In the new medical reform, the "boots" with quite high gold content finally landed.
On May 17, the Guiding Opinions of the General Office of the State Council on Comprehensive Reform of Urban Public Hospitals (hereinafter referred to as the Opinions) was officially announced.
The Opinions comprehensively deployed the most difficult part of China's medical reform-the reform of public hospitals, especially the reform of urban public hospitals. The full text is more than 9,000 words, with 30 articles, involving many key issues in the reform of public hospitals, such as management system, operation mechanism, payment method, staff salary, graded diagnosis and treatment, etc.
The opinions clarified the reform objectives for 20 17 years. This means that this opinion will play a vital guiding role in the reform of urban public hospitals in China in the next three years. In view of this, the 2 1 century business report "New Health" combined with the views of relevant experts, made a comprehensive analysis and interpretation of the Opinions.
First, the overall requirements: three "basics"
In the general requirements section, the Opinions put forward the basic principles, objectives and paths.
20 17 target: the comprehensive reform pilot of urban public hospitals has been fully launched, the modern hospital management system has been initially established, the capacity of the medical service system has been significantly improved, the order of medical treatment has been improved, and the proportion of general outpatient visits in urban tertiary hospitals to the total number of medical and health institutions has been significantly reduced; The unreasonable growth of medical expenses has been effectively controlled, and the growth of total health expenses is coordinated with the growth of GDP in this region; The burden of medical expenses has been significantly reduced, and the proportion of personal health expenditure in total health expenditure has dropped below 30%.
Explanation:
On the guiding principle of classification, the Opinions innovatively put forward that "starting from reality, different public hospitals in different regions, different levels and different types should implement differentiated reform policies in terms of medical insurance payment, price adjustment and performance evaluation".
Liu Yuanli, Dean of School of Public Health, Peking Union Medical College, said, "In view of the differences between different types of hospitals and different regions, classified guidance is the basic principle that any reform measures must be effectively implemented in China. For example, although they are all public hospitals, because of their unique' externalities' (that is, social influence), infectious disease hospitals are more worthy of government financial support than ordinary hospitals. In addition, the reorganization of public hospitals will not be fully rolled out, but it will be carried out first in areas where public hospitals have sufficient resources. "
It is particularly noteworthy that in the basic goal part, the goal of medical cost control is to coordinate the growth of total health expenditure with the growth of regional GDP.
Previously, the research of collaborative innovation center for health risk early warning and governance led by Fudan University showed that from 199 1 to 20 13 years, the average annual growth rate of per capita medical expenses in China was 17.49%, which was significantly higher than the growth rate of GDP in the same period, which brought a series of serious problems.
The "significance" makes it clear that the total health expenditure growth service should be coordinated with the GDP growth in this region. This means that controlling the total health expenditure will become one of the regulatory objectives of regional governments in the future.
Second, reform the management and salary mechanism of public hospitals.
1. medical management level of management system: who will perform medical management functions?
It is suggested that each pilot city can set up a management committee led by the responsible comrades of the government, composed of relevant government departments, some deputies to the National People's Congress, CPPCC members and other stakeholders, to perform the government's medical functions and be responsible for development planning, constitution-making, implementation of major projects, financial investment, operation supervision, performance appraisal, etc. For public hospitals, it is necessary to clarify the office and undertake the daily work of the management committee.
Explanation:
In terms of medical system, the separation of government administration and office is still the basic content. In the previous stage of medical reform, how to separate management from management is the most concerned and controversial. Different places have made different attempts in this regard, such as Shenkang Center in Shanghai and Hospital Authority in Beijing. After the previous accumulation, the Opinions put forward a distinct way of running a medical service: setting up a management committee, and listed six responsibilities to be undertaken by this medical service institution.
In this regard, Liu Yuanli analyzed that "the separation of management and operation is the first step to change the old administrative management model and move towards a modern hospital management system. Modern hospital management system has two propositions: one is the reform of governance structure, and the other is the improvement of governance capacity. At the macro level, the former is reflected in the establishment of a management Committee led by the government and attended by major stakeholders. Theoretically, this structure is more representative than simple administrative management, and can better reflect public opinion. The microscopic embodiment of modern hospital management system is to establish a corporate governance structure characterized by independent operation. After the establishment of these new macro and micro governance structures, the improvement of governance capacity has become the key. Therefore, how the management Committee can effectively exercise its functions and how the hospital director can become an excellent manager of modern hospitals requires a lot of education and training. "
2. Hospital hierarchical management system: two paths of "one wide and one strict"
The "Opinions" put forward: improve the corporate governance structure and mechanism of public hospitals, and implement the autonomy of personnel management, internal distribution and operation management of public hospitals. Take effective forms to establish the internal decision-making and restriction mechanism of public hospitals. Strengthen the refined management of public hospitals. Improve the multi-party supervision mechanism.
Explanation:
The Opinions adopted two directions of "one wide and one strict" in the management system reform at the hospital level. The "lenient" level is to implement the autonomy of public hospitals, including personnel, distribution and management. Only by giving public hospitals full autonomy can we truly establish a corporate governance structure, effectively participate in market competition, and finally form a modern hospital management system.
Whether it is at the level of running a doctor or implementing the autonomy of public hospitals, the Opinions are trying to change the original management system with strong administrative color, which can be more flexible and efficient. However, the Opinions put forward many requirements in terms of "strictness" as well as "leniency".
These "strict" requirements include the selection, assessment and accountability of the dean, as well as the assessment and evaluation of the hospital. In particular, the description of the multi-party supervision mechanism in the Opinions is very specific.
This multi-party supervision mechanism includes industry management, audit supervision and information disclosure of health and family planning administrative departments, self-discipline, supervision and professional ethics construction of industry associations, and social supervision including evaluation by third-party institutions. It is particularly noteworthy that in terms of information disclosure, the Opinions clearly lists information such as financial status, performance appraisal, quality and safety, price and medical expenses. Does the disclosure of prices and medical expenses also help to control costs?
3. Break the operating mechanism and supplement the doctor with medicine.
The Opinions suggest that public hospitals in pilot cities should promote the separation of medicines, actively explore various effective ways to reform the mechanism of medicine supplementation, and cancel the addition of medicines (except Chinese herbal medicines). The compensation of public hospitals is changed from three channels of service charges, drug bonus income and government subsidies to two channels of service charges and government subsidies. By adjusting the price of medical services, increasing government investment, reforming payment methods, reducing hospital operating costs, and establishing a scientific and reasonable compensation mechanism.
Explanation:
Reforming the mechanism of supplementing medicine with medicine is still a breakthrough for public hospitals to build a new operating mechanism. The general idea is to reduce the proportion of drugs and materials in hospital income, and at the same time increase the proportion of technical labor income in business income. The Opinions also put forward a clear goal, and strive to reduce the proportion of drugs (excluding Chinese herbal pieces) in public hospitals in pilot cities to about 30% by 20 17; The consumption of sanitary materials in medical income 100 yuan (excluding drug income) drops below 20 yuan.
Recently, Feng, director of Beijing Hospital Administration, revealed in an interview with the media that by the end of February, the proportion of outpatient drugs used in five pilot hospitals in Beijing had dropped from 70% in the past to 58.8% now. In these pilot hospitals with strict management in Beijing, the proportion of drugs after reform is still not low, which shows that the goal of 30% after three years is still quite arduous.
4. "Streamline" and "straighten out" the operating mechanism
The "Opinions" put forward: reduce the cost of drugs and medical consumables. High-value medical consumables must be purchased through the provincial centralized procurement platform. Pilot cities should formulate reform plans for medical service prices in public hospitals.
Explanation:
In reducing the cost of drugs and consumables, the Opinions emphasized the importance of centralized procurement. No matter whether it is drugs or high-value consumables, the opinions strongly point out that centralized procurement should be implemented.
However, from the aspects of improving the current distorted price system and reflecting the labor value of medical staff, it is more important to rationalize the price of medical services for the future reform of public hospitals. The "Opinions" clearly stated that pilot cities should formulate a reform plan for the price of medical services in public hospitals.
5. Operating mechanism of government investment: What responsibility does finance bear?
The "Opinions" suggest that governments at all levels should implement the investment in public hospitals' capital construction and equipment purchase, development of key disciplines, personnel training, retirees' funds and policy loss subsidies in line with regional health planning. Reform the way of financial subsidies and strengthen the connection between financial subsidies and the results of performance appraisal of public hospitals. Improve the mechanism of government purchasing services.
Explanation:
As a government-run hospital, how much responsibility should the government bear? What responsibility do you assume? The "Opinions" listed six items that belong to the government's input, including other aspects of funding guarantee, which further clarified the boundary of the government's input responsibility.
It should also be noted that the Opinions propose that the inspection price of large-scale equipment purchased by the government in public hospitals should be set according to the cost after deducting depreciation; Large-scale equipment purchased by loans or funds that meet the planning and relevant policies shall be repurchased by the government at the price after deducting depreciation, and the inspection price shall be reduced within a time limit when it is difficult to repurchase. This means that local governments have to "pay" for large-scale equipment in public hospitals.
In addition, it is more important to reform the economic compensation model. Previously, the financial compensation of public hospitals was mainly based on the number of establishments and beds, and the Opinions proposed that future financial compensation would be linked to the results of performance appraisal.
6. Personnel compensation system reform: filing system.
The "Opinions" put forward: within the total local staffing, reasonably check the total staffing of public hospitals, innovate the organizational management methods of public hospitals, gradually implement the filing system and establish a dynamic adjustment mechanism. In terms of post setting, income distribution, professional title evaluation, management and use, we will make overall consideration of the treatment of internal and external personnel and promote the reform of the endowment insurance system in accordance with state regulations.
Explanation:
The reform of personnel and salary system in public hospitals has not made much breakthrough before, because it involves the overall pattern of state institutional reform. However, the Opinions put forward quite a number of specific measures for the reform of staffing, including the establishment of filing system, dynamic adjustment mechanism, overall consideration of internal and external staffing, implementation of appointment system and post management system.
The industry has been calling for the salary of medical staff for a long time. This Opinion puts forward several reference factors on how to determine the salary of medical staff, including long training period, great occupational risk, great technical difficulty and heavy responsibility of medical industry.
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 a human society or a health department) establishes this system according to what standards and what processes will directly affect the realization of this goal. I am more optimistic about the change from the establishment system to the' filing system', because the development of public hospitals is inseparable from a more flexible personnel compensation system, and the' establishment' system has always been one of the biggest obstacles affecting the establishment of a modern hospital management system. "
Third, the medical insurance control fee is "approaching"
The "Opinions" put forward: give full play to the basic role of basic medical insurance, strengthen the income and expenditure budget of medical insurance funds, establish composite payment methods such as paying by disease, paying by head and paying by service unit, and gradually reduce the payment by project. Encourage the implementation of payment by disease diagnosis related groups (DRGs). The reform of medical insurance payment method should cover all public hospitals in the region and gradually cover all medical services.
Accelerate the establishment of an open and equal negotiation and consultation mechanism and risk sharing mechanism between various medical insurance agencies and designated medical institutions. Gradually extend the supervision of medical insurance to medical institutions to the supervision of medical service behavior of medical personnel.
Explanation:
Previously, project-based payment was considered to have played the role of "big inspection and big prescription", and reforming the payment method of medical insurance has almost become the knowledge of all parties in the industry. At the same time, from the reform trend of public hospitals, the supervision and restriction of medical insurance on medical behavior has been paid more and more attention, and the key to this attention lies in effectively controlling the rapidly rising medical expenses and controlling medical costs. And in the future, this kind of supervision will not only be aimed at medical institutions, but also at medical personnel. In other words, the role of medical insurance supervision and restriction will become more and more detailed.
Fourth, rebuild the medical service system.
1. Coordinated development of reconstruction system
The "Opinions" put forward: optimize the planning and layout of urban public hospitals. Strictly control the bed size, construction standards and large medical equipment of public hospitals, and take comprehensive measures to gradually reduce the beds in public hospitals that exceed the scale standards. Control the scale of special services in public hospitals, and the proportion of special services provided shall not exceed 10% of all medical services.
Explanation:
The Opinions still continues the idea of controlling the scale of public hospitals in the past, but it is clear that special needs services do not exceed 10% of all medical services. Previously, there was great controversy about whether public hospitals could provide special needs services. The opinion also responds from another angle, which can be done, but it does not exceed 10%. This means that in some local medical reform versions, "franchising" and other ways will become the channels for the development of public hospitals.
2. The graded diagnosis and treatment of the reconstruction system.
The "Opinions" put forward:
Gradually increase the number of sources of registration and referral services provided by urban public hospitals through primary medical and health institutions and general practitioners, and superior hospitals provide priority consultation, priority examination, priority hospitalization and other services for patients who make appointments or referrals from primary medical and health institutions and general practitioners. In the end, the proportion of public hospitals making appointments for referral to outpatient clinics should be increased to more than 20%, and the number of general outpatient visits in tertiary hospitals should be reduced.
Explanation:
Graded diagnosis and treatment is a very good vision. The Opinions set a hard target of 20%, which is undoubtedly the power source to promote the implementation of graded diagnosis and treatment (12.05,-1.34,-10.0 1%).
At present, the idea of promoting graded diagnosis and treatment is mainly from two angles: first, improving primary medical security, including the sinking of high-quality medical resources, convenient and fast referral channels, and a higher proportion of medical insurance reimbursement; The other is to increase the cost of medical treatment in large hospitals, including reducing the number of general outpatient visits in large hospitals, and reducing the proportion of medical insurance payment or not paying according to regulations for those who do not follow the referral procedure.
3. Reconstruct the medical information system.
According to the Opinions, by the end of the year, all public hospitals above the second level and more than 80% primary medical and health institutions in the administrative area will be connected with the regional platform. Fully implement the action plan of medical and health information benefiting the people.
Strengthen the construction of telemedicine system, strengthen the service functions such as remote consultation and education, and promote the enjoyment of high-quality medical resources. By the end of this year, all pilot cities have basically completed the construction of information standards for all hospitals above the second level, and 60% of grassroots medical and health institutions have established telemedicine information systems with superior hospitals.
Explanation:
Medical informatization has high hopes in expanding the radiation range of high-quality medical resources, improving patients' medical experience and strengthening residents' health management. The goal of the regional medical and health information platform proposed in the Opinions is to gradually realize the business collaboration between residents' basic health information and application systems such as public health, medical services, medical security, drug management and comprehensive management. Moreover, in terms of information platform construction, hospital informatization standard construction and telemedicine, the Opinions all put forward a fairly clear timetable. This provides considerable imagination for the development of medical informatization.