The goal is to actively play the advantages of large and medium-sized hospitals in terms of talent, technology and equipment, while making full use of the service functions and network resources of community hospitals, so as to promote the gradual sinking of basic medical care to the community, and the treatment of critical and difficult diseases of the community to large and medium-sized hospitals, so that “small diseases into the community, large diseases into the hospital”. However, although the goal is good, but in reality the implementation of two-way referral is very poor, the good goal is affected by the medical system and face all kinds of difficulties!
What caused the abnormal development of the medical market?
In our country, public hospitals hang the brand of government public welfare but in the market unrestrained unlimited development. The local government, while shouting vigorously to develop public hospitals, does not pay for the construction of due funds. Behind the vigorous development of public hospitals has actually become the process of expansion and reproduction of medium and large hospitals. This expansion must undoubtedly adapt to the laws of the market, which is to add as many beds as possible and fill every one of them to get as much money as possible from health insurance.
Therefore, the patient has become a source of wealth, grabbing patients, stay patients also became the hospital’s greatest desire. Because, with “inpatient” patients can reasonably “generate income”, in this mechanism, how can easily let patients flow away?” Keeping old customers, developing new customers” has become the goal of hospital management at all levels, which is one of the situation of “excessive marketization” of hospitals, objectively causing the loss of public interest.
Another situation, since the implementation of the new health care reform program, most of the township hospitals, community health service centers, patients are not increased, but reduced, in some places even reduced by 50%, while at the same time the patients of secondary hospitals increased by 50%, actually aggravated the difficulty of seeing a doctor, see a doctor expensive. After the implementation of the new health care reform program, the original township hospitals, community health service centers to carry out some of the projects were banned, patients had to go to the second-class hospitals.
In addition, many primary care doctors reflected that many basic drugs in the national basic drug catalog they use are not available (in some places, even the commonly used antipyretics and drugs for diarrhea are not available), and patients have to go to higher-level hospitals for medical treatment. Zero price difference in some primary medical institutions has also become a “legend”, the people simply can not buy zero-price drugs, township hospitals, community health service center internal staff are not enough to buy! What’s more, the township hospitals, community health service center physicians each month’s salary is pathetic, and sometimes not issued.
No patients will not be able to complete the task, but also can not get “performance income”. If it is said that the original doctors rely on “drugs to feed the doctor” can barely subsidize, now is almost completely unmotivated. So it seems that most township hospitals and community health centers should be normal to have fewer patients.
So, forced to survive the pressure, some people through a large number of referrals to receive kickbacks, although this illegal transaction is tantamount to drinking hemlock to quench thirst, but precisely reveals the medical “market-oriented” mechanism “excessive” another layer of meaning, that is, if the government’s lack of investment in primary care institutions continue, a “market-oriented” mechanism will be eliminated these “weak”. For patients, once to the higher hospitals are also reluctant to return to the poor medical capacity and environment of the community and health centers, and even in the community even rehabilitation patients are almost extinct. In essence, the graded segmentation of medical care has long become a pavilion in the air.
Shouting more, doing less
Medical reform advocates the development of two-way patient referral, but basically remains at the level of policy encouragement, government-led initiatives at the implementation level is clearly insufficient, the hospital implementation of zero price difference in drugs, the government does not have the corresponding support measures and reasonable compensation. While drug prices have decreased, the total price charged by the hospital has not, and the entire hospital is still operating under a “market-based” mechanism.” Excessive medical care”, “thin profit more sales” “promotion” approach, there is no and can not be in the market driven by the interests of change. The result is undoubtedly to drive patients to the big hospitals, and the total cost is even higher than before the reform. While the patient reimbursement rate has increased, it has actually increased the total amount paid by the payer (patient and health insurance).
Many of the reforms seen so far are operating under the laws of the market. Without government leadership and input, running solely under the laws of the market will not achieve the goal of promoting the return of the public good in public hospitals. The health care reform has been shouting for a long time to promote the return of public interest in public hospitals but no substantive measures are in sight.
The return of the value of doctors’ labor is an issue that cannot be avoided or circumvented in the health care reform. For many years, the value of doctors’ labor has not been fully and reasonably reflected. With insufficient government input and market distortion, the medical market has formed a disguised situation of “income generation” through non-medical.
The new health care reform must take effective policy measures to attract doctors to sink. In some countries, the government has provided direct subsidies to doctors who are willing to go to the grassroots level, allowing them to maintain a competitive income. Such examples are not uncommon, and we cannot simply “call on” doctors to go to the grassroots. If there are no good doctors at the grassroots level, patient triage will not be possible. If the difference in the value of doctors’ labor between large and small hospitals is small, and doctors are not over-medicated to get bonuses, there will be doctors willing to go to the grassroots.
Not only do some current policies not effectively incentivize and arrange for patient and hospital-initiated two-way referrals, but some policies are contrary to patient and hospital-initiated two-way referrals. For example, the requirement for tertiary hospitals to have a full range of subjects has led to a number of specialties that could have been “decentralized” or do not require so many beds, because of the accreditation and not one less. The major and minor diseases are “all-inclusive” in large hospitals, and there is almost no room for the survival of primary hospitals. Another example is that the establishment of rehabilitation departments is particularly demanding for large hospitals, while ignoring the decentralization rate of rehabilitation patients and the radiation power of rehabilitation guidance services to the grassroots, so that there are many more rehabilitation patients in large hospitals than in the grassroots.
In addition, how the payment system has its own binding force is also an indispensable part of graded segmentation treatment. Local health insurance must not only be supervised in place, but importantly, be very much in the field. The lagging level of professional management of the health insurance team has made the position of large hospitals very strong. As a result, in the big hospitals everything can be reimbursed, the health insurance does not play a binding role, while the primary hospitals have difficulties. Combined with weak incentives, hospitals and patients are willing to use up the “limit” as much as possible. Who would want to return to the grassroots level when both the patient and the hospital are in a favorable situation?
Government must take the lead
The practice of health care reform proves that two-way referral, which is advocated only by the market mechanism and the government’s high profile, will always be a castle in the air. The market mechanism can only gradually eliminate the lower level hospitals that are in a relatively weak competitive position, and it is impossible to have a situation where the upper and lower level hospitals are functioning normally. Therefore, strong government-led measures are imperative!
First, for patients, it is often easy to transfer up and difficult to transfer down. The safety and effectiveness of medical services make it objectively easy for patients to accept upward referrals but difficult to accept downward referrals. Therefore, in the process of implementing two-way referrals, how we can make patients trust primary hospitals and provide them with a quality healthcare experience is the focus of government financial investment, and all reform measures must not deviate from this direction.
The government should take the lead in carefully and strictly subdividing and defining the main scope of care for hospitals at all levels, delineating various responsibilities and room for growth. All initiatives of medical reform should be favorable to the development of primary care, and all preferential conditions should be directed to doctors who develop at the primary level. The people feel that a small disease, a prescription in the grassroots and in the big hospital is not very different, who would like to squeeze the big hospital?
Secondly, a mandatory first-visit system should be established. Unless there is an emergency or the patient is completely free to choose at his own expense, all medical insurance and public expense patients must first pass the first consultation at the community hospital before they can be referred. The propensity of the attendee to have a good first consultation facilitates the implementation of two-way referrals. Therefore, it is important to actively promote the community-based primary care system and try to change the health care habits of those who visit the hospital, so that more people tend to choose to be first seen in the community after they become ill.
Of course, the first-call system is a good provision, and the government has instructed health insurance to issue a document to “solve” the problem, but the first-call system requires the premise that the effectiveness of primary care services can be recognized by the public. The level of diagnosis and treatment, clinical pathways, protocols, medication, etc. for some common diseases and illnesses should be the same or similar to that of large hospitals. If your primary care service is short of people, drugs, equipment, doctors are not only limited and not motivated to treat patients, even a small disease are unable to cope with the patient’s recognition, how to stipulate that people go to the first consultation? Who is to blame for the delay?
Also, in addition to the fact that patients may not want to be transferred to community hospitals, it is also common for large hospitals to be reluctant to transfer patients in recovery back. A patient in rehabilitation after a brain hemorrhage has been in a large hospital for 3 months, but in fact, he only has 1 hour of rehabilitation training and simple medication every afternoon. Comparing the cost of rehabilitation treatment at the community health facility and the large hospital, it was found that the large hospital charges were several times higher than the community health facility. Why didn’t the patient transfer back to the community health service for rehabilitation treatment? The reason given by the large hospital was that it had to be responsible for the patient and it was difficult to say what the responsibility was when problems arose after transferring out. Who can rule out that it is the profit motive that is at work?
The two-way referral, which is regarded as an important tool in the medical reform to solve the problem of difficult access to health care, has been piloted for at least seven or eight years, which has encountered many difficulties, such as: the test checklist is difficult to mutual recognition, social security payment problems, the public perception of medical care, hospitals for profit and so on. Although it seems that all the problems that have surfaced are in the process of being solved, there has been no breakthrough in two-way referrals. The people expect the vision of “small diseases into the community, big diseases into the hospital” will not be just a beautiful legend ? The answer is being unveiled.