Three reforms of medical reform won three returns

“The medical reform of Sanming is forced out.” Talking about the reform initiated in February 2012, Zhan Jifu, the Standing Committee member of the Sanming Municipal Party Committee and head of Sanming Deepening Medical Reform Group, was blunt.

It is located in Sanming, a mountainous area in the northwestern part of Fujian Province. The 12 counties (cities, districts) under its jurisdiction are all old districts, including 10 provincial-level hardship transfer payment counties. At the same time, Sanming is an old industrial city, with many retired employees and a heavy financial burden. “In 2010, Sanming’s employee medical insurance co-ordinating fund failed to reach 143.97 million yuan, and the finances were unable to reach the bottom. At that time, the fund owed more than 17 million yuan in medical expenses in 22 public hospitals in the city,” said Zhan Jifu.

Under the predicament, Sanming began to implement a new medical reform model starting from 22 public hospitals in the city, striving to “make public hospitals return to the nature of public welfare, doctors return to the role of the doctor, and drugs return to medical treatment functions”.

Axe

Cancel drug additions and cut off the interest chain

“The purpose of the reform of public hospitals is to effectively reduce the burden on the people to pay for them.” Zhan Jifu said that more than 60% of the 22 public hospitals in Sanming before the medical reform have annual income from medicines (including consumables), and the medical income is only 30%. This kind of "drug-based medicine" and the state of maladjustment of income are the crux of "expensive".

"We have explored the field of drug circulation and found that drug companies have scolded votes from enterprises outside the province. The price in provincial procurement is several or even several times the ex-factory price." Zhan Jifu said that high drug prices directly lead to medical resources. Serious waste, over-examination, over-use of drugs, and excessive treatment are common.

The elimination of drug additions and cutting off the interest chain of hospitals and drugs has become a breakthrough in Sanming's medical reform. On February 1, 2012, Sanming implemented zero-dip sales in public hospitals at and above the county level (including county level) in the entire city, and cut the "sharp axe" of the reform to a falsely high drug price.

In order to ensure the implementation of the policy, Sanming City imposes price-based procurement on pharmaceuticals, that is, after the provincial-level drug bidding is completed, it is screened, and then each hospital purchases according to the selected price.

At the same time, Sanming identified 30 disease types as implementing the single disease payment reform. The medical reform team also specifically screened 129 auxiliary, nutritive, and high rebate medicines, and monitored the use of these diseases.

In addition, Sanming adopts the "two-vote system" in the distribution of pharmaceuticals: drug manufacturers to drug distribution companies issue an invoice, and drug distribution companies issue invoices to medical institutions. The city's food and drug regulatory authorities monitored the flow of drugs and the price increase through the two invoices and the ex-factory price of the company's network.

Squeezing out the imaginary high price of drug prices, the reform dividend immediately appeared. “In 2014, the per capita outpatient expenses at the county and city hospitals in Sanming City were RMB 129.19 and RMB 160.24, respectively, which were the lowest in the province. The medical insurance funds also lost RMB 144 million from 2010 to the balance of RMB 86.374 million in 2014. This is true. Real results," said Xu Zhiyu, director of Sanming Medical Insurance Center.

Two axes

From the big pot to the annual salary system, turning gray income into annual sunshine salary

"Last year, my performance assessment was 80 points, and I received an annual salary of more than 200,000 yuan. Before the implementation of the doctor's annual salary system, wages and bonuses were also reduced by more than 70,000 yuan a year." Changes brought about by medical reform, Sanzuo Youxi County Hospital of Traditional Chinese Medicine chief physician Mao Zuguan feel particularly evident.

The annual salary system in Mao Zuguan's mouth is another innovation in Sanming's medical reform. In 2013, the annual salary system, a new assessment mechanism, was fully rolled out in 22 public hospitals in Sanming.

"The annual salary system is divided into the dean's annual salary system and the doctor's annual salary system depending on the object of inspection." Zhan Jifu said that the dean's annual salary is paid by the local finance department, and the assessment items include service evaluation, office orientation, safe construction, and effective management. There are 34 sub-categories in the five major categories of sustainable development; the annual salary of doctors includes the basic annual salary and the annual salary of performance: the basic annual salary is paid monthly, and the annual salary of performance is linked to job workload, medical ethics, and social assessment. The department's two levels of assessment determine the actual salary.

The baton became the subject of examination. The traditional “big pot rice” broke down and the enthusiasm of doctors greatly improved. In the first year of the annual salary system, Huang Yue, the head of the First Hospital of Sanming City, obtained the highest score of 90.04 points in performance appraisal; after conversion, his actual annual salary income was 315,100 yuan, which was 150,000 yuan more than the last dean. .

"The annual salary system assessment is not only a great liberation but also a high demand for us." Mao Zuguan said that the salary fund for the doctor's annual salary system is entirely derived from the hospital's medical income, including medical treatment, surgery, nursing, and beds. "From under the table The gray rebates have become the annual salary of the sun on the table, and now doctors prescribe things that are largely suppressed, and everyone is working hard to improve their own business."

Three axes

Open up policy barriers and explore grading clinics

“Before medical reforms, I have to pay the full amount of hospitalization fees before visiting the hospital, and I have to get a lot of materials for my reimbursement after I left the hospital. Now that it's all right, I don’t have to pay the full amount for hospital admission. With 70,000 yuan, Medicare also reimbursed about 55,000 yuan, which was nearly 15,000 yuan more than in previous years.” Chen Xia, who is preparing to leave the hospital in Youxi County, gave the Sanming medical reform a point of praise.

From the full prepayment to the discharge checkout, Chen Xia’s convenience was benefited from Sanming’s implementation of the working capital system. Since 2012, the Sanming City and County Level Medical Insurance Agency has used the monthly average of the funds allocated by the designated medical institutions for the previous year as the base, and allocated one quarter of the funds for working capital. Today, each quarter, more than 20 hospitals at and above the county level in Sanming City can obtain over RMB 33 million in working capital. This not only eases the financial pressure on the hospital, but also makes the amount of advance payment not exceed 1,000 yuan when people are hospitalized.

The working capital system makes the “everyone see the disease” as a basic realization, and it is also a microcosm of the Sanming medical reform efforts to open up the policy barrier.

In order to open up regional barriers, Sanming City will use the 12 counties (cities, districts) in the city as a clinic area to encourage competition in hospitals in this city. Patients can choose either high-level hospitals or more convenient outpatient clinics; Sanming carried out outpatient consultations to guide insured personnel to treat common and frequently-occurring diseases in outpatient clinics, reduce hospitalization of “hanging beds” and reduce hospitalization rates; open up the medical insurance system, Sanming took the lead in the overall management of three types of medical insurance funds in the city, and implemented the integration of medical insurance policies in urban and rural areas. At the same time, the gap between the payoff line and the reimbursement ratio between different levels of fixed-point medical institutions has been opened, and further tilted toward the basic medical institutions.

In May 2014, Sanming further promulgated the "Notice on Deepening the Second Round of Reforms in Basic Medical and Health Institutions." It issued a series of new policies in the areas of grassroots institution construction and financial security mechanisms, personnel management systems, and internal revenue distribution mechanisms. The “recruitment on demand” of the staff of the grass-roots organizations and the open recruitment system of the dean have once again broken through the policy framework of multi-sector containment.

“This is the reform exploration of the implementation of a hierarchical diagnosis and treatment system to promote the flow of quality medical and health resources to the grassroots.” Zhan Jifu said, “We hope that through the construction and improvement of the system, we will guide patients to treat minor diseases and common diseases at the grassroots level, relieving them from the source.” "It's hard to see a doctor."