China on expanding mode of hierarchical medical system
IN CHINA, HOSPITALS AT DIFFERENT LEVELS FORMED A REGIONAL MEDICAL CONSORTIUM (RMC). THE GOVERNMENT IS URGING HOSPITALS AT DIFFERENT LEVELS IN AN RMC TO STRENGTHEN THEIR COOPERATION AND RECOGNIZE EACH OTHER’S PATIENT MEDICAL RESULTS, WHILE ENCOURAGING TWO-
The hierarchical medical system has become an essential system in many developed countries.
It plays an important role of forming the basis for guaranteeing health care. The basic working of a hierarchical medical system involves initial diagnoses at primary medical institutions and twoway referrals among hospitals. In China, which has a population of over 1.37 billion, there are many problems in the medical system, such as biased resource allocation and extremely high patient flows to large hospitals. Since 2009, China has vigorously promoted the implementation of the hierarchical medical system to realize rational allocation of medical resources, promote the equalization of primary medical services, and reduce the cost of medical services. The hierarchical medical system launched in April last year with separation of clinic
from pharmacy started showing some positive results as Beijing announced in January 2018 that it saved $1.06 billion on medical costs in 2017. This
system is likely to provide a new perspective and strategic choice of health care service, not only for
China, but also for other countries.
The Beijing Municipal Commission of Health and Family Planning said on January 28 that Beijing saved about 6.7 billion yuan ($1.06 billion) on medical expenses since the separation of clinic from pharmacy in April 2017. As hierarchical medical care advances, the outpatient visits in large hospitals have decreased by over 10 per cent, and 20 per cent less patients are seeking appointments with experts. In the meantime, the outpatient visits have increased by 16 per cent in community hospitals.
The recent report on the work of the municipal government highlighted the establishment of hierarchical medical system as this year’s primary task. Each district in Chia will build a compact medical treatment unit that strengthens primary medical care. Meanwhile, the reservation service will be improved to facilitate patients and crack down on scalpers. The Beijing Municipal government has also announced that, by 2020, it will provide at least three general medical practitioners and five rehabilitation nursing beds for every 10,000 residents, and help to raise the average life expectancy to 82.4 years old. By the end of 2017, a total of 251 community medical centers, or 75 per cent of the
total, had changed the payment method to paying after diagnosis and treatment, instead of paying upfront.
Since April 2017, more than 3,700 hospitals have eliminated the margins in sales on medication, according to the commission. The separation of clinic from pharmacy has propelled the establishment of hierarchical medical care, rendering 12 per cent and 3 per cent less outpatient/emergency visits to tertiary and secondary hospitals respectively, as well as 16 per cent and 25 per cent more visits to primary hospitals and community healthcare institutions respectively. The number of outpatient and emergency visits to medical experts has also decreased, making it easier for patients with real needs to make such appointments. From January 1, this year the city merged urban and rural medical insurance policies to become an integrated insurance policy for both urban and rural residents in Beijing. This expanded the number of medical institutions under insurance
coverage to over 3,000. The hospital hierarchy is also helped by the new reimbursement system, which provides higher coverage for primary hospitals and below (55 per cent) and lower coverage for secondary hospitals and above (50 per cent). In addition, the new system standardized the insured categories of medication, medical service and medical facility for all the urban and rural residents, and expanded the types of medicine under coverage from 2,510 to more than 3,000.
Intensifying medical reform
It may be recalled that in January last year, the Chinese State Council released a circular in an effort to enhance medical reform during the 13th Five-Year Plan period (2016-2020). According to the circular, China has made substantial improvement in medical undertakings since the 12th Five-Year Plan, with 95 per cent basic medical coverage and steady integration of urban and rural insurance. The circular notes that in the next five years, the nation looks to build a complete public hygiene and medical service system, guarantee medicine supply and decrease personal expenses on medical care. Meanwhile, efforts should be made to optimize distribution of medical resources, clarify roles of medical institutions at different levels and promote the sharing of resources and diagnosis results. Health centers in towns and communities should improve capacity in diagnosing common diseases. Public hospitals should be guided in the hierarchical system to play a role in treating complicated and serious diseases.
SINCE APRIL 2017, MORE THAN 3,700 HOSPITALS HAVE ELIMINATED THE MARGINS IN SALES ON MEDICATION. THE SEPARATION OF CLINIC FROM PHARMACY HAS PROPELLED THE ESTABLISHMENT OF HIERARCHICAL MEDICAL CARE, RENDERING 12% AND 3%
LESS OUTPATIENT/EMERGENCY VISITS TO TERTIARY AND SECONDARY HOSPITALS RESPECTIVELY, AS WELL AS 16% AND 25% MORE VISITS TO PRIMARY HOSPITALS AND COMMUNITY HEALTHCARE INSTITUTIONS RESPECTIVELY. THE NUMBER OF OUTPATIENT AND EMERGENCY VISITS TO MEDICAL EXPERTS HAS ALSO DECREASED, MAKING IT EASIER FOR PATIENTS WITH REAL NEEDS TO MAKE SUCH APPOINTMENTS.
The circular notes that as part of the hierarchical system, family doctors should be expanded to cover the entire population by 2020. The circular also pushed for establishing an efficient system for modern hospital management separating government administration and business operation, while also laying out policies to ensure public hospitals’ role as an independent legal entity.
At the same time, the government should increase input and adjust medical service prices to reduce operational costs of public hospitals while curbing the unreasonable rise of medical expenditures. It urges the establishment of human resource management and a payment system that operates well in the medical industry, providing performance-related salaries to hospital employees. According to the circular, an efficient national medical insurance system should also be established, with sustainable fundraising channels, and an adjusted reimbursement ratio.
In May last year, the National Health and Family Planning Commission (NHFPC) announces that the hierarchical medical system pilot programme will be expanded to reach at least 85 per cent of prefecture- level regions. The commission further states that more policies will be issued regarding the hierarchical medical system, hospital management, medical insurance, medicine supplies and comprehensive supervision. China has earmarked over 1.4 trillion yuan ($203 billion) in its budget for health and medical expenditure in 2017.
Issues need attention
China has not established an effective model of the hierarchical medical system. In China, hospitals at different levels formed a regional medical consortium (RMC). The government is urging hospitals at different levels in an RMC to strengthen their cooperation and recognize each others’ patient medical results, while encouraging two-way referrals among them. However, an RMC cannot achieve the results that can be expected from a hierarchical medical system.
According to a report - ‘Hierarchical medical system based on big data and mobile internet: A new strategic choice in health care’ published in JMIR Medical Informatics in August 2017, from 2005 to 2014, the number of hospitals in China increased by an average of 716 per year, whereas the primary medical institutions increased by an average of 6785 per year. By contrast, the average annual growth rate of outpatients in hospitals and primary medical institutions were 11.43 per cent and 6.82 per cent, respectively. The growth rate of outpatients in primary medical institutions has not matched the growth rate of outpatients in institutions. Additionally, the number of beds and the rate of bed utilization increased more in hospitals than in primary medical institutions. Large hospitals are still overcrowded, while primary medical institutions are sparsely populated. High-quality medical resources are concentrated in large hospitals, but primary medical institutions are seriously lacking in medical resources.
In addition, the health-information-sharing platforms and associated mechanisms have not been established. Patients’ information cannot be shared among hospitals at different levels so patients cannot enjoy the continuity of medical services between different hospitals. These problems increase the difficulty and cost of medical services in China, the report added.
There is need for more research and dialogue on these issues and the impact associated with this innovative model of hierarchical medical system. This model is likely to provide a new perspective and strategic choice of health care service, not only for China, but also for other countries.