Where does the general practitioner come from before starting medical reform？
If the reform of China’s medical and health system is regarded as the object of diagnosis and treatment, Liu Yucun, member of Chinese People’s Political Consultative Conference, deputy secretary of the Party Committee of Peking University and secretary of the Party Committee of the Ministry of Medicine, gives three diagnoses: the contradiction between limited financial investment and the growing diversified demand, the difference between the overall social evaluation and individual feelings of the effectiveness of medical reform, and the balance of interests among different social groups. "This is a world problem."
Medical reform has been on the way. Premier Li Keqiang mentioned the word "doctor" 27 times in this year’s government work report. The State Council’s institutional reform plan submitted to the National People’s Congress for deliberation on March 13th has made important adjustments — — Establish the National Health and Wellness Committee and the National Health Insurance Bureau.
Medical reform has been advancing, and China has woven the largest universal basic medical security network with more than 1.35 billion participants. The 60-year-old drug addition policy was cancelled, and the proportion of residents’ personal health expenditure in total health expenditure fell below 30%; Medical reform hot words such as medical association, graded diagnosis and treatment system and general practitioner surfaced … …
Medical reform is in a dangerous beach, as Wang Guoqing, a spokesman for the 13th session of Chinese People’s Political Consultative Conference, said: "Medical reform has entered the deep water area, and there are still many problems and problems to be solved urgently."
Farewell to medical supplement with medicine, where should public hospitals go?
The top priority of the new medical reform in the past 10 years is to comprehensively push forward the comprehensive reform of public hospitals. A big move in 2017 is to completely cancel the drug addition. This impressed Sun Tieying, member of Chinese People’s Political Consultative Conference and director of the Department of Internal Medicine of Peking Hospital, because it meant bidding farewell to the era of "supplementing medicine with medicine".
According to Sun Tieying, "drug addition" brought development opportunities to hospitals in the 1950s. With the changes of China’s economy and society, it gradually evolved into a profit-seeking mechanism, which increased medical expenses. "Reform is imperative".
Ordinary people expect to solve the problem of "expensive medical treatment", but for medical workers, this is a realistic question: when the old financing and compensation model of public medical service system withdraws from the historical stage, can the new compensation mechanism play its due role and make medical staff realize the value of labor? The pace of the "compensation mechanism" has stepped on different beats in various places.
Liang Wannian, full-time deputy director of the State Council Medical Reform Office and director of the System Reform Department of the National Health and Family Planning Commission, revealed that at present, about 80% of the reduced drug price increase is made up by service price adjustment.
Jiang Jun, member of Chinese People’s Political Consultative Conference, member of the Standing Committee of the Central Committee of the Democratic Progressive Party and deputy mayor of Shenyang, noticed that hospitals in some parts of China had a premium phenomenon after canceling the 15% drug surcharge. "Originally, the government subsidized 10% and hospitals subsidized 5%, but in the end, the medical service fee increased by 20%, which was higher than before."
A member of the medical and health sector expects the policy to be better implemented. "Is there still room for adjustment in the price of doctors’ technical services? Let doctors have no distractions, not spirits. "
In Jiang Jun’s view, with the continuous advancement of deepening medical reform, many new and old problems are superimposed.
For example, the complete cancellation of drug addition has solved the problem of "supplementing medicine with medicine", but it has reduced the attention of hospitals and medical staff to drugs, resulting in some problems such as insufficient supply of drugs in hospitals, joint sales of drugs by medical staff and pharmacies, and "supplementing medicine with medicine with medicine" through multiple inspections. "Sometimes doctors prescribe drugs and suggest you to buy them at the opposite pharmacy, which may be really short of drugs, but it does not rule out that this is a new gray area."
Some analysts believe that these phenomena are related to "zero drug addition" and the compensation mechanism has not yet been put in place. In view of the "drug shortage" and the problem of arrears of medical insurance funds, Jiang Jun suggested further improving the supply guarantee mechanism of drugs and medical devices; Reform the medical insurance payment management system according to the market rules of who consumes, who pays, who supplies and who charges. At the same time, explore a variety of compensation ways, relax the scope of hospital business, and form a diversified compensation mechanism.
Sun Tieying hopes that the adjustment of the compensation mechanism can further consider the operating cost and redevelopment ability of the hospital.
The establishment of the National Health Insurance Bureau may bring hope. "The Medical Insurance Bureau will lead the supervision of public hospitals." Tang Xudong, member of Chinese People’s Political Consultative Conference and president of Xiyuan Hospital of Chinese Academy of Traditional Chinese Medicine, believes that the inclusion of many responsibilities, including drug and medical service price management, in the National Health Insurance Bureau will profoundly affect the reform of public hospitals. He hopes that the future policy can not only standardize the doctor’s diagnosis and treatment behavior, but also respect the labor achievements of medical workers, so that the patient’s experience can be optimized.
How to realize the prospect of benefiting the people by graded diagnosis and treatment
Wu Hao, member of Chinese People’s Political Consultative Conference and director of Fangzhuang Community Health Service Center in Fengtai District, Beijing, keenly noticed that China patients’ attitude towards medical treatment showed two extremes. One was "to be sick" because the hospital was overcrowded and the medical treatment process was cumbersome; The other is that the third-class hospitals must be selected for chronic diseases and common diseases, which aggravates the problem of "difficulty in seeing a doctor". "If the first consultation system of primary medical care is more popular and the people trust primary family doctors more, both attitudes will be changed."
It is an important measure to solve the problem of "uneven fat and thin" of medical resources and make it more convenient for ordinary people to see a doctor. Ao Hushan, member of Chinese People’s Political Consultative Conference and director of the Medical Insurance Department of Fuwai Cardiovascular Hospital of China Academy of Medical Sciences, explained it as follows: medical institutions at all levels have their own duties, which really keeps people from leaving the community for minor illnesses, makes serious illness referrals orderly, and normalizes health guidance.
To realize such a picture of benefiting the people, Ao Hushan believes that patients can be guided to seek medical treatment in the community by medical insurance, that is, by adjusting the reimbursement ratio of different levels of medical institutions, people can be guided to go to community hospitals for minor illnesses. However, he stressed: "Using medical insurance as a lever to promote graded treatment itself has certain limitations. The medical insurance department and the health department should take a two-pronged approach and enforce it with many relevant departments to promote the graded diagnosis and treatment system more effectively."
Gu Jin, deputy to the National People’s Congress and president of Peking University Shougang Hospital, believes that the construction of a close medical association can sink experts in common diseases, respiratory diseases, cardiovascular diseases, endocrinology and other hospitals into the community, "allowing patients to see the experts they want to see and improve their enthusiasm for treatment". Wu Hao believes that if the establishment of information system is strengthened and patient information is shared in time, the trouble of repeated examination can be reduced for patients in the referral process.
At the end of 2017, data from the Beijing Municipal Health Planning Commission showed that the number of outpatient and emergency departments in tertiary hospitals in Beijing decreased by about 12%, secondary hospitals decreased by about 3%, and primary hospitals and community service centers increased by 15% to 16%.
Where does the general practitioner come from?
With a headache, brain fever or other discomfort, a family doctor can make a home visit with a phone call — — The interpretation of family doctors in film and television dramas makes people look forward to "family doctors". However, based on the current situation of medical resources in China, "family doctors are actually family doctors’ services, which are not equivalent to private doctors". Wu Hao explained that this medical model is mainly that the community health service team provides active, continuous and comprehensive health responsibility management for residents by signing contracts with residents, "just like a healthy 4S shop".
"The grassroots is an acquaintance society, and the key is continuity and trust." Wu Hao said that to provide health consultation, disease analysis, auxiliary diagnosis, medication advice and other services for ordinary people, family doctors replace the doctors and relatives around everyone to solve the problems of "what disease to get, what department to see, which doctor to find, and what medicine to take".
According to Wu Hao, at present, general practitioners are basically providing services at the grassroots level. Xie Liangdi, vice president of the First Affiliated Hospital of Fujian Medical University, said that unlike the mission of "treating diseases" by clinicians, general practitioners are all-round care from birth to death, from maternity guidance, infant care, geriatric diseases to hospice care, etc. "In the past, everyone thought that specialists were skilled, but general practitioners required a wide range of knowledge to go beyond the clinic".
In the past ten years, China’s medical training has been mainly based on the specialist education model. He revealed that domestic medical colleges have just started to set up a general practitioner department. "According to the training cycle of doctors in China, it will take at least 10 years to train a new general practitioner."
How to speed up the training progress of general practitioners? Member Chinese People’s Political Consultative Conference and Lu Chuanjian, vice president of the Second Clinical Medical College of Guangzhou University of Traditional Chinese Medicine, and many other members suggested that the training mode of integrated traditional Chinese and western medicine could shorten the cycle to 4-5 years. However, in order to train general practitioners who can stick to the front line for a long time, in Xie Liangdi’s view, it is the key to break the shackles of personnel, salary and professional accomplishment: going to community hospitals may not be compiled, but the top three and second-class hospitals may be compiled, and the future will be guaranteed; When doctors ask each other "which hospital are you from", one is in the top three and the other is in the street, "obviously the former is more fulfilling".
Wu Hao revealed that although the people’s demand for primary health care has gradually expanded, the annual income of community health center staff has always been at a low level, "less than half of that of hospitals above Grade III", and the ceiling of salary has become the biggest obstacle to the recruitment and introduction of community health talents. Wu Ming, member of Chinese People’s Political Consultative Conference, director of the Central Medical and Health Committee of the Jiu San Society and member of the expert committee of the leading group for medical reform in the State Council, said that if the enthusiasm of primary doctors is difficult to mobilize, even if patients "sink down", it will still face great challenges to realize graded diagnosis and treatment.
"The establishment of the National Health and Wellness Committee provides a leadership and organizational guarantee system for promoting the construction of a healthy China." Rao Keqin, member of Chinese People’s Political Consultative Conference and vice president of Chinese Medical Association, believes that the institutional reform program emphasizes the concept of "great health" and "great hygiene" in medical and health services, which has released a positive signal for the training and development of general practitioners.