** Desperately seeking revenue is not enough government compensation?

“There is no strict public hospital in China.” Cai Jiangnan, director of the China Europe International Business School and director of the Center for Health Management and Policy, stated at the high-level forum of the 10th China Hospital Dean held in Wenzhou, Zhejiang on September 6th. amazing". His reason is that 90% of the income structure of public hospitals now comes from the market, and government investment is very small. The real public hospitals are invested by the government and are public welfare. They provide basic medical services and even free medical care.

According to the reporter’s investigation, due to insufficient financial investment, the public hospitals in China are basically “self-financing”. Among them, a large part of their income depends mainly on medicines. According to incomplete statistics, the income from drug addiction in public hospitals in the country accounts for 4 to 50% of the hospital's income. The more basic hospitals, the higher the proportion. In the new round of medical reforms, the emphasis on “separation of medicines” is one of the most important means of “zero drug addition.” Hospitals no longer rely on a 15% increase in drugs to earn income, which is equivalent to cutting off some important sources of income. However, the hospital must maintain normal operation. After this "cut down", who is going to fill the hospital's funding gap? Can the elimination of drug additions promote the reform of public hospitals? The reporter interviewed a number of industry insiders at the forum.

Straighten out the price mechanism

The core problem of removing drug additions lies in how to compensate them reasonably. Cai Jiangnan believes that hospitals can rely on their own medical services to maintain their operations in accordance with the laws of the hospital. The key to “preventing medicine through medicine” and “excessive medical care” lies in artificially restricting the price of medical treatment. Reflect its true cost.

"People's Daily" has reported that a foreign patient came to Beijing for a doctor's visit. On the day of the visit, he required immediate hospitalization. The reason was that the hotel was too expensive. "The cheapest hotels in Beijing also need one or two hundred yuan. The hospital bed fee is only 7 yuan. How much money is saved!” This shows from a side that China’s medical services are priced unreasonably.

Beijing has performed costing on medical projects in eight public hospitals. The results showed that they all showed serious losses. Nearly half of the loss-making projects are policy-related losses, that is, hospitals cannot turn to losses through strengthening management and improving efficiency.

“The human cost of our medical care is considered too cheap, and the labor value of doctors cannot be reflected. Over the years, our country’s economy has developed rapidly, and the income of various industries has also increased significantly. Doctors, as a part of social labor, should also increase their income. In the past, a pack of cotton was used to sign a few cents, and now it has risen by six or seven yuan. All costs are increasing. The same is true of manpower.” Shi Bingyin, dean of the First Affiliated Hospital of Xi'an Jiaotong University School of Medicine, said with emotion. He believes that after the elimination of drug additions, it is necessary to rationalize the price system and price medical services according to market rules. "To increase our service fees, to measure how much this person is worth at work, how much money I would give him, and how much the bed fee should be, we should reasonably charge."

Chen Xiaoming, director of the First Affiliated Hospital of Wenzhou Medical University, also believes that the most feasible thing in the current situation is to increase the price of medical services. "Because government compensation is harder."

Some people think that the increase in the price of medical services has increased the burden on patients and it is still expensive. At present, the relationship between doctors and patients in China is tense. Raising prices will “cause public anger”. In this regard, Cai Jiangnan believes that although the price of medical services has risen, the excessive use of drugs has been reduced, and the money saved can make up part of the price increase of medical services. "It should be reasonable to raise the price."

In addition to reforming the pricing mechanism, the hospital itself can also make a difference. "As the hospital itself, we should make up for this loss by reducing the cost by grasping quality and grasping services," said Qin Chengyong, dean of Shandong Provincial Hospital Group.

Government compensation is not in place

In 2012, Beijing Friendship Hospital took the lead in piloting the “separation of medicines” and canceled drug additions. The patients no longer need to pay registration fees and medical treatment fees for medical treatment, but pay medical service fees according to the rank of the doctor. This can be said to be an attempt to increase the price of medical services. However, more and more deans are expecting compensation from the government if the price increase policy is not yet universal.

"The medical institutions' managers are more worried that they should take it away. The supplement will not be added." Beijing Friendship Hospital's exploration of medical service fee reform has run for two years. Director Liu Jian felt this. Quite deep: "If there is no supplement to this cost, the cancellation of the loss caused by the addition of drugs will most likely affect the normal operation of the hospital."

“The hospital has such a few revenues, government input, medicines, and medical services. The elimination of drug additions and the need to maintain the operation of the hospital must be complemented by two other things. If the government does not invest enough, then there must be an article on medical services. Zhuang Yiqiang, deputy secretary-general of the Chinese Hospital Association, believes that it is best for the government to make compensation. If the government’s current fiscal system does not have the means to compensate for it, improving labor efficiency is not a bad idea.

For a long time, public hospitals in our country have suffered losses. After the elimination of drug additions, the hospital’s income is even smaller. If the government does not make up for the compensation, it will be difficult for the hospital to “make a fuss” on profitable projects. For example, laboratory fees, inspection fees, special beds, etc. are profitable items, and hospitals will earn more profits through multiple tests, more inspections, and more specialized services.

Wang Hongzhi, a consultant of Beijing University Management Consulting Group, believes that the implementation of zero-plus drugs is very simple, but there is no supporting compensation policy is not enough. "Policy should address the hospital's income problem, so that the hospital is motivated. At least economically, there is an incentive to lower the price, rather than how high or low the drug price has nothing to do with him. How to use less, not more."

"If the compensation mechanism is not in place, the hospital will become more incapable of developing." Wu Jia, president of Wenzhou Medical University, said: "The president of the hospital is really in distress. To maintain such a large number of medical personnel, there are so many expenses, and there are many new ones. Technology and facilities need to be invested. Where does this money come from? How is the part of the compensation paid for? From the perspective of our hospital, many compensation mechanisms are not in place and hospitals cannot continue."

What is the difficulty of canceling drug addiction? Liao Xinbo, inspector of the Guangdong Provincial Health and Family Planning Commission, frankly stated that the biggest obstacle is the government. “The worry of the hospital is extenuating and it is real. In fact, when the zero markup is implemented, the government does not count. For example, if you cancel 15% of the bonus, 80% will be provided by medical insurance, and 10% by the government. The government provided that 10% was digested by the hospital. However, many local governments did not do this."

From April 1 this year, all public hospitals in the province of Zhejiang have fully implemented the "zero-dose drug ratio." Zhejiang Province will adjust such measures as adjusting the prices of medical services that are too low, increasing financial compensation, and strengthening the hospital’s own management. “Now the government does not make up for this one,” said Dean Chen Xiaoming. “The Zhejiang Provincial Department of Finance gave us some indicators. If the running indicators are completed well this year, they may make up part of the drugs due to the loss of zero-maturity drugs.” He also frankly stated that different local governments have different financial capabilities, and some governments cannot make up for it.

Obviously, the dean believes that government compensation is necessary, but it is also very difficult. "For example, some counties are poor and the economy is not good. The compensation depends on whether the government has the determination or whether it has any financial resources." Qin Chengyong said.

Cut off related interest chains

Since the cancellation of drug additions for more than two years, at the Beijing Friendship Hospital, drugs have entered hospitals and are sold to patients through doctors. The hospital does not earn a penny from it. “Even though public hospitals are organized by the government, 60%-80% of the funds are earned by the hospital itself. Objectively, there is a conflict between the interest of the hospital and the patient. When no longer need medication When will it be possible to eliminate the phenomenon of competing interests between patients and doctors?” said Liu Jian.

At the same time, Liu Jian believes that this matter will continue to deepen. The relationship between drugs and doctors is cut off and there are other links. “A drug has gone through many links since it was produced and circulated in the market. From pricing, bidding to sales, every interest link, every interest in the operation link is gradually cut off, and it is expensive to see a doctor at that time. The problem can be solved."

Cai Jiangnan also agreed with this: “The elimination of 15% of drug additions only cancels part of the use of medicine to provide medicine. There is a chain of interests behind the drug, which includes drug dealers, doctors and hospitals. It also includes relevant government departments and drug tendering departments, some of whom have benefited from corruption, good bribery, and bribery, and those benefits will be lost.”

Chen Xiaoming believes that when compensating for the gap in the elimination of drug additions, it is necessary to pay attention to whether the target value of such compensation is correct. “These compensations are according to the original pattern, that is, how many medicines and how much money hospitals used originally. What we need to do in health care reform is to deepen the reform of institutional mechanisms. It is not the original pattern. Reform is a revolution and must change the pattern of interest. There is no change in the pattern of interests. We should call improvement."

In addition, he also proposed that do not make "the use of drugs to support medical care" has become "the use of medicine to support medicine." “Now the medicine is zero, and the pharmacy has changed from a profit unit to a cost. Some local hospital chiefs want to sell the pharmacy. No, because there is no profit. Cancel the use of medicine to provide medicine, pharmacy personnel, What can we do with equipment, site, and loss? We can't say that we can use medicine to provide medicine, but we can't use medicine to support it."

At present, the state encourages social capital to enter the medical field. In recent days, the separation of medicine advocated by the Ministry of Commerce is also expected to make the pharmacy universally blossom. Patients can make prescriptions in hospitals and buy medicines in pharmacies. In this case, how should the hospital manage the pharmacy? Chen Xiaoming believes that this requires policies to focus and think.

Around the Spring Festival in 2014, "pharmacy trusteeship" has mushroomed all over the country. Why did this happen? Wang Hongzhi believes that this is related to the unreasonable design of the hospital's drug addition system. “One of the important reasons is that the zero-plus-plus policy of drugs has caused the price mechanism to fail. In the face of widespread drug prices, hospitals have been forced to use alternative methods to drive down drug prices. The zero-plus-plus-drug policy is in line with medical laws, but it violates The economic law. The analysis of the advantages and disadvantages of 'pharmacy trusteeship' is not important, it is important to improve the compensation mechanism of public hospitals to address the root causes of this phenomenon."

Qin Chengyong believes that after the abolition of drug additions, the hospital, for operational reasons, seeks benefits from excessive medical treatment in order to survive and develop.

Cai Jiangnan also put forward similar views. "Last time we began to see a trend that cancels 15% of drug additions and the cost of medical examinations is increasing. Losses outside the embankment are filled up. Hospitals, doctors, medicines, and services are bundled together. If not To solve the problem of the rational distribution of medical resources, the mere elimination of drug additions cannot solve the core problems."

“The medical reform should have a comprehensive top-level design to deepen reforms, incorporate all policies into the entire system, and implement them. The drug zero rate is the first step we take. It is just a beginning and there are many issues that need us to go. Solve.” Chen Xiaoming said.