Looking at the development of doctors' groups from the differences between China and the United States, the domestic doctors' group may have four kinds of "fusions" in the future.

At present, doctors in the United States and China practice medicine, the intrinsic value of doctors varies greatly. In the case of appendicitis surgery, the same appendicitis surgery costs about 6,000 yuan in China, and the US needs 22,000 dollars. The surgery service fee that reflects the value of doctors is about 10% in China, which is about 600 yuan. The United States accounts for about 38%, about $8,300.

If you only look at the absolute cost of surgery, the cost of appendicitis in the United States is about 20 times that of China. If you look at the cost of surgery services that reflect the value of doctors, the United States is almost 90 times more expensive than China. This is the gap between the intrinsic value of Chinese and American doctors, and it is also the internal driving factor that more and more doctors will come out of the "institution".

The difference in the degree of attachment of doctors to hospitals is the core difference between Chinese and American medical service systems.

Under the huge intrinsic value difference, it is the difference in the degree of attachment of doctors in China and the United States to hospitals. In the United States, doctors are mainly practicing freely. More than 84% of practicing doctors in the United States are freelancers, and only about 7% of doctors are employed. Nearly 96% of the nearly 5 million practicing doctors in China are employed or appointed, which is commonly known as the “unit person”.

Due to special historical and institutional reasons in China, the government firmly controls medical service institutions and medical insurance payments, and doctors as special service personnel are bundled as core resources in the system. The hospital is a doctor, similar to the urban-rural household registration system or the peasant's land system, the doctors' group is firmly locked, and it has not been able to fully market freely.

In the United States, free practice is the main form of practice for doctors, most of whom are group practitioners. Among all the more than 1 million practicing doctors in the United States, group practitioners account for 67% of freelance doctors, and 43% of them are group-based doctors in a single discipline, reflecting the trend of fine division of labor in the US medical service system. . Nearly half of the group practitioners are mainly small and refined doctor groups of 10 or less.

Stark Law: The first legal norm that laid the foundation for the development of American doctors' groups

In 1988, the United States introduced Stark Law, which detailed the regulations for the doctors' group and laid the foundation for its later development. The core of Stark Law includes four aspects:

The doctor group practice (doctor group) requires more than two doctors to jointly register as a single legal entity. Both for-profit and non-profit can be used, but it must be targeted at providing Designated Health Services (DHS). Doctor groups come in a variety of forms, including medical services companies, limited liability companies, foundations, non-profit companies, and unincorporated associations.

The doctors' group should focus on medical services, and the medical services for patients account for at least 75% of the group's workload.

The doctors' group shall establish a decision-making mechanism to coordinate the control of the group's assets and income and expenditure. The medical service income of all doctors and doctors of the doctor's group shall be managed by the group.

The total profit of the doctor group is mainly derived from medical insurance funds.

The overall profit of the doctor group is mainly due to the health service payments specified by Medicare or Medicaid and other medical insurance programs in the United States, as well as the reimbursement for commercial medical insurance. The Current Professional Terminology (CPT) code is used as the main basis for medical insurance to determine the amount of payment and the distribution of benefits within the doctor's group.

"Ju-Distribution-Gathering": American doctors practice and return to employment system

The free practice of American doctors began in the 1930s and was first promoted by the Mayo Clinic and Caesars Medical Group. By the end of the 1980s, nearly 90% of doctors were freelancers. Since the 1980s, some doctors have turned from free practice to employment.

This change comes from three reasons: First, the introduction of the Stark Law mentioned above has allowed the development of the doctor's group to be regulated at the legal level.

Second, the development of new managed medical organizations (HMOs) has squashed the doctors' groups. The medical service system has always been a process of three-way dynamic game of “doctor-hospital-insurance company”. The interests of the three parties are uneven and conflict, so it has been in the process of this trade. The emergence of HMO organizations is a typical example of the formation of a community of interests between hospitals and insurance companies, thus enhancing the right to speak of doctors.

Third, with the rapid development of HMO organizations, and with the intensification of competition, many freelance doctors can not afford the high fixed costs of self-employment (such as information systems and labor costs), resulting in many freelance doctors starting to return to employment, through The group operation has amortized fixed costs, and this trend has continued to this day.

In contrast, China is in the 1930s, similar to the United States. From the employment system to the multi-point practice to the beginning of free practice, doctors began to step out of the system, so the number of small doctors group registration began to surge.

Driven by five core factors, the capital market favors, and the domestic doctors group develops rapidly.

The registration of the domestic doctors' group began in 2014 (the first Bodejialian). With the liberalization of the multi-point practice policy, more and more doctors' groups began to spring up, and the registration of the doctors' group in 2017 There has been a massive outbreak of quantity. The main drivers include five points:

From the perspective of the capital market, more and more doctor groups have received favor from the capital market and obtained financing. But most doctor group financing is still in the relatively early days of Angel and A. It is foreseeable that as time goes by, more and more doctors' groups will get financing in the future, and at the same time, they will advance to the more mature middle and late stages.

The dynamic game of "doctor-hospital-insurance", the doctor group can be divided into four categories

As mentioned above, the medical service system is a dynamic game process of the three core players “doctor-hospital-insurance”. Therefore, according to the attachment relationship between doctors and medical institutions (mainly hospitals) and the degree of docking with payers (mainly social security and commercial insurance), we divide doctor groups into four categories: comprehensive doctors' group and hospital-type doctor's group. , Insurance Doctor Group and Platform Doctor Group.

Among them, the comprehensive doctor group in the first quadrant is a relatively leading group of doctors, such as Zhang Qiang Doctor Group, Dong Lei Brain, Zhuozheng Medical and Bode Jialian. These medical groups often have deep medical resources. From the wired medical institutions, some or all of the payment side insurance companies have been docked.

The platform-type doctors group in the third quadrant often does not have its own doctors or medical institutions, and more serves as a third-party service to the doctors' group. It helps the docking doctors, hospitals and patients through the Internet platform to form a platform-type business, for example, a doctor-in-chief Almond doctor, good doctor, etc.

The domestic doctor group is still in the early stage of development, and there may be four kinds of "fusion" in the future.

At present, the development of the entire doctors' group is still relatively early, and there are still many challenges in the future, mainly from two aspects:

On the one hand, it comes from policy and supervision, which is reflected in the relatively backward practice of freelance medical practitioners, the slow progress of doctors' free practice, and the lack of laws and regulations on the nature of doctors and supervision. The medical attributes of doctors' groups are not clear.

On the other hand, from management and operation, the core issue is an excellent doctor. Is it a good manager? The operation and management of the doctor group not only needs to accumulate at the level of medical resources, but also requires deep operational experience in the personnel system, financial system, marketing and sales system, and information system. It is higher for doctors as management. Ability requirements.

In the future, looking forward to the future development trend of the doctors' group, it is more reflected in the four aspects of "fusion":

All in all, we are firmly optimistic about the development of the future doctors' group, and we firmly believe that doctors' free practice will come. Although the doctors' group is still in the early stages of development, there are still many challenges, but the opportunities must be greater than the challenges.

We believe that with the continuous opening of policies, with the continuous development of commercial health insurance, with the constant awareness of doctors' self-worth, as the individualized needs of patients continue to increase, doctors' groups will become indispensable in China's medical service system. Part of the shortage is even an important provider of future medical service systems.

This article is based on the author's speech at the inaugural meeting of the China Medical Association of Non-Public Medical Institutions.

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