Gu Ke: Why is the new medical reform so laborious?

Although the first game of the three-year medical reform period is close to the end game, no matter whether it is the reformer or the bystander, there is still no clear judgment on the outcome of the chess game. In view of many people, the government has spent a lot of money in the past three years, but the medical improvement show is not satisfactory. In short, the new medical reform is very laborious. This is probably an undeniable fact.

It is worth exploring that why is it strenuous? In my opinion, the root cause lies in the deep-seated thinking and habits of administration. Although the top level of the Chinese government has listed the “build mechanism” as one of the goals of the new medical reform, many people are also calling for the implementation of market mechanisms in all aspects of the medical field. However, what is a "market mechanism"? In the medical field, what are the basic elements of the "market mechanism"? In the process of new medical reform, what factors have hindered the establishment of a new mechanism? Unable to get a clear idea of ​​the problems, the new medical reform will always be hard.

In fact, in my opinion, to establish a “market mechanism” in the medical field, we must complete the following three major events:

1. Promoting universal health care and forming third-party buyers of medical services;

2. Let Medicare Group buy medical services;

3. The formation of a pattern of diversified medical services.

The three major events are plain, that is, the way to settle the bills, get the way to pay the bills, and get a place to pay the bills.

Get settled: the purchasing power to form universal health insurance

The function of universal health insurance is not only the risk sharing of costs, but also the establishment of third-party purchasing mechanisms, that is, to settle the bills. The medical insurance organization appears in the medical field as a third-party buyer outside the doctor and the patient. This is a necessary condition for perfecting the medical system, although it is not a sufficient condition. This is precisely the core of the so-called "new medical reform market school."

The third party purchase is to make the medical insurance agency the main payer of medical expenses. "Primary" to what extent? At least 70%, preferably 80%. If this goal is not met, the purchasing power of the medical insurance institutions will not be strong, and they will be unable to negotiate with the medical institutions. The negotiation mechanism between the medical insurance institutions and medical institutions mentioned in the new national medical reform plan cannot be established.

In order to increase the purchasing power of health insurance institutions, it must be rich. The money in the health insurance fund is not paid by the ordinary people anyway, it is a subsidy from the government's finances. Recently, the central government has made it clear that in 2012, the financial subsidies for urban residents' basic medical insurance and new rural cooperative medical care will be raised from a minimum of 200 yuan per person to 240 yuan, and by the end of the 12th five-year plan will reach 360 yuan. As for the level of contribution of the participants, it is set by the local government. The new rural cooperative medical insurance contribution level is approximately 30 to 50 yuan per person per year in recent years. If we do not raise the level to 100 yuan, it is probably a question as to whether the basic medical insurance system can "guarantee the basics." However, the level of contribution of urban and rural insurgents has actually increased. Local governments are not willing to put on the agenda. This is a thankless thing.

Get a way to pay the bill: Medicare "group purchase" medical services

Since it is determined that the medical insurance institutions are the main providers of bills, the second major event of the new medical reform should promote the purchase of medical services by the medical insurance institutions. Among these, the most important thing is to settle the way of paying the bills. In academic terms, it is to promote the reform of medical insurance payment.

If there is no health insurance, individual patients deal with medical institutions, and patients can only pay “by project”, that is, they pay for one of the billing details. This is likely to induce medical institutions to over-treat. In the words of the people, it is "to make more medicines, to open up expensive medicines, and to inspect more."

For over-medical care, the world is advancing the reform of medical insurance payment. The essentials are group purchases, or simply "group purchases." The reason is very simple. If a health insurance agency signs a contract with a medical institution, it will pay the latter for a certain group of medical services in a “packaged payment” way. The medical institutions will overspend their own expenses and make savings on their own. Excessive medical treatment. The total amount of prepaid system, pay per capita, and case-based payment mentioned in the national new medical reform program are nothing more than the basis for “packaging”.

Since 2006, I have been stressing the importance of the reform of the medical insurance payment and regard it as the top priority of the new healthcare reform. But inside and outside the medical community, people's common thinking habits still rely on administrative inspections or price controls to control costs. Everyone knows that the reform of Medicare payment is not easy, and it is not smooth in the actual progress. I found that there are some common factors in the exploration of local governments that hinder the reform of Medicare payments. These factors have one thing in common: administrative.

There are many factors in the administration, and one of them is price control. As mentioned above, the current prevalence is still paid for by the project, and the paid standard (ie the price of most medical services, medicines and consumables) is set by the government.

However, it is very strange that, in almost all places, there has been a situation of "one price at a time, while checking the details." As a result, medical institutions have no inherent enthusiasm to control costs so as to “balance themselves” while health care institutions are struggling. In fact, in many places, the reform of medical insurance payment has just begun, and complaints from health care institutions and medical institutions have become commonplace. The emergence of this phenomenon, in the final analysis, is due to the fact that marketization and administration have been fighting each other.

Place to pay the bill: Public hospitals get rid of administration

Even if the purchasing power of the medical insurance institutions is stronger, even if the health insurance payment method is smarter, if the person who pays the bill does not have any choice, then it would be no good. This is a very simple truth. What is a pity is that there is not much room for choosing a person to pay the bill. It is precisely the status quo in the field of medical services in China.

In China, public medical institutions (especially public hospitals) occupy a dominant position in the medical service market in various regions, and even occupy a monopoly position in many places (especially small and medium-sized cities). Although the number of private hospitals is quite large, overall, they are small in size, weak in talent, and low in income. They have no place in the medical service market. Although the new medical reform program has clearly made great efforts to promote the diversification of medical services, supporting implementation documents that actively encourage social capital to enter the medical service sector have also been promulgated. However, in many places, there are various “hidden rules” that hinder the establishment and development of private hospitals. Most of the private hospitals are in a difficult situation. The "glass doors" that surround them all make them difficult. Many of these “hidden rules” are in fact the rules of the game left over from the planned economic system period, especially the establishment of management systems and the practice of doctors' practice. As long as these administrative "hidden rules" have not been eliminated, private hospitals will not be able to form attractive forces for medical personnel. The pattern of public hospitals occupying a dominant position in the field of medical services will not change qualitatively in the short term.

If the reform of public hospitals is not successful, then the integrity of the entire medical service system will become empty words.

The organizational and institutional models of public hospitals in China today are in a state of "administrative marketization" or "administrative commercialization." It is said that it has the characteristics of "marketization" or "commercialization" because the main source of income for public hospitals' day-to-day operations is charging, which is called "business income" in official statistics. It is said that it has the "administrative" feature because public hospitals are "market-oriented" and all aspects are subject to the administrative coordination mechanism, thus presenting the characteristics of "pseudo-marketization." Among them, the formation of the pattern of “remedy for medicine” in public hospitals is rooted in the administrative price control rather than the “inadequate government investment” that is popular in the general public.

The deep-rooted administrative thinking and habits, coupled with the lack of clarity on how to implement the market mechanism in the medical field, are the reasons why the new medical reforms have been so exhausting.