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According to the 49th Statistical Report on the Development of China's Internet Network released in 2022, by the end of 2021, the number of online medical users in the mainland reached 298 million, accounting for 28.9% of the total Internet users; since the report first released online medical user data in 2020, the user scale has reached a new high.
Changes in online medical users in the past two years, data source @ Statistical Report on the Development of China's Internet Network
The growth of user scale has witnessed the rapid development of Internet medical care and achieved two major service forces.
At present, the two main forces of Internet medical services include: enterprises lead the construction and operation of Internet platforms, attract doctors from different hospitals to settle in, and serve users (hereinafter referred to as "third-party platforms"),second, the hospital, especially public hospitals, lead the construction and operation, mainly using the hospital's doctors to provide consultation and follow-up and related services for patients in this hospital (hereinafter referred to as "public Internet hospitals"), of course, the technical or operational work of some public hospitals is still involved by enterprises.
The epidemic has accelerated the progress bar of Internet medical treatment, and promoted the construction and upgrading of public Internet hospitals. According to the statistics of the Eggshell Research Institute of Arterial Network, public Internet hospitals currently account for about 70% of the national Internet hospitals, and the number has occupied an absolute advantage; the operation of public Internet hospitals represented by the top three has also begun to gradually enter a better situation.
Public hospitals grasp the core medical service elements such as doctors, equipment, and places, and have perfect offline service capabilities, which has become an important support for online services. With the growth of public Internet hospitals, will the living space of third-party platforms be squeezed? Does the relationship between the two have to be "one way or the other"? Where is the path of cooperation between the two sides? These are all questions worth pondering.
Accounting for 70%, public Internet hospitals present three major characteristics
Public Internet hospitals have not stopped since they entered the outbreak period in 2020.
Before 2018, Internet hospitals were mainly explored by enterprises, and public hospitals were less involved. However, since 2018, it has gradually entered the stage of hospital dominance, especially since the epidemic, the gap between the two is even greater. According to the Internet hospital information combed by the Arterial Network Eggshell Research Institute based on public information, public Internet hospitals have accounted for 70% of the total Internet hospitals.
At the same time, compared with the construction of technology platforms during the epidemic period in 2020, public Internet hospitals have been upgraded again, with increasingly rich types of services and gradually increasing service volumes, and have now played an important role in the medical service system. Arterial Network has previously sorted out a number of eye-catching operational data and experience in "".
On the whole, public Internet hospitals at this stage show the following characteristics:
First, it can better solve the reimbursement problem for patients.
This is mainly reflected in the access to medical insurance payments.
Public Internet hospitals as a whole migrate some offline patients online, and medical insurance costs are essentially moved from left hand to right hand. As a public hospital that is the designated point of medical insurance, its Internet diagnosis and treatment services have a smoother channel whether it is signing a supplementary agreement or opening up the corresponding interface. During the epidemic emergency, some hospitals in Beijing, Shanghai and other places even went online at the same time as the Internet hospital was launched, and the medical insurance payment was launched simultaneously.
According to a survey conducted by arterial network, 53% of the hospital-led Internet hospitals have been able to achieve medical insurance payment. Medical insurance has become a major advantage for public Internet hospitals to attract patients. In the future, with the expansion of medical insurance coverage of public Internet hospitals and the expansion of the scope of off-card payment, this advantage will be more obvious.
Secondly, based on the closed loop of treatment in a single hospital, it can realize the effective connection of online and offline services.
Public Internet hospitals are supported by perfect offline services, including inspection, treatment, hospitalization, etc., and the advantages of these projects have been reflected in online services.
For example, online self-service issuance of inspection and examination forms has become a project with a high service volume of public Internet hospitals. Tongji Hospital affiliated to Tongji Medical College of Huazhong University of Science and Technology will serve more than one million patients online in 2021, and the number of self-service invoices will reach 567,000. In 2021, the number of online follow-up visits in Hunan Children's Hospital was 11,000, and the number of self-service pre-diagnosis tests reached 176,000. Whether the patient is visiting online or offline, the doctor can retrieve the report of these tests.
On the basis of various service projects, public hospitals can form a closed loop of online and offline treatment in individual hospitals. In the closed loop, online consultation and follow-up, offline inspection and examination, offline diagnosis or treatment and other links are connected; and these links belong to the same hospital system, which can maximize data interoperability and bring a seamless medical experience to patients, which not only reduces the number of patient visits to the hospital, but also achieves sufficient doctor-patient communication based on comprehensive, true and convenient data.
Finally, the benchmark of public Internet hospitals represented by the top three has emerged.
In addition to the earlier hospitals such as Guangdong Provincial Network Hospital, Zhejiang Yi Internet Hospital, and Shandong Provincial Third Hospital, public hospitals have emerged a number of benchmarks under the promotion of the new Internet medical policy and the catalysis of the epidemic, such as West China Hospital of Sichuan University, Tongji Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology, Peking University Cancer Hospital, etc.
Most of the new benchmarks are the country's top three hospitals, which have a high level of diagnosis and treatment, experts and famous doctors gather, the scope of patients covers all parts of the country, and the convenience of online services is more obvious; among patients, the proportion of patients with difficult and serious diseases is high, and the demand for follow-up is strong; at the same time, large hospitals also have more sufficient funds to invest in the construction and operation of Internet hospitals.
These benchmark hospitals provide online and offline integrated diagnosis and treatment services, effectively solve the problem of patients traveling long distances to seek medical treatment, save expenses for patients, and their service effects are also reflected in the operational data. For example, the Internet Hospital Management Office of West China Hospital coordinates the work of the hospital's medical quality and safety management department, clinical pharmacy department, information technology service department, external development department, financial performance management department, etc., to provide patients with online and offline integration services; at present, the average daily online diagnosis and treatment volume has reached about 2,500 person-times, and the average daily inspection and examination is more than 3,000 times, accounting for a large proportion of the overall outpatient service volume.
But on the other side of the good development momentum, public Internet hospitals also reflect shortcomings: limited by medical insurance policies, no matter what level of doctors are charged according to ordinary doctors, doctors and hospitals have limited enthusiasm; the hospital itself is online and offline closed-loop, the convenience of patients outside the closed-loop is not high, in most cases, not in the hospital corresponding department offline treatment, it is impossible to follow up online, the Internet value has not been fully reflected; the third-class hospital is certainly at the forefront, However, the Internet hospitals of many other medical institutions are still in a state of construction and non-use.
"Two-way rush" between public hospitals and third-party platforms
In view of the shortcomings of public Internet hospitals, there have been third-party platforms that have generated positive interaction with public hospitals: public hospital doctors have settled on third-party platforms, becoming the basis for platform services and receiving corresponding returns; after years of accumulation, third-party platforms have a wide coverage of patients, diverting their flow from outside the closed loop of public Internet hospitals, and even directly participating in the operation of public Internet hospitals.
The enthusiasm of experts is high, driving young doctors to enter the third-party platform
In the past, when we talked about the enthusiasm of doctors on the line, we theoretically thought that the enthusiasm of expert doctors was not high, because they already had saturated offline work and had no time to provide online services. Is this really the case?
A recently published data study shattered that perception. In 2022, researchers at Peking University, Imperial College, and Harvard University published a cover research paper on understanding online dual practice of public hospital doctors in China: a mixed-methods study in Health Policy and Planning. The paper examines the multi-site practice of doctors in mainland public hospitals on third-party platforms.
The registration of doctors in public hospitals with Internet medical platforms, source: Health Policy and Planning
The article selects four platforms with early establishment and large scale of doctors, namely Good Doctor Online, Spring Rain Doctor, WeDoctor, and Ping An Health, and uses its registered doctors as research samples. The paper points out that at least 16.51% of doctors in the country have registered on Internet platforms to provide services.
From the perspective of doctor level, about 33.49% of the chief physicians of public hospitals in the country register to provide services on the Internet platform, and the proportion of deputy chief physicians online is about 21.5%; the proportion of attending physicians and residents is slightly lower.
Combined with the regional dimension, in Beijing, Shanghai, Guangzhou and other areas where medical resources are concentrated, the proportion of chief physicians in public hospitals is about 70%, the proportion of deputy chief physicians is between 40% and 50%, and a large proportion of attending physicians and residents have also been online; online multi-point practice is more concentrated in the group of doctors in public hospitals in large cities.
The arterial network believes that these data can illustrate at least two problems:
First, from the numerical point of view, the higher the level of doctors, the less the number, if you compare between the doctor levels, the number of high-level doctors online will naturally be less than the number of general doctors. However, from the perspective of the proportion of doctors at all levels on the line, the above data still changes our cognition from another perspective: even if the expert doctors are busy, the social status and income have reached a certain level, and there is still a high enthusiasm for going online.
Chief physicians and deputy chief physicians represent high-quality medical resources to a certain extent, and more and more of them recognize the Internet medical platform, which also has a leading role for young doctors. In fact, the model of receiving doctors by the doctor team implemented on many platforms is the model in which expert doctors lead subordinate doctors to provide services. Access to more and more doctor resources is the basis for the development of third-party platforms.
Second, the above research data is taken from the epidemic, that is, after public hospitals began to vigorously build Internet hospitals; among them, the development of Internet medical care in Guangzhou was originally earlier, Beijing and Shanghai were affected by the epidemic, public Internet hospitals developed rapidly, and a large number of top hospitals joined. In this context, doctors in Beijing, Shanghai and Guangzhou, especially experts, still maintain a high up-to-line rate, which means that public Internet hospitals have not "snatched" doctors.
In addition, doctors of different levels receive treatment on the third-party platform, and while meeting the needs of patients at different levels, they can also obtain income corresponding to their qualifications and diagnosis and treatment levels.
The third-party platform accurately introduces closed-loop patients for public hospitals
What can doctors gain after entering the Internet medical platform?
From the perspective of direct revenue, accurate patient and offline revenue growth can be obtained.
In 2021, the School of Public Health of Capital Medical University conducted an analysis of the impact of doctors opening online medical services on third-party platforms. The results showed that the doctors who opened personal homepages on the third-party platform increased their annual outpatient volume by 748 times compared with the doctors who did not open them, and the annual diagnosis and treatment income increased by 27.55%.
Another case is that in the case that Shanghai Children's Medical Center already has its own Internet hospital, 80% of the doctors above the attending doctor still open services on the third-party platform. President Zhang Hao once mentioned that while the doctor receives treatment on the third-party platform, the hospital will also register with the third-party platform to achieve accurate patient diversion. For example, after the patient is consulted through a third-party platform, if necessary, he can directly click on the appointment link to achieve an accurate appointment. In 2021, the hospital's accurate appointment of patients hit the highest value in the calendar year, and Zhang Hao believes that a large reason is that the hospital and the third-party platform open a registration channel and are imported by doctors online.
Wang Hang, founder and CEO of Good Doctor Online, believes that public Internet hospitals are first of all a kind of emergency capacity reserve to ensure that basic medical services in special periods are not interrupted; for tertiary hospitals, the daily online follow-up business should be to ensure the continuous treatment of difficult and major cases, rather than the ordinary follow-up diagnosis of common diseases and chronic diseases. The main positioning of the third-party platform is online grass-roots hospitals: first, use its own Internet technology to expand patient coverage; second, as far as possible to reach more doctors, through AI triage, live broadcast, free diagnosis and other ways to accurately screen patients, and so that doctors can refer patients to their own hospitals; third, do some low-risk common diseases, chronic diseases online follow-up.
"The cooperative relationship between the two sides is the relationship between grass-roots hospitals, specialized hospitals and general hospitals, and it is also similar to the cooperative relationship between the upstream and downstream industrial chains." Wang Hang said that the focus of the cooperation between the two is screening and referral, which may be the online hierarchical diagnosis and treatment system of the future network society.
From the perspective of indirect benefits, hands-on practice on third-party platforms will become the experience of self-built Internet medical services. Zhang Hao, president of Shanghai Children's Medical Center and pediatric cardiac surgeon, and Gong Daxin, director of the management department of the Wisdom Hospital and deputy director of the Department of Urology of the First Affiliated Hospital of China Medical University, are all doctor users of the third-party platform for many years, and after the boom of public Internet hospitals, they have become the managers of self-built Internet hospitals. It is understood that when these senior Internet doctors develop the Internet medical services of their hospital, they have learned from the practices of third-party platforms in terms of doctors' personal homepages, fragmented time utilization, and patient treatment procedures.
Co-construction and operation, third-party platforms and public hospitals complement each other's advantages
The operation of Internet hospitals involves market development, how to absorb patients, relying on the hospital itself will have various difficulties. At present, most of the large-scale Internet medical platforms have laid out the business of jointly building and operating Internet hospitals with public hospitals, and tried to cooperate with the model.
Third-party platforms and medical institutions at all levels in the region to carry out online and offline resource restructuring, is one of the types of attempts.
"During the extraordinary period of the epidemic, platform-based Internet hospitals have fully demonstrated the advantages of resource allocation and accurate services. It is also at this point in time that the National Medical Insurance Fund has introduced policies to purchase digital medical services in Internet hospitals on a large scale. Liao Jieyuan, founder, chairman and CEO of WeDoctor, concluded.
In Liao Jieyuan's view, in a period of new development opportunities, the key value "landing point" of Internet hospitals at present and in the future is the Internet medical association, which is jointly established by third-party platforms and medical institutions at all levels; the Internet medical association shares the pressure of large hospitals, enhances the capacity of grass-roots hospitals, improves the efficiency of medical insurance and commercial insurance payments, and improves the efficiency of supply chains, explores the establishment of Chinese-style health management organizations (HMO), and also shows the commercial value and development potential of great imagination.
In view of the lack of operational capacity of public Internet hospitals, third-party platforms can also participate in supplementing operational manpower, integrating out-of-hospital resources, and improving pre-diagnosis and post-diagnosis services for hospitals.
Qiu Jialin, founder of MicroMai, said that the state has put forward high requirements for the high-quality development of public hospitals: grasp the fine management, improve the quality and efficiency of medical services, and shift from scale expansion to improving quality and efficiency. So, how to "use" the original Internet hospital on the basis of "having"? This became the most important development point for the next step.
"The third-party platform and the hospital jointly use the 'Internet + whole course management' model to establish a continuous connection between patients and hospitals and medical care, realize the efficient operation of limited medical resources, provide technical support and management paths for doctors, and turn a single random medical service into a cyclical and customized active management." Qiu Garin said that through this model, the tracking and management of patients after diagnosis, examination, postoperative and post-hospital can improve patient compliance, and also promote the proportion of medical service income in hospitals.
"The cost of public hospitals to build internet hospitals is relatively high, relying on third parties or cooperating with third parties, which may share the construction costs, but the game between the public welfare and interests pursued by both sides may have certain restrictions on the development of Internet hospitals." Wu Yongkang, director of the Internet Hospital Management Office of West China Hospital, believes that "how to build it specifically? Different hospitals need to comprehensively consider taking their own construction and operation mode according to their needs and their own conditions, and perhaps they can explore different hospitals to build an Internet hospital construction data model according to their respective needs, positioning, goals, and offline operations, and obtain a construction model suitable for this hospital through the calculation of different parameters. ”
Wu Yongkang said that in any case, the construction of Internet hospitals in the early stage of everyone is a "guinea pig", some projects may fail, but successful projects will become pioneers and leaders, therefore, we need to work together to explore and actively communicate, reduce the cost of exploration, and promote the rapid and healthy development of Internet hospitals across the country.
Overall, public hospitals provide the most basic service strength for the third-party platform, and the third-party platform gives back to patient traffic, operational capabilities, etc., and the two sides do not have a direct meaning of "one after the other", but a "two-way rush" of mutual achievement. For a long time to come, the most important task is to jointly accelerate the penetration of Internet medical services.
The cooperation mechanism is not yet mature, where is the direction of exploration?
Of course, it is undeniable that there are still many public hospitals that hold a wait-and-see or exclusionary attitude towards third-party platforms. Arterial Network learned from its exchanges with public hospitals that its concerns mainly come from several aspects: the professionalism of the platform, whether it will affect the public welfare of public hospitals due to excessive profit pursuit, and whether it can effectively play the value of medical services.
At present, the cooperation mechanism between public Internet hospitals and third-party platforms is not mature, and these concerns have become obstacles to the establishment of cooperation mechanisms. In response to these concerns, how should third-party platforms respond? The arterial network believes that there are mainly the following points.
Improve the professionalism and standardization of third-party platforms.
Medical care has a very high threshold, and the operation and practice of Internet hospitals have also been constrained by a series of policies. However, in the view of public hospitals, in addition to registered doctors, third-party platforms have different backgrounds, insufficient professionalism, and insufficient standardization of medical procedures. Even if public hospitals intend to introduce third-party platforms, they dare not rush to cooperate because they are worried about the security risks brought about by non-standardization.
In 2021, the National Health Commission issued the "Detailed Rules for the Supervision of Internet Diagnosis and Treatment (Draft for Comment)", which proposes that Internet diagnosis and treatment should be carried out by the entity medical institutions on which it relies to carry out online and offline integrated quality control. Although the new regulations have not yet been officially implemented, this also puts forward higher requirements for the standardization of online diagnosis and treatment. If a third party and a public hospital jointly build and operate an Internet hospital, it is necessary to carry out integrated quality control with it.
In addition, before the Detailed Rules for the Supervision of Internet Diagnosis and Treatment (Draft for Solicitation of Comments), the relevant policies on Internet medical treatment did not have separate requirements for the preservation of medical record data. In practice, some Internet medical platforms ignore the importance of this link. Public hospitals, on the other hand, refer to offline outpatient regulations to regulate the retention of medical record data for online services. In the view of public hospital managers, Internet medical treatment is essentially a medical behavior, and in the absence of separate provisions, it should be carried out with reference to existing regulations, which is also one of the embodiment points of professionalism and norms.
In general, in the case of a mature regulatory system, public hospitals have always tightened the "string" of medical safety, and some third-party platforms are still lacking. Therefore, whether it is from the requirements of the industry norm itself or the cooperation needs with public hospitals, the third-party platform should be standardized with higher standards.
Since 2021, enterprises such as the Medical Federation and Jingdong Health have begun to unite medical experts to establish expert consensus on corresponding diseases and formulate standards for Internet diagnosis and treatment and disease management, which is expected to become one of the ways to standardize the industry.
Explore the balance between public welfare and for-profit and achieve complementarity.
The long-term goal of the third-party platform is to achieve profitability and profitability, which is understandable, while public hospitals should adhere to the public welfare. In the process of cooperation, it is particularly important to find a balance.
Zhejiang Taizhou Enze Medical Center has cooperated with a third-party platform to carry out Internet medical services for 5 years. At the end of 2021, Grace Medical Center carried out a special work survey on Internet hospitals, and the commercialization of innovative service products was one of the problems found in the survey.
How to hack? Chen Tsunami, director of Taizhou Enze Medical Center, suggested that it is necessary to make good use of existing laws and regulations, build an organizational structure conducive to long-term cooperation and sustainable development, and standardize the sharing mechanism of benefits and risks on a contract-based basis; establish a socialized standardized audit system to timely discover problems in Internet medical operations and jointly solve them to enhance the risk prevention and compliance management capabilities of both partners; the service subject, that is, medical personnel independently establish service companies and become the main stakeholders. It has obvious orientation for the business direction and service projects of hospitals and third-party Internet platforms, which is conducive to giving full play to the main role of medical personnel.
Finally, establish a "first aid channel" for special periods.
This is mainly based on emergency considerations such as the epidemic. In fact, during the pandemic, both public Internet hospitals and third-party platforms have done their best to solve problems such as return visits and delivery of drugs to patients – although these efforts cannot be comprehensive, because from the results, they cannot meet all the needs.
At the policy level, Internet diagnosis and treatment can only be followed up, and Internet hospitals also have tips in the pre-diagnosis instructions, if the patient's condition is urgent, please go to the offline hospital immediately for medical treatment. Based on the policy framework, the frequency of patient demand and other reasons, the Internet medical industry has also been taking chronic disease follow-up diagnosis and chronic disease management as the main business force.
However, in the face of urgent needs, can Internet healthcare do more? Recently, at the expert seminar on scientific prevention and control of the new crown epidemic hosted by the Internet Medical Branch of the China Healthcare International Exchange Promotion Association (online meeting), Yu Guangjun, president of Shanghai Children's Hospital, mentioned that the biggest problem encountered in the operation of Internet hospitals in 2022 is not medical treatment, but drug protection. "The logistics problem is the most prominent, bringing unprecedented pressure to the Internet hospital, and we have to let the hospital pharmacy department organize volunteer distribution."
At present, Shanghai Children's Hospital is cooperating with more drug circulation enterprises and Internet platform enterprises to cope with the problems and challenges faced by drug distribution. At the same time, Yu Guangjun suggested that it is necessary to speed up the establishment of a platform for the circulation of electronic prescriptions to solve the bottleneck of the drug supply chain; set up an Internet medical hotline to dock the emergency emergency demand for help, guide patients and their families to prepare, and improve the direct contact rate of patients and guide them to use Internet hospitals.
In the face of urgent protection needs, the third-party platform can use the characteristics of wide coverage of medical resources to connect patients with the required resources in the case of shortage of medical staff and staff in the hospital.
At present, all walks of life have joined the wave of digital transformation, and Internet medical care is essentially the digital transformation of medical services. However, medical services are not purely technical issues, it involves many people, things, things, and complex processes and interactions, and digital transformation is not something that can be done overnight or relying on a single force. I believe that the development path of public Internet hospitals must also have a platform for the power of third-party platforms.
Resources:
Duo Xu, Jiajia Zhan, Terence Cheng, Hongqiao Fu*, Winnie Yip. (2022). Understanding online dual practice of public hospital doctors in China: a mixed-methods study, Health Policy and Planning, czac017, https://doi.org/10.1093/heapol/czac017
Jiu Jiu, Chen Tsunami, Quan Yu, et al. How can hospitals efficiently utilize third-party Internet platforms? [J]. Chinese Health Talents, 2022(02): 27-33.
MA Chengyu. Will the opening of online medical services affect the amount of offline services and the income of diagnosis and treatment of doctors? Empirical research based on PSM-DID model[J]. Chinese Health Policy Research, 2021, 14(9): 47-53.