Lecture 2: Planning-the reform of the medical system under the market economy system

The reform of the medical system is a big issue for the whole people. At present, many doctors have opinions, because their hard work is not fully recognized by society; patients also have opinions because they are worrying about "difficult to see a doctor" and "expensive medical treatment"; relevant government departments that control medical insurance costs also have opinions because "it is" based on "Medicine" has continuously pushed up medical insurance premiums, so that the problem of incompleteness is becoming increasingly serious. Is everyone arguing that the hospital should "make money" or "treating the disease"? The focus is that if the hospital takes "cure" as its own responsibility, then it should highlight "public welfare", and it is best not to make a profit. In fact, this dispute has been missed. On the one hand, hospitals and doctors are hospitals and people at the beginning of socialism. If they can only dedicate and cannot gain, then enthusiasm will be reduced. If the doctor loses the enthusiasm of healing, the patient will lose the doctor who is good at treating the disease. On the other hand, if the hospital and the doctor only make money, it is obviously not possible.

Change the way of thinking: If you can grasp the key to the medical industry of "efficacy", link the reimbursement of drug expenses to the "efficacy", so that the "efficacy" hospitals and doctors earn enough wages to get the best in other industries. Do n’t the patient cure patients if they have the same or more income? Of course, isn't the doctor satisfied like this? Well, look at the patient, and the "efficacy" patient is naturally satisfied. Looking at the managers of medical insurance, due to the linkage of drug expenses to the "efficacy", there is no possibility of "support for medicine", and the medical expenses will be reduced. As a result, the results of a relevant party were satisfied and happy, and this was the starting point and home point of the reform of the medical system.

(1) Difficulties in the reform of the medical system

The problem of the reform of the medical system is: on the one hand, public hospitals are overcrowded, and the number one is difficult to find; on the other hand, small hospitals have no disease and difficulty in survival. On the one hand, doctors' labor cannot be recognized and respected, and can only rely on "medicine" to make up for "lack"; on the other hand, patients are always in the weak position, shuttled in people's piles, and cannot enjoy medical services under competition. Obviously, this system is the national interest, but the reform is also difficult. Introduce private capital to apply for medical treatment. The reputation of private hospitals cannot be trusted to patients. After all, treating people's lives is related to people's lives. Any mistakes may never be remedy. Service and expensive treatment and service costs, such as the introduction of unpredictable impacts on the entire medical system. The reason is obvious: the main undertaking of the medical expenses of social employees is social medical insurance. For employees who enjoy medical insurance, who is unwilling to go to a more expensive foreign -funded hospital to enjoy better medical and services in the case of medical insurance! If these hospitals are opened, the consequences are imagined:

First, the national medical insurance fund cannot afford it;

Second, the existing local public hospitals will face a comprehensive elimination, and a large number of medical personnel may change or laid off;

Third, the patients full of people will be transferred from today's public hospitals to large foreign hospitals.

The above results obviously do not meet national interests.

This contradiction result shows that it is necessary to face the reform of the medical system with new reform ideas.

(2) Grasp the "efficacy", the road to reform is at the foot

Plan-The market economy system has grasped the unified goal of the interests and power restrictions between hospitals, patients, and medical insurance managers among the interests and power constraints. The new system will take the "efficacy" of hospitals, patients, and medical insurance administrators in the game of the power game of several associated body power. The "hub" of the government management region is responsible for formulating the rules of medical insurance reimbursement in accordance with the macro -carrying capacity of medical insurance, and the implementation of the regulatory rules; each hospital achieves checks and balances of "medical" power through the competition of efficacy; Change the status in the relationship between doctors and patients.

Under the "efficacy" reimbursement system, the medical expenses reimbursed in medical insurance in medical insurance will be reimbursed by the "hospital's medical expenses notes" to "reimbursement according to the treatment effect" in the hospital's bill, that is, the patient is in The part of the pharmaceutical expenses that can be reimbursed in the medical insurance is just a list of details published by the "hub" effect evaluation and management department in the new system, and the reimbursement quota determined according to the category such as "healing", "maintaining", and "not cure".

(3) Difficulties defined by "efficacy"

"Efficacy" is the starting point and home point of medical care. "Effective efficiency" is used as the "bull nose" for the reform of the medical system and the basis for reimbursement of "efficacy" as the basis for reimbursement of medical expenses. It is easy to accept. The key is whether it is operable. First of all, find difficult points.

1. Difficulty in the definition of disease definition

How to measure the name of the "efficacy" is defined. For example, the doctor's diagnosis is "a cold" -really "a cold"? For many chronic diseases, what is the possibility of cure difficulty, control and slowing the development of the disease? and many more. Facing so many complex situations and special circumstances, you need to solve the problem of defining the disease based on the reimbursement.

2. The difficulty of lagging efficacy

When you see a doctor, you must pay medical expenses first, but the efficacy needs to be delayed for a while to know. There is also a situation: there was no cure in a hospital, and a hospital was changed. The result was cured. The fact that the previous hospital was a hospital that really cured the disease. There may be a lot of such special circumstances, and there are many problems that need to be solved. 3. Difficulty in the efficacy definition

The disease is complicated. For example, how to define whether a chronic disease is cured or not cured, how to quantify the treatment effect, how to quantify it during reimbursement, and so on. Such some specific problems are not solved, and medical reforms with efficacy as the outline cannot be achieved.

(4) Difficult to overcome the strategy

The surface of these problems is a problem, but as long as the difficulties are subdivided and some difficulties are handed over to the designed constraint mechanism to solve it, the problem will have a policy of overcome.

1. Confirmation and unrealistic diagnosis

The diagnosis and unprepared diagnosis of disease treatment are two basic states in the treatment process.

(1) Questable medical treatment. The diagnosis medical treatment is a medical behavior after the doctor has made a diagnostic conclusion. The conclusion of this diagnosis may be correct or wrong. Assume that the new system has a compulsory decision: "Confirmation" can double the reimbursement of reimbursement and treatment costs with "unrealized" (hypothetical value), and then increase the doctor's "diagnosis" treatment fee to the main income level of the hospital's main income level superior. Such a restriction system design makes the "diagnosis" medical treatment in the treatment become the basis for hospitals to survive and develop. With such a constraint mechanism, the hospital will definitely have the internal motivation to do a good job of "diagnosis" medical treatment, because only the "diagnosis" can be incorporated more than the medical expenses.

In accordance with the principle of "correct inference" first, the doctor's "confirmed" conclusion is used as the name of the disease, and reimbursed according to the "hub" directory, and then uses the subsequent constraint mechanism to ensure the correct "confirmed diagnosis" conclusion of the mechanism.

(2) "Unprovable" medical treatment. "Until diagnosis" medical care can only be reimbursed for examination costs and maintenance costs at the level of patient disease (the medical expenses for reimbursement should be lower than the cost of diagnosis medical treatment). In other words, if a hospital cannot always "confirm the diagnosis" in time, the hospital's medical expenses will be less, so that it is at the level that can only be maintained and difficult to develop. This design generates the inherent driving force of the hospital's "diagnosis" medical treatment from the mechanism.

The "unrealized diagnosis" was not only restricted by the reimbursement system, but also was restricted by the choice from the patient. When a hospital never gives patients "diagnosis", the hospital will definitely be converted, and this conversion itself is the competition between hospitals.

2. Determination of efficacy

(1) Cure. Patients are cured without looking at the same disease within a prescribed time (time were announced by the "hub" directory). It should be said that this identification method is scientific (there may also be some special cases, but it will not affect the implementation of the overall plan, and it can be made up by improving the system), and it can be implemented. First of all, this behavior is unable to directly control the patient's patient, and is inherently restricted. Secondly, the use of the network of computers to be reimbursed by medical expenses reimbursement management institutions can make precise and timely judges, because the patient's consultation situation is accurately found in the country and the world's networking systems. Through this technical means, you can achieve precision assessment of the curative effect, so that the curative effects are based on reimbursement.

(2) Maintain. Patients continue to use the same diagnostic conclusion for treatment. Maintaining the efficacy will obtain the reimbursement quota that is less than "healing".

(3) No effect. The patient used another diagnosis to cure the same disease; or healed the same disease multiple times, and exceeded the time and number of times allowed in the "Hub" release directory. It can automatically determine "no efficacy" by the computer system. "No efficacy" means negation of hospital treatment plan, which means economic losses of hospitals. The hospital may deliberately conceal the illness of repeating the doctor -the design of the constraint mechanism can be restricted by giving a certain subsidy for "no efficacy" patients. When the patient can receive a certain compensation after "no efficacy", the patient will definitely strive for this right, and this fight is exactly restricting the hospital. Of course, patients also need to provide a test conclusion, rather than relying on their own feelings to prove "no efficacy."

3. Mastery treatment of curative effect

The efficacy requires treatment before it can be known, and the payment must be completed before the treatment starts. How to deal with this time difference also needs to be considered. It is necessary to pay attention to this here:

(1) The hospital is a continuous fixed institution. Since its establishment, it must have the minimum medical conditions. In other words, the hospital has certain compensation. If you adopt regular settlement, more retreat and less supplement, the lag in time is no longer a problem. Hospital's compensation capacity is the guarantee of implementation.

(2) You can also extract a certain percentage of treatment risk funds from the medical expenses paid for each payment as a measure to solve the effective time difference.

(3) As long as the hospital wants to continue to survive, any requirements that meet the requirements can be implemented, including refund and compensation.

4. Medical expenses reimbursement and periodic total settlement

According to this design, all reimbursement is divided into two stages. The first stage is forecasting. In principle, according to the "diagnosis" of the hospital, the "hub" catalog is expected. During the reimbursement, the emergency and outpatient clinics are also distinguished to ensure the timely treatment of emergency patients. For example, the patient is reported to actual sales, but the number of reimbursement has been restricted by the emergency department; while normal outpatient clinics, patient medical expenses reimbursement will distinguish "confirmation" and "unrealized diagnosis". You can reimburse directly by the "Hub" directory. The "hub" catalog forecasting will be supplemented in the implementation. After the prediction of sales, the medical expense management system will track the subsequent medical reimbursement of patients to sell patients to automatically confirm whether it is "cure" or "maintenance" or "no efficacy". These judgments will determine the regular summary. For example, "no efficacy" will deduct the prepaid medical expenses, and "cure" may double the medical expenses, while "maintenance" will not return nor deducted. Of course, this requires re -calculation and design, which is a topic from practice. 5. Computer management system ++ network provides technical support

It is difficult for people to manage so many things for each patient, but it is not a problem for computer systems. The Internet provides information channels, computer technology, data storage technology and other information processing technology can fully support such a medical system reform.

6. The principle of handling of unsatisfactory matters

As an important reform design, it is difficult to think of all issues, but as long as the following principles are grasped, the reform of the medical system with efficacy as the core of reform can be completed.

(1) Establish an internal constraint mechanism to make the mechanism solve difficult problems. No one has the ability to manage every patient with a variety of problems, and it is also not able to manage the hospital's problems with so many problems. However, when designing a mechanism of mutual restraint, the constraint mechanism can use the most serious and responsible attitude to make people unable to use the most serious and responsible attitude to make people unable to use the most serious and responsible attitude. Do what you complete.

(2) Equipped details. Any system will have an incomplete place, and there are also a lot of problems in the current medical system. The new reform plan should pay attention to the reform of the fundamentals, and give up the resolution of small problems. First, solve the large and main problems, and then gradually improve it to avoid small issues affect the entire reform.不要追求表面的完美，不要追求没有任何问题，不要追求不出现任何问题，因为人们只能在大问题的解决下开启改革，又在改革中不断解决小问题，再在解决小问题中继续推动和Improve reform.

(3) More dependent procedures and rules. The reform of the medical system must be standardized and procedural, so that more tasks are automatically completed by computers and systems. The work should be implemented in accordance with the rules to avoid human intervention.

(5) Open under effective control and promote competition in the medical industry

1. The qualification for medical insurance reimbursement is expanded to all hospitals with qualifications

In the new system, hospitals that can enjoy medical insurance reimbursement can be expanded to all qualified hospitals. Regardless of public, private, domestic, foreign capital, as long as there is medical qualifications, they can obtain medical treatment fairly. It not only realizes the fair competition in different types of hospitals, but also expands the number of hospitals that patients can choose.

2. Patients choose the hospital according to their own wishes

Patients with different spending power can choose hospitals with different service levels under the premise of how much they may pay -to realize the free choice of patients to hospitals at different service levels. At the same time, through the free choice of patients' medical treatment, the mutual competition of various hospitals has been promoted.

3. Reimburse in medical insurance according to "efficacy"

In the new system, the medical expenses for the reimbursement of patients are reimbursed from the medical insurance fund based on the "efficacy", and "adopting medicine with medicine" is no possible. As a result, it triggered the competition of the hospital around the essential goal of "efficacy". For example, if a cold patient, no matter which hospital, you can only reimburse 100 yuan according to the directory of the "hub" effect evaluation and management department, then the patient can choose to see a more effective hospital to see a doctor. In this way, no matter the surname or the surname of the hospital, it will grow in the competition. On the contrary, hospitals with expensive medical expenses and no effect will be eliminated. This is the goal and direction of the hospital's focus on the efficacy and reducing treatment costs.

4. Regional "hub" adjust the treatment reimbursement directory in a timely manner

In the new system, the "hub" effect evaluation management department will regularly adjust the reimbursement quota of the disease reimbursement catalog according to the changes in medical technology, and dynamically balance the income and expenditure of medical insurance premiums. For example, when the cost of treating colds in each hospital is only 100 yuan, the reimbursement amount will be automatically reduced to 90 yuan (hypothetical value); when the medical insurance premiums are balanced, the scope of the insurance reimbursement catalog is expanded, and it costs to the people. Of course, if everyone needs 200 yuan or more, it will naturally adjust the quota management in real -time adjustment according to the tolerance of the medical insurance fund.

Through these measures, the advancement of hospitals to compete around "efficacy" and services, and will provide patients with high -quality and effective treatment services.

Reprinted from the "Plan-Market Economic System Theory" (Published in April 2019) Chapter 13 "Planning-The State-owned Enterprise, Public Economic Economic Economic System and Pension Plan for the Market Economy System," some texts have been deleted and of Adjustment.

Text/Pan Zhikai: "Planning-Market Economic System Theory" (Published in April 2019 in Intellectual Property Press) Author

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