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    Home > Active Ingredient News > Drugs Articles > The reasons for the institutional mechanism that is difficult to form in the order of graded diagnosis and treatment in our country

    The reasons for the institutional mechanism that is difficult to form in the order of graded diagnosis and treatment in our country

    • Last Update: 2021-02-13
    • Source: Internet
    • Author: User
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    Realizing a reasonable order of graded diagnosis and treatment is an important problem that the central government has solved since the new medical reform, as Ma Xiaowei, director of the National Health and Health Commission, stressed, "The day when the graded diagnosis and treatment system is realized is the time when the reform of China's medical system is successful".
    in order to correct the misplaced "inverted triangle" medical service system centered on large medical institutions as the "positive triangle", the central government has continuously introduced a number of hierarchical diagnosis and treatment policies in recent years.
    the current reform effect of graded diagnosis and treatment, the "inverted triangle" medical service system is still showing a solid trend.
    2015, the total number of medical and health institutions in China was 7.7 billion, of which 19.48%, 15.19%, 2.72% and 56.3% were in third-level hospitals, secondary hospitals, first-level hospitals and primary medical institutions. By 2018, the total number of visits had increased to 8.31 billion, with 20.82 per cent, 15.28 per cent, 2.65 per cent and 53.31 per cent of the number of visits to primary, secondary, primary and primary medical institutions.
    data reflect that the current situation of medical service supply deviates from the reform orientation of the system of graded diagnosis and treatment.
    Graded diagnosis and treatment" has its own shape, but not in fact", the third-level hospital is still overcrowded, if the city, the grass-roots hospital door can be ronch, difficult to maintain; Concentrated in large hospitals, the development of outpatient and inpatient services in large hospitals out of control, large-scale, even group development trend, resulting in "reform siphon" phenomenon is obvious;
    the original intention of the reform of the system, the author believes that this is related to many institutional problems in the field of medical and health care in China, which mainly includes the following four aspects.
    The reform of public hospitals has the institutional defects of "two big ones" and the construction of china's reasonable medical service system and the promotion of the hierarchical diagnosis and treatment system, and the reform of public hospitals are two parts which are interrelated and inextricable, which together constitute the core element of the medical service supply system.
    since the "new medical reform", although the state has made great efforts to promote the reform of county-level public hospitals and urban public hospitals, it is difficult to make a substantial breakthrough in the difficult situation of public hospital reform, the fundamental reason is that there are "two public" institutional defects in the reform of public hospitals in China.
    The institutional defects of "two big ones" are the result of the inadequate administrative control and social governance of the planned economy, which is as follows: First, the supply mode of medical services in our country is centered on large public hospitals, the local blind expansion of the hospital scale and the pursuit of the growth of the number of beds, and the vast majority of county-level public hospitals can not control the major diseases in the region, resulting in a significant increase in the number of off-site referrals in recent years; As a result, more than 80% of medical insurance funds into large hospitals, squeezing the survival space of primary medical institutions, the third is to confuse the public welfare of medical and health services and the public welfare of medical service providers, resulting in a deviation of public hospital public welfare issues, public hospitals are not equal to public hospitals, whether public hospitals or private hospitals, are only the carrier of medical services provided rather than the main body, the surname "public" is not equal to the provision of public welfare medical services, nor is it only public hospitals can provide public welfare basic medical services.
    this kind of institutional defect causes the supply of medical resources in our country to produce the "inverted triangle" type of misplaced structure, 80% of the medical and health resources are concentrated in the city, of which 80% are concentrated in large and medium-sized public hospitals.
    but from the point of view of demand, the vast majority of health service needs are concentrated in rural areas and grass-roots level, is the "positive triangle" demand structure.
    The inverted triangle of medical supply and the positive triangle of medical demand in reality is the inverted behavior of general practitioners, specialists and medical experts, which to some extent cures the inertia of residents' visits to large hospitals and aggravates the problem of patient accessibility and medical burden.
    And this large-scale public hospital as the center of the medical service supply model led to the reform of the "siphon effect", between different levels of medical institutions is not a division of labor and cooperation relationship, but the interests of competition, strengthen its "circle resources" and monopoly capacity, since 2013, the number of primary medical institutions in the decline year by year can be seen as a strong proof.
    The primary care system of the nature of "gatekeeper" should strengthen the basis for the realization of graded diagnosis and treatment lies in how to strengthen the grass-roots first consultation, that is, the "gatekeeper" system, the grass-roots first consultation can standardize the order of medical treatment, promote the division of labor and cooperation between different medical institutions, guide the rational allocation and utilization of medical resources.
    Foreign practice shows that the more developed the medical service system, the more unable to seek medical treatment at will, and those countries that strictly implement the "gatekeeper" system have basically formed a clear division of labor of the medical network, its primary clinics, community hospitals and other primary health care places of high efficiency in the use of medical services, medical institutions between the graded treatment order is good.
    countries have been emphasizing the
    strong grass-roots level", the implementation of the family doctor contract system and the current promotion of the construction of a close-knit medical society, but the poor results are due to the "gatekeeper" system lack of sufficient quality "gatekeepers."
    the "new medical reform" so far, the central and local governments have invested trillions of dollars in infrastructure construction and medical equipment allocation of primary health care institutions, but a large number of gaps in general practitioners or family doctors have limited the implementation of the first consultation system.
    according to the international low standard of 5,000 residents per GENERAL, the gap of qualified general practitioners in China is still 400,000 (China Hospital Dean, 2019).
    and the current "can not go up and down" personnel management system, too low pay distribution system, is not conducive to the stability and development of the grass-roots physician team.
    addition, strengthening the primary care system at the grass-roots level will require the state to carry out homogeneity medical education reform and promote the reform of the financial management of the "two lines of income and expenditure" and the catalogue of essential drugs.
    the absence of a reasonable off-site consultation mechanism for off-site referral is a civilian policy to meet the needs of patients with high-quality medical resources and to solve the "last kilometer" problem of graded diagnosis and treatment.
    But the current lack of a reasonable referral mechanism to guide medical treatment in different places, the performance of disorderly medical treatment "chaos", resulting in its flow direction to Beijing, Shanghai, Guangzhou, Chengdu, Nanjing, Wuhan, Hangzhou and other cities, the flow of the number of several times the growth trend.
    2018, the cost of hospitalizations across provinces was settled directly 1.32 million times, 6.3 times higher than in 2017 (National Health Insurance Administration, 2019).
    disorderly medical treatment not only causes the payment pressure of the medical insurance fund of the reimbursement place, weakens the ability of local medical institutions, but also increases the burden of patients.
    , it is urgent to build a reasonable mechanism from the aspects of population definition, referral filing, reimbursement ratio, payment method, supervision and management.
    Graded diagnosis and treatment needs to establish a scientific hierarchical payment mechanism in primary care, most regions of China, through different levels of medical institutions medical insurance differential payment policy, and gradually open the primary health care institutions and large hospitals of the starting line and payment ratio gap, in order to promote graded diagnosis and treatment.
    But the effect of this differentiated payment policy is not obvious, no graded payment can not achieve graded diagnosis and treatment, how to motivate large hospitals to release the first diagnosis and chronic diseases, how to strengthen the service capacity of primary medical institutions, the need to establish a scientific hierarchical payment mechanism.
    graded payment should not only classify the current type of medical services, but also establish a multi-composite payment model for different medical institutions with different attributes such as health management-slow disease management-outpatient services-inpatient medical treatment-rehabilitation treatment-long-term care-peaceful treatment. Incentive reimbursement, comprehensive and specialized hospitals to establish DRG-PPS payment mechanism based on total budget management, to control the quality of hospitalization of major diseases, while primary medical institutions to establish based on health promotion, chronic disease management and other performance payment mechanism, improve the treatment of common diseases and health management effects.
    In addition, the establishment of a hierarchical payment mechanism to promote graded diagnosis and treatment also requires the implementation of the financial responsibility for reasonable compensation to medical institutions, the establishment of a health file, chronic disease management, outpatient treatment and inpatient treatment integration of personal health information and diagnosis and treatment information system, the establishment of family doctors, outpatients, residents and clinical experts, the establishment of primary medical institutions non-clinical performance evaluation, hospital clinical efficacy evaluation mechanism, and the gradual establishment of "the same disease homogeneity and price" of medical services pricing mechanism.
    a whole, the practical problems at the level of these institutional mechanisms hinder the formation of a reasonable hierarchical order of diagnosis and treatment of "primary consultation, two-way referral, rapid and slow division of treatment, and up-down linkage".
    , it is imperative to reconstruct China's hierarchical medical service system, focus on promoting the reform of public hospitals, strengthening the primary consultation system at the grass-roots level, regulating medical treatment in different places, and implementing graded payments.
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