** Payment reform advancement

Medical insurance will not pay for it

First, the new rural cooperative medical institution pays the disease according to different clinical pathways, and at the same time develops an information platform. Doctors and nurses' "intake" and "outbound" operations are all monitored in real time.

In the pediatric ward of Yiyang County, Henan Province, Xiao Shibiou was in the infusion and his father Li Zhanfeng held him and looked at the infusion tube from time to time. The family lives in Li Zhanfeng, a village of Tienweisi Village, Zhaobao Township, and is a leading peasant. However, he can actually tell how doctors treat each day, how nurses care, and how much money they will spend before they leave the hospital.

"My son had pneumonia. Just as soon as he was hospitalized, the nurse gave me a list. I knew that I would spend 2,300 yuan and I would squat about 700 yuan." Li Zhanfeng pointed to the colored pattern on the bedside sticker - "Patient Edition Clinical Pathway."

The so-called clinical pathway is a standardized treatment flow chart, how to treat, how to charge, at a glance. Since October 2010, the Institute has consulted the management of disease diagnosis related classifications (DRGs) commonly implemented in the world, and divided 188 disease types into three groups of routes. New rural cooperative medical institutions pay according to disease types according to different clinical pathways and develop simultaneously. Information platform, doctors and nurses' "intake" and "outbound" operations are all monitored in real time.

At present, of the 16,000 inpatients in the year, 65% of the patients are “arranged” to see the doctor. The average medical cost is 5% to 8% lower than that of patients who have not been included in the clinical pathway management, and the proportion of self-payment is reduced by 10%. The average length of stay is shortened. In 0.5 days, the hospitalization rate was 0.2012 in two weeks after discharge, and the satisfaction of the people reached 95% or more.

The reform of payment methods is the first step, and comprehensive reforms are encouraged. This is the characteristic of the reform of county-level public hospitals in Henan. Since May of last year, 30 county-level public hospitals in the province have been paid by disease trials. Up to now, 82 cases (including 124 treatment methods) have been introduced for disease treatment of new rural cooperative medical insurance. A total of nearly 50,000 inpatients have been admitted to the hospital. The cost of hospitalization is 10% lower than that of the same type of disease. It is directly New rural cooperative medical institutions and patients save more than 47 million yuan in medical expenses. Next year, pay according to the disease type in the county-level public hospitals in the province.

The reform of payment methods involves the interests of patients, medical personnel, and new rural cooperative medical institutions. To this end, five counties, such as Yiyang and Wuyi County, initiated unified reform pilots for various systems such as compensation, management, and distribution in accordance with the unified design of the World Bank's Rural Health Development Project. In August this year, Henan took the pilot experience as the starting point and launched the comprehensive reform of county-level public hospitals.

After the cancellation of the drug addition, the drug price has dropped, and the cost of inspection fees and supplies will rise. Wuxie County piloted the comprehensive payment reform and adjusted the price of medical services in a timely manner, thus eliminating the “two-headed war”. Mu Guoxing, deputy director of the Wuyi County Health Bureau, said that the reform of payment methods has changed the incentive mechanism for medical services, eliminated excessive medical practices such as over-prescription and major inspections, and established a reliable institutional guarantee for canceling drug additions.

Secretary of the Party Committee of Yiyang County Health Bureau Kong Dongliang said that canceling drug additions and paying according to the type of disease requires the reform of the compensation, management, and distribution systems, and the establishment of a new compensation mechanism for county-level hospitals. This is exactly the county-level public hospital. The core content of the reform.

Second, the hospital proposed "path quotes", the new rural cooperative agencies and hospitals to determine the final price after negotiations, and signed service contracts with the hospital, in accordance with the performance of the payment

The comprehensive reforms of public hospitals at the county level in Yiyang and Wuyi have a major feature: they have ameliorated institutional and structural reforms at a relatively low cost, and reversed the drawbacks of “remedy for medicine”.

The evaluation report led by Meng Qingyue, director of the China Health Development Research Center of Peking University, believes that this is a “new type of payment method that has not yet been seen in the country” and the reform proposes a new way of “with medicine to supplement the medical care” mechanism, which can fundamentally Solve the problem of "remedy for medicine."

The data show that after the reform, the proportion of medicines in the five counties dropped to 45%. With the abolition of the advancement of drug addition reforms, medicines have completely become the “costs” of hospitals, and the income of medical staff is no longer obtained from the initiation of medicines, but from treatment, Obtained in nursing and management.

According to Xie Shuangbao, deputy director of the Department of Health and Finance of the Health Department of Henan Province, reform is an adjustment of the pattern of interests. In general, vested interests have a greater influence on the reform of public hospitals. In the past, health care reforms often achieved one goal and damaged another. This is because most of the reforms focus on single reforms, lack of overall and systematic design, and the results are difficult to predict. However, Henan not only designed a new payment system for classified packaging and payment, but also carried out reforms in quality, performance, and supervision, and hospitals' compensation, distribution, and management systems have undergone changes.

Liu Hetang, deputy director of the Yiyang County Health Bureau, said that the core of the reform is to promote the medical insurance institutions to become service buyers. Each year, the hospital proposes a “path quote”. The NCMS and the hospital negotiate the final price, and sign a service contract with the hospital to pay according to the performance. If there is a balance, it is awarded to the responsible medical staff. The balance costs accounted for 4%-6% of the total cost of the disease, and medical personnel became active participants in the reform. The survey results show that the monthly per capita income of medical staff increases by about 330 yuan compared with that before the reform.

Under the new incentive mechanism, active control of fees and quality assurance have become the conscious behavior of medical staff. Mai Xiaoli is the head nurse of the pediatric ward of Yiyang County People's Hospital. She said: "Before nursing was taught by hands, there are rules and regulations at every step. It is operating under the guidance of a computer, and my heart is even worse."

“Previously relying on selling medicines to obtain revenues, the proportion of medicines has reached 67%. Now that the proportion of medicines has dropped to around 30%, medicines have become a cost, and the proportion of expenses for surgery, treatment, and nursing has increased from 33% before the reform to the present. 51% of the medical personnel's labor value is reflected. The compensation for the new rural cooperative medical system has reached 60%, and the income structure has become more reasonable.” said Zhao Yinzhi, director of the People’s Hospital of Yiyang County.

Ma Xiaowei, vice minister of the Ministry of Health, pointed out that the reform of payment methods as an entry point and the elimination of medicines to supplement medical services can change the incentive orientation of medical behaviors, change the income of medicines, consumables, and inspections into costs, and promote hospitals and doctors' scientific diagnosis and treatment and control of costs. However, the elimination of the mechanism of medicine supplementation and medicine needs a process that requires medical insurance, price, and financial linkage.

Third, the establishment of intrinsic mechanisms such as incentives and performance is more important than external investment. Reforms are like doing puzzles. The coordination between systems is particularly important

During the International Health Conference held in November, Thomas Palu, deputy director of the Human Development Bureau of the Southeast Asia and the Pacific Region of the World Bank, and Annis Baris, deputy director of the Human Development Bureau of the Central and North East Africa of the World Bank visited Henan to learn about the World Bank. Rural Health Development and Reform Project in Henan.

Thomas Palu believes that China’s health care reform is worthy of praise. It is the determination of the government’s reform. It has great implementation and rapid progress. Basic medical insurance has covered 95% of urban and rural residents. This is a very remarkable thing. At the grass-roots level in China, the hardware has made a great improvement and the funds invested by the central government have played a role. However, reforms are not simply building houses. They also need to establish mechanisms to make hardware work. The establishment of intrinsic mechanisms such as incentives and performance is more important than external investment. Reforms are like doing puzzles. The coordination between systems is particularly important.

He said that Henan's reforms have attached great importance to local governments and hospitals. They have explored a way to allow the implementation of policies and combined hardware investment with the construction of internal mechanisms and achieved good results. China now has a very good policy, but how to implement it, Henan's pilot gives the answer.

Of course, public hospitals in Henan and China face a major challenge - prevention and control of chronic diseases. To cope with this challenge, we must not simply solve the problem by improving the conditions of service in the hospital. We must manage chronic diseases through strong grass-roots organizations and construction mechanisms and keep minor illnesses in the community. Therefore, grass-roots organizations must train general practitioners who can see the disease; establish correct incentive mechanisms; and establish a service system that can prevent and cure orderly and coordinated operations.

If hospitals still charge by project and make up for medicine, this incentive may lead to over-service and expensive medical treatment. All these need reform. In addition, price and hospital management must provide service cost information. This is the most ideal path for public hospital reform. Henan has learned about some service cost information through the negotiation of medical insurance and hospitals. The government departments and the NCMS institutions have some basis for the mastery of costs, and some changes have taken place in the hospital's profit-sharing behavior. Positive incentives have provided the basis for further reforms.

During these five or six years, Anis Baris has been paying attention to China's medical reform. He did not expect that China’s reforms will proceed so quickly, especially with respect to the construction of the mechanism. And five or six years ago, people here talked about illness and talked little about the system. This is not the same. It is very good to look at the whole health industry from an overall perspective. Henan's reforms focus on the balance between quality and cost control, and promote it very quickly. For example, in the management of clinical pathways, Bulgaria only took 30 disease pathways in 4 years, while Henan reached 188 disease pathways in 2 years.

He pointed out that the reform of the payment methods of all countries will never end, and both quality and cost control will need to be balanced, a reasonable distribution mechanism will be needed, and more refined management tools will be needed. In general, all aspects of supporting measures are needed. Henan's comprehensive payment is more concerned about the improvement of efficiency, but also need to assess the corresponding health effects, such as the health improvement of the entire population. The reform of payment methods means a series of reforms and it is impossible to achieve perfect results in a short period of time. In this regard, there are many lessons for foreign countries to learn from.