Do doctors still want to start a business and open a clinic six months after the new regulations of the clinic are issued?

Wen Xiaoxu In May this year, five ministries and commissions, including the national health and Health Commission, issued the opinions on carrying out pilot projects to promote the development of clinics (hereinafter referred to as the opinions), which were piloted in 10 pilot cities of clinic reform, including Beijing, Shanghai, Shenyang, Nanjing, Hangzhou, Wuhan, Guangzhou, Shenzhen, Chengdu and Xi'an The opinion simplifies the process of setting up clinics, and has formulated several measures to encourage the establishment of clinics It also encourages doctors who have worked in medical institutions for more than 5 years and have obtained intermediate and above professional titles to open specialized clinics full-time or part-time On November 8, the national health and Health Commission also released the basic standards for clinics in pilot areas of clinic reform (revised in 2019), which is a new version of the standards launched since 2010, and is open to 10 pilot cities of reform announced in May this year This document has been adjusted and updated in terms of the requirements for professional titles of medical personnel, the cancellation of building area setting, and the increase of information system construction In fact, in recent years, the state has successively issued policies to gradually simplify the access process of social medical services, and promote the "two certificates in one" of examination and approval and practice registration of medical institutions below the second level; in terms of free practice of doctors, it has also been liberalized and continuously encouraged This year's new rules for clinics are further defined and refined on the basis of the previous ones Now, the opinion has been published for half a year How about the implementation of the pilot area? After simplifying the access process, will a large number of clinics emerge overnight? Will encouraging doctors to open clinics lead to a wave of entrepreneurship? Arterial network interviewed many medical institution managers, and combined with the data, made the following findings According to the data released by the national health and Health Commission, there are nearly 220000 registered and operating clinics in China, with an average of more than 7000 clinics in each province; the average number of clinics is 2.6, including 1.4 doctors and 1.2 nurses; the common and frequently occurring diagnosis and treatment businesses of internal medicine, Stomatology, internal medicine of traditional Chinese medicine, surgery of traditional Chinese medicine, orthopedics and Gynecology account for clinics The proportion of business is more than 90%, which plays an important role in the primary medical service But at the same time, the development of clinics is facing the main problems such as the shortage of human resources, the low capacity of medical services, and the difficulties in industry supervision In this context, in May this year, the opinions on the pilot project of promoting the development of clinics was issued The opinions put forward several measures to promote the opening of clinics and strengthen the supervision of clinics, which are mainly reflected in simplifying the access procedures of clinics, adjusting the basic standards of clinics, encouraging qualified doctors to hold clinics, and requiring clinics to establish information systems, and also determined 10 pilot cities in Beijing, Shanghai, Shenyang, etc Subsequently, a number of pilot areas have followed up and issued corresponding implementation plans for the local situation Relevant policies to promote the pilot development of clinics, arterial network mapping In the may notice of the health and Health Committee, it was proposed to adjust the clinic standard At the beginning of November, the newly released basic standards for clinics in pilot areas of clinical reform (revised in 2019) finally arrived Compared with the previous 2010 version, there are mainly the following changes: 1 According to the new standard, clinicians need to obtain the qualification of practicing doctors After registration, they have been practicing in medical institutions for more than 5 years and have the title of attending physician or above Previously, it was required to be a licensed doctor 2 If relevant service agreements are signed with other medical institutions for clinical examination, medical imaging, ECG, pathology, disinfection and supply, and other services are provided by other institutions, relevant equipment may not be provided Compared with the 2010 edition, ECG, pathology and medical images have been added 3 The use area and building layout of the clinic can meet the medical needs of diagnosis and treatment subjects The 2010 version requires a building area of no less than 40 square meters 4 It added "establish information system, and connect with medical service supervision information system according to regulations and standards of health administration department" It can be seen that the standard continues the principle of the opinions Compared with the old version, the biggest change lies in the adjustment from the key audit equipment, facilities and other hardware to the audit of the qualification and ability of doctors, which improves the qualification of clinical doctors, raises the threshold of clinical practice and increases the requirements of information system Specific differences between the two versions of the standard, arterial network mapping It took a long time and a lot of processes to run a clinic, which was once a headache for a large number of founders Yu Ying, CEO of Youlin clinic, once complained about the difficulty of approval on Weibo In the process of the implementation of the new regulations, have the clinic operators experienced changes? We interviewed a number of managers of medical institutions in Shanghai, Chengdu and other places Combined with previous policies, we sorted out the changes in the application process of the clinic, as shown in the following figure: Start up flow chart, arterial network mapping According to the regulations on the administration of medical institutions, in general, the process of opening a clinic involves seven steps in the administrative department of health; in these steps, there are many uncertain factors: for example, the location cannot be next to a restaurant, school, and other commercial or residential access, etc., otherwise, the approval for setting up a medical institution cannot be obtained if it cannot pass the address The next step can't be carried out; even if it passes the address, the publicity stage is also a test, and if someone objects, it will affect the subsequent process These factors lead to a long approval process and a high risk If there is a problem in one of the links, the clinic may not be opened According to the opinions issued this year, it only takes four steps to open a clinic, canceling the steps of setting up application and publicity in the general process (i.e canceling the steps in the dotted line box in the figure above) At the same time, it changes the setting approval to the filing management system, implements and submits materials for filing in accordance with the clinic standards in the pilot area, and after the local county (District) level health administrative department has passed the examination, it will The "medical institution practice license" may be issued "Our Sijun surgical clinic in Shanghai, which is in accordance with the new regulations, has obtained a license for practice." According to Dr Bao Yuke, vice president of Dr Zhang Qiang's group, it took half a year for the clinic to prepare for the site selection and obtain the practice license, of which only 20 working days were spent for filing and obtaining the license "Normally, our construction period is only three or four months, but in order to cooperate with the park management, the construction progress of Shanghai Sijun surgical clinic is affected to some extent, otherwise the whole process from site selection to certificate acquisition will be faster In the previous experience, the whole process may take a year " The opinion also stipulates that the chain and group clinics operated across administrative regions shall be put on record by the health administrative department at the next higher level, and those operated across provincial administrative regions shall be put on record by the health administrative department of the province where they are located Baoyuke said that since the trans provincial operation also involves the relationship between the industrial and commercial parent company, subsidiary company or the head office and branch company, the next step is to try the specific start-up process The convenience brought by the opinions to the establishment of clinics is certain, not only to improve the efficiency of process simplification, but also to directly reduce costs Because the planning of medical institutions does not restrict the clinic, it means that the location of the clinic is wider and the place with higher cost performance can be selected "According to the previous requirements, medical institutions should have independent channels In most cases, they can only choose the first floor, but the rent on the first floor is high Now we can choose the second floor or above to save a lot of rent directly," said Bao At the same time, the new clinic standard no longer requires the area of clinics For small clinics run by individuals, they can also be located and arranged as needed to save costs Under the promotion of the new regulations, this year Zhang Qiang medical group not only completed the landing of Shanghai clinic rapidly, but also many clinics nationwide have entered the preparatory stage "One of them has completed the site selection and several others are in the process of doing so." Bao Yuke revealed The new rules seem to lower the threshold for setting up clinics, and encourage doctors who have been in medical institutions for more than five years and have obtained the qualification of intermediate and above professional titles to open specialized clinics full-time or part-time It seems to herald another wave of clinic construction boom However, we checked the registration of clinics in each pilot city since the new regulations were issued in May this year Compared with the same period last year, the overall number has not changed significantly This is probably related to the lack of motivation for doctors to open clinics, stricter access conditions and supervision The simplification of the approval process does not mean that it is easier for the clinic to be opened Doctors should also consider the market, environment and their own capabilities Doctors don't flock to clinics First, doctors lack the motivation to open full-time clinics In this regard, Bao Yuke's view is that for doctors who are still in the system, big experts are well-known, have a large number of patients, have better research platforms and welfare benefits, and don't necessarily need to open their own clinics; while ordinary doctors don't have such a good personal brand, once they leave the system, especially the third tier hospital, they will have little appeal to patients , full time consultation with all certain risks Second, the environment for doctors to open clinics is not mature In recent years, the state has issued a series of policies, which are more and more open to doctors' free practice, but in reality, doctors are still regarded as "unit people", hospital managers must hope that doctors will serve the hospital full-time; if doctors open clinics part-time, whether to use the main practice institutions to "guide" their clinics, and how to pursue medical disputes in case of medical accidents Responsibility, these problems are difficult to define in a short period of time, which makes it difficult for hospitals and doctors to deal with each other's relationship if doctors want to open clinics part-time Third, a good doctor is not necessarily a good manager It takes a lot of energy and financial resources to open a clinic, such as location, brand building, dealing with doctor-patient relations, public relations, medical disputes, etc., which tests not only the level of diagnosis and treatment of doctors, but also the ability of management and crisis management However, most of the doctors in the system have strong ability of diagnosis and treatment, but they do not have the ability of operation and management, so they may not be able to manage a clinic well At the same time, doctors have to undertake a lot of clinical, scientific research and other work They lack of skills and energy to open part-time clinics Therefore, doctors are also rationally aware of these problems, it is difficult for doctors to open clinics in succession Registration and cancellation of clinics in pilot cities, data source: enterprise inspection, arterial network mapping The clinic also faces many challenges We also found that while a large number of clinics were newly registered, there were also a large number of clinics being cancelled This situation, of course, is related to the operation of the clinic itself, but it should also be noted that the new regulations put forward higher access requirements and more stringent regulatory measures for the clinic, both in the start-up and operation, are facing various challenges First, there are still risk points in the bidding process The cancellation of the application process for setting up a medical institution means that a large amount of money has been invested to complete all aspects of the preliminary decoration, software and hardware construction at the time of the clinic's final filing If there is a problem in the construction process itself, which does not meet the basic standards, it will lead to the failure of audit at the time of filing After that, whether it is rectification or abandonment, the investment at the early stage will cause huge losses This puts forward higher requirements for the preliminary work of the clinic Thirdly, doctors are required to practice more According to the new clinic standard, clinicians need to obtain the qualification of practicing doctors and be registered in medical institutions