The reform of public institutions should take the "fine" reform

Abstract: In the future, the reform of public hospitals should take a refined reform. The reform, development, and management are well unified and coordinated. At the same time, they must be very elaborate. They cannot simply mention the goals and principles but cannot implement them. Therefore, it is necessary to be more elaborate, more elaborate in design, more elaborate in organization, and more elaborate in implementation. Only in this way can public hospital reforms be better promoted.

"Medical support for drugs" has become a long-standing malpractice in the medical field. "Difficult to see a doctor and expensive to see a doctor" has become an increasingly prominent problem in the field of people's livelihood. Recently, the State Council issued the "Deepening the Plan for the Reform of the Medical and Health System during the Twelfth Five-Year Plan and the Implementation Plan." It is required that the "remedy of medicine" mechanism be the key link and actively promote the reform of public hospitals. In this regard, the view that China invited the director of the Medical Reform Research Center of Renmin University of China and professor Wang Hufeng of the School of Public Management of Renmin University of China to make an in-depth analysis of the issues related to “public hospital reform”.

Views China: Welcome, Professor Wang.

Wang Hufeng: Hello.

Viewpoints China: “The use of medicine to support medicine” has long been criticized. How much impact does it have? In the end, what causes the highlight of the problem of “difficult to see a doctor and expensive to see a doctor?”

Wang Hufeng: In the past, one misconception about “medical reform” was that it was the most prominent problem of “taking medicine to support medicine” or “doing medicine to supplement medicine”. However, it was actually not. It should be said that there was a problem with the medical system. In general, it is caused by various reasons such as lagging system reform, misaligned policies, and extensive management.

Views China: Please talk about these reasons.

Wang Hufeng: First of all talk about the lag in the reform of the medical system. In the past, it was indeed allowed to increase the quantity of drugs. However, it should also be noted that reforms in many fields of social undertakings including the medical field after the reform and opening up have apparently lags behind. The lag in these reforms led to many “unadaptions”, including some management. Institutions, policies, management methods and methods, etc. all lead to the problem of “difficulties in seeing a doctor and expensive medical treatment”.

The second is a policy misalignment. We have explored several rounds of “medical reform,” but overall, the reform of medical institutions, especially public hospitals, involves all aspects, not only our health departments, but also financial, personnel, and price departments, including senior management personnel of hospitals. This is obviously not just the problem that the health department can solve. If we do not see this level, we only stress that “the use of medicine to support medicine”, all aspects of the policy is not well coordinated and unified, I am afraid that the deep problems can not be a good solution, and is not conducive to promoting our public hospital reform.

Third, the management of public hospitals is very extensive. A horizontal comparison will reveal that, up to the present, the management efficiency, treatment cost, hospital bed turnover rate, per capita labor productivity, wage income, etc. of public hospitals can be said to be unclear to several people. Like these questions, there is no doubt that management is still bold. These have some direct effects on the highlighting of the medical problems.

Therefore, "taking medicine to support medical care" has a great influence on the medical behavior and expenditure structure of public medical institutions as a whole, including some medical problems. However, this is not the only problem. We should see that it has many institutional and institutional reasons. Only when we understand the reasons behind this deeply and look for countermeasures based on these reasons can we be able to solve the problem of “taking drugs to support medicine”. problem.

In Other words, drug licensing does bring about some problems, but because the current social environment has undergone complete changes compared with the planned system, if we simply believe that relying solely on the elimination of drugs and achievements can completely improve public hospitals, I am afraid that Unrealistic.

Viewpoint China: Last year, Sun Zhigang, director of the State Council's Medical Reform Office, stated that the first step in breaking away from “taking medicine to support medicine” lies in the government’s own reforms. How can we understand this position?

Wang Hufeng: Through a new round of medical reform, we have had a lot of understanding of the categories, objects, and contents of the “medical reform”. The position of the leaders of the Medical Reform Office shows that we have made great progress in our understanding and not only when we say “medical reform”. It is to change hospitals and doctors, and the government should also be one of the major responsibility entities for “medical reform.” If we only change the following areas, change localities, and change medical institutions, the government itself will not reform, and medical reform will be difficult to really put in place.

Views China: As a scholar, what is your thinking about the reform of public hospitals?

Wang Hufeng: From a scholar's point of view, through analysis and research, I proposed a basic idea for the reform of public hospitals, which is called hierarchical collaborative governance. The so-called hierarchical collaborative governance is to focus on the reform of some medical institutions in the past. Some local governments focus on reforms to “separate management and management”, but the effect is not particularly obvious. In fact, the reform of public hospitals should be based on three levels. .

The first level is the government level, including local governments at all levels. This level includes not only the health sector but also related departments. The second level is public medical institutions. Public medical institutions need to establish a corporate governance structure. How do we combine the management and decision-making power of state-owned assets with the overall decision-making power of operations, implementation, and supervision so that they can each get their own positions and can exert their enthusiasm; The third level is that we have not paid enough attention in the past but it is also very important. At the doctor level. As a public hospital, in the past, even if the dean was in charge of management, it now appears that many disciplines, personnel training, and patient services are provided directly by doctors and departments. In other words, it does not mean that the management of the hospital is complete, but there are still many problems at the department and doctor level. Therefore, the point of view now is to divide the reform of public hospitals into three levels: the government level, the hospital level, and the departmental level.

Perspectives China: Distinguish the level, then how to coordinate governance?

Wang Hufeng: It is clear that these three levels are divided in order to achieve coordinated management. For example, in order to improve the quality of service, speed up bed turnover, improve doctor-patient relationship, or improve performance, no matter which theme, we need to form a synergistic interaction on three levels. In other words, the above documents were issued, and then the hospital would have to move and the department doctors would have to move. Each of these three levels must be coordinated from the above-mentioned major policies, policies, specific management rules, to the following specific behaviors. Only in this way can the work be implemented and public hospital reforms can be pushed forward. If any aspect is out of line, or is lagging behind, obstruction, even the best policy is difficult for patients and the general public to experience. This is why we have produced many and many documents. There are many, many benefits to people's policies in the middle. Our people feel that they are not so deeply concerned. Because we are in the middle and lower levels and many places are not well coordinated, we must recognize that the government’s own responsibilities are an improvement on our reform tasks. Next, we must stratify collaborative governance.

Perspectives China: How should we advance the reform of public hospitals?

Wang Hufeng: In the future, public hospital reform should take a refined reform. The reform, development, and management are well unified and coordinated. At the same time, they must be very elaborate. They cannot simply mention the goals and principles but cannot implement them. Therefore, it is necessary to be more elaborate, more elaborate in design, more elaborate in organization, and more elaborate in implementation. Only in this way can public hospital reforms be better promoted.

Perspectives China: With regard to the reform of public hospitals, apart from the profits derived from the divestment of pharmaceutical income, there are mainly two parts: service charges and government financial subsidies. Can you be accepted if you increase your service charge in addition to your profits? What problems will arise?

Wang Hufeng: Stripping off drug revenues is mainly to use service income and financial subsidies to solve the income problems of medical institutions. It should be said that this is a very good goal and ideal, but this goal is ideal on the other side. How to go from this shore to the other shore, I am more concerned about how to achieve this goal and how to solve the problem of “crossing the river”.

Viewpoint China: In other words, the current problem is not to worry about whether service charges can be accepted, but rather, is it because the income from drugs has been divested? Can other income surely grow?

Wang Hufeng: Between drug income and other income, the two should be in this relationship. However, its premise is to increase the service charge through a control mechanism that can be monitored and monitored. Or if the financial supplement is a little more, the income of medicines will naturally be less. This is not a natural relationship. It is an approach that requires governance, such as operational mechanisms and monitoring measures, to ensure that it will increase. However, for this piece of work, I believe that there is not enough emphasis on the actual operability, and this practical operation is still too thick. There may be such a situation: When the hospital says that the subsidies of the relevant departments are not enough, the relevant departments will say that if I want to make up, it will definitely depend on your income and expenditure accounts. The hospital needs to calculate very carefully, otherwise I will make up for it. Calculate fill in place? There is also a situation where some hospitals worry that once they take the initiative to bring their medicine revenue down, service price adjustments cannot be implemented, and financial subsidies cannot reach. Can hospitals fail to do so? How to solve?

Opinions on China: How can we make the "actually manipulated things" more detailed?

Wang Hufeng: I think public hospitals are the first to use public characters first. All public organizations and non-profit organizations should be open and transparent. They also agree that our medical departments should also have duties and responsibilities such as fiscal and taxation, so that they can be connected. Otherwise, we are also worried that the income of medicines in medical institutions will really drop, subsidies will not come, and their own development, including the loss of personnel and talent, may occur.

However, if we only talk about these principles or good ideas, and do not have good concrete measures, we must not be able to do this thing and do it thoroughly. Whether it is financial subsidies or adjustments to service fees, there must always be a “preview,” and we must have a degree. We must always go forward step by step. How to let all parties have confidence and how to solve the problem of “crossing the river”, I think it is still necessary to rely on a safeguard approach. A suitable system can connect it.

If we are to solve this problem, we need an actionable, monitorable approach to achieving "removal of drug withdrawals", that is, specific plans for other subsidies to follow up, so I think that we should pay attention to the actual operations in this area. Pilot medical institutions must work hard in this direction.

Perspectives China: How can private hospitals win their competitive advantage in the reform of public hospitals?

Wang Hufeng: “Private hospitals” is a term that many of us like to use. In fact, academics are more inclined to use the concept of “non-public medical institutions” or “for-profit and non-profit medical institutions.” This title also refers to a specification. , standard, international issues. Private hospitals are also classified, and they are also profitable and non-profit. Whether it is for-profit or not-for-profit, we believe that it should be encouraged by law to establish development.

In terms of total medical resources, we are still a developing country with a large population. We need higher input from the society. In addition, social needs are also diverse and stratified. The entry of social capital should be said to fill the shortage of government investment. There is no doubt that multi-level services are beneficial. The problem now is that we should not regard public hospitals and non-public hospitals as two different things. On the whole, both public and non-public hospitals are important components of our medical service system. When formulating policies, we should study on various types of medical institutions. Therefore, I have always maintained that public hospitals should be reformed. Private hospitals also need reform.

Views China: Tell me about your reasons.

Wang Hufeng: For example, now whether it is a public hospital or a private hospital, the so-called hospital management is often internal to the hospital. There are many things in the hospital, but between the hospital and the hospital, it is also a public hospital, in an area, The convergence, referral, and the like of a region are not really smooth, and the collaboration between public and non-public medical institutions is not established. Now the two are completely different, and this will affect our establishment. A complete and coordinated medical service system is not conducive to the effective allocation and use of our entire medical resources. So I think that private medical institutions should be a very important component. In the future, there will be a lot of management policies, especially supervision, including scientific research projects, talent flow, and convenient two-way referral for patients. It is a great convenience for patients that private medical institutions consider the establishment of a systematic, coordinated and complete medical service system.

Perspectives China: Do you think free medical care is feasible under China's current national conditions?

Wang Hufeng: The so-called "free medical care" is actually a common name, and its attractiveness is very great. In fact, this common name is to some extent distorted the pattern of foreign medical services. Under certain conditions, it covers up the essence of this medical model. To a certain extent, it misleads the Chinese people about its understanding. There is no academic reason why The concept of "free medical care" is conceptually unclear.

The so-called “free medical care” we are talking about now is actually talking about the British model. I can responsibly say that the true core of the British model is not free, but there is medical management, and it is the general practitioner who is the gatekeeper. The medical system of the people system is a true medical model with total control, equality for all, strict procedures, and waiting for long queues. Many people only talk about free, not to mention these restrictions, which is actually misleading.

Perspectives China: What is the specific model of medical care in the UK?

Wang Hufeng: First, the implementation of the National Health Service in the United Kingdom is first and foremost supported by a sound general practitioner system. Residents who are participating in Medicare in Beijing can go to the top three hospitals at any time to see a doctor. This situation has made British residents aware that they will be eye-popping. It seems unimaginable to them because all people must first see a doctor. Find the most basic general practitioner. The general practitioner is responsible for seeing if there is a need to take medicine and there is no need to continue to see a doctor. If he really needs to go to a specialist hospital to find an expert, he is responsible for contacting the referral. At present, China obviously does not have this condition. There are not so many general practitioners who can provide this kind of initial diagnosis and treatment service for the common people.

Second, suppose that if you allow some residents to start today, you must first go to the community to find doctors for medical treatment. Many residents can't accept them, they can't get used to it, and reality is unrealistic. I think this issue can be discussed.

Third, there are strict procedural controls in the UK's medical model, as well as the queuing system. The average waiting time in previous years exceeded several months, even one year, and it seems unimaginable to us. If our patients make appointments for a few months, I believe patients are unacceptable, but this is a reality in foreign countries. Later, the United Kingdom also adopted some measures, such as increased the proportion of investment and budget, and so on, and now the average waiting time is controlled within eight weeks. What concept? If you have an emergency, of course, you can go directly to the hospital, but if you go to the hospital for examination or elective surgery, you must wait a few weeks. This is normal. However, I think that such a so-called free model may be difficult for us to accept and it is difficult to accept.

Fourth, we can hardly imagine that, with the free medical care in the UK, about 12% of people still buy commercial health insurance, and the share of commercial health insurance in the total health expenditure is about 8 times that of China. Buying commercial health insurance, that is, those who do not want to wait and want better medical care, are paying for themselves. I am afraid that in China, it is impossible for people with rights and rich people to pay for themselves. Some people are now talking about the “free medical stories” that do not clearly explain the characteristics of people’s systems and mislead many people.

But also objectively speaking, the model cannot be divided simply. Regardless of the model, only suitable and appropriate is the best. We cannot say that a certain model is wrong, nor can we say that this model is extremely good. . At present, even if we double our input, even if we do not do anything else, we will only solve the medical problem. The existing foundation still cannot achieve the required management level of free medical care.

China: Why?

Wang Hufeng: If all the doctors and nurses go to the hospital to start the norm from the grassroots level, and everyone waits in line to wait for this kind of game rules, if you find someone to support the relationship can be modified and added, then this so-called "free medical care" will lead to serious Corruption, this is a social disaster. Also, if the facilities and doctors' level of hospitals in our hospitals differ greatly, they will also create another kind of inequality.

Therefore, if we do the kind of medical model in the United Kingdom, the premise is that the medical resources and technology are equalized. We cannot see the people. We only see the “free” one. Actually, even if it is free, it also masks extreme inequality.

In addition, we simply look at people's models and we do not see their treatment arrangements for medical personnel, performance appraisal, and operational efficiency. It is equal to seeing only fur. Now our medical institutions provide services with certain economic incentives. Objectively speaking, some doctors have both pressure and motivation. But if it's all free, the doctor's money is all-inclusive, and if so many doctors can work overtime, it becomes a question. In other words, our management of the doctor's performance, our salary design has not yet reached that level, our management is still crude, and that kind of big pot of rice, completely free of charge, I feel very different from our reality. Personally speaking, I also hope to enjoy free, high-level medical services, but rationality tells me that academic conscience tells me that there is no such condition in China now. I expect it to arrive earlier this day, but it does not work now.