(a) "expensive" is not solved - the introduction of the market mechanism after the introduction of another distortion of health care costs
1. Digital paradox: medical costs expensive or cheaper.
2. Theoretical analysis: to play the market mechanism, can not avoid the medical field of its own laws.
3. The reality - in line with the theoretical inference, the formation of another distortion of medical costs.
(1) The phenomenon of blind development of medical equipment to the high-end is very serious.
Suqian's health care reform has clearly appeared "medical equipment race" trend, the hospitals are trying to expand the scale, have embarked on highly sophisticated equipment. A little larger hospitals are equipped with color ultrasound, CT, nuclear magnetic **** vibration, and even some of the first-class hospitals have purchased CT, and electronic gastroscopy, automatic biochemistry and other medical equipment in the first-class hospitals are common equipment.
When you walk into various hospitals in Suqian, you will be able to see a graphic introduction of various medical equipments and checkups that the hospitals have. Shuyang County Ping'an Hospital is a first-class hospital, treatment rooms and ward facilities are very simple, toilets are built on the wall of the simple shed, but the hospital outpatient hall erected CT, electronic gastroscope and other equipment, the introduction of the plate, posted 34 pages of the hospital's price list of treatment programs.
Shuyang County People's Hospital and Renji Hospital are competing with each other in terms of projects, equipment, hardware and talent. Renji Hospital has built a 10-story new clinic building, with a total investment of more than 30 million yuan, forcing Shuyang County Hospital of Traditional Chinese Medicine to increase its investment by 10 million yuan, the county hospital is planning to build a 19-story complex, but also plans to introduce a number of high-frequency nuclear magnetic **** vibration and other advanced equipment.
Currently, many of China's health facilities and equipment are ahead of the level of economic development, and the misuse of high technology is an important reason for driving up medical costs. What poor areas like Suqian lack most is not high-tech equipment, but a large number of low-cost, effective services.
(2) Doctors induce patients to undergo more tests and surgeries.
Compared with other regions, the problem of large prescriptions in Suqian's hospitals has been somewhat alleviated. According to some deans, outpatient clinics now have thinner margins, and their income depends mainly on tests and surgeries. But many anomalies have emerged, creating another distortion of medical costs:
First, doctors are more likely to ask patients to undergo various medical tests. We go to some hospitals to see headache or leg pain, almost all hospitals require CT; go to some hospitals to see gastric disease, most doctors say that they need to do gastroscopy; we meet many patients when we visit the doctor also do gastroscopy and other tests. A hospital is the local people's best reputation of the hospital, even so, the hospital director said every day more than 500 outpatients, there are nearly 100 times the CT examination, 15 times the gastroscopy (500 outpatients to see the gastroenterology is not a lot of patients), which is far higher than the proportion of Beijing and other urban hospitals.
Second, patients are made to undergo surgery for diseases that don't require it. Some hospitals have a 90 percent C-section rate.
Third, diseases that are not serious are deliberately made to look very serious. A 50-year-old rural woman with a wrist fracture, the doctor strongly recommended that the patient for artificial joints, and said that 52-year-old women have reached menopause, the bone stops growing, the fracture can not be recovered, you have to replace the artificial joints. This is what we saw with our own eyes when we visited a hospital in Suqian (one of the best hospitals).
What's even more worrisome is that most of the Cebu area is made up of rural residents who have very little medical knowledge, making it easier for doctors to entrap these patients.
(3) The local health bureau's explanation validates the research and analysis.
Suqian Health Bureau officials believe that the reason for the increase in hospital revenue is threefold. Second, patient restructuring. After the medical reform some major diseases can be treated, surgery can be done, and the return rate of treating major diseases is higher than treating minor diseases, and the return rate of surgery is higher than the outpatient clinic. Third, the total number of patients increased. Some outflow patients are attracted back. All of these validate the results of our research and analysis, and now hospitals do increase revenue by expanding tests and surgeries.
For the authenticity of the data, Suqian Health Bureau officials believe that these data are reported by hospitals, and if there is water, the revenue figures are only likely to be under-reported, not over-reported, otherwise the hospitals will have to pay more taxes, and the hospitals will have no incentive to report higher.
By the same logic, there is reason to believe that with such a data collection system, hospitals have an incentive to underreport average outpatient costs and average hospitalization costs, since these are key indicators for the government to evaluate hospitals.
4. The phenomenon of "red packets" and "kickbacks" in hospitals manifests itself in other ways.
Private hospitals have a flexible internal management mechanism, and shareholders, with profit as their main goal, will certainly incentivize doctors by improving their treatment and restraining them from receiving red packets. But the point is that the hospital as a whole has not changed its profit motive, but rather strengthened it -- hospitals built on a shareholding system can't survive if they don't aim to maximize profits.
So while the problem of individual doctors receiving red packets and kickbacks has been eliminated, the benefits have not returned to patients, but have been concentrated in the hands of hospital shareholders. It's just that the red packets have been transferred from underground to above ground, from doctors receiving red packets to shareholders sharing dividends.
The way to solve the "red packet problem" is to make hospitals no longer have a profit motive. As long as that doesn't change, red pockets and kickbacks will manifest themselves in other ways.
We found similar phenomena extensively during our visits. Based on interviews with doctors, both the original public hospitals (e.g., People's Hospital) and the new private hospitals (e.g., Mercy Hospital) have been found to be engaged in the practice of doctors prescribing medicines and tests on commission. This is consistent with our predictions.
A department head at a hospital told us that doctors are paid a commission for prescribing medicines, surgeries and examinations, including CT and ultrasound checklists. There is a target for turnover in a health center, and two doctors with prescriptive authority are each required to meet a target of 5,000 yuan; if they fail to do so, they will not even get the most basic salary. As the director of a hospital said, he has direct control over the procurement of drugs, and there is no need to say anything about the control of the purchase price. This mechanism dictates that doctors have every incentive and ability to drive down the price of incoming drugs so that the hospital can make a bigger profit, but may not have the incentive to lower the price for patients.
5. The feeling of the people - "money is like paper in the hospital".
According to our interviews with local residents, they don't feel strongly about the difficulty of getting to the doctor, but they do feel that it's still expensive. In one hospital, we asked an elderly patient from a rural area, and the old man's response was, "Money is like paper in the hospital!"
(2) The lack of regional health planning, the three-tier medical network is broken
China's original three-tier medical service network covering urban and rural areas was initially designed to efficiently allocate medical resources through the referral system to prevent patients from tending to be higher.
Suqian, while encouraging hospitals to compete and introducing social capital to run medical services, has violated the specificity of medical care and health care, without any regional health planning, and completely broken the original three-tier network and referral system, leading to an over-supply of medical institutions in Suqian City, which will surely induce an excessive demand, and increase the people's burden of medical care; moreover, hospitals of various sizes are all competing at the same level, and their functions have not been division, leading to the waste and inefficiency of medical resources.
Under the profit motive, hospitals at all levels are competing to buy equipments and do major surgeries as long as they are in a position to do so. At the same time, the patient, no matter what the disease, to which hospital can be seen, and hospitals "old death", there is no incentive to refer. The result is that the best medical resources do not serve the people who need them most, resulting in an inefficient allocation of medical resources.
The People's Hospital, which has the best quality and strongest technical force in the area, still sees a lot of general outpatient clinics, while many township health centers have begun to purchase CTs and other equipment to perform major surgeries. The Xinhe Township Hospital, for example, in addition to gastrectomy, appendicitis, such as surgery can be done, but also opened a spleen stitches, kidney stone surgery, myocardial infarction rescue and other difficult projects.
On the other hand, hospitals at all levels are fighting for patients at all costs, with hospital advertisements all over the place and some hospitals competing for patients through kickbacks and other means. Many community doctors have a membership card issued by Shuyang County People's Hospital. If a community doctor introduces an outpatient to Shuyang County People's Hospital, he or she can get a rebate of 100 yuan; the rebate for hospitalized patients is 10 percent of the cost of surgery. Other doctors told us that hospitals rely on doctors in townships and village health units to recommend patients and then give them rebates. Such kickbacks have even become an important source of income for village health room doctors, artificially increasing medical costs and burdening patients.
Another manifestation of the lack of regional planning is that the pattern of Chinese and Western medicine is broken. Since Chinese medicine does not have many tests and surgeries, and since Chinese medicine is less expensive, local Chinese medicine practitioners, who depend entirely on the market for their survival, have shrunk further.
(3) Unexpected blow to rural medical care: weakening of primary care
1. Rural doctors are moving to the city, and village doctors are moving to the countryside, weakening the strength of the rural primary care team.
The short-term surge in demand for medical personnel in the rapidly growing medical market has led to a weakening of grassroots technical strength; it has also caused problems with the quality of care in some emerging hospitals.
The rapid increase in the number of hospitals has led to an increase in the market demand for medical personnel, and it is difficult for the Suqian area to attract many foreign medical personnel in the short term. Now the direction of the flow of doctors is, "good doctors in the countryside into the city, state-owned hospitals, good doctors out of the partnership to open hospitals". The sources of medical personnel for new hospitals are mostly township health centers, and some of them are even unlicensed doctors. And township medical institutions are beginning to absorb some of the former village doctors.
This on the one hand makes the quality of basic medical services in rural areas or communities weakened; on the other hand, if the supervision is not enough, the quality of medical care in some emerging hospitals can not be guaranteed. According to the survey, many private hospitals to "foreign expert clinic" to solicit patients, but the name does not match the reality. This is not an isolated phenomenon, but a common phenomenon of urban emerging hospitals (dozens).
2. The level of medical care in townships and villages has declined.
After the reform, township and village health centers were bought by individuals. Since you can buy a hospital as long as you have the money, it makes many of the owners of this level of hospitals are rich and do not know anything about health care. This, coupled with a market-oriented health care environment that has relaxed restrictions on the movement of medical personnel, has led many skilled doctors to disdain working in their old hospitals and look for work in emerging hospitals in urban areas, resulting in a decline in the level of medical care in township hospitals until they are no longer able to provide general medical care.
A case in point is that a certain boss who is engaged in slaughtering bought out the hospital and managed the medical staff harshly, which led to the resignation of all the medical staff. Rural hospitals that have been bought out by the doctors themselves have developed relatively well, but these hospitals account for a small proportion of the total. There are cases where rural patients go directly to urban hospitals after a quick visit to the village health center.
(4) Hospitals are not highly motivated to train doctors, and the sustainability of the development of a high-level medical team is insufficient
The decline in the stability of the medical staff has made hospitals lack the motivation to train medical technicians, and the sustainability of the development of a high-level medical team faces challenges.
The increasing number of medical institutions and the fact that doctors can jump ship at any time have made hospitals prefer to "rob" rather than "train" their own technical staff, in case they are trained to leave immediately. The health care personnel lack of successors, the quality of medical care to a standstill.
(E) the government is no longer running the hospital, but the government's supervision of health care is not effective, and face new problems
government function change, the first key is to realize the government to change the "run the hospital" for the "management of hospitals". The situation of government-run hospitals has been fundamentally changed, but according to the research, the government's supervision of medical care needs to be strengthened urgently.
1. Lack of supervision of medical access.
Suqian in vigorously encouraging social capital to enter the medical services market at the same time, lowering the threshold of access to hospitals, not conducive to the quality of medical services. The qualification of hospitals is related to the safety of people's lives, the management of the medical industry is quite specialized, the approval of hospitals should not only look at the assets, but also the experience and qualification of the management.
Because of the simple approval procedures, as long as the money, anyone can apply for hospitals, the government is now more emphasis on assets, rather than qualifications. In practice, the power to approve access to medical institutions actually lies in the hands of mayors and county governors, not in the health administration.
According to our interviews with the people involved, running a hospital requires handing over a sum of money to the government. Since the government approves hospitals at different levels and charges different rates, and new hospitals try by all means to get high-level approvals, the government has enriched itself through this power, which has also led to the emergence of some second-tier hospitals that don't live up to their names.
2. The industry has a single means of supervision and insufficient quality control.
The government's supervision of private medical institutions in the end, how to manage, is still a matter of exploration. Jiangsu Provincial Department of Health and Suqian Health Bureau of the relevant personnel have mentioned that there is no clear legal provisions. Therefore, economic means such as incentives and penalties are mainly used in the regulatory process. Due to insufficient supervision, it is very common for some first-level hospitals to perform major surgeries in violation of relevant medical regulations; excessive medical treatment, examination and surgery; medicines being substituted for good ones; the use of irregular medicines, or even three-less medicines; and insufficient dosage of medicines for diseases that can be cured quickly and prolonging the treatment period, as mentioned in the previous part of the report.
3. Inadequate financial supervision and profit-making behavior of non-profit hospitals.
Suqian all hospitals have been restructured, and mainly to private, many hospitals have also declared non-profit medical institutions. But the research found that these non-profit medical institutions still practice profit-sharing.
After the conversion, the health department basically can't get hold of the data on hospital operations, and what hospitals report is what they report, and hospitals will tend to report data favorable to themselves and make profits in the name of non-profit.
4. Poor coordination mechanism with higher authorities.
There is a top-down management system in health care, and after the reform, how to make the new mechanism able to connect with health authorities at all levels is also a problem that has not yet been solved by the medical reform in Suqian.
The long-term mechanism of public **** health investment has not been established
The second key to the government's change of functions is to realize the government's commitment to public **** health construction. According to the design of the health care reform, the funds obtained through the replacement of medical asset property rights are invested in public **** health. The government's assumption of public **** health is a completely correct direction for reform, but at present there needs to be a mechanism to guarantee that the government does this.
1. Funds obtained from medical asset replacement are limited, and public **** health institutions have begun to operate on a market basis.
Municipal hospitals have mainly invested funds from asset replacement in the construction of buildings in five major centers. Subordinate county-level public **** health organizations have adopted the same approach. The scale of these buildings is top-notch in the region.
There is no continuity in the use of funds raised from the replacement of medical assets as an investment in public **** health. You can only sell a hospital once, it's a "stock", whereas public health investment is needed all year round, it's a "flow". The use of "stock" to supplement "flow" is not sustainable. Once the funds from asset replacement are exhausted, it will be difficult to guarantee public health inputs. In fact, the five new centers basically did not play a big role.
We learned in our research that the five centers have also begun to take advantage of market-oriented operations. 120 emergency system to adopt a membership system, selecting a number of hospitals to enter the 120 system, the annual membership fee of 500,000 yuan, the hospitals to prepare their own emergency vehicles. The government does reduce the burden, but this undermines the EMS system's principle of emergency care, and hospitals are more willing to pull patients with the ability to pay to their own hospitals. The CDC will rent out the building and establish a medical examination center; the MCH center will also establish a maternity hospital, hosted by the Shanghai Maternity Protection Hospital; and the blood center (central blood station) has become a voluntary blood donation by the public after the blood station sells blood to hospitals, with a small amount of the money being turned over to the government, and the rest retained for its use.
2. Public **** health at the grassroots level is still underinvested.
Government investment in community medical services and public **** health is still insufficient, and management is not standardized. In Shuyang County, we learnt that the government does not subsidize the public **** health functions that should be undertaken by the community health centers, and that immunization programmes rely on the voluntary participation of the public. Because of the tense relationship between doctors and patients and the high risk of giving children injections, community health centers have no incentive to provide these services.
Residents around the Yanji township health center told us that the township health center is actually privately contracted, and that the only responsibility of the health center now is to provide vaccinations. But for children's planned immunization vaccines, which are free under state regulations, there is still a charge, priced at 100 yuan per person, and children are still charged two yuan for taking sugar pills. An official in the Suqian healthcare system, who asked not to be named, believes that the government is investing money in public **** health services, yet at the township level health centers are not doing what the reforms envisioned.
As a result, public **** health lacks a long-term investment mechanism. On the one hand, local finances are, after all, not yet very plentiful; more to the point, local governments and health authorities have come to regard the marketization of health care as the most effective approach, and even believe that public **** health can also rely on the market to build. Local health bureau officials even believe that public **** health does not necessarily have to be run by the government, as long as someone is willing to do, let the community to do. But at present, after all, philanthropy has not been well developed, social capital office **** health also carries the goal of profit-seeking.
Several theoretical issues to discuss
(A) the positioning and responsibility of health care in poor areas
Since the 1980s, China's financial system from a highly centralized "collect all revenues and expenditures" to the evolution of hierarchical tax financial system, the redistribution of responsibility for expenditures between all levels of government, the central government The central government has given more responsibility for healthcare spending to local governments. This is contrary to the institutional arrangement in most market economies around the world, where the central government and provincial governments are usually the main bearers of health care expenditures. Higher levels of government have shifted the responsibility for health financing to lower levels of government, and lower levels of government, in the face of financial constraints, have shifted the main task of financing to health organizations, essentially handing the difficult problem over to the market, which was already dysfunctional.
Under the incentive mechanism that takes GDP growth as the performance indicator, local governments are only keen on GDP, investment promotion and other indicators. Local governments have neither the motivation nor the ability to engage in health care and education, especially those in poor areas. This has led to the local government of some public health institutions funding subsidies are increasingly reduced, or directly sell them. The impulse of local finance to unload the burden can be said to be an important reason for the marketization of health care reform.
The key to solving the problem, therefore, is to adhere to the scientific concept of development and clarify government responsibilities. The central government must ensure that all citizens enjoy public **** health and the most basic medical services through effective means, and clarify the standard of financial subsidies for poor areas and the poor population. The problem of inter-regional differences in financial capacity should be resolved on a level-by-level basis through enhanced transfer payments.
(2) "Suqian model" can not solve the "expensive" problem
"Suqian model" to the health care business as a "business industry". The "Suqian model" positions health care as an "operational industry" and believes that "as long as it is an operational industry, it can be put on the market to compete, lower prices, improve quality and improve service through competition. We think this positioning is inaccurate.
Because of the uncertainty, externality, monopoly and highly asymmetric information in the medical industry, profit-oriented marketization will inevitably lead to soaring prices in the medical industry, which are difficult to control. The United States is a typical example.
The idea of controlling medical prices through competition may work in the short term. But in the long run, competition in the healthcare market does not lead to a decline in healthcare prices. This is because the means by which hospitals compete is not primarily price. We note that as long as the conditions of the hospital are trying to expand the scale, the introduction of equipment, even township health centers are not satisfied with the outpatient income, to upgrade, major surgery. In other words, hospital competition is mainly manifested as "non-price competition", that is, hospitals are competing to provide the most advanced high-tech medical services to enhance the brand. Theoretically, as long as supply exceeds demand in a competitive market, prices may fall. However, in the healthcare market, as analyzed above, excess supply can be absorbed by inducing demand, and doctors can make patients spend more, which results in the expansion of hospital services and the rise of overall healthcare costs, with the stronger the competition and the higher the costs. The more competition there is, the higher the cost. If this continues, the problem of "expensive medical care" will only get worse. This point is the health care market is very different from other consumer goods market, but also the current theory and practice of one of the weak points of understanding.
(3) "Introducing market mechanisms" and "government-run hospitals" are not contradictory
"Government-run medical institutions" and "introducing market mechanisms" are not contradictory
"Government-run medical institutions" and "government-run hospitals" are not contradictory. "The two can be combined, combining the advantages of both market and government intervention to create a system that has the fairness and cost-control of government intervention and the efficiency and sensitivity of the market.
We found in our research that the people have more trust in Suqian People's Hospital (which used to be the best public hospital in the area), and will go to the People's Hospital whenever they can afford it or for major illnesses, and that despite the loss of doctors from the former People's Hospital, the people's trust in the government hospitals is still stronger than that in other hospitals.
We also found from our interactions with hospital directors and medical staff that hospital ownership is not the key to hospital business performance, and that hospital directors and internal management are important factors in hospital success.
As far as the current situation in China is concerned, a considerable number of public hospitals should be retained and total costs should be strictly controlled by the government. At the same time, the government's management mechanism for hospitals should be improved to create competition among public hospitals, but the profit motive of public hospitals should be completely eliminated, so that competition among them cannot be profit-oriented, but rather cost-control and quality-improvement competition.
Summary - Suqian medical reform is actually forced out
Suqian's medical reform, through the conversion of public health care institutions, changed the situation of the government directly run the medical situation; through the introduction of social capital, the rapid expansion of medical resources, and the formation of a competitive pattern of the health care market, prompting the introduction of medical institutions to the enterprise Through the introduction of social capital, medical resources have been rapidly expanded and a competitive pattern in the medical market has been formed, prompting the introduction of enterprise management mechanisms in medical institutions, thus increasing the motivation of medical personnel, improving the quality of medical services, expanding medical service programs, and lowering the registration fee, the unit price of medicines, and the unit price of examination items. But the most important goal of the health care reform: the development of public **** health and the problem of "expensive medical care" has not yet been solved.
The reason for this is that the market mechanism can not avoid the role of the health care business of its own laws. After the reform, the profit motive of hospitals has not been eliminated, but rather strengthened; too rapid opening of the medical services market, the pursuit of the expansion of the total amount of resources, which indeed led to the existence of a large number of unregulated competition; due to the asymmetry of information, the hospitals are always able to increase revenue through various means, are competing for the introduction of specialists and technology, and the purchase of more advanced medical equipment.
The increase in supply has led to overuse of medical services, tests, surgeries and medicines, and the result has been a rapid rise in medical costs, which not only wastes medical resources but also may jeopardize patients' health and even their lives, and also makes it even more expensive for the people to see a doctor.
While the government's functions have changed, no longer "run the hospital", but the government "management of hospitals" has to be strengthened, public **** health has not been greatly strengthened, especially the long-term investment mechanism has not been formed. An objective reason is that the Suqian economy is not rich, the government has not been very large ability to invest, the more important reason is the development of the concept of the problem.
Suqian health director once told the media, Suqian health care reform dare to risk, in fact, was forced out. According to our research, this way of reform is a way out of no way and is not suitable for all places.
In the long run, it is believed that if the government adjusts its thinking on the construction of public ****health, increases its investment in public ****health and the basic medical service system, and strengthens the supervision of medical care and medicine by government authorities; with the development of competition in the medical market and the further standardization of hospitals and doctors' behavior, Suqian's medical and health care system will provide convenient, high-quality services to the local people in the future. However, this development model is fully consistent with the theory and international practice embodied in the marketization of health care, and therefore there will also be the theory and a large number of international practice confirmed the results - the people bear the burden of health care will become heavier and heavier.