Step by Step, Perspective | Sanming Medical Reform for Chronic Diseases | Center | Perspective | Sanming Medical Reform

Experience "putting the people first and daring to be the first" from three "micro scenes"

At the convenience clinic window of Shaxian District General Hospital, the masses were consulting about reimbursement for chronic diseases. Photo by Xu Yan

For Wang Xiaoming, a 65 year old hypertensive patient, Yu Xin, the chief physician of the cardiology department at the First Hospital of Sanming City, Fujian Province, has become the most familiar stranger. "I'm not prescribing medicine here anymore." If it weren't for an interview at the hospital, Wang Xiaoming wouldn't have known when he would have seen his former treatment doctor again. "In the past, I used to see Dr. Yu for treatment, and his medication was very effective. Later, this kind of medicine could be prescribed for free in community hospitals, so I rarely came to the First Hospital for treatment."

In order to do a good job in chronic disease management, Sanming provides 39 kinds of basic drug interventions free of charge for six types of patients who have been diagnosed with hypertension, diabetes, etc. Wang Xiaoming, who has a "red book" of outpatient special disease records, can now enjoy this guarantee as long as they go to community hospitals and other grassroots online medical institutions for treatment. At the same time, through long-term prescriptions, grassroots guidance, and other methods, Yu Xin has lost a lot of "familiar faces" in front of him, leaving more sources for the most needed difficult and difficult patients to use on the cutting edge.

After more than ten years of reform, the Sanming medical reform has basically solved the problem of "difficult and expensive medical treatment" for the masses in the previous stage. It is continuously expanding the depth and breadth of the reform, promoting graded diagnosis and treatment, and striving to achieve the goal of "treating diseases before they occur, and promoting good health" for the masses. "The Sanming medical reform has gone from a 'big breakthrough and big establishment' in the mechanism system to a 'simultaneous breakthrough and big establishment' in specific work. Zhou Xianbao, a full participant in the Sanming medical reform and deputy director of the Secretariat of the Sanming medical reform leadership group, said that the time has come to 'patch up' the situation, and Sanming will 'break through small and establish big'.".

Sanming City First Hospital to carry out drug zero difference rate, put an end to the drug to support doctors. Photo by Zhou Zhihong

Scenario 1: Sanming First Hospital

The burden of medical treatment for retired workers in the second generation of Shanghai has decreased, and the integrated reform of DRG collection and payment has been streamlined

Solving the heavy burden of medical treatment is the starting point of the Sanming medical reform. Sanming is an old industrial city with a large proportion of retirees. Before the healthcare reform, the prices of drugs and consumables were inflated, making it difficult and expensive for the people to seek medical treatment.

"Previously, I used to be afraid of spending money, and treatment went on for a while." Wang Xiaoming, who has a 15 year history of hypertension, is a "second-generation" from Shanghai. In the 1950s and 1960s, many companies moved from Greater Shanghai to the third tier, and tens of thousands of Shanghai children came to Sanming. His father was also one of them and joined Sanming Construction Company. After the elderly retired, Wang Xiaoming took over and started working. In the past, these Shanghai children and their families made contributions to the construction of Sanming. Now, as they enter their later years, they enjoy the benefits of the Sanming healthcare reform. "I take medicine on time and don't spend much money on medical treatment. I have good blood pressure control now and I have the strength to do odd jobs to support my family."

Sanming's medicine is increasingly benefiting the people. On the basis of previous work, from last year to present, Sanming has continued to promote centralized procurement and price reduction of pharmaceutical consumables. The "Sanming Procurement Alliance" for joint limited price procurement of pharmaceutical consumables covers 35 cities in 16 provinces across the country. The average decrease in selected consumables is 62.92%, with a maximum decrease of 90.73%, saving 568 million yuan in costs.

While lowering fees, there is also sunshine and convenience. Wang Xiaoming's child had a torn tendon in his leg last week and was admitted to the orthopedic ward through the green channel of the emergency department. Admission procedures can be completed from the bedside. The nurse told him that orthopedics is a pilot unit without accompanying patients, so he doesn't have to worry about patient care. After a detailed understanding of his condition, the management doctor told him that Sanming is now implementing a paid packaging price for C-DRG, and even if he spends more, his personal expenses will be calculated based on the packaging price, which made him feel at ease.

Wei Hong, the head of the Medical Records Department of the First Hospital, fully participated in the integrated reform of C-DRG collection and payment. In the early stages of the pilot program, the team wrote over 9000 clinical disease diagnosis terms in Sanming City, drafted basic settlement procedures, and gradually gained the trust of regulatory departments such as the Health Commission and the Medical Insurance Bureau; Subsequently, in order to ensure that each hospital's understanding of the policy was not biased, they also used their spare time to provide training to their brother hospitals one by one, promoting consensus.

"Patient first. To be joking, it's most convenient for us to make a complaint when we go out and turn right to the Health Commission or left to the Medical Insurance Bureau," said Wei Hong.

At present, the overall operation of the Sanming C-DRG reform is good, with an increase of 31800 terms and an optimization adjustment of the disease group from 788 to 839. In 2022, the C-DRG settlement medical insurance fund expenditure accounted for 72.94% of the hospitalization fund, resulting in a relative savings of 59.4323 million yuan in medical expenses.

Let public hospitals return to public welfare, doctors return to focused medical care, and drugs return to their therapeutic function. During this process, the proportion of consumables revenue from Sanming Pharmaceutical decreased from 60% in 2011 to 29.5%, and the proportion of medical service revenue increased from 18% to 46.31%. Public hospitals maintained a stable development trend; At the same time, Sanming has implemented a series of reform measures such as the target annual salary system for all employees and the annual salary system for all positions. The average annual salary of doctors has increased from 56500 yuan to 201100 yuan in 2022, with an average annual growth of 8.08% after the implementation of the salary system.

Director Yu Xin has a clear feeling about this. His examination fee increased from 10 yuan to 48 yuan, and there was also an increase in treatment and surgical expenses. The cost of consumables, such as stents, gradually decreased from 3000 to 5000 yuan to 800 yuan. "We are now exploring rewards based on good health performance, no longer based on quantity assessment, and fewer and fewer unnecessary examination items. In the future, the public will have fewer illnesses, fewer relapses after treatment, and the doctor's income will actually be higher," said Yu Xin.

At the Gaoqiao Town Health Center in Shaxian District, villagers can enjoy professional medical imaging services through remote diagnosis and treatment at the township health center.

Scenario 2: Shaxian District General Hospital

How close is a "close" medical community, where every family in the county and rural areas has one heart and one account?

County level hospitals are the treatment centers for common, frequently occurring, and critically ill patients in the county. All 11 counties in Sanming city have established a close medical community - the General Hospital, which unifies the management of county-level and rural medical institutions under the General Hospital. Township health centers and community health service centers have been established as branch hospitals of the General Hospital, breaking horizontal and vertical barriers and forming a community of shared responsibility and benefits.

Wan Xiaoying, the Secretary of the Party Committee of Shaxian District General Hospital, felt a deep sense of responsibility in this role change, from hospital leaders to the "gatekeepers" of the county's health. In Sanming, through the annual salary system reform, the government manages the leaders of the hospital, and the hospital leaders manage the doctors. She currently manages more than 1400 medical personnel in the county.

The management mechanism is gradually maturing, as can be seen from the number of night calls by Wan Xiaoying. "The hospital's complaint hotline is reserved for me, and the health bureau directly reports my phone number when it receives a supervision call. It used to be common to call at 1 or 2 in the morning, 5 or 6 in the morning. Now that the team has grown and they can handle it better, I rarely receive calls in the middle of the night."

As the key to "preventing major illnesses from leaving the province, resolving general illnesses in cities and counties, and addressing daily illnesses at the grassroots level", the improvement of medical standards is an inescapable responsibility of the medical community. "I received a phone call from a patient with nasopharyngeal carcinoma who said there was no department to take him in. At that time, I directly contacted the facial features department related to the nasopharynx and the general surgery department that can perform tumor surgery. However, due to a lack of chemotherapy knowledge, they were afraid to take the call and were afraid of causing disputes." Wan Xiaoying said, "I also understand the patient's phone number. The patient must have been very helpless when making this call, but there was really no way that time."

What should we do? Wan Xiaoying gave three prescriptions - borrowing strength upwards, exerting strength at the same level, and assisting downwards.

The process of pesticide application is accompanied by a lot of innovation. For example, with the support of the Fujian Provincial Health Commission, in May this year, experts were dispatched by the Provincial Cancer Hospital to serve as the deputy director of the hospital, assisting the newly established oncology department and becoming the first county-level hospital in the city to have an oncology department. "There is not just one expert standing behind the oncology department, but a provincial-level hospital."

There is also the establishment of a comprehensive rural inspection team, which will gather 106 medical personnel with intermediate or higher professional titles from the north and south districts of the general hospital, divided into 6 small teams. By fully utilizing assessment methods, inspection will be included in performance management, and 6 teams will be organized to compete with each other to enhance their enthusiasm for "sinking". At the same time, we will further promote the sharing of resources in county-level imaging, testing and other technology centers, radiating and driving the capacity improvement of grassroots medical and health institutions.

Wan Xiaoying summarized the tight definition in nine words: a family, a heart, and a ledger.

By establishing a flexible two-way flow mechanism for personnel within the scope of the general hospital, coordinating the use of the approved total number of personnel, implementing "county managed township use and township hired village use", internal personnel of the general hospital become "one family" and help each other.

In the current situation where the development status of grassroots networks varies, "one mind" is quite important. "Some elderly people cannot move, so we need to go to their homes for B-ultrasound. However, some township health centers do not have B-ultrasound doctors, so we can solve this problem through adjustment."

"One account" refers to the implementation of county level medical insurance fund package payment in Sanming, which distributes the medical insurance fund to various general hospitals on an annual, county-level, and per capita basis. The policy of "not making up for overspending and retaining surplus" is implemented, with less medical treatment for the public and surplus medical insurance, which can be used for salary distribution and health promotion. It guides hospitals and medical staff to prioritize "treating already ill" and "treating before ill".

Why can branch hospitals cooperate well with the general hospital in terms of resource allocation and hierarchical referral?

This is precisely where the close value lies. "People and property are all under the management of the General Hospital, and their assessment is with me..." Wan Xiaoying said, closely bringing not only responsibility, but also opportunities for high-quality development.

Medical reform: contracted rural doctors on-site service Deng Shurong photo

Scenario 3: Sanming Municipal Health Commission

It is urgent to cultivate leading professionals in specialized general hospitals, from large-scale breakthroughs to small-scale breakthroughs

The Sanming Municipal Health Commission is located in a deep alley on the east bank of Shaxi, which is a five story small building that has been around for some time. In recent years, with the rise of fame in the Sanming medical reform, this place has become increasingly busy.

"From 'treating diseases as the center' to 'putting health as the center', health management is the focus of the next step of the Sanming medical reform." Starting from the entrance of the corridor, Zhou Xianbao enthusiastically "popularized" the Sanming medical reform with his strong Fujian accent. Zhou Xianbao believes that the major action of the Sanming medical reform mechanism system is almost complete, and the next step is how to "patch it up".

"Talents, especially the leadership positions in the general hospital, are one of the most urgently needed 'patches' at present. Now we can only test the vision of county leaders, and the selection of personnel is accurate. Zhou Xianbao admitted that one of the main purposes of building a close medical community is to promote graded diagnosis and treatment, solve the problems of refusal from superiors, inability to connect with grassroots, and distrust from the people.". However, after investigation, it was found that some deans still remain in their previous roles or their management level cannot keep up with the new situation, resulting in a lack of close linkage between the upper and lower levels within the general hospital.

They have considered that to solve this problem, if internal communication is relied upon, there are only a few cases involving differences between county and city management, from bottom to top; It's not that easy to introduce from outside. Therefore, the optimal solution is to promote specialized and professional training, continuously improve management and operation, cost control, salary distribution, and other directions. A special fund of 35 million yuan will be established locally to implement the "4+1" talent training plan for the Party Secretary of the General Hospital, outstanding discipline leaders, outstanding young physicians, compound medical and preventive talents, and rural doctors.

"Medical reform is problem oriented. The main leaders of the municipal party committee and government are all working one after another, one after another, and it is not achieved overnight." Zhou Xianbao believes that the transformation of the source of reform dividends is urgent.

In the early stage, Sanming achieved an increase in doctors' income, a decrease in patient payment fees, and a balance in medical insurance funds through bird swapping. However, the space for this dividend is getting smaller and smaller - after 10 adjustments in medical service prices, it is impossible for drug consumables to be infinitely reduced. What is the driving force for pharmaceutical companies to produce innovative drugs? How to safeguard the interests of distribution enterprises? Therefore, the Sanming medical reform will shift more towards health management in the later stage to seek dividends.

For example, multiple general hospitals have carried out the construction of "two teachers and two centers", trained health management physicians and disease management specialists, carried out screening and health management for key populations, and implemented early intervention actions for common diseases. For example, in the management of chronic diseases, local "cause of death spectrum" and "disease spectrum" should be established, key disciplines and specialties should be targeted, and corresponding health intervention strategies and health control mechanisms should be established based on trends.

Health is 1, while others are 0 behind it. As the only experience promotion base for deepening medical reform in the country, Sanming Medical Reform is not stopping.

Photo by Zhou Zhihong from Sanming Medical Security Fund Center

End:

Excitement and immobility, Shanghai Ming cooperation brings new possibilities

Every Sanming person is a firsthand witness to healthcare reform.

Wang Xiaoming believes that the reform of traditional Chinese medicine can save money, while Yu Xin believes that it has improved the efficiency of medical treatment. Wei Hong thinks that medical reform is "interesting", Wan Xiaoying believes that medical reform is full of responsibility, while Zhou Xianbao said that if we succeed in the cause of medical reform, we will live a life worth living.

Of course, healthcare reform will still face thorns: can the salary system reform not only stimulate the enthusiasm of doctors, but also not make the people feel too much? Can graded diagnosis and treatment gain more understanding and trust from people? Can medical insurance provide more support for the development of new technologies?

But it did make a name for itself nationwide.

"When we do training, the audience is often very excited, but after they go back for a while, they 'don't move'. 'Their experience is worth learning from in different regions,' and it's not easy to advance. Zhou Xianbao believes that the Shanghai Ming cooperation provides new possibilities for the improvement and promotion of the Sanming medical reform. 'What Sanming needs is what Shanghai can do. Shanghai experts have first-class vision, technology, and experience, which can help us better summarize and refine, and guide the future of Sanming medical reform.'"

Author: Special correspondent Zhao Zhengnan

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