(This article was first published on the WeChat public account: Eight Points Jianwen)
At the beginning of 2020, when the most cunning new crown virus in a hundred years attacked Wuhan, only a few hospitals in this city with a permanent population of 11 million had fever clinics and the ability to isolate and deal with new crown virus infections. Many people lined up all night to register because of ordinary fever, and unfortunately cross-infected with the virus in the hospital.
After the epidemic, one day in July 2020, Wuhan started construction of 6 hospitals in one go, including 4 large tertiary hospitals and 2 national medical centers, with a total investment of more than 10 billion yuan – as a reflection on the public health system and some kind of remedy.
This is not an isolated case. Since May, when the domestic epidemic tended to subside, there have been many initiatives and calls to build high-standard medical institutions and professional diagnosis and treatment centers in various places, and the expansion of medical supply capacity has seen action in some cities.
This looks like the opposite: because for infectious diseases, we lack a strong primary health system more than the big three hospitals. The fact that the United States, with some of the world's top hospitals, doctors and medical devices, cannot stop the virus from infecting 4.6 million Americans, is a case in point.
Almost every major public health event is followed by a rethink of the healthcare system, often resulting in a new wave of hospital expansion.
The decade after SARS was the golden age of the development of China's major hospitals, giving birth to a number of black hole-type super hospitals, resulting in a large number of primary medical institutions shrinking day by day.
After this epidemic, there seems to be signs of reincarnation.
This is simply the mystery of the Sphinx in China's medical and health field since the reform and opening up: from policy makers, regulators, to medical reform experts, to media opinion, it seems that they are all supporting "strong grassroots" and "hierarchical diagnosis and treatment", these two words are also the most fashionable words in the field of medical reform in the past 10 years, but the big hospitals still seize the time window of each crisis and reform, divide most of the policy dividends, and drain the medical resources at the grassroots level.
As a result, we have the largest super hospital complex in the world, but it's getting harder and harder to see.
<h1 class="pgc-h-arrow-right" > super hospital, super black hole</h1>
In 2005, 20 years after the first proposed medical reform in 1985, China's State News Agency Xinhua threw out a proposition that will continue to plague China's medical reform for decades in the future: The people of the whole country went to concord - why do ordinary people have to go to big hospitals to see a doctor?
The short essay, which is less than 3,000 words, basically encompasses half of the picture of the medical system (the other half of the picture is expensive to see a doctor): patients from afar have turned the "big" hospital into the railway station site of the Spring Festival, scalpers are peddling number sources at prices tens or even hundreds of times more than a few meters away; small hospitals are empty in the afternoon; and there is a community medical and health center that cannot see one or two patients for a day.
△ Obstetrician and gynecologist Gong Xiaoming made a comparison of the hall of the Union Hospital where he worked and the Cleveland Clinic where he studied Picture source: Gong Xiaoming Weibo
Also in the same year, the Development Research Center of the State Council released an assessment report on the reform of China's health care system, declaring that China's health care reform over the past 20 years has been "generally unsuccessful."
This is an extremely rare official publicly acknowledged failure of reform, and the reason for the failure is attributed to the marketization and commodification of health care.
"The root of the problem is that the trend of commercialization and marketization violates the basic laws of the development of medical and health care, and the problem since China's reform and opening up is to re-take the road that has been identified as wrong." This tendency must be corrected. ”
Policymakers have prescribed two major prescriptions for China's troubled health care reform: one is to increase direct investment in public hospitals, such as building high-rise buildings to buy equipment; the other is to increase financial investment at the central and local levels to build a universal health care network covering 1.3 billion people as soon as possible.
But looking back today, these two prescriptions are actually a prescription: because whether it is the direct investment in hospitals that have increased year by year at all levels of finance, or the growing universal medical insurance, most of them have flowed to public hospitals, especially large hospitals.
Since 2005, in the whole 15 years, large hospitals have taken advantage of the power of policy and taken advantage of China's economic take-off to expand rapidly at an unprecedented speed, and one after another "super hospitals" with excellent equipment and huge scale have grown rapidly.
Today, 15 years later, Peking Union Medical College Hospital, which is the bull's ear of China's medical community, cannot even rank in the top 30 in the ranking of China's "big" hospitals in terms of scale.
As of 2019, there are more than 100 hospitals with more than 2,500 beds, 63 hospitals with more than 3,000 beds, and 11 hospitals with more than 5,000 beds, and the Zhengda First Affiliated Hospital, known as the "world's largest hospital", was born, which had 10,000 beds in its heyday and an annual outpatient volume of 7.76 million.
What is the concept of 10,000 beds in a single hospital? Take Johns Hopkins Hospital in the United States, for example, the two-hundred-year-old hospital that has been ranked third in the list of the best hospitals in the United States for many years has 1154 beds. Several other top hospitals in the United States, such as Massachusetts General Hospital and Mayo Clinic, have around 1,000 beds.
Since 1985, the market and government factions of China's health care system reform have been arguing for many years, and they have been fighting on almost all issues. There is little disagreement on this one issue: China's super hospitals are so big that they almost become a black hole.
A medical professional once compared the super hospital to a pumping machine, which continuously siphoned" the patients, excellent doctors and medical insurance funds of the entire region and even the entire province into their own pockets.
A healthy medical system should have presented a positive pyramid structure, and the number of reliable community health centers and clinics is the base of the pyramid tower, providing medical services such as rehabilitation of common diseases and multiple diseases, and guarding the door of referral; few and fine third-class hospitals are on the tip of the tower, solving problems that medical institutions at all levels cannot solve.
However, after years of expansion of large hospitals, China's healthcare system has become a deformed inverted pyramid.
As the topest existence in China's hospital system, the top three hospitals should have undertaken critical diseases, difficult diseases and scientific research tasks, but the reality is that from organ transplantation to fever, headache and hypertension injection rabies vaccine, it has entered the business scope of the top three hospitals. The First Affiliated Hospital of Zhengzhou University was once the "largest township health center" because of "all patients to receive". (For a detailed report, see "Double-sided Close-up of ZhengDa First Affiliated Hospital, a Super Hospital")
△ The Parking Lot of the First Affiliated Hospital of Zhengzhou University Image source: Visual China
The real community health centers, township health centers, and even first-level and second-level hospitals are shrinking in the loss of patients and the shortage of doctors.
That's why there has been 20 years of pain from the people of the whole country, the patients are angry in the long wait and the short and lack of communication in the process of diagnosis and treatment, and the doctors (mainly the top three hospitals) are full of complaints in the ultra-long standby work.
<h1 class = "pgc-h-arrow-right" > the first year of the medical reform - two mines were planted</h1>
Rome wasn't built in a day, and black holes weren't built in a day.
If you want to know the past and present lives of Chinese-style super hospitals, you have to go back to 1985, the first year of China's medical reform.
Later, it was thought that super hospitals grew up in 2003 when China's universal health insurance became increasingly powerful, but in fact, the seeds of super hospitals have been planted since the late 1980s.
For the evolutionary history of China's medical industry, the financial budget investment over the years constitutes a distinct main line, and every major historical event corresponds to the super inflection point on this curve.
At the beginning of reform and opening up, the only thing that was struggling in the national economy was the phenomenon of "shortage." Lack of medical care and medicine is a common state in urban and rural areas, and most of the country's residents have access to minimal medical and health services. However, due to insufficient financial resources, the past model of relying solely on government expenditure has been unable to meet people's growing demand for medical services and support the development of medical services.
△ Rural clinics with few doctors and medicines Image source: Visual China
The book "Revealing Huaxi" mentions the dilapidation of Huaxi Hospital, which later grew into a super hospital sample, "The house is in tatters, there are rats running everywhere in the hospital, two or three pounds, and sometimes biting the ears of patients; the heating supply in the building is insufficient in winter, the doctor wears a thick cotton jacket and a white coat outside, which is bloated and ugly; there is no air conditioning on hot days, and the doctor wears pants to shuttle back and forth." ”
In 1985, the State Council forwarded the Ministry of Health's "Report on Several Policy Issues Concerning the Reform of Health Work" to give public hospitals the policy of delegating rights and retaining profits. In 1989, the Ministry of Health led five ministries and commissions to issue the Opinions on Issues Related to the Expansion of Medical and Health Services, proposing to "actively promote various forms of contract responsibility in the medical and health industry" and even "encourage doctors to carry out paid amateur services".
Translated into the current vocabulary, these two sentences mean to encourage contracting departments and encourage multi-point practice. Even from today's perspective, these policies seem ahead of their time.
But the cold fiscal figures beneath the table tell us that this is a last resort. In 1978, fiscal input covered 32.2 per cent of the total cost of health in society; by 1992, that share had fallen to an embarrassing 20.8 per cent.
Later medical reform experts mostly focused on the comparison of the pros and cons of market-led or government-led medical reform, and an important detail - the breaking of hierarchical diagnosis and treatment - was ignored by many people.
In fact, before 1985, in the context of the publicly-funded medical system and the national low-income level, it was realized in China, where urban workers seek medical treatment in designated hospitals, and farmers seek medical treatment in health stations and medical stations built by communes and production brigades.
After the financial burden, due to the actual economic pressure, the hospitals as suppliers began to gradually open up to accept patient restrictions, and the restrictions on what level of hospital in the past began to be broken.
Since then, public hospitals have begun to gain the possibility and motivation to accept patients freely – a necessary condition for the formation of future super hospitals. However, at that time, due to the low ability of patients to pay on the demand side, the siphon effect of large hospitals was not immediately formed.
The second overlooked detail is the establishment of a hierarchy of hospitals.
In 1989, the Ministry of Health issued the "Hospital Grading Management Measures (Trial Draft)", according to the number of beds, the number of high-level doctors, the area occupied, equipped with different equipment, the hospital was divided into ten grades (above the third-class hospital, there are also third-level special hospitals, but no hospitals are currently selected), the top three hospitals are at the top of the eyes of all sentient beings, with the highest level of professional titles of doctors, the most advanced medical equipment.
For medical care such a strict information barrier industry, the demand side (patients) almost no ability to judge the quality of medical care, administrative means to medical institutions artificially demarcated three six nine, etc., for the future of the super hospital cluster laid the biggest hidden danger, it will become the most important medical choice for 1.3 billion people, when obtained a certain ability to pay, people will be like a tide of the top three hospitals at the top of the pyramid.
This is the strangeness of history, a reform that hoped to activate supply through market forces, but because of the inertia of planned economy thinking, it laid two mines for the later Chinese medical system.
<h1 class = "pgc-h-arrow-right" > Chang Gung landing difficulty - another possibility of loss </h1>
Even after the two seeds of super hospitals were planted in the 1980s, China's hospital landscape still had another possibility from the 1990s to the early 20th century – provided that there were high-quality private medical institutions to form a healthy competition with them.
Taiwan's "god of management" Wang Yongqing, whose great legacy is not only Formosa Plastics enterprises, but also the world's model private hospital system - Chang Gung Hospital. The seven hospitals known as the "Seven Sons of Chang Gung" account for 10% of Taiwan's medical service supply, relying on huge market advantages, to reduce the purchase price of equipment, consumables, and drugs, and save the funds, on the one hand, to benefit consumers, with a "catfish" attitude to bring down the price of medical services in Taiwan; on the one hand, to enhance the treatment of medical personnel, high treatment and a favorable scientific research environment, attracting medical celebrities to continue to come. The success of Chang Gung is a benchmark relied on by Taiwan's health insurance system, driving Taiwan's medical system to continuously reduce prices and improve quality.
In the past 40 years of reform and opening up, Taiwan businessmen have relied on their profound understanding of the same language and the same kind, hijacked advanced management experience and marched westward, reduced their dimensions and struck down on those counterparts on the mainland who were born out of the remnants of the planned economy, and gained an overwhelming market advantage. However, in the field of medical treatment, Wang Yongqing's landing battle suffered a Golden Gate-style failure.
In the 1990s, Chang Gung Group planned to invest US$400 million to build private hospitals in Beijing, Xiamen and Fuzhou. However, 10 years later, the Hugely Invested Chang Gung Group could not wait for the approval of the mainland regulatory authorities, and the official reason for the delay in obtaining approval was that it had not yet introduced an approval system for foreign investment in hospitals.
Under the logic of "I haven't figured out how to approve so I don't approve", the project has been dragged into the 21st century. Wang Yongqing is easy to live with, Beijing is difficult to break through, just in Xiamen, Luoyang and Zhengzhou to find opportunities, thousands of calls to wait for the "Interim Measures for the Management of Sino-Foreign Joint Venture Cooperative Medical Institutions". However, at this time, the window of opportunity of history has slowly closed: the "gray rhinoceros" in the island's politics has reared its head, the Green Camp election has come to power, the investment policy on the mainland has been changed to "no haste and patience", and Formosa Plastics has been locked in the huge amount of funds that Areos is ready to invest in the mainland. Wang Yongqing moved his left and right branches to mobilize overseas assets, and he was unable to make up enough funds for investment, delaying the opening of Xiamen Chang Gung Hospital in 2008, and the mainland has entered an era of super public hospital competition. The strength of Taiwan's leverage has not been able to pry the entire industry. Later, Wang Yongqing died unexpectedly during his travels.
In the more than 10 years that Chang Gung has been waiting for approval, the market-oriented force that replaced it is the Putian system.
In the 1990s, the hottest word in China's economy was "contracting". Field wisdom from Xiaogang Village, Anhui Province, is used in various fields ranging from the distribution of financial resources of the central local government to the calculation of bonuses within the unit.
Hospitals are no exception, in the context of the policy of "building by the country and relying on ourselves for food", the hospital has begun various forms of contract responsibility system, of which the most "successful" contractor is the Putian department that we later became familiar with.
Putian travel doctors, who started by selling dog skin plaster secret recipes in the rivers and lakes, encountered the era of large contracting of public hospitals, starting with contracted departments and later the entire hospital.
Fly the banner of public hospitals and provide products that public hospitals cannot offer – false psychological comfort and services for incurable and unspeakable diseases. This differentiated competition made the Putian department a great success, and in that era it occupied almost half of the private medical institutions.
The essence of the Putian department and public hospitals is not the same product, high-quality private medical institutions are subject to policies and can not enter the market, in the market, the supply side of providing high-quality medical technology is actually less.
At the same time, the national economy began to take off in the 90s of the last century, GDP grew at a rate of more than 10% per year, and people's medical demand began to blow up. On the one hand, the huge increase in demand, on the other hand, the insufficient supply, coupled with the hospital grades that are divided into three, six, and nine grades, the rapidly rising incomes of people quickly fill the top three hospitals located at the top of the hospital level.
△ The corridor of the eye clinic of a top three hospital Image source: Visual China
In this era, the country's fiscal share of total health costs continued to decline from 20.8 per cent in 1992 to a dangerous 15.5 per cent in 2000.
The consequences of the imbalance in fiscal input have begun to appear:
For public tertiary hospitals, although the subsidies for real money and silver obtained from the treasury have been reduced year after year, and the price of the technology provided by doctors has been artificially suppressed to a very low level, in a market where demand is far greater than effective supply, monopolists will never lack the means to generate income; for the two fields of primary medical and health institutions and public health institutions, funds are cut off, talents are withered, and it is difficult to exercise their basic functions.
This is a period when it is difficult to judge the merits.
From the patient's subjective experience, this is the worst of times:
In addition to the painful experience of "the people of the whole country to see a doctor and go to the concord", the medical price has increased significantly, the personal hygiene expenditure of residents has increased from 3 billion yuan in 1980 to 367.87 billion yuan in 2003, and the average outpatient and inpatient expenses of residents to hospitals have increased by 66 times and 171 times respectively.
The universal health care system has not yet been established, and by 2003, the health insurance network covered only 155 million people. The poor do not have access to even the most basic health services. In the 2000 WHO assessment of the fairness of health financing and distribution in member countries, China ranked 188th, ranking fourth from the bottom among 191 member countries.
On the other side of the coin, the medical industry has developed rapidly in the context of successive years of decreasing government investment, and through the stimulation of market means, the number of medical institutions, the number of doctors, the number of beds and the efficiency of operation have been comprehensively improved, and the density of hospitals in large cities and the number of high-end service equipment have reached the level of Western developed countries.
In the first 10 years of the medical marketization, due to the lack of checks and balances and stimuli of health forces outside the system, and the first taste of the sweetness brought by the policy dividend, public hospitals began to expand in disorder, and the two important forces that dominate China's medical pattern in the future- super hospitals and putian departments - have taken shape at this stage. The medical industry across the continent missed out on another possibility.
< h1 class= "pgc-h-arrow-right" > the rise of super hospitals – the West China sample</h1>
Located in the southwest corner of Huaxi Hospital, it is a pioneer of the super hospital model and an outlier.
Most mega hospitals emerged between 2003 and 2013, when health care grew stronger, while the expansion of West China Hospital began in the mid-1990s. At that time, Shi Yingkang, known as the godfather of hospital management, took over the position of president, and during his 20-year tenure, any major changes in West China Hospital predate the national reform program by five to ten years.
Unlike the later super hospital doors, which were keen on borrowing money for infrastructure construction, Shi Yingkang's style of expansion carried a distinct mark of the era of economic scarcity: make a little money, build a building; make a little money, build another building.
After Shi Yingkang took over as president, the money for the expansion of the first inpatient building came from the 6 million yuan financial appropriation he won by his previous president and the hospital's self-financing saved through cost accounting.
In 1996, when the new inpatient building was inaugurated, Shi Yingkang keenly noticed that outpatient visits began to increase dramatically, 200,000 more than in 1993, when he took over as dean, and he realized that this was a sign of the rapid growth of medical demand in China.
Shi Yingkang therefore decided to continue to expand the hospital, becoming the first hospital in China to take the road of large-scale expansion. In 1998, Huaxi hired a senior design team with Experience in Hospital Design in the United States to reformulate the reconstruction and expansion plan of the main campus. Ten years later, in 2007, the 4,500-bed campus plan was finally completed. West China Hospital, which has laid out and expanded its scale in advance, has already harvested the dividends of the development of public hospitals. When other hospitals realized this, they wanted to catch up, but it was too late. (For a detailed report, see "Past Events in West China")
△ A citizen who went to Huaxi Hospital for treatment on a certain day in February 2009
Although Huaxi Hospital is considered the founding father of the super hospital, the super hospital is not Shi Yingkang's ultimate goal, his goal is the top hospital.
In order to improve the scientific research ability of West China, Shi Yingkang continued to recruit outstanding medical talents overseas, and in 1996 alone, he introduced 19 returnees.
After the scale of the hospital reached its peak in 2007, Shi Yingkang once again captured the denial of the policy level for the super-large hospital in advance, and Huaxi stopped the expansion road and turned its energy to refined management and the improvement of the level of research.
Unlike the later super hospitals that became bigger and then stronger, Huaxi is more like becoming stronger while becoming bigger, and being stronger is his ultimate goal, and being bigger is just a by-product of being stronger.
In the first list of best hospitals released by the Institute of Hospital Management of Fudan University, West China Hospital ranked second, second only to Xiehe.
After the Wenchuan earthquake, the major hospitals across the country who rushed to support gathered in west China, which was a public review of the West China model from peers across the country.
This public review has greatly enhanced the reputation of West China, and seeing the huge energy contained in the super hospital model demonstrated by West China, the presidents of China's large-scale top three hospitals will dominate the pattern of the entire Chinese medical system along the trajectory of West China in the next 10 years.
<h1 class="pgc-h-arrow-right" > Medical insurance entry - evergrande</h1>
In the heart of almost every public hospital president, there is a West China dream.
The growing universal health care system since 2003 gave them the best opportunity:
The hierarchical diagnosis and treatment system has been broken, and 1.3 billion residents can freely choose hospitals; the official provides a widely recognized hospital grading system, with large tertiary hospitals at the top; there is no high-quality private hospital, there is no competitor in the market; predecessors have already written out a super hospital model for reference.
Now everything is ready, only the East Wind is owed, the demand side (the patient) continues to improve its ability to pay.
In 2000, the State Council issued the Guiding Opinions on the Reform of the Urban Medical and Health System, announcing the establishment of basic medical insurance for employees; in 2003, the Ministry of Health began to establish a new type of rural cooperative medical care in rural areas, gradually covering all rural residents; in 2007, the former Ministry of Labor and Social Security began to establish basic medical insurance for residents in cities to cover all urban non-employed people.
Three medical insurances appeared in turn, and after more than a decade, the coverage of 1.3 billion people was finally completed, a superpayer was formed, and the hospital obtained a new financing guarantee mechanism. By 2010, a typical top three public hospital would have roughly more than 60 percent of its funding coming from Medicare settlement.
Before and after the gradual strengthening of medical insurance, the government's direct investment in medical institutions has also increased significantly.
Hospital leaders who are proficient in this way have continuously built buildings and added equipment by providing various health care services to leaders in the system, and by taking advantage of the east wind of medical reform investment.
△ Image source: Visual China
In any case, the medical insurance entry bureau and the upgrading of the facilities and equipment of the top three hospitals correspond to the counterattack of financial investment in this period, and the total financial investment in medical care has also increased from 83.1 billion yuan in 2003 to 1007.1 billion yuan in 2014, exceeding one trillion yuan for the first time.
The most benefited, of course, is the large public tertiary hospital standing at the tip of the hospital pyramid.
Da Vinci robotic surgical system, multi-image fusion composite operating room, positron emission magnetic resonance imaging system and other top medical equipment that cost tens of millions of dollars have become the standard in super hospitals.
Now, "smart" hospitals have grasped the magic weapon of "siphoning" medical insurance funds - riding the express train of modern medical technology, upgrading medical behavior, and increasing the consumption unit value of each disease.
From a phenomenon point of view, it is the popularization of minimally invasive surgery, the upgrading of examination and testing methods, more consumables, better equipment, and more expensive drugs, because the name of treating diseases and saving people is used in the clinic, and each behavior is not carefully demonstrated whether it is worth it.
A researcher in the field of medical reform mentioned a data that the capital city of a central province has hundreds of medical institutions, but 60% of the city's medical insurance funds have flowed to three of the large third-class hospitals.
As a self-financing market player with a monopoly position, large tertiary hospitals naturally have the impetus to expand.
When the last piece of the puzzle was completed, the managers of the large third-class hospitals rushed to follow the model opened up by Shi Yingkang: with the help of the source advantage brought by the large population and the signboard of the top three hospitals, use performance incentives to introduce high-quality doctors, first attract local patients, and upgrade medical technology; the influx of patients brought more income, continue to buy expensive equipment, extend more top doctors, build taller buildings, expand more beds, and in turn attract more patients from other places.
There is a way that there are as many beds as there are patients. No matter how many tall buildings these hospitals build and how many beds they build, a steady stream of patients can quickly turn them into a dammed lake for medical treatment.
And so on, and so on, patients, quality doctors, and Medicare funds in surrounding cities and even entire provinces are included in the pockets of super hospitals.
The First Affiliated Hospital of Zhengzhou University is the integrator of this model, seizing the dividends brought by the increase in medical insurance investment, and in less than ten years, it has grown from an ordinary tertiary hospital in Henan Province with only more than 1,000 beds to a super hospital with an annual income of more than 10 billion and more than 10,000 beds.
In the article "Endless Smoke of Gunfire: Fifteen Years of Medical Reform Tug-of-War", it is mentioned that super hospitals are taking root in almost every province, beginning to prevail in provincial capitals, and later even prefecture-level cities have begun to appear super hospitals: medical resources have been further centralized, super hospitals have done everything from colds and fevers to smoking cessation consultation, the surrounding small hospitals are at the door of the sparrow, the grass-roots hospitals are further centralized, and patients are congested to the super hospitals, which further aggravates the difficulty of seeing a doctor.
"10 years ago, the income of more than 1 billion can be called a super hospital, and now the annual income is not 5 billion, and it is difficult for the president to participate in the national forum."
<h1 class = "pgc-h-arrow-right" > epilogue – a car that can't brake</h1>
This new round of medical system reform, which began in 2005, was originally hoped to solve the two major problems of difficult and expensive medical treatment by increasing the government's investment in medical expenditure.
Its success lies in the fact that in just a decade, it has established a universal health insurance system covering 1.3 billion people, partially solving the problem of expensive medical treatment. However, due to the mismatch between the system and the market, it has also become the fastest expanding decade of super hospitals, which has exacerbated the dilemma of difficulty in seeing a doctor.
The expansion of super hospitals has alarmed policymakers, who have called for control of the size of public hospitals since 2008, and at first it was more euphemistic, but it was suggested that "the number of beds in provincial and above general hospitals is generally about 1,000, and in principle it is not more than 1,500."
After 2014, the policy became more stringent, and words such as "strict control", "strict prohibition" and "suspension of approval" appeared in many government documents. But in the words of the ruler, "no matter how you control it, you can't control it."
Since the new medical reform, the government has been investing a lot of money to build a primary medical system. At the same time, with the difference in the proportion of medical insurance reimbursement, we try to divert the source of diseases in overcrowded large tertiary hospitals, and guide patients to diagnose and treat common diseases and referral rehabilitation in primary medical institutions.
△ Clinic in a small mountain village in Jiande, Zhejiang Image source: Visual China
In 2017, the then National Health and Family Planning Commission released a message that 500 million people in China have family doctors. This data, which is extremely contradictory to real feelings, has been questioned a lot.
In terms of the supply of primary medical institutions and general practitioners, the Health and Family Planning Commission is not wrong: since 2009, the number of primary medical institutions has shown positive growth, and primary medical institutions and doctors have reached 500 million people by signing contracts (mainly filling out forms).
The problem is that no one buys the contract, and people's first choice for treatment is still a large tertiary hospital. No amount of investment can change the current situation of insufficient supply of high-quality doctors in primary medical institutions - high-level hospitals mean higher incomes, titles, pensions, in a medical industry where price elasticity is negative, the difference in medical insurance reimbursement ratios has limited effect on guiding hierarchical diagnosis and treatment, the outpatient volume of primary medical institutions is accelerating and shrinking, and people continue to run to large third-class hospitals.
For a long time, China's large-scale top three hospitals have formed a super moat, and its powerful ability to block opponents and capture supervision comes from Chinese characteristics, some from state-led systems, and some from the particularities of the medical industry.
In particular, the last attribute, naturally derived from the severity and urgency of the medical treatment scene, also comes from the sea of medical expertise, the doctor not only has an overwhelming information advantage over the patient, even for the regulator, so the evolution of this industry has always reflected the will of the hospital: on the one hand, as far as possible under the wing of the government, to obtain various institutional resource support; on the other hand, fully enjoy and use the free choice brought by the marketization mechanism and its own characteristics, siphon whale swallowing patients; at the same time exalted The "public welfare" banner rejects opponents outside the system; it can be described as lying and winning.
The Chinese-style super hospital group that has grown up under the policy dividends of medical reform has its historical inevitability and rationality, and they have objectively improved the level of China's overall medical technology through large-scale and intensive development, but its huge siphon effect has caused damage to small and medium-sized medical institutions, and has also made one of the two major goals of medical reform - the solution of the problem of difficulty in seeing a doctor - failed.
Once the large and small super hospital groups are formed, they have their own lives, and dominate the pattern of the entire medical system, like a black hole in the universe, devouring the surrounding patient resources, and having a super high escape speed - so that the doctors in it are unable to leave even if they are full of complaints, and even the upstream large manufacturers such as drugs, consumables, and equipment are also wrapped around the periphery and run according to the track delineated by the hospital.
Today, when the huge expansion inertia of super hospitals runs counter to the torrent of medical reform, where will China's hospital pattern go?
After SARS in 2003, China began to rethink its previous medical system, ushering in a new medical reform and a wave of super hospital birth. After this outbreak, will it be the same as the last time?
Chen Xiaorong xu Zhuojun | writing
Xu Zhuojun | responsible editor
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