To solve the problem of China's medical reform: the government has increased the total cost of medical care from 5.6 to 8-9% of GDP.
The reform of the medical and health system is a major event related to the national economy and people's livelihood, affecting thousands of households, and is highly valued by the Party Central Committee. In April 2009, the central document No. 6 "Opinions on Deepening the Reform of the Medical and Health System" was released, marking the official launch of a new round of medical and health system reform. After more than four years of pilot operation and gradual advancement, major phased results have been achieved, successful experience has been accumulated, and a broad consensus has been reached. The idea of using Chinese-style methods to solve the global medical reform problems has been clear. Today, it is necessary for us to sort out some key issues in-depth theory and comprehensively promote the in-depth development of the new medical reform.
"Supplementing medicine with medicine": a freak in the transformation of the old and new systems
Under the planned economy system, the construction of public hospitals, employee wages and welfare<待遇由政府财政支付;药企的生产由国家计划安排，价格实行微利原则。在这种情况下，医院的运行费用有个弹性缺口。为了弥补这一缺口，国家出台了“药价加成”的政策，即医院在药品进价基础上可以附加一定比例(一般是15%)，借以弥补医院的运行费用。
At the beginning of the reform, the government gradually reduced its subsidies to public hospitals, with the dominant idea of "giving more policy and less money". The state's budget allocation to hospitals showed a downward trend, and the proportion of government subsidies in hospital income decreased from 24.0 per cent in 1983 to 10.6 per cent in 2008. However, due to the public nature of hospitals, the government still uses the low-cost standard under the planned economy in the pricing mechanism of medical services. At this time, market-oriented reforms have been fully implemented in the field of drug production and circulation, and the market mechanism of drug prices has been formed. Under the squeeze of this dual plate of full market economy and incomplete planned economy, a freak of "supplementing medicine with medicine" was born in the embryo of "drug price addition", and gradually evolved into the central focus of various drawbacks.
Under the encouragement of the policy of "relying on the country for construction and relying on oneself for food", the hospital has linked the income of doctors with the income of using drugs, and continuously stimulated medical staff to use more drugs, use expensive drugs, and rely on drug income to support the operation of the hospital. The key problem is that once the magic box is opened, the magic gets out of hand. The "drug price increase" was originally used to make up for the hospital's operating expenses. The "drug price increase" was tacitly accepted because the drug price increase not only made up for the hospital's operating expenses, but also made up for the medical staff's due remuneration and welfare benefits due to the reduction of subsidies. At the same time, drug distribution companies have added fuel to the flames, choosing to occupy the market by raising drug prices to leave room for "rebates" for medical staff, vicious competition, and even profiteering. For a time, "medical representatives" were all over the hospital, and even some well-known foreign pharmaceutical companies were involved in this disgraceful transaction.
It should be pointed out that the "medicine" of "supplementing medicine with medicine" here not only refers to the medicine in the medical prescription, but also includes medical consumables, such as vascular stents, fixed parts in orthopedic surgery and high-value consumables in dentistry. Doctors recommend these supplies to patients as if they were encouraging medication. Therefore, "replenishing medicine with medicine" has actually become a general term for the legitimate mechanism for hospitals to use drugs and consumables for profit.
On the surface, this mechanism of "replenishing medicine with medicine" reduces the financial burden of the government and forms a pattern in which hospitals, medical staff and pharmaceutical enterprises all benefit. In fact, it distorts the medical process, leads to a serious waste of resources, an unreasonable rise in medical expenses, increases the burden on society and patients, worsens the relationship between doctors and patients, corrupts medical ethics, and even breeds corruption, bringing serious social consequences. Therefore, it is imperative and urgent to completely eliminate the "medicine supplement.
Improving the Value Return of Medical Labor and Returning to the Professional Dignity of Medical Staff
The institutional arrangement associated with the malpractice of "supplementing medicine with medicine" is the long-standing defective underestimation of the value of medical labor in our medical system. Under the planned economic system, the wages and benefits of medical personnel in China are paid by the state. The labor payment of medical staff is a symbolic payment in the hospital, that is, the registration fee, which does not represent the labor value of medical staff. In the early stage of the reform, the financial subsidies to hospitals were reduced, and the market prices of drugs and consumables were opened, but the price increase of medical labor was strictly restricted. In this mechanism, the labor value of medical staff is inexplicably evacuated, just like a game in which the protagonist is marginalized. Hospitals that lack funds can only make up for the lack of wages and benefits of medical staff by generating income, while the channels of income generation are nothing more than medicine to supplement medicine, consumables to supplement medicine, and inspection to supplement medicine, and finally develop into a link between personal income and the "performance" of medical staff, forming a chaotic value chain.
According to the Marxist theory of labor value, in the economic operation structure of the hospital, the constant capital input is divided into two parts, namely fixed assets and raw materials. Inputs in fixed assets (construction, equipment, etc.) are amortized into the current economic operation in the form of depreciation and form part of the total value; the other part of the constant capital is drugs and consumables, which enter the total value at the purchase price. Both parts enter the total value at the initial equivalent and do not add value. The labor service of the medical staff and management personnel in the hospital is the real value creation process and the real value-added part in the operation of the medical economy. Specifically, in the medical value chain, the most important thing is not drugs, equipment and testing facilities, but medical staff rely on the knowledge they have learned and the valuable experience accumulated in long-term work to decide which tests should be done by patients, and carefully analyze and judge the condition according to the test results, make a correct diagnosis, and finally form a scientific treatment plan. This process requires not only a rigorous scientific attitude and a wealth of knowledge reserves, but also the sense of responsibility and moral care of medical staff, and even the intervention of psychological knowledge. Once a doctor treats a patient, he assumes the corresponding moral responsibility, and the pressure can be imagined. Therefore, the labor process of medical personnel is a dual creation process of knowledge value and spiritual value, which should be reflected in the medical economic process. Not only should it not be ignored, but it should not be implemented in other circuitous or disguised forms.
Therefore, we must reasonably improve the return on the labor value of medical staff while breaking the system of "replenishing medicine with medicine. In the modern medical system, a qualified medical personnel requires more rigorous and longer formal education, internship practice and assistant process than other industries. Due to the rapid development of modern medical technology, employees in the medical industry have greater pressure on continuing education than those in other industries. According to foreign data, the professional income of medical staff in Western countries is generally 2 to 4 times higher than the average social professional income.
Only by reconstructing the medical economic value chain through the reform of the medical and health system, and reasonably reflecting the labor value creation of medical staff, can the professional dignity of medical staff as an angel of life be restored. The famous British economist Adam Smith pointed out in his book The Wealth of Nations: "We entrust our health to doctors. Such great credit must not be entrusted to the humble and insignificant. Therefore, the remuneration they receive must be sufficient to maintain their social status necessary for this important task."
Chinese Way to Solve the Worldwide Problems of Medical Reform
People may ask, why is the health care system always in the process of reform? Why is health care reform so difficult all over the world? This is because the health care system involves everyone and every family. It not only involves the rationality of the interest relationship between the government, individuals and enterprises, but also takes into account the efficient use of social resources, so as not to waste and abuse. The most important thing is that the medical system needs continuous reform because in today's world, the medical system involves the realization of the basic human right-the right to health. "Without the health of the whole people, there will be no comprehensive well-off society." General Secretary Xi Jinping pointed out the internal relationship between the health of the people and the realization of the Chinese dream.
The first thing to be established is the principle of fairness in the burden of medical expenses. Looking at the medical security systems of various countries in the modern world, no matter how different, a general principle is that the government, society (including enterprises, groups, institutions, etc.) and individuals participate and share the burden (except for a few countries such as Cuba, the United Kingdom, and North Korea) It is the general trend, and the difference lies in the proportion of each.
From our current situation, the government to increase investment is the key to the problem. Although financial investment has rebounded year by year since the launch of the new medical reform in 2009, the scale is still not large enough. If we take into account factors such as population growth, currency devaluation and price growth, the growth of government expenditure is still not enough to support the demand for reform. Statistics show that by 2013, the country's total expenditure on medical and health services was 3166.15 billion yuan, accounting for 5.6 per cent of GDP. Compared with other parts of the world, this proportion is indeed low. This figure is 17% in the United States, mostly about 10% in European countries, and between 8% and 9% in other moderately developed countries. The problem is that our country's distribution of this total expenditure is about three 1/3, namely, the State, society and individuals each account for 1/3, 30.1 per cent; 36.0 per cent and 33.9 per cent, respectively. In fact, individuals and society account for 70 per cent and the State accounts for 30 per cent. The 1/3 of individuals here is really unfair in the current disparity between the rich and the poor in the distribution of wealth in our society. Fortunately, China's current medical insurance system is making great strides towards a more equitable direction. By the end of 2014, the government's per capita subsidy for NCMS and urban residents' medical insurance had been raised to 380 yuan. The unfairness of the urban-rural dual system is gradually being eliminated. Today, the new health care reform has entered a critical stage, can the proportion of total government expenditure on health services be raised to about 50 per cent in five to ten years? Raise the total cost of health care from 5.6 per cent of total GDP to 8 to 9 per cent of the current moderately developed countries. At the same time, specific measures should be formulated to ensure that the increased funding focuses on rural areas and focuses on solving the medical security of the poor, such as allocating special funds to increase support for the establishment and improvement of major disease medical insurance and assistance systems.
The second is to strengthen management to ensure the efficient operation of the new medical and health system after the reform, and to ensure that government investment is appropriate and makes the best use of it.
The first is to establish a new type of hierarchical diagnosis and treatment network covering the whole population. Scientific and comprehensive hierarchical diagnosis and treatment is an effective way to reasonably allocate medical resources. We must make full use of government resources and borrow the guidance of the medical insurance system to bring each family into the scientific network of graded diagnosis and treatment. A strong foundation is the key to hierarchical diagnosis and treatment. We must build a new hierarchical diagnosis and treatment system into a comprehensive health management system, which must combine disease prevention, aging care, health counseling and other services to make it a modern health service system that everyone cannot do.
Second, it is urgent to strengthen medical education and scientific research innovation in China. "Everything is man-made", no matter how to reform, a certain number of medical team is the key. At present, the total number of medical staff in my country is 7.62 million, and the number of doctors per 10,000 people is 14.6. This number is generally between 20 and 40 in developed countries; the number of nurses per 10,000 people is 15.1, and the number of nurses in developed countries is generally between 50 and 100. Therefore, we must vigorously strengthen the training of medical professionals, especially the training of general practitioners into the key plan. Recently, the national 5 3 and 3 2 general practitioner training program is a major initiative. In addition, compared with the rapid development of global medicine, the development of medical scientific research in China is not satisfactory, which makes us in a passive situation in the international medical equipment and drugs, especially patented drugs and generic drugs market. It is necessary to increase efforts to support scientific research institutions and pharmaceutical companies to develop new drugs and equipment with an innovative spirit. The health of the Chinese people must be in our own hands.
Third, the comprehensive reform of the internal management system of public hospitals. Public hospitals will face a new and complex situation after the three major reforms of abolishing "replenishing medicine with medicine", improving the value of medical services and increasing government investment. On the one hand, public hospitals should strike a balance between public welfare services and market-oriented supply, formulate a scientific price system, and gradually implement measures such as paying by disease; on the other hand, they should mobilize the enthusiasm of personnel in internal management and make efforts to re-determine the new performance appraisal methods. Public hospital managers must take improving the quality of service and advocating medical ethics as their work focus, and can no longer take increasing the total income as their work goal.
The fourth is to actively encourage social forces to run medical services. By 2013, the total number of non-public hospitals in my country will be 11313 with 1.739 million employees. The government will give priority to supporting the development of private non-profit medical institutions and include them in the designated scope of medical insurance. Support should also be given to the development of private and foreign-funded for-profit hospitals. This specific for-profit hospital improves the structure of the medical system and can provide necessary services for special groups. In addition, we must pay close attention to the impact of emerging market mechanisms on the medical system, and actively use new platforms such as the Internet and e-commerce to serve the medical reform. Today, with the rapid development of information technology, we should pay special attention to the application and development of medical big data, speed up the construction of medical and health service information, and promote big health with big data.
Fifth, it is recommended that China's "basic medical law" be formulated as soon as possible. It is necessary to draw on the advanced experience of the world in the light of China's actual conditions and formulate a legal system with the Basic Medical Law as the core as soon as possible. Governing medicine according to law is a fundamental measure to ensure the long-term stable development of China's medical and health services.
In short, the Chinese-style medical reform will establish a modern medical service system dominated by government-led public welfare, diversified coexistence, public participation and everyone's enjoyment.