Suqian analysis of health system reform debate
mm and the path of market reform options
Wei Fengchun
First, the reform of the controversial Suqian What?
Suqian City by the community health system reform concern, which can be summarized as the view of two odds: First, the medical and health system reform Suqian increased burden on the residents, not the failure of reform in other areas, especially in underdeveloped areas to promote. Second, the practice of representatives of the Chinese Suqian Yiwei direction of reform, not an exception, but a general rule, for the economically less developed areas Yiwei system provides a valuable experience.
the dispute expressed in a specific motivation for reform, methods with the results of the different views. motive for reform focus of the dispute as controversy summarized as Based on the study can be summarized in Suqian reform experiences and lessons. This Suqian itself, and the country, especially in economically underdeveloped regions Yiwei system are of great significance.
Tsinghua University Health System Reform Meanwhile, the three dispute a clear answer. In this paper, to answer three questions based on the evaluation of Suqian reforms.
second, whether the reform is the Government's motivation to reform the different views of the most controversial reform was the focus of Suqian. Suqian Yiwei pre-reform system is is four one, that is, management from operation, health, medicine, medical anti-unity. the hospital all the government investment, direct provision of medical services. reform, the government no longer directly hold hospitals, medical services are mainly produced by the market. This is not the Government in the Before reform, health care or the demand side, supply-side there was a big problem.
1, supply-side problems
this mainly as a shortage of medical and health resources. source of personal risk from the disease point of view , a serious shortage of medical resources, medical supply and demand contradiction, expensive and difficult to see a doctor .2000 exist, Suqian 515 million people, only the medical and health assets of 588 million yuan. only 1.07 beds per thousand, per thousand 168 health staff person. per capita health assets and thousands of people with health technicians in Jiangsu Province, the last one, below the national average. low level of local medical care, residents are out for medical treatment. Urban health insurance coverage, the level of protection low, almost no health insurance of farmers rely mainly on their own expense for medical treatment is a heavy burden.
source of public risk from the disease point of view, it is difficult to survive township hospitals and tertiary health prevention security system in name only. in the original system, the township health hospital and community health service centers, on the one hand to provide preventive health services, on the other hand to provide medical services, the former is free service, which is paid services. At the time, system, crowding out the free service paid services, health prevention security system in name only. Meanwhile, the viability of rural township hospitals is extremely low self-survival is difficult to ensure the year 1999, 124 township hospitals Suqian total assets of 170.58 million yuan, total liabilities 83.167 million yuan, asset-liability ratio 48.8%, bed utilization rate is only 20%, non-medical personnel accounted for 40%. There is not two-thirds of the normal payment of salaries of township hospitals, faced a new crisis.
2, to be side of the problem mainly for the residents
this serious lack of capacity to pay. Suqian the disaster in history, theater and agricultural areas, a city in 1996 after the economic pillar is the first industry, secondary industry and tertiary industry is very backward In 1996 after the inflation-adjusted real per capita net income of farmers was only 1,848 yuan, the real per capita income of urban residents is only 2733 yuan .2000, urban residents consumption expenditure in the health care spending accounted for 10.90% in rural areas residents, compared with 11.85%. because of financial difficulties ratio of 34.15% without treatment, in patients discharged own request, due to financial difficulties required rate of discharge up to 81.82%.
objectives of the reform is to solve medical and health resources inadequate and the problem of insufficient capacity to pay residents.
(b) reformers on the different perceptions of the medical and health reform
Suqian They are considered a do not agree.
Suqian reform, from the theory of medical and health were re-interpretation. The local government believes that health care and public health have different properties, which were provided by the market and the government can achieve maximum efficiency . to maternal and child health, communicable disease control, first aid as the main content of the health services are public goods should be provided by the Government, and the need for the central government or local government to choose between. medical services are mainly private goods, the main by the market mechanism through hospitals, clinics, clinics, clinic, etc. available. for medical services outside of strong, such as SARS, AIDS, etc. can be provided by the government. for the poor medical services can be funded by the government.
ideal example of the pre-reform after reform
pure public goods public health
central government
the level of government
the levels of government
offside
SARS
local public goods local government
the level of government
the appropriate level of government maternal and child health
medical
market private goods market, the appropriate level of government
renal transplantation
local public goods local government
the level of government
lack
Government + market
health care
1, the financial pressure and public spending determines the order of the Government to ensure that public health expenditure in the financial position
the background, the Government in the provision of health services, to provide medical services. If the government financial pressure significantly, the Government can only guarantee that he must be expenditure priorities. This is the public health, compulsory education and basic administrative expenses.
Suqian Statistical Yearbook (2000) data show that the former government in health care reform is a very fragile financial . Although from 1996 to 1999 fiscal revenue from the 767.68 million yuan rose to 1.0162 billion yuan, but the total financial expenditure has increased to 1.42779 billion yuan from the 807.37 million yuan. budget deficit growing, from the deficit-GDP proportion of view, the deficit ratio increased from 0.32% to 2.26%. in accordance with international standards, this indicator means that the pressure of being in great financial.
1999, the Suqian financial expenditure of the project, accounting for Education Expenses 30% of all expenditures, administrative costs accounted for 15%, accounting for 8% of the basic construction costs. health expenses account for only 5%. the government's budget deficit growing, education and administrative expenses of the statutory nature of the decision its expenditure in the priority of capital expenditures to increase in emerging market economies of the basic requirements. In this context, the Government's financial resources is difficult to guarantee the health of adequate investment. government limited funds into medical services suppliers, and refused access to social capital. The Government can not afford much-needed assistance to the demand side of medical services and public health service inputs, and thus bear too much responsibility. responsibility and ability to asymmetric, making the government with the reform dynamic health care.
public risk from the disease control sources is fundamental to improve citizen health initiatives. The Government clearly their main functions of providing public services, the implementation of a separate management from operation, medical anti-separation reform. The Government will prevent security functions of township hospitals to separate from. township hospitals conducted by the government, mainly responsible for disease prevention, health education, health monitoring and other public health functions, do not engage in general medical activities. township hospitals conducted by the market engaged in basic medical services. For the preventive function of township hospitals and the financial support of the implementation of the system, township hospitals and village staff members against insurance subsidies by the fiscal year were less than 6,000 yuan per person (president of 8,000 yuan) and 1,200 yuan payment. in accordance with the standard 6 yuan per capita of rural public health services to establish special funds for rural public health services.
government ownership of public hospitals after the replacement of special account funds used for other purposes. permutation with the first funds paid workers in pension, medical and unemployment insurance, and the rest as a health development fund for investment in health and development. the government began constructing a system Mining for the center. cooperative medical care system.
2, not to property rights reform can improve efficiency
lack of resources to solve the core of health care is to improve efficiency. the original low efficiency of public hospitals is your doctor and the doctor is difficult to source. reform, Suqian public hospitals by the government monopoly, the lack of incentives and constraints, full redundancy. The results, not only provides inadequate medical care, and poor service quality and service attitude. The Government is the owner, but also managers, can not be effectively implemented on the hospital possible supervision. received a red envelope, drug rebates and other chronic illnesses despite severe blow, but still difficult to eradicate.
under the old system makes the Government's determination to carry out the drawbacks of mechanism innovation, the Government faces two options, or stocks that incremental reform reform? to now, the biggest reform of the outside world Suqian question is why the reform of hospital property from the start? If you do not reform public hospitals, the medical market is only open to allow other forms of ownership into the medical field is more reliable? This is necessary to answer problem.
health under the existing system of mechanisms and development of market economy can not meet the objective requirements. Prior to this, the hospital Suqian also been the reform of property rights, but none were successful .1997 Shuyang The president of contract responsibility system reform, the effect is very poor. the one hand, there is no active management; the other hand, few hospitals have the backbone to do more, surgery, medicine, nurse income less the same egalitarian serious, extremely unfair distribution.
The reason why health care reform Suqian reform of property rights from the start, reformers have given the following reasons:
First, the shortcomings of public hospitals is caused by the ownership, only the reform of ownership, ; medical treatment is difficult, a platform for fair competition.
Third, market-oriented reform in the Suqian background, property rights reform is the rapid development of the economy is relatively backward areas of the party. the idea has gone deep into the minds of local government officials. Shuyang reform successful example of interpretation of this philosophy.
Fourth, the policy of the central support of Jiangsu Province. Shiliu Tai, the Central Government that health reform policy to become straight Suqian policy basis for property rights. In addition, the Jiangsu provincial government support for the reforms of Suqian its attempt to provide an opportunity for reform of property rights.
public hospitals if the government just sold to a private, certainly is cast it, because it is only a government monopoly into a private monopoly. monopolization is the result of high prices of medical services less. Only the introduction of competition will improve efficiency, increase output. and thus the stock of government reform during the time while incremental reforms, the introduction of different owners to compete. the result of competition is beginning to improve efficiency, a substantial increase in medical and health resources.
3, the government does not produce health care services does not mean that the Government does not provide medical Service
reform, mixed ownership, the government no longer directly hold hospitals, means that the government no longer directly the production of medical services, this does not mean that the government no longer provides health care services. the way the provision of medical services, mainly the following Species:
First, subsidies to rural cooperative medical care .2003 October, under the jurisdiction of Suqian Shuyang in the new rural cooperative medical experiments conducted in 2004, expanded to all counties in the city, when the city from the new type rural cooperative medical care there are 314.29 million farmers, according to 30 yuan per person (individual farmers 10 yuan, 10 yuan County supporting the provincial fill 10 million) financing, insurance rate of 79.8% .2006, the urban and rural as 343.57 million, according to 50 yuan per capita (individual farmers 10 yuan, 10 yuan supporting the county, city, Jiangsu Province, on the residential standard of 25 yuan per person grants to other counties in the standard 30 yuan per person supplement) Financing. Meanwhile, the government introduced a management, the end of July, the city's new rural cooperative medical care funds raised a total of 106.423 million yuan, of which 34.357 million yuan paid by individuals, counties supporting 23,126,000 yuan, 48,940,000 yuan provincial meeting. the city's total compensation amount of 56,396,400 yuan, of which total compensation for outpatient 8,126,400 yuan, 48.27 million yuan hospital total compensation; total compensation 1.1082 million people, including compensation for 59,400 patient visits, outpatient visits compensation 1,048,800.
two persons for the establishment of urban low ill hospitalized medical aid co-ordination and co-ordinate fund. Government plan before the end of 2006, will bankrupt the city shut down all enterprises included in the basic retiree medical insurance. some of the basic medical insurance premium payable by the competent department of units affordable, all levels of financial reveal all the details. for the enjoyment of the minimum living allowance for urban residents who, on the non- Building personal accounts, a single set overall fund management practices, the establishment of co-ordination and ill hospitalized medical aid system to co-ordinate regional financial subsidy 240 yuan per person per year, individuals paid 120 yuan per year.
the quality of these mechanisms is the way government subsidies changes in government subsidies to the original supplier, is now the subsidies to the demand side. through the new rural cooperative health insurance, and urban poor relief, etc., were free to choose the hospital. Because the hospital is no longer fixed, in order to attract patients and gain government subsidies, the hospital only at low prices, friendly service, high-tech efforts. In this system, the enthusiasm of doctors and nurses substantial increase in the output of medical and health services are also large-scale growth.
4, important regulatory functions of government ownership after
mixed, private capital is certainly to be profit-driven. private hospitals out of policy concerns and forced financial pressure, short-sighted phenomenon occurs in the operation, which targets the people there the great conflict. transpose public hospitals, the health departments and hospitals no longer have a direct interest, began to increase the independence of regulators. through market competition and government regulation of the conflict with the public hospitals began to decline medical treatment is difficult and your doctor initially solved the problem.
(c) Summary: Financial mechanism under the pressure of innovation
Therefore, the government health system reform Suqian in the context of great financial pressure, seek medical market economy the process of health system. essence of reform is the professionalization of government and market division, which provides medical services to market-based, public health to government, a government purchase of medical services for the poor funding.
third, health care reform by reform, whether it is sold out?
Suqian revitalize the stock of hospital restructuring and expansion, including incremental levels. revitalize the stock refers to the original restructuring public hospitals and health centers. expand the increment refers to the release medical market, encourage the development of private hospitals. until July 2006, the city Suqian 135 township hospitals in more than 134 were property replacement, type of reform was called sold out.
way to understand the reform not sold Reform, the need to convert the program from the property, transfer and use of funds set after the reform of ownership structure.
(a) replacement of property rights reform program
Shuyang hospital procedures, as Suqian City, representatives of the hospital reform program. It can be summarized in six steps:
one of the hospitals in the fixed assets, current assets, special clean production assets accounting; Second, qualified by the rating agencies to assess the situation of assets, evaluation report issued by then recognized by the state-owned sector; third, 7-10 days in advance notice to the community restructuring, and reform organized by the leaders in charge of the staff of the hospital personally to each staff meeting was held, unify their thinking; Fourth, the transfer of property held public auction the General Assembly, the official auction; five hospitals after the reform of land use rights to the transferee by the Land Bureau of assets according to relevant procedures; six, regulate the use of property rights transfer of funds. property rights transfer of funds to implement special accounts stored, used for other purposes, mainly payment of pension insurance for employees, the introduction of unemployment insurance funds and the establishment of health development fund for rural health, particularly the development of anti-Paul.
transfer process from the perspective of property rights, reform the legal framework is based on the way transpose the property. not all sell public hospitals to private, public hospitals began to break the monopoly.
(b) use of funds
property replacement process of restructuring in the public hospital does not appear the phenomenon of loss of state assets . Many hospitals reflect the hospital system when the president of bids too high, too high a premium auction individual hospitals. such as asset evaluation sold 200 million of the hospital 400 million, a premium of as much as 2 times. Suqian Party Secretary Zhang is 2006 June 27 interview with Shanghai Dragon TV interview that the restructuring of the funds recovered, greatly exceeded the reserve price at the time the Government.
how to use the funds after the replacement, is widespread concern. Suqian City Health Bureau, according to statistics restructuring the city's capital of 422,863,700 yuan exchange, is capital in place of 330,910,100 yuan, the use of these funds is as follows:
17.8 million yuan for Disease Control Building, the blood center 7.9 million yuan, , City Centre, 80.59 million yuan infectious diseases, maternal and child health center outpatient 1800 yuan. Suqian three counties and two districts City township hospitals, disease prevention and control system, maternal and child health system funds 50 million yuan. To pay the full insurance workers 41.19 million yuan. The total expenditure of 26,317 yuan. Suqian surplus funds into the health care development fund account.
(c) the reform of ownership structure after the hospital reform Suqian
medical services is a mixed-ownership The. which the Government has Siyang county owned hospital. shareholding hospitals, including various forms: state-owned shares, state-controlled, full ownership, personal holding, and the medical system and other shares. Some township hospitals and clinics, mostly taken by individuals wholly-owned.
(d) Summary: property rights reform of property rights reform is just the beginning
the greatest benefit is the ability to improve efficiency, the same resources, the market more efficient output. output efficiency is reflected in two aspects: First, the provision of medical services, and second, the ability of patients to purchase services. medical services to the final output is not entirely determined by the system, it depends on the payment pattern of reform. whether it is state-owned hospitals or private hospitals, If you pay for the lack of an effective incentive or a blending of services, medical services, the output will be high quality and low price.
This means that if the corresponding set of reforms, especially the standard of medical services and lack of supervision, the effectiveness will be greatly reduced so that property rights reform. Suqian reason why the reforms did not achieve the desired objectives, the main reason is that facilities are not in place.
Fourth, the medical services provided by the market can solve, difficult balance. through increased efficiency to solve the problem of shortage of medical services, increase service availability, reduce the
(a) medical treatment is difficult problem
1, growth in demand for medical services
According to number of visits by a 2.36 times increased to 2.49 times, increased 5.51%. two weeks visiting rate fell 2.84%, no treatment within two weeks prevalence rate has dropped 44.45%, within two weeks of illness should be hospitalized without hospitalization rate has dropped 15.73% , two weeks increased 0.26% prevalence rate of hospitalization, hospital delivery rate increased by 7.47%, while the rate of home births decreased by 7.77%. This shows that the medical needs of the residents improved significantly Suqian.
judge reform ; the issue is resolved, must be based on the medical needs of the residents on the basis of improved significantly.
2, and sexual health services can be enhanced, and above the county hospital patients waiting a long time, but the basic rural hospitals do not need to wait, you can receive timely diagnosis and treatment of common diseases.
2005, the Suqian City households less than 1 km from the nearest percentage WHO 76.5%, 1 -2 km to 17.24%, 5.30% for 2-3 km, 5 km above was only 0.12%, relatively rational layout of the medical WHO. township hospitals and village clinics and community hospitals widely distributed, it is Investigation from the supply perspective, the residents can truly enjoy the convenience of the services also need to be the result of their choice.
2005 and 2000 compared to rates of primary care visits decreased by 10.66%, rural district hospitals attendance rate has dropped by 0.27%, above the county hospital rate increased by 12.5%. This shows that although people close to the WHO from the nearest, to reach a relatively short time, but due to reasons such as medical technology, the patient chose to relatively high level of hospital. Suqian county rapid development of a secondary hospital, talent and technology and equipment capable of gathering to provide more medical services. township hospitals because the flow of talent, competitiveness is difficult with large hospitals compared. In addition, the convenience of transport also makes people have the ability to a higher level of technology hospital.
3, ability to significantly enhance the supply of medical services is enhanced medical services and basic medical services
availability of medical services mainly attributed to the increase in supply of .2005, Suqian hospitals from 148 in 2000 grew to 188, an increase of 27%. beds increased by 57.40%, 51.68% growth in the number of beds per thousand, per thousand Health Professionals who grow 16.45%, medical institutions, asset growth of 139.64%.
increase in medical equipment to improve the ability to supply medical services. restructured before the city's only 5 CT, Shuyang People's Hospital, Siyang County People's Hospital , Sihong County People's Hospital, Suyu County Chinese Medicine Hospital, City People's Hospital, one each .2006 7 months ago, the city's total of CT machine 32, in which municipal 7 sets, 3 sets of urban places, Suyu District 3 sets , Sihong 4, 5 Siyang, Shuyang 10.
4, the establishment of incentive and restraint mechanisms liberated Yiwei staff productivity
mechanism innovation, making the stimulation and Yiwei more reasonable restraint mechanism, the productivity of medical services has greatly liberated. five years, the total number of health institutions increased by 11.11%, 20.85% increase in health professionals, including physicians and over the number of titles rose 115.42%, managers decrease by 27.54%.
after the reform, the income of doctors has improved a lot. If a hospital president Shuyang monthly income of 800 yuan five years ago, the current monthly income of 3,000 yuan. Shuyang a rural hospital treatment by a physician up to 1,200 yuan 2,000. incomes, inspired Yiwei staff motivation, which is prerequisite for the sustainable development of the hospital. in the hospital competition, talent competition to further promote brand competition triggered the development of productivity.
5, non-qualified clinic
survey data still exists, residents see a doctor on the choice of location, proximity to the first choice, the percentage is 50.33%. quality in second place, 17.22%. low prices only in third place, 11.26 %. the attitude of only 2.87%, ranked fifth. and thus can be said that although the doctor has eased the difficult problem, but to take time to achieve the desired state.
residents in some of the choice extent, non-statutory medical organizations say there's an important reason. Task Force found that the clinic is known as black or repeated unlicensed practitioners. the patient feels the services of these clinics are convenient, prices are low, but the service quality is not guaranteed. ailment patients feel no need to go to regular hospitals will choose this type of clinic. They reflect, as its identity is not clear, it is sometimes difficult to distinguish between formal and informal clinics clinics. Some very low-income people because the price of reasons for choosing these clinics. We work with some of the exchange of unlicensed physicians, most of them because of low qualifications, who has suffered punishment, inadequate capital and other reasons, do not meet the criteria for access to government clinics.
(b) Suqian list provided by the Municipal Health Bureau show that the substantial increase in hospital revenue after the reform than in 2000 .2005 prices nominal income growth rate 964%, 473% growth rate of outpatient visits, number of visits per thousand population growth rate 454%. hospital visits also increased. hospital incomes, whether the increased burden of patients?
this is changes in prices of medical services, not only vertical and horizontal comparison, patients also need to look at changes in capacity to pay.
1, the reform of medical services before and after the change in the price of Longitudinal
1.1 Suqian City Health Bureau, according to data provided by the health care reform, the price five years following changes have taken place.
first five years, municipal fees and charges for each hospital outpatient visits increased 7.11%, 6.31% growth in county hospitals, township-level hospitals decreased by 6.26% .
second, five years, the level of charges per bed day down 1.40% municipal and county hospitals, township-level hospitals fell 3.91%.
third, five years, the average medical cost of hospital and municipal hospital rose 21.78 %, 0.66% increase in county hospitals, township-level hospitals decreased by 5.25%.
data collected from the research group can draw the following conclusions:
First, lower-level hospitals, the basic registration fee to cancel, a large The registration fee to keep the hospital at a lower level.
Second, the general decline in the cost of surgery, the higher the cost of the higher-level hospitals. with simple appendicitis, for example, county hospitals, the cost of the pre-reform general yuan in 2000, after the reform costs at 1,500 yuan. township roughly the cost of hospital reform in 1200 before the yuan, reform, remain at 700 yuan. the cost of cesarean section before the reform in general in 4000 yuan , the reformed county hospital costs from 2,500 to 3,000 yuan, 1,500 yuan in rural hospitals. eutocia surgery, the pre-reform cost around 2,000 yuan, county hospital costs after the reform in 1200 yuan, 500 township hospitals yuan.
Third, routine examination costs down. CT in the pre-reform cost of single-site single is about 300 yuan, 120 yuan or so after the reform. new inspection costs of the project began to grow. Some pre-reform Suqian large hospital equipment does not exist, so this can not be compared with the pre-reform.
Fourth, the conventional drug prices within the government's limit. Hospital, the higher the level, the higher drug prices. new drugs prices down than before. lower prices of non-prescription drugs, prescription drug prices are relatively high, unit prices also declined.
1.2
horizontal comparison of the same disease in different hospitals in the local and foreign cost analysis is the horizontal comparison .
county hospitals, in addition to cerebral infarction and cerebral hemorrhage and thyroid tumors, a number of common diseases such as appendicitis, cesarean section, stones, cancer and other treatment costs are generally lower than the field at the county level hospitals. This shows that health care reform increased competition in the hospital, the general decline of the hospital medical expenses. However, due to being in its infancy, for some heavy treatment of the disease, not the formation of a fully competitive local hospital, in a few cases, the hospital costs of monopoly are relatively high.
municipal hospitals, local hospitals are generally lower than the cost of field hospitals, the treatment of lumbar disc herniation of the local cost of 2578 yuan, the field is 5343 yuan; esophageal local as 6394 yuan, the field was 7418.29 yuan.
the local provincial hospital costs are generally higher than outside the provincial hospital, the cost of the treatment of esophageal cancer than the local provincial hospital provincial hospitals outside the high 52%, 83% higher lung cancer, gastrointestinal bleeding in high 79%. cancer, ectopic pregnancy and other local the hospital than outside the hospital.
2, medical services, the reasons for price changes
2.1
residents ability to pay changes with the increase of disposable financial resources, the potential consumer demand into real demand. Reform Ten years, after inflation-adjusted real income per capita Suqian overall upward trend. the real per capita net income of farmers by the 1848 yuan to 3782 yuan increase. In addition to 7% in 2003 fell outside the rose in other years, especially 2004 and 2005, respectively, an increase of 9.31% and 13.66%. the real per capita income of urban residents rose from 2,733 yuan to 7,101 yuan, after 2004 growth rate of over 11% year on year. For farmers, agricultural policies in recent years, the effectiveness of the central re-start show, the burden has been reduced. the local market-oriented reform, especially the adjustment of industrial structure, attracting southern Jiangsu, Zhejiang and other places in the industry shifted to the Suqian, the increase in local employment led to increased revenue.
the same time, health care Insurance .2005 participation rate improved significantly compared with 2000, the ratio of residents to have health insurance increased significantly. which, to participate in health insurance rate increase of 6.90% to 87.90%, up 81%. and members of rural cooperative medical care of the population the proportion rose from 5.97% to 84.30%, an increase of 78%.
these have shown the capacity to pay for medical services improved. from 2000 to 2005, no treatment because of financial difficulties down the rate of 21.80%, in their own requirements discharged patients, due to financial difficulties required rate of discharge decreased 16.12%.
2.2 competition reduces the price of conventional health care, technology upgrading to increase the supply of services in the Suqian
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