【This chapter is changed from 10 to 11:00 tomorrow

The following are the medical reform opinions just issued, including pilot reforms on the salary of medical staff, but there is still a question mark on how much it can be implemented.

There are too many things to be changed in medical reform. Some can be changed by tolerant, but some cannot be changed, and the interests are already incomplete. Medical care is not an industry that can be stopped at any time, and once the equipment is cut off, there will be big problems. Therefore, medical reform is to do minimally invasive when people are awake, and do it little by little.

Because of this relationship, there will always be strange reform content in medical reform. The more abnormal the parts, the more difficult the bones you encounter are to chew and need to detour.

Whether the reform can be implemented, or how much it can be implemented depends on the final pilot results. Of course, this matter is the same as housing prices, with policies and countermeasures at the top. For money, there are some methods for the people below. At that time, it will become a local model, and this model is everywhere in the medical circle with particularly strong feudal nature.

The same goes for the same sentence, medical reform is long and long. Anyone who insists on medical reform, insists on breaking the existing medical pattern and pursues perfection is worthy of respect. Even if his reform is wrong, there is no need to blame him.

Because medical care is very troublesome, if you eat more money, the country will have less investment, and if you eat less money, you will have to take it from the people. Therefore, every step is a brand new attempt, and trial and error is certain, not to mention that they are all warriors who risk being silenced,]

On October 15, the official website of the National Health Commission issued the "Implementation Opinions on Deeply Promoting the Experience of Sanming City, Fujian Province and Deepening the Reform of the Medical and Health System" issued by the State Council Medical Reform Leading Group (National Medical Reform [2021] No. 2, hereinafter referred to as the "Implementation Opinions").

In addition to clarifying the need to seriously implement the "Sanming Experience", the "Implementation Opinions" also mention expanding the scope of centralized procurement, retention of medical insurance funds for centralized procurement of drugs and consumables, reform of medical service prices, adjustment of salary structure, reform of medical insurance payment methods, and cost control.

It is worth mentioning that the Implementation Opinions clearly mentioned at the beginning of the document: "Promote the main responsible persons of local party committees and governments or a main responsible person to serve as the leader of the medical reform leading group, and give full play to the overall coordination role of the medical reform leading group. The Standing Committees of the Party Committees of each province (autonomous region, municipality) will study medical reform work at least once a year."

Xu Zhiluan, one of the core members of the medical reform leading group when Sanming Medical Reform was launched, and director of the Sanming Municipal Medical Security Bureau, once said that the commendable nature of Sanming medical reform lies in the strong leadership and strong support of previous party committees and governments. Not only does it fully trust the medical reform leading group, but it also gives the medical reform leading group full authorization at some key nodes of the reform.

Before the Sanming Medical Reform was launched in 2012, Zhan Jifu, then deputy mayor of Sanming City. When the then mayor Deng Benyuan asked him to find a solution, he asked the mayor and secretary for corresponding management rights: to change the situation under different jurisdictions of the deputy mayors, and the medical reform will be managed by himself.

As a result, the right to make the decision of Sanming's medical reform was moved from the previous municipal government standing meeting and the municipal party committee standing committee to the municipal medical reform leading group.

Adjust the salary structure: play the role of salary guarantee

The reform of the salary system of public hospitals has been mentioned again.

Article 7 of the "Implementation Opinions" mentioned that it is necessary to implement the "Guiding Opinions on Deepening the Reform of the Salary System of Public Hospitals" (Ministry of Human Resources and Social Security [2021] No. 52) and comprehensively deepen the reform of the salary system of public hospitals.

It is required that "after deducting costs based on the medical service income of the year and withdrawing various funds according to regulations, hospitals of different levels and nature will reasonably increase the total salary of public hospitals according to the requirements of "two permits", and not include them in the total verification base, and reasonably determine the proportion of personnel expenditure to public hospital business expenditure. Promote public hospitals to reasonably determine the internal salary structure, pay attention to the stable income of medical personnel, and give full play to the salary guarantee function."

It is worth mentioning that when mentioning the pilot goals of high-quality development of public hospitals, Xu Shuqiang, director of the System Reform Department of the National Health Commission, pointed out that the proportion of fixed part of personnel salaries should be gradually increased, and by the end of the "14th Five-Year Plan", we strive to reach about 50% and by the end of the "15th Five-Year Plan", we strive to reach about 60%.

In addition to adjusting the salary structure, the salary form was also mentioned in this "Implementation Opinions".

Article 20 of the Implementation Opinions clearly states: "Encourage localities to explore and deepen the reform of public hospital compensation system based on actual conditions. They can explore the implementation of annual salary system, job compensation system, agreement salary system, project salary and other forms of compensation, and gradually establish a salary system that reflects the value of job responsibilities and knowledge, and give full play to the effective incentive role of the salary system. Encourage and support local governments to explore salary distribution policies that are conducive to mobilizing the service enthusiasm of grassroots medical and health institutions. Fully consider the characteristics of traditional Chinese medicine services and promote the reform of the salary system in the field of traditional Chinese medicine in light of actual conditions."

Regarding the implementation of the annual salary system and the job salary system, the latest plan explored by Sanming is the total annual salary, which includes the total basic annual salary and the total performance annual salary:

The standard for determining the total basic annual salary is:

The basic annual salary of chief physician     300,000 yuan,

The basic annual salary of the deputy chief physician is RMB 250,000,

The basic annual salary of the attending physician     200,000 yuan,

The basic annual salary of resident doctors                                                           

The basic annual salary of technicians and pharmacists is determined according to 80% of the basic annual salary of physicians of the same level;

The basic annual salary of nurses is 70% of the basic annual salary of physicians of the same level;

The basic annual salary of administrative logistics personnel is verified at 40% of the average basic annual salary of the physician;

The basic annual salary of the village health center staff is 100,000 yuan.

When the total annual performance salary is determined, the total annual performance salary of public medical institutions is withdrawn at 10% of the medical service income and is linked to the annual performance appraisal results of the secretary (dean) and chief accountant.

It is worth noting that in the "Sanming City Implements the "Six Major Projects" Action Plan to Promote Restart Medical Reform", the annual salary base will no longer be distinguished from the hospital level, and all basic annual salary will be determined based on the professional title of medical staff.

In the "Implementation Opinions", it is clearly encouraged that localities with conditions should learn from Sanming's practices, reform and improve the method for judging the total salary of public hospitals, calculate the total salary of hospitals based on medical service income (excluding drugs, consumables, inspections, and laboratory income) as the base, implement the target annual salary system for all employees, improve the work-point system, informatization and openness performance appraisal system, and maintain the public welfare nature of public hospitals.

Expand the scope of centralized procurement

Retention of medical insurance funds for centralized procurement of medicine and consumables

Articles 3 and 4 of the "Implementation Opinions" mention the issue of expanding the scope of centralized procurement and the retention of medical insurance funds for centralized procurement of drugs and consumables.

Article 3 points out that "the centralized procurement of drug consumables organized in a normalized and institutionalized manner will be carried out, and the scope of procurement will be gradually expanded, and the number of general names of drugs purchased by more than 300 by the end of 2022 will be purchased. At the end of the 14th Five-Year Plan period, the number of general names of drugs purchased in national and provincial organizations in each province will exceed 500. Strengthen the procurement and inventory management of medical institutions to adapt to the requirements of centralized and volume-based procurement."

At present, the first five batches of national procurement have covered 218 varieties (general names). If the "Implementation Opinions" states that "the number of general names of drugs purchased by the end of 2022 is more than 300", it means that nearly 100 drug varieties will be included in the national procurement one after another.

In order to promote the smooth implementation of centralized and volume-based procurement of drugs, encourage medical institutions to give priority to purchasing and using selected drugs, encourage and mobilize medical institutions and doctors to participate in centralized procurement, Article 4 of the "Implementation of the national policy of retention of medical insurance funds for centralized procurement of drugs and consumables."

It is worth noting that in the "Opinions on Promoting the Normalization and Institutionalization of Centralized and Volume Procurement of Drugs" issued by the General Office of the State Council in January 2021, the health community noticed that the "national procurement" that previously competed within the generic drug names, on this basis, proposed that "concentrated and volume-based procurement of different generic drugs with similar indications or functions" should be explored.

This means that while expanding the scope of centralized procurement, the competition for drugs may be more intense and further follow-up is needed.

Establish a dynamic monitoring system for medical service prices

Article 5 of the "Implementation Opinions" proposes that before the end of June 2022, all provinces should issue relevant documents to establish a dynamic adjustment mechanism for medical service prices, scientifically set the conditions for starting medical service price adjustment, trigger standards and constraints, and stabilize price adjustment expectations; and include medical service price items that meet the requirements in a timely manner in the scope of medical insurance payment.

Article 6 proposes to strengthen the monitoring and evaluation of public hospital prices, accelerate the establishment of a monitoring system for the distribution of medical services in public medical institutions, and provide a basis for implementing dynamic adjustments to medical service prices.

Article 16 proposes to optimize the management of new medical service price items, select some provinces to formulate management measures for new medical service price items, simplify the application process for new price items, speed up the acceptance and review progress, clarify the processing time limit, promote the innovative development of medical technology and clinical application; explore and improve the price items of pharmacy medical service.

Based on the above three points, the focus of future medical service prices is on dynamic adjustment, scientific evaluation, timely monitoring, and project optimization. This puts higher requirements for hospital managers, and special attention should be paid to the quality and specification of services.

Huang Huabo, director of the Medical Service Management Department of the National Health Insurance Administration, once pointed out that "among the three major medical insurance catalogs, the most difficult thing is the medical service."

Establishing sensitive and moderate indicator conditions and triggering mechanisms can better solve the problems of expectation management and price adjustment windows, and avoid the situation of "long-term immobility and sudden big moves".

This not only avoids the possibility of blindness and arbitrary in the adjustment process, but also prevents the occurrence of "extraordinary high or abnormally low prices" through monitoring. The relevant person in charge of the National Health Insurance Administration previously stated that the price monitoring, assessment and evaluation will be expanded from simple observation and discovery functions to a certain supervision and management function, providing institutional guarantees for the effectiveness and long-term vitality of the reform.

For public hospitals, on the one hand, the reform of medical service prices and dynamic monitoring mechanisms will help increase the reasonable work income of medical staff and increase enthusiasm; on the other hand, hospital managers also need to open their horizons and pay attention to medical services with high clinical demand and strong clinical effectiveness.

According to the editor, Hunan Province has taken the lead in establishing a monitoring and evaluation system for dynamic adjustment of medical service prices across the country. The evaluation indicators cover regional social development indicators, medical development indicators, medical insurance operation indicators, etc. According to the difference between pricing costs and medical service prices, select medical service items and adjustment ranges that need to be adjusted to determine whether and how to adjust the medical service prices in the region.

The final year of 200 pilot cities

Article 8 of the Implementation Opinions proposes to deepen the reform of medical insurance payment methods, implement diversified and complex medical insurance payment methods that mainly pay by disease type, gradually reduce the proportion of medical insurance funds pay by project, increase the proportion of medical insurance payment methods such as group payment by disease diagnosis, score payment by disease type, daily payment by bed, and outpatient payment by person. By 2025, the proportion of medical insurance funds that are grouped by disease diagnosis or paid by disease type accounts for 70% of all eligible inpatient medical insurance funds.

Article 17 proposes to accelerate the reform pilot projects such as group payments based on disease diagnosis, total budget of regional point method and payment by disease type score. All pilot cities will enter the actual payment stage by the end of 2021, and timely summarize experience and promote it nationwide. Encourage exploration of payment methods that meet the characteristics of traditional Chinese medicine services.

Previously, Huang Huabo, Director of the Medical Service Management Department of the National Health Insurance Administration, introduced at a regular policy briefing that in 2019, the National Health Insurance Administration launched a DRG payment pilot in 30 cities across the country. At present, all of these 30 pilot cities have entered simulated operation, and some cities have already carried out paid work. In addition, since 2020, 71 cities across the country have launched DIP payment pilot, and all of these 71 pilot cities have completely pre-grouped work. So far, there are more than 200 DRG and DIP pilot cities in China, and actual payment will be carried out in 2021.

In other words, 2021 is the final year of the DRG and DIP pilot, and it is also a key year for the summary of pilot experience and national promotion.

Drg and Dip payment have different footholds, different grouping principles, and their own advantages and disadvantages. However, as a more advanced payment system than the traditional "pay by project", a diversified and complex medical insurance payment method mainly pays by disease type will help realize the important change in medical insurance "pay for value".

The phenomenon and problems such as insufficient use of new technologies, insufficient diagnosis and treatment, insufficient compensation for critically ill patients that may be caused in this process may be avoided in the future through reasonable systems.

For example, for innovative technologies that meet clinical needs, first choose "pay by project"; encourage trials of clinical pathways and strengthen medical quality assessment; for patients who are indeed critical, different payment standards will be used to achieve this.

For public hospitals, under the background of reform of medical insurance payment methods, profitable businesses that once paid by project may become the operating burden of the hospital, and therefore, the hospital will be forced to calculate the cost of the disease.

Public hospitals in the future need to find their own positioning, not only paying attention to medical efficiency, but also operating efficiency.
Chapter completed!