd to the big hospitals.
China's "unpreparedness and old age" is not only the lack of pension preparation, the lack of family doctors is also a very important aspect of the public **** these policies in the field of health to limit the development of family doctors space, which is contrary to the needs of the entire aging society.