Starting at a monthly salary of 1600 yuan! Doctor Income Survey Doctor | Medical | Income

In August, the medical anti-corruption campaign shook the entire industry, and the issue of doctor income became a focus of social attention.

Amidst the boiling public opinion, a renowned expert from a top tier hospital in China reposted a report from three years ago on his social media, with a meaningful title: "People's Daily Review: Please Always Remember, Doctors Have Died for Us.".

According to data from the National Bureau of Statistics, there were 4.4 million practicing physicians and assistant physicians in China at the end of 2022.

Is the income of over 4 million Chinese doctors really high? Does a doctor's income match their dedication and dedication? The public has their own opinions on these issues, with dissatisfaction, anger, suppression, and grievances intertwined, making people dizzy and unsure of where to go.

Seeking medical treatment and seeking medication is a basic human need. Providing doctors with a decent income and fair compensation that matches their efforts is the key to achieving sustainable high-level medical services.

What should be done to achieve this goal in China? First Financial reporters interviewed a large number of frontline practitioners, some in first tier cities and some in mainland counties. There were experts from top tier hospitals and trained doctors who had just stepped out of medical schools. They expressed their opinions and hoped to find an ideal answer.

Doctor's income geometry

In various industries in China, doctors are very unique. The younger they are, the more they can only sit on the bench and have lower incomes.

A department director at a tertiary hospital told First Financial that a college graduate from a medical school must go through the stages of regular training and residency to gradually become an attending physician, deputy chief physician, chief physician, etc. A doctor explained that master's regular training is at the bottom level and involves the most tedious work, with a monthly salary of only 1600 yuan.

A doctor who is undergoing standardized training at a tertiary hospital in Guangzhou told a reporter from First Financial News, "Taking peers as an example, those who can become doctors are generally those who have better academic performance. Some practitioners in other industries have already owned cars and houses around the age of 30, becoming winners in life, but we are still relying on 'emotions' to support them. For doctors, the age range of 25-30 is the most difficult five years of life."

A attending physician at a tertiary hospital in Shanghai told a reporter from First Financial that generally speaking, it takes three years for a standardized training program. After completing formal work for two years, one can apply for the position of attending physician, and after five years, one can be promoted to associate high school. In the training stage, due to the lack of a professional license in the first year, the monthly salary is only 2000-3000 yuan. In the following two and three years, the monthly income is approximately 5000-6000 yuan. At the stage of being a resident doctor, the monthly salary obtained ranges from 7000 yuan to over 10000 yuan. But before being promoted to vice high school, income mainly relied on departmental "big pot rice".

There are many departments in the hospital, and the income of doctors in different departments also varies.

For example, emergency department is one of the most important departments in medical institutions and also the most difficult and tiring department in hospitals, but the fees are low. Some good hospitals optimize their systems to encourage doctors to go to the emergency department, increase the income of emergency department doctors, and encourage doctors to treat illnesses and save lives on the front line.

A person from a top tier tertiary hospital told a reporter from First Financial News, "Many people think that our hospital's surgical income is high and the emergency department is a loss making department, but in fact, the income of the emergency department is not low because the emergency department needs good doctors very much, and their labor value must be reflected."

A doctor told a reporter from First Financial that the biggest source of income for doctors is actually bonuses, which are distributed based on the income of the department. This mainly reflects the workload, seniority, and professional level of the doctors. "The specific bonus distribution system is still quite complex, and each hospital is different, but the principles are similar," he told a reporter from First Financial.

In 2019, the author of China-Japan Friendship Hospital and other units published a study on the Current Situation and Trend Analysis of Doctors' Salary Income in China's Public Hospitals, which showed that the average actual annual income of doctors in China's major tertiary public hospitals increased from 95700 yuan in 2016 to 122200 yuan in 2019. The actual annual income of doctors in major tertiary public hospitals in China increased slightly from 2016 to 2019, but the overall change was not significant.

Choosing the profession of a doctor is equivalent to a long-term investment for many families. A doctor laments that many of those who choose to become doctors in big cities like Shanghai are children from well-off families who have certain financial strength and can provide long-term financial support. "Many people who become doctors are driven by their ideals, or the ideals of their parents. If they are driven by money, they may not necessarily meet their expectations," he said.

Behind the imbalance

The population of China exceeds 1.4 billion, and the demand for seeking medical treatment is very strong. Faced with a massive demand for medical treatment, China has been working hard, but there is still a gap in the number of doctors. Long queues of patients are common in tertiary hospitals in first tier cities.

Before the COVID-19 epidemic, the total number of medical and health institutions throughout the country showed a steady upward trend. In 2021, the total number of medical and health institutions diagnosed and treated in China was 8.47 billion, an increase of 730 million compared to the previous year. In 2021, the average number of visits by residents to medical and health institutions was 6.0, which has returned to the level of 2018. In the same year, the number of medical and health institutions admitted nationwide was 24.726 million, an increase of 17.13 million compared to the previous year. The annual hospitalization rate of residents was 17.5%, an increase of 2.18 percentage points from six years ago.

Although the number of diagnoses and hospitalizations has recovered and increased, the number of doctors is still limited.

According to the China Health Statistics Yearbook, the number of medical and health institutions in China has been increasing year by year in the past decade, reaching approximately 1.031 million in 2021. In recent years, the number of practicing physicians in China has also maintained an annual growth of about 200000. However, overall, the problem of insufficient total medical resources in China remains prominent. In 2021, there were approximately 2.55 practicing physicians per thousand people in China, and only 1.81 in rural areas.

According to data from the World Health Organization, the number of doctors in China for every 10000 people is 23.9, while in the United States it is 35.6, Japan it is 26.1, France it is 33.2, Germany it is 45.2, and the UK it is 31.7.

Medical school graduates are the "reserve army" of the Chinese medical team. The enrollment scale of medical schools in our country is increasing year by year, but a considerable proportion of medical students are lost to other positions after graduation.

According to public data, Shanghai Jiao Tong University School of Medicine, one of the universities that trains the most medical students, has partial employment destinations for its 2023 graduates. Among 553 undergraduate and long-term graduates, only 276 signed with medical institutions.

The shortage of doctors is large, further increasing the workload. Multiple interviewed doctors have stated that departments such as infectious diseases and pediatrics may have low salaries and benefits due to limited disease sources or the inability to make money for the hospital based on the existing pricing system, resulting in the inability to retain talent and attract equipment.

Taking second level public hospitals as an example, according to the "National Examination" transcript released by the National Health Commission in April this year, in terms of personnel structure, although the number of anesthesiologists, pediatricians, critical care physicians, pathologists, and traditional Chinese medicine physicians in second level public hospitals has increased to some extent compared to 2020, the growth rate is lower than the overall growth rate of practicing physicians in second level public hospitals. In addition, there are still some secondary public comprehensive hospitals that are not equipped with anesthesiologists, pediatricians, or pathologists, or the proportion of doctors in short supply is significantly lower than the national average.

The specialized abilities and high-level talents of county-level hospitals are even more lacking. According to the "Letter of the National Health Commission on the Assessment of the Medical Service Capacity of County Hospitals in 2021-2022", the setting rate of psychiatry, otorhinolaryngology, ophthalmology and other departments is still less than 80% in the first level departments, and the setting rate of infectious diseases, critical care medicine, rehabilitation medicine, dermatology, pathology and other departments is less than 90%. On average, there are only 16 people with a master's degree or above in each county hospital, with 40, 11, and 5 people in the eastern, central, and western regions respectively; The number of people with senior professional titles is 60, with 99, 61, and 40 people in the eastern, central, and western regions respectively, indicating a significant regional gap.

Experts have pointed out that doctors have a heavy workload, coupled with the inability to receive reasonable compensation, which can easily lead to psychological imbalances, laying the groundwork for pursuing "gray income".

It is worth noting that the salary of doctors in public hospitals is mainly composed of the cost of medical services provided by doctors and the government's financial investment in hospitals. At present, the average investment of the Chinese government in public hospitals accounts for only 10% of the total hospital revenue, and the remaining 90% is paid by public hospitals through medical service fees and other means. In recent years, China has also been deepening the reform of the medical and health system, weakening the profit oriented nature of public hospitals. However, with the reduction of financial investment and the need for public hospitals to still be "self reliant on profits and losses", it has also prompted public hospitals to use the number of patients and the number of medical services provided as direct means of obtaining benefits, leading to unreasonable medical service behaviors such as excessive medical treatment and relying on medicine to support medicine.

In 2015, the former National Health and Family Planning Commission issued the Provisional Regulations on the Budget and Final Account Reporting System for Public Hospitals, which proposed that "hospital revenue indicators shall not be decomposed into various departments, and the income of medical personnel shall not be directly linked to the income of departments.". Subsequently, China has successively issued multiple policy documents, requiring strict prohibition of issuing revenue generation targets to departments and medical personnel.

At the same time, although policies have repeatedly emphasized that "the salaries of medical personnel should not be linked to business income such as drugs, sanitary materials, inspections, and laboratory tests", as a secondary public institution subsidized by fiscal differences, public hospitals are often burdened with debt due to the overall low prices of medical services and long-term insufficient financial investment, which cannot offset their expenses. Under the pressure of revenue generation, a journalist from First Financial News learned that there is still a tendency in the salary management of medical personnel to simply rely on "more work, more pay" as an incentive, which may also lead to the phenomenon of "excessive medical treatment".

Difficulties in reforming doctor salaries

Compared with developed countries, there is still a significant gap in the number of doctors in China. The workload of doctors is large, and they have strong expectations for income growth. To ensure that doctors meet their needs openly and honestly, it is necessary to reform their doctor salaries, which is a "hard nut to crack".

A doctor said that his hospital has always advocated that doctors should follow the principle of "more work, more benefits", "better work, more benefits", "higher risk, more benefits", and "higher technology.". "In fact, hospitals are also striving in this direction in the actual income distribution process, and we must encourage doctors to improve their technical skills," he told reporters from First Financial News.

On July 24th this year, the National Health Commission and six other ministries jointly released the "Key Work Tasks for Deepening the Reform of the Medical and Health System in the Second Half of 2023", which clearly stated the implementation of the policy of retaining surplus medical insurance funds for centralized procurement of drugs and medical consumables; Reasonably determine the internal salary structure, pay attention to the stable income and effective incentives of medical personnel, and further leverage the guarantee function of the salary system. At the same time, promote the evaluation of medical service price adjustments in each province in 2023, and adjust prices in a timely manner within the total amount range that meets the adjustment.

Therefore, the prospect of reforming doctor salaries is highly anticipated. How to change the salary of doctors? The above "Task" once again mentioned two key points: first, the main leaders of public hospitals are exploring the annual salary system; The second is to focus on stable income and effective incentives for medical personnel.

In the public hospital system, the dean plays a very important role, and under various temptations of interests, some deans are prone to accidents. Most healthcare reform experts, hospital deans, and frontline doctors interviewed by First Financial believe that the deans are equivalent to the entrusted agents of government managed public hospitals. The operational management ability of hospital deans and their emphasis on improving employee salary levels are related to the actual income and treatment of doctors.

The "Dean's Annual Salary System" is an institutional guarantee that enables the above two goals to be achieved. Currently, provincial pilot reforms have been carried out in Fujian, Anhui, Hebei and other places.

Jiang Ping is the director of a tertiary hospital in a certain county of Anhui province. He told reporters that currently, the "annual salary system" is generally divided into basic annual salary and performance-based annual salary, and the proportion of performance varies in different regions. Among them, performance-based annual salary has a base salary standard, which is deducted based on certain assessment requirements. For the deans of municipal hospitals, a certain proportion and duration may result in a salary reduction; For the deans of county-level hospitals, whether they will receive a salary increase depends on whether the average salary level of employees can be increased. If done well, it may double.

According to the "Implementation Plan for Deepening the Reform of the Salary System in Public Hospitals in Anhui Province" issued by multiple departments such as the Anhui Provincial Department of Human Resources and Social Security and the Anhui Provincial Health Commission in June. The main responsible persons of public hospitals implement an annual salary system, which is generally 2-4 times the average salary level of employees in the hospital.

At the same time, the annual salary system often linked to high salaries is also used in hospitals to attract some high-end talents. Jiang Ping stated that in order to attract talents, the county hospital where he is located not only implements an annual salary system that is 3-4 times higher than the dean's income for an introduced academician, but also implements an annual salary system for some young backbone members. These welfare benefits are all expenses of the hospital.

However, according to Jiang Ping, according to the proportion of employee salaries set by local health departments for tertiary public hospitals in hospital expenditures, 40% is a benchmark line. After several years of effort, the hospital can only reach a maximum of about 38.5%, which is a "quite good" level in the local area.

The National Health Commission issued the "Guiding Opinions on Deepening the Reform of the Salary System in Public Hospitals" in 2021, which put forward seven requirements. One of them is to "broaden the funding channels for deepening the reform of the salary system, gradually increase the proportion of medical services such as diagnosis and treatment, traditional Chinese medicine, nursing, and surgery in medical income. Under the premise of ensuring income and expenditure balance, the proportion of personnel expenditure to public hospital business expenditure is reasonably determined. Public hospitals can allocate medical insurance surplus retention funds based on the assessment results, mainly for the performance of relevant personnel."

According to the original intention of the reform of the medical insurance payment system, the aim is to convert income incentives into cost incentives. According to an article by Wu Lin and others from the International School of Medicine and Business at China Pharmaceutical University, cost incentives generally refer to a prepayment system in which the hospital's medical insurance fund surplus can be fully or partially converted into doctor income and career development support, thereby generating incentive effects. The cost incentive mechanism of "surplus retention" significantly increases the motivation for hospitals to reduce costs. The "surplus funds" can benefit doctors in the form of economic income or welfare protection, allowing doctors to regulate their service behavior independently and improve medical service efficiency.

"But in fact, it's not easy to have a surplus, and whether to use the surplus to increase personnel income is also a question." The deputy director of the Health Commission of a certain county in the north told a reporter from First Financial News that in recent years, the operating income of local county hospitals and traditional Chinese medicine hospitals has been declining, but the proportion of personnel income is also decreasing. "Every year, we visit several young backbone doctors."

During the investigation, the reporter found that with the change of medical insurance payment methods, some clinical doctors have become fearful of saving lives and prescribing medication. The common challenges faced by multiple interviewed clinical doctors include "too much effort and too much deduction", "hospitals have no surplus, where can cost incentives come from", and "increased accountability pressure".

Zhang Li, the director of the Infectious Diseases Department at a tertiary comprehensive hospital in a provincial capital in central China, gave an example to reporters: In the second quarter of this year, their department encountered a patient with a complex abdominal infection. According to the payment model based on disease type, the maximum reimbursement for medical insurance was about 10000 yuan. However, due to complications, drug resistance, and other issues, the actual medical expenses reached 200000 yuan. That is to say, after deducting the 10000 yuan paid by the medical insurance fund, the remaining amount had to be counted as a loss for the hospital. The hospital will deduct the loss from the monthly overall performance of the department.

What should we do? Zhang Li said that if he chooses not to save the patient, he has already been rejected by some tertiary hospitals in several major eastern provinces, and his life is beginning to be in danger. If he is saved, he and his department will have to bear the monthly performance deduction, which may even affect the annual departmental assessment. This is undoubtedly adding insult to injury for the department that originally did not make money. Of course, the medical insurance department also considers high rate cases in the system design, but after appeal, the reimbursable proportion is only the part that exceeds the high rate amount, and the remaining 20000 yuan difference still needs to be borne by the department.

"In my decades of employment, salary calculation has always been based on 'basic+performance', which includes length of service, professional title, and annual teaching task income. Performance, in simple terms, is the 'income expenditure' of consultation volume, that is, more work, more pay. The only change is that in order to achieve the same income as before after implementing payment by project to payment by disease, it is necessary to reduce some drug consumption as much as possible. In addition, if the above situation occurs, the department may also suffer losses, that is, more work, more loss." Zhang Li said.

The main sources of revenue for public hospitals are medical service revenue and fiscal allocation revenue, among which fiscal allocation revenue includes special allocations and basic subsidies. In terms of labor cost expenditures, the funds for retirees and subsidies for trainees are funded by the government, while the basic salary and performance-based salary of in-service medical personnel are mainly borne by hospitals. The basic subsidy funds from the government can provide support.

"Price reform is crucial," Cai Jiangnan, founder and executive chairman of Shanghai Chuangqi Health Development Research Institute, said in an interview with First Financial.

He explained that the difficulty in improving the income and benefits of doctors is fundamentally due to the insufficient size of the "plate", which is the problem of losses in public hospitals. There are generally two ways to resolve the issue, one is through fiscal expenditure, which was a common method in the past. However, due to the current financial constraints of local governments, it is not realistic to expect the government to increase its allocation of funds; The second is the reform of medical service prices. In the past, due to the fact that the relative proportion of doctors in public hospitals was within the establishment, if the income of doctors was improved by raising the price level of medical services, other groups within the establishment such as teachers, civil servants, police, etc. may have a competitive mentality. At the same time, finding a reasonable balance point with patient expectations was also a game process, so the progress in the past decade has been slow. But in the long run, this is a hard nut to crack but not enough.

How difficult is the reform of medical service prices? Xu Yucai, an expert in healthcare reform, gave an example to reporters. After piloting the "new price" in 2015, Chongqing suddenly halted the reform due to a significant increase in treatment costs for some patients. This is known as the "shortest healthcare reform in history" by the industry.

He analyzed that the medical insurance department, as the main payer of medical services, can improve the operational efficiency of hospitals through three aspects: freeing up space, adjusting structure, and connecting insurance, and then provide feedback to doctors. However, at present, the main focus of the medical insurance department is on "vacating space" and "connecting insurance", and no effective path has been explored for "adjusting structure", that is, the reform of medical service prices. There are pilot projects in local areas, but they are mostly like Chongqing, and currently they have ended in failure.

In this context, Xu Yucai believes that hospital medical service expenditures actually bear some financial "arrears", which are used to pay doctor salaries. Therefore, the treatment of ordinary doctors may not decrease, but it is also difficult to see a significant increase. As a response, it is necessary to allow the flow of medical resources, which can make some income generating channels for doctors more transparent, and also help improve the problem of uneven distribution of medical resources, benefiting multiple parties.

For example, in recent years, although policies have allowed doctors to practice at multiple locations, registered physicians can legally practice outside their registered practice locations. However, due to the dual approval of the affiliated unit and local health authorities required for multi-point practice, and the hospital setting restrictions layer by layer due to concerns about patient loss, this policy loosening is often difficult to implement. If a doctor goes to another place for consultation or surgery without the hospital's knowledge, they will face disciplinary action from their original unit.

"I believe that the next step in solving China's medical problems is towards freelance work. For example, exploring the concept of 'multiple practice points for registered physicians' in healthcare reform is a good attempt. However, the contradiction lies in the fact that relevant government departments are focusing on strengthening the staffing management of public hospitals. There are inherent contradictions between these policies, which can give public hospitals more room for explanation that is in line with their interests. Whether the interests of hospitals and doctors are unified, or how to form a mutually reinforcing relationship between the two, is worth further exploration by policy makers and hospital managers." Xu Yucai believes.