"The day when the graded diagnosis and treatment system is realized is the time when China’s medical system reform is successful." Ma Xiaowei, director of the National Health and Wellness Commission, said this in the "Ministerial Passage" of the National People’s Congress in 2019, which revealed the essence of China’s medical service system and the ultimate goal of medical reform.
However, to achieve the goal of graded diagnosis and treatment can not be achieved overnight. The top-level design of the National Health and Wellness Committee has long been preset, and the connection between medical associations will be included in one of the primary tasks leading to graded diagnosis and treatment.
Medical association inserts "wings" for graded diagnosis and treatment
The medical association refers to the regional medical association, which integrates the medical resources in the same area, and usually consists of three-level and two-level hospitals, community hospitals and village hospitals in a region.
In fact, as early as 2016, at the National Health and Wellness Conference, the General Secretary of the Supreme Leader emphasized: speed up the construction of graded diagnosis and treatment system, improve the level of primary medical services, and for the first time in his speech, positioned "graded diagnosis and treatment" as the first of the five basic medical and health systems, demanding "breakthrough". Subsequently, the National Health and Wellness Commission and other departments issued a number of documents and policies to promote the development of medical associations.
On April 23, 2017, the General Office of the State Council issued the Guiding Opinions on Promoting the Construction and Development of Medical Consortium, which officially promoted the construction of medical consortia to a national policy. The opinions clearly required that all tertiary public hospitals should start the construction of medical consortia before the end of October 2017, and comprehensively start various forms of medical consortia.
On January 3, 2018, the Action Plan for Further Improving Medical Services (2018-2020) issued by the National Health and Wellness Commission proposed to provide continuous medical services with the medical association as the carrier in three years from 2018 to 2020.
In 2019, it entered the second year of implementing the medical association, and the related promotion work reached a new height. On May 22nd, the National Health and Wellness Commission and the State Administration of Traditional Chinese Medicine jointly issued the Notice on Carrying out the Pilot Work of Urban Medical Consortium Construction, which clearly proposed to promote the construction of graded diagnosis and treatment system and medical consortium, build a high-quality and efficient medical and health service system, and gradually realize the grid layout management of urban medical consortia; It is planned that by the end of 2019, 100 pilot cities will fully start the grid layout and management of urban medical associations, and each pilot city will build at least one medical association with obvious results, initially forming a medical association management model led by urban tertiary hospitals and based on primary medical institutions, rehabilitation, nursing and other medical institutions.
On June 4, 2019, the General Office of the State Council issued "Key Tasks for Deepening the Reform of Medical and Health System in 2019", proposing to formulate management measures for medical associations, which indicates that the work of medical associations tends to a comprehensive and standardized stage, and the era of medical associations has begun.
Compared with the official implementation of the medical association in 2017, after two years, the medical association has gradually leapfrogged from "nothing" to "existence" to the development trend of improving "quality" and "quantity".
With the promotion of graded diagnosis and treatment, problems such as vague grading positioning, insufficient grass-roots capacity, lack of coordination at all levels, lack of continuity of medical services, disorderly flow of patients, poor experience and payment support have gradually surfaced, which need to be solved urgently.
The mode of urban medical group is one of the four modes of medical association. As typical representatives, Shenzhen Luohu Medical Group and Jiangsu Zhenjiang Rehabilitation Medical Group have made many explorations and achieved good results, which are worth learning from.
Luohu model: management, service, benefit and responsibility are four in one.
In 2015, taking Luohu District as a pilot, Shenzhen initiated the collectivization reform of medical institutions with administrative districts as a unit.
The medical reform in Luohu integrated five hospitals and 23 community health centers to form a hospital group. Under the principle of integration of staffing, operation management and medical services, doctors in the group realized free flow, solved the problem of lack of medical care at the grassroots level, and provided residents with the whole service of "prevention-health care-treatment-rehabilitation-nursing-old-age care".
In terms of resources, optimizing and reorganizing "similar" resources within the hospital and intensively setting up resource sharing centers such as medical examination, radiological imaging, disinfection supply, health management, logistics distribution and information management have greatly reduced operating costs.
The Group adopted a new medical insurance payment model of "lump sum of medical insurance funds and reward for savings", which forced the hospital to continuously improve its technical level and service quality and realize the transformation from "making money by treating diseases" to "preventing diseases and saving money". Because residents are not restricted from choosing hospitals, and the medical insurance expenses for residents seeking medical treatment abroad should be paid from the total amount of the group, the hospital group can only benefit more by doing a good job in preventive health care and health management, so that the contracted insured can get less sick and have fewer serious illnesses.
In terms of organizational structure, Luohu Hospital Group has established a unified legal person to co-ordinate the medical resources in the whole region, constructed a new corporate governance structure, established a responsibility community, and solved the problems of small and comprehensive hospital setting, redundant construction, low efficiency and homogeneous competition. By strengthening the community health center, implementing the contract service of family doctors, we will try our best to solve the problem of "lack of doctors, medicines and examinations" in community health, and establish a healthy community to solve the problems of lack of quality resources in community health centers and people’s distrust.
A major innovation of Luohu Medical Group is to establish an incentive mechanism of "total amount management, balance retention and reasonable over-value burden" with the hospital group as the link. Another highlight is that the health status of residents is taken as a quantitative indicator, and the assessment results are linked to financial subsidies and the annual salary of the group leadership; Implement the measure that grass-roots general practitioners enjoy the same treatment as the staff of public hospitals, and take grassroots work experience as the condition for the medical staff of the group to return to the city and be promoted.
The success of Luohu Medical Group lies in the integration of management, service, interests and responsibilities.
Rehabilitation group: minor illness in the community, serious illness in the hospital, rehabilitation back to the community.
As early as its establishment, Jiangsu Rehabilitation Medical Group was positioned as a compact medical group with assets as the link.
First of all, in terms of organizational structure, Zhenjiang Municipal Government entrusts Health Bureau as the investor to perform the function of running medical services, and establishes a medical group with Zhenjiang First People’s Hospital as the core, including 5 secondary hospitals and 10 community health centers, which makes an innovative breakthrough in management system: separating management from health administrative departments, and establishing a corporate governance structure of public hospitals, which is both public welfare and arousing enthusiasm.
Secondly, in terms of resource integration, six centers have been set up, including clinic, imaging, procurement and supply, disinfection and supply, information and community health management, and a two-way referral mechanism has been established between public hospitals and community health institutions. At the same time, community standardization construction has been strengthened, and grid management has been implemented for grassroots medical and health services, so that the overall service level of community health service institutions has been significantly improved, and patients have been rationally diverted to promote the formation of "minor illness in the community, serious illness in the hospital, and rehabilitation back to the community" While alleviating the "difficulty in seeing a doctor", group hospitals can share medical resources, so that the overall efficiency of the medical and health service system can be fully exerted, the utilization rate of medical resources can be improved, and the operating cost can be reduced.
Establish a reasonable and effective incentive mechanism, be more flexible in the mechanism of selecting and employing people, and introduce a performance-based salary system in the distribution system to mobilize the enthusiasm of medical staff; Financial subsidies will be provided to the community where doctors are dispatched from large hospitals, and the dispatched doctors will be given priority in promoting their professional titles. A joint rehabilitation ward will be set up in the community, and the hospital will send directors and head nurses to the rehabilitation patients transferred to the community, and solve the problems of equipment, medicines, nurses, referrals, etc., and carry out homogeneous medical care services.
Finally, in terms of supporting policies, Zhenjiang has given full play to the advantages of health departments in managing medical insurance and medical and health services as a whole, and carried out the reform of combined payment methods combining total budget, payment by disease type and payment by head.
The future of "communication" of medical association can be expected
Through the representative cases of Shenzhen Luohu Medical Group and Jiangsu Zhenjiang Rehabilitation Medical Group, it is not difficult to find that the construction of urban medical association has realized the effective allocation of medical resources, and has formed graded diagnosis and treatment, which has promoted health management to a certain extent and achieved the goal of medical reform. Therefore, it is a long-term project to establish a graded diagnosis and treatment system and build a medical association.
The construction of medical association and the signing service of family doctors are two important starting points for establishing a graded diagnosis and treatment system. The medical association has rebuilt and reorganized China’s medical and health service system, allowing ordinary people to enjoy all-round, full-cycle and continuous medical services in the medical association through family doctors, and to get rid of the current situation that they tend to "go up" in different medical institutions and accept fragmented and discontinuous medical services.
In addition to the strong promotion of the government, the most important thing in the construction of medical associations is to establish an internal benefit sharing mechanism, so that the institutions of medical associations can realize their own interests and development through division of labor and cooperation, resource sharing, etc. This is also the key factor for Shenzhen Luohu Medical Group and Jiangsu Zhenjiang Rehabilitation Medical Group to achieve results.
Based on the strong support of the national level for the medical association, major medical institutions are actively practicing and exploring. It can be predicted that in the next few years, by organically integrating the construction of the medical association with the contract service of family doctors, the medical association can finally achieve the "communication" of the medical association and solve the "pain" of the masses in seeing a doctor.
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