Editor's note: March 23 this newspaper "Suqian 3 years for the first time to respond to the" sold out "health care reform" in the newspaper, Peking University, deputy director of the China Center for Economic Research, health economic experts, Prof. Li Ling, called this newspaper, said he will personally go to the Suqian research.
Suqian's health care reform has been in the midst of controversy among national media and experts.
If Suqian's reform is recognized, the market-driven healthcare reform model, with property rights reform at its core, will be a powerful argument for the "market school". On the contrary, the "government-led school" will find a target for criticism in this debate. In other words, the evaluation of the Suqian medical reform is related to the choice of the direction of China's health care reform.
In April this year, Prof. Li Ling, who has always advocated government-led health care, and her group of about 10 people went to Suqian twice. The first time, they went directly to the hospital as patients; the second time, they went public to make contact with officials.
In order to ensure that the information is not lost or distorted in the process of transmission, according to the request of Prof. Li Ling, the newspaper published the full text of the research report of the group after a slight abridgement (which has been agreed by the author). It is said that the report has been sent to the relevant state departments at the same time.
Previously, the newspaper published a series of articles on health care reform, which indicated that the government, the media, experts and scholars should take a more prudent attitude toward the health care reform, which is a major issue involving the people's livelihood. The newspaper will continue to act as a faithful recorder of this special historical period.
From April 6 to 10, 2006, and from April 28 to 30, 2006, a health care reform team from the China Center for Economic Research at Peking University went to Suqian City, Jiangsu Province, to study the health care situation in Suqian City, Shuyang County, and the countryside.
The basic methodology of the research was to leave the local government unperturbed, and nearly a dozen health economists and students went to the hospitals as patients, surveyed and interviewed the doctors and patients in the course of the visits, and then communicated with the leaders of the health authorities and the hospital directors and the relevant personnel to report what they had seen and heard, and to listen to their opinions and explanations, in order to calibrate and confirm the results of the research.
We believe that the economic construction-centered reforms carried out by the leaders of Suqian City in recent years, led by the people of Suqian City, are bold and daring, thrilling and praiseworthy, but the reform ideas in some respects go against the objective laws of social and economic development, especially the use of comprehensive market-oriented means of reform in the field of health care, which has been proved to be unworkable in theory and practice. Therefore, the current Suqian City, "expensive" problem has not been solved, the people's medical burden on the contrary, the potential health care problem is worrying.
This report combines research, background information, and theories of health economics to provide a preliminary analysis of the achievements and problems of health care reform in Suqian City.
Suqian's extraordinary catch-up development is the background
(1) Before the health care reform, the government was incapable of making the necessary investment in health care
Suqian is located in the north of Jiangsu Province, and it is a newly formed prefecture-level city in 1996, with three counties under its jurisdiction: Shuyang, Sihong, and Suyang, and two districts of Suyu and Suicheng, as well as a provincial-level economic development zone, and a total population of 5.17 million people, with a land area of 8555 square kilometers and a relatively backward economy. For example, Shuyang, one of the country's 19 old revolutionary zones, was at that time at the bottom of Jiangsu in terms of economic strength, and eight of the county's 38 townships were provincial-level poor townships.
The backwardness of the economy has led to financial difficulties in the Suqian area, which is basically in a situation of "eating money". The development of social programs such as healthcare and education, which need financial support, is facing great difficulties. Especially after the financial decentralization reform, the responsibility of social public **** expenditure is also decentralized to the local, Suqian government really does not have a lot of money to invest in health care, directly leading to the lack of health resources, the grass-roots medical and health units in poor condition, low level.
(2) Medical reform is part of Suqian's economic super-conventional catch-up development
Faced with the reality of economic backwardness, Suqian has adopted a super-conventional development model to catch up with economically developed regions. Through the "above make up a little, the enterprise pad a little, the people raise a little, the government out a little" to speed up infrastructure construction, optimize the environment to attract investment. First borrowed money to improve the environment and infrastructure, investment in enterprises will increase, more tax revenue, land prices will appreciate, and land premiums and taxes to pay off the borrowed money to recreate a better environment, in order to achieve rolling development.
In this process, the local adopted a lot of special policy means, such as ordering public officials to lend their salaries to build roads, requiring enterprises to advance funds to build office buildings, 9 municipal roads in the city contracted to the District Personnel Bureau and other 9 departments responsible for the construction, and as the main person in charge of the assessment task, the investment target down to the various units. In Suqian, it can be clearly felt that all cadres are committed to economic construction efforts, all to economic development as the starting point, to improve efficiency as the goal.
Corresponding to this, Suqian's construction of social undertakings, especially education and health care, is through the dumping of baggage (the government's complete withdrawal from the medical field), the sale of schools and hospitals (to revitalize the stock of assets), the introduction of social capital in order to expand resources, and the promotion of competition in order to improve efficiency. Thus, the real-world context of Cebu's more radical approach to health care reform is that poverty is a no-win situation.
Achievements of Suqian's healthcare reform
(I) Reducing the government's financial burden
Suqian's 134 public hospitals in the region have carried out reforms of the property rights system, including 124 township health centers and 10 hospitals at the county level and above, and have formed partnerships, mixed ownership, shareholdings, sole proprietorships and other mainstays of running a healthcare system. Although individual hospitals and external public hospitals joint (such as Gulou Hospital Group Suqian City People's Hospital), or there are individual external public hospitals in Suqian to build a branch (such as the Shanghai Oriental Hospital Suqian branch), at present Suqian region of all levels of health care services have been purchased or operated by the private capital, Suqian regional government has been completely withdrawn from the operation of health care.
In such a restructuring process, the government is the most direct beneficiary, both through the restructuring of the revitalization of the hospital's assets, cashing in on the government's accumulations in the medical field over the past 50 years, and, at the same time, waiting until the expiration of the tax exemption period for private hospitals, the government's tax revenues will also increase.
(ii) the rapid increase in the number of medical resources
Suqian has adopted a series of policies to encourage social capital to enter the field of medical services, the number of hospitals and the total assets of health care has expanded rapidly. 2000 to 2005, the city's health care assets increased from 4.95 billion yuan to 1.778 billion yuan, which is 3.59 times more than the pre-reform period. 5 years ago, Suqian City had more than 130 hospitals of all kinds, but by 2005, there were more than 1,000 hospitals in the city. Five years ago, Suqian had 130 hospitals of various types, but by 2005, Suqian had more than 400 hospitals of various types. Our research found that various types of hospitals and clinics have been established on the streets of Suqian, most of which were opened in recent years. The increase in medical institutions has led to a corresponding expansion and increase in the medical workforce and medical equipment.
(3) Changes in the way hospitals operate, strengthened management, and enriched means of competition have increased the motivation of medical staff
The restructured hospitals no longer receive financial subsidies from the state, and there are currently no donations from the community, and are completely self-supporting.
Under the pressure of competition, the owners of the hospital (mostly shareholders) introduced the enterprise management mechanism, effectively strengthen the management of the hospital; improve the attitude of medical personnel services, especially in attracting patients, advertising vigorously promote the hospital's specialists and advanced equipment, local television programs, newspapers can be seen everywhere in the hospital and drug advertisements; reduce or waive the registration fee, reduce the cost of a single medical checkup, The price of medicines has been lowered, and additional services such as mobile buses for free transportation of patients have been provided. Many of these measures have really brought benefits to the people and have been recognized by them. The research has learned that the people's satisfaction with the hospital's service attitude has increased significantly.
Our research found that some doctors will ask the patient to bring enough money, if not much money to bring, will be less prescribed some drugs, and ask the patient to come back after a period of time with the money, and can give the patient the prescription of the future together with the patient, the next time to come to the next time you can prescribe drugs directly without registration and consultation. On the one hand, this shows that hospitals are thinking more about patients, and on the other hand, it may be one reason why the average outpatient cost has fallen, with patients coming in for multiple visits, and the cost of each visit dropping.
It is worth noting that both for-profit and non-profit hospitals have strong profit-making motives and capabilities. At the same time, the current instability of health reform policies has exacerbated the profit-seeking behavior of investors who demand rapid short-term recovery of their investments. Therefore, the first and foremost consideration of almost all investors in healthcare organizations is to try to recover their investment quickly under the current competitive and regulatory conditions in the market. According to the director of a hospital in Shuyang, the profit margins of hospitals are now generally above 50 percent, so it is said that investment in hospitals can generally be recovered in two years.
The excessive profit motive has led most hospitals to continue to incentivize medical staff by paying them according to the performance of their departments. According to our interviews, hospitals use a variety of methods to qualify for health insurance and rural cooperative medical care, and they pay kickbacks to village doctors and primary care physicians for referring patients, and the kickbacks are on the rise. One local village doctor said the orthopedic hospital would give him a 10 percent kickback if he referred a patient, and the hospital would pay cab drivers and emergency centers to get patients.
(4) Increased mobility and income for medical staff
The reforms have rationalized the hospital's hiring mechanism, which allows the hospital to win and lose staff. Under the pressure of competition, hospitals need excellent medical staff to attract patients, and the competition among hospitals to "poach doctors" is very fierce. The movement of medical personnel has become freer, especially the movement of higher level medical personnel between hospitals is very frequent. Many doctors come back from training today and get their titles, and then "jump ship" the next day.
In order to retain and attract good medical staff, hospitals must change their internal distribution and incentive mechanisms to improve the income of medical staff. According to our research, the average monthly salary of doctors in Suqian rose from 2,000 yuan to 3,000 to 4,000 yuan, hospitals have opened up the income gap within the hospitals, skilled doctors, chief physicians and doctors with shares have higher incomes, the general income of the doctor worse, the hospital nurses and logistical staff in the privatization of the salary is very low, from more than 1,000 yuan down to 500 to 600 yuan. 600 yuan.
It is worth noting that in the process of increasing income, the sense of belonging has become a greater concern for many medical staff in return. From the results of the restructuring, the development of hospitals in which doctors hold shares has been relatively more stable and more recognized by the general public. We visited a hospital in Shuyang, which was auctioned off to private capital. An old retired doctor told us that he used to feel a sense of belonging when he worked in the hospital, but after the restructuring, his job was just a part-time job. The next night, just over a dozen medical staff resigned en masse to go to another newly built hospital, the main reason, because that hospital gave them shares.
(E) Rapid increase in medical services
Competitive pressures have prompted hospitals to introduce medical specialists and advanced equipment to expand the scope of medical services. After the medical reform, the medical service programs in Suqian area have increased by more than 200, and many complicated surgeries can be performed in Suqian. This has facilitated the people's access to medical care to a certain extent.
It is worth noting that there is a tendency for overdevelopment of medical equipment in Suqian, and the development of software such as the technical level of medical staff has not kept pace with the over-expansion of medical services into highly profitable programs. According to our research, the operation of many examinations is not in line with the norms, and there are also some hospitals that perform surgeries in violation of the law. For example, a first-class hospital in Shuyang actually also performs stomach cancer surgeries, and the attending doctor is a former township health center doctor who graduated from a health school.
(6) Registration fees, individual examination prices and unit prices of medicines have been steadily decreasing
Competitive pressures have prompted hospitals to lower registration fees, individual examination prices and unit prices of medicines. Almost all hospitals have low registration fees, and some hospitals allow you to see multiple departments with a single number, while some hospitals don't even need to register at all. Some basic medical care and routine treatments have created competition, and the individual charges for many routine medical services have been lowered, for example, the price of CT has been reduced from more than 300 yuan to more than 100 yuan; ultrasound has been reduced from more than 100 yuan to more than 60 yuan.
Because of the liberalization of the opening of pharmacies, hospitals not only face competition among hospitals, but also face competition with pharmacies, generally there will be pharmacies at the entrance to the hospital, and the perimeter of the large hospitals will be opened several pharmacies, so the unit price of medicines in hospitals has indeed also declined, and some common low-priced medicines have also re-emerged.
The core problems of health care have not been solved, while some new problems have arisen
(1) "Expensive medical care" has not been solved -- another distortion of medical costs after the introduction of the market mechanism
From the phenomenon above. Medical institutions have increased, competition has been strengthened, the people do have more choices to see a doctor, but also really feel the improvement of hospital service attitude. At the same time, hospital registration fees have been reduced, and the charges for individual tests and the unit prices of medicines have indeed declined steadily. So, can we say that the people have received convenient, high-quality and inexpensive medical services after this health care reform?
1. The paradox of numbers: expensive or cheap health care.
Suqian Health Bureau provided data show that: 1999 and 2005 comparison, per capita outpatient costs city and county hospitals fell by 8.3%, rural hospitals fell by 25%. Charges per bed day city and county hospitals fell by 10 percent, rural hospitals fell by 15.5 percent. The average cost of medicine for discharged patients fell by 1.0 percent in city and county hospitals and by 13.5 percent in rural hospitals. In an exchange with officials at the Suqian Health Bureau, they acknowledged that the figures may be unreliable because there is no good statistical methodology available.
Even if these figures are correct, not only did none of the hospitals go out of business at the same time as these prices fell, but many saw their revenues rise sharply. For example, it was reported that Suqian People's Hospital earned more than 90 million yuan in 2004, while in the first half of 2005, the hospital's income reached 65 million yuan; "Shuyang People's Hospital ...... grew from 1.8 million yuan to 7.2 million yuan from the incoming income of an orthopedic department alone "; a department head of Renji Hospital also told us that the 30 million yuan loan for building the new building was earned back in three years. And, until now, new hospitals have continued to settle in Suqian, a trend that would not have been possible without higher profit margins.
Per capita outpatient and hospitalization costs are falling, while the number of hospitals is increasing rapidly, as are hospital revenues. If the data is correct, then the demand for healthcare must have substantially continued to grow. Suqian is located in the north of Jiangsu Province, relatively closed, the population size is relatively stable, the number of foreign patients is not very large, medical demand is unlikely to be so sustained large-scale increase. Is healthcare more expensive or cheaper?
2. Theoretical analysis: play the market mechanism, can not avoid the medical field of its own laws.
The field of health care has its own laws, the first is the supply and demand side of the information is seriously asymmetric, the supply side is in a natural monopoly position, is a forced sale of the market. If the supply side has too much profit motive, hospitals always have a way to get enough revenue by some means, such as being able to induce demand, and the interests of patients will be damaged.
Theoretically, "price reduction" and "cost reduction" are two concepts. In fact, the current price of medical services and some drug prices are state-controlled, the people feel the "expensive" mainly refers to the cost of medical care, is the product of price and quantity.
The people are most able to observe and compare price information. Hospitals attract patients by lowering the price of individual items, while the "volume" is basically at the mercy of doctors. The people's total medical expenses are still rising because they can limit "price" but not "volume".
Secondly, there will be a "medical equipment race" in the competitive medical market. Theory and practice have shown that because of the serious information asymmetry between doctors and patients, patients lack the ability to search for the lowest price, patients usually choose brand-name hospitals, famous doctors and high-tech equipment. Therefore, the competition between hospitals is not mainly in the price competition, but the so-called "medical equipment race" between doctors' technology and equipment, which will lead to the rise of the overall medical costs. This will lead to a rise in the overall medical cost. This is because these high-tech and advanced facilities are often in excess and unnecessary. The wool comes from the sheep's body, the hospital's new building, new equipment, digging talent of the inexpensive cost, eventually sooner or later to be borne by the patients.
(space limitations, for Suqian health care reform can solve the core problem, as well as some of the new problems arising from it, this edition will continue to publish tomorrow, Peking University, China Center for Economic Research, health care reform research group survey report of the relevant parts - editors note)
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