On minutes: can residents "vote with their feet" when choosing medical community to sign a contract?

More than 3000 County medical communities have been established in China, and this year, the national health and Health Commission also requires to build more than 500 County medical communities relying on the national key county hospitals Especially in document (2019) No 2 issued by the leading group of medical reform of the State Council recently, it is also required to continue to carry out the pilot of close medical group (which can be understood as urban medical community) and county medical community (which can be understood as rural medical community) in 2020, and encourage traditional Chinese medicine and private hospitals to take the lead in establishing medical community and participate in the competition equally Based on the above situation, the construction of medical community in China is imperative What we are facing is not the question of whether medical communities should be established, but how to build them In recent years, the construction of medical communities in China has achieved obvious results; however, it is regrettable that the advantages of these medical communities have not been fully exerted, especially there are many problems in this and that way The main reason is that it generally relies on excessive administrative intervention and does not have sufficient market mechanism So, how to give full play to the advantages of the existing medical community? How to resolve the difficulties and problems faced by Chinese medical community? It has been suggested that the residents should vote with their feet when choosing the medical community to sign the contract, and take corresponding supporting measures to further promote the healthy and steady development of the medical community in China In order to verify whether the proposal is necessary and feasible, the wechat group of "using four in one medical community to seek residents' health" and the wechat group of "Lu Medical Association publicity group" were launched two times recently to discuss whether it is necessary and feasible to select medical community to sign a contract and let residents "vote with their feet" Discussion All of them are influential senior medical reform experts in China Combining the results of the two discussions: It is highly agreed that it is necessary for the medical community to sign a contract and the residents themselves "vote with their feet" Only in this way can we break the administrative monopoly, establish the market competition mechanism of survival of the fittest, and improve the level of medical and health care of urban and rural residents Otherwise, it will always be a hot topic that the masses are expensive and difficult to see a doctor However, there are different opinions: some believe that it is not feasible for the residents to "vote with their feet" to sign a contract with the medical community in practice (that is, the opposite view); while some believe that the practice is completely feasible in practice (that is, the right view) The author summarizes the discussion results in the following aspects: The opposite view: if the residents themselves "vote with their feet", they must have at least two or more County medical communities for residents to choose However, there are many county-level hospitals with poor conditions and small population, so it is difficult to build a medical community, let alone a number of medical communities If this is the case, how can residents choose? Positive view: for those counties (districts) with poor conditions and small population, the relevant departments of the municipal government can take the lead to integrate the medical resources of several neighboring counties (districts) and establish multiple medical communities with equal strength Even county medical community can be extended to city medical community In this way, there are more medical communities for urban and rural residents (including employees, the same below) to choose to sign a contract, which will never be just one Just recently, the leading group of medical reform of the State Council issued a document (No In 2020, the pilot provinces of comprehensive medical reform should take the lead in exploring more than two cities " Close medical association is actually medical community, which means that from 2020, the "Tianchang medical community model" (that is, close medical group + medical insurance pay per head model) in Anhui Province can be expanded from county to city The opposite view: all along, our country's community medical institutions are set up by the government according to the existing administrative areas, each township and street has only one township health center and one community health service center Each medical community is composed of a leading hospital and several community medical institutions If the residents choose the medical community to sign the contract and "vote with their feet", and if the residents want to choose the medical community in their location but there is no grass-roots service network, then the residents can not enjoy the convenient and fast community medical and health services If this problem can not be solved, it is a matter of paper to choose the medical community to sign a contract and let the residents "vote with their feet" Positive view: the way to solve this problem is to let the medical industry, like the communication and financial industry, break the existing restrictions of administrative divisions, and allow each medical community to set up their own grass-roots service outlets according to their actual work needs In this way, there should be multiple primary service outlets in the same community As long as the medical community has local basic service outlets, coupled with the survival of the fittest competition mechanism, no matter which medical community residents choose, it will also be convenient and quick for residents to go through the local signing procedures and receive medical and health services What's more, the transportation is very convenient now The country has basically realized the road "connecting villages", and basically every family has a motor vehicle The vast majority of residents in the primary service network of the medical community can reach it in about 10 minutes Even in the leading Hospital of the medical community, the vast majority of residents can reach it in about half an hour 3、 Discussion on how to make residents have more advantages in hospital The opposite view: if only a medical community is built in a county, there are not many superior specialties (for example, some hospitals have more advantages in pediatrics, some hospitals have more advantages in gynecology, and some hospitals have more advantages in elderly rehabilitation) that can be selected by patients in the member hospitals of the medical community If residents have the option to sign up for the medical community, there are two or more hospitals in a county Medical community, then in the medical community members of the hospital for residents to choose the advantages of less specialty There are old people, children and women in a family They have different needs for superior specialties in county-level hospitals, which makes it difficult for residents to choose medical communities The positive view: first of all, the residents and the medical community can sign a contract not necessarily based on the family, but also by individuals Each family member can choose a different medical community The premium standard of different groups (children, adults and the elderly) should also be different At the same time, if the medical community is chosen to sign the contract by the residents themselves "voting with their feet", rather than being defined by the local government, then the market competition mechanism of survival of the fittest can be established quickly between the medical community, and the excellent medical community will continue to grow and strengthen, and become many medical centers with strong technology, as well as many specialized hospitals and grass-roots medical and health services throughout the community Large regional network, and even the national chain medical community The world-renowned Caesar medical group is actually a large medical community with more than 10 million contracted residents (i.e members), more than 100000 employees and more than 10000 doctors At that time, this kind of large-scale medical community can provide residents with free choice of superior specialties, and the technical level of the superior specialties of the current county medical community is not known how many times stronger, and the range of diseases that can be selected is not known how many times larger If the residents can't "vote with their feet" to sign the contract, today's County medical community will always be just the county medical community, and will never be bigger and stronger So the hospital advantage specialty that residents can choose freely can only be limited in the scope of a county forever 4、 Discussion on whether to replace the "signing freedom" of residents' selective medical community with "freedom to see a doctor" of residents' selective medical institutions The opposite view: although some counties do not allow residents to have the option of "signing a contract freely", they allow residents to choose any medical institutions (including signed medical communities and non signed medical communities and medical institutions) within the county scope to "see a doctor freely" (to go out of the county, they still need to go through the referral procedures) Some people may think that as long as residents have "freedom to see a doctor", there is no need for residents to have the option of "signing a contract freely" in the medical community "Freedom to see a doctor" can be used instead of "freedom to sign up" Positive view: these two "freedom" are two completely different concepts Let residents have the choice of medical institutions "freedom to see a doctor" can never replace let residents have the choice of medical community "freedom to sign a contract" There are four reasons: First of all, if the residents are not allowed to have the option of "signing a contract freely", then the excellent medical community will never be bigger and stronger, and the scope of residents' free choice of medical treatment will always be limited to the scope of a county, beyond the scope of the county must be reviewed and approved, which will no longer have the "freedom to see a doctor" If the residents have the choice to "sign the contract freely", through the survival of the fittest, make the medical community bigger and stronger, and become a large-scale medical community across counties, cities and even provinces, it will be much easier to transfer hospitals within the same medical community system, which can truly feel the "freedom of medical treatment" Second, if the residents are not allowed to choose to "sign a contract freely", then social forces will never want to lead or independently build and build a non-public medical community, and the monopoly situation of the public medical community will never be changed Monopoly inevitably leads to low efficiency Third, this "freedom to see a doctor" will inevitably lead to "bad money drives out good money" The contracted medical community can control the waste and loss of medical insurance fund consciously and strictly because of the implementation of capitation payment But the health care foundation it saved was swallowed up by non contracted medical communities and medical institutions (including excessive medical treatment and fake insurance) The reason is simple: because the common practice in these places is that the medical expenses incurred by residents in non contracted medical communities and medical institutions are borne by the contracted medical communities "It's not painful to spend other people's money", so it's inevitable for residents to have excessive medical treatment and fake insurance in non contracted medical institutions Fourthly, because the contracted residents spend the contracted medical community's money to see doctors in the non contracted medical community and medical institutions, in order to prevent improper behavior, the contracted medical community's review of the expenses incurred by the contracted residents in the local non contracted medical community and medical institutions is bound to be quite strict, and the efficiency is extremely low, so the medical expenses incurred by patients in the non contracted medical community and medical institutions are often The patient's opinion in this respect is generally strong 5、 Discussion on how to avoid the disparity of service capacity between integrated medical communities in neighboring counties The opposite view: it's a good idea to take the lead of the relevant departments of the municipal government, through the integration of medical resources of two or more neighboring counties, establish multiple public medical communities, and change the situation that the medical community is the only one However, there is a big gap in the medical technology level of county hospitals between neighboring counties, so how to narrow the difference between them? It's a problem Positive view: there must be a gap between the hardware and software level of county hospitals in several neighboring counties How to narrow the gap between them? In the initial stage, the municipal government can adjust the leaders of public medical communities through administrative means