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-

BioSpectrum (Asia) - - Bio Content - Narayan Kulka­rni narayan.kulka­rni@mmac­tiv.com

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.

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