How Sanming Can? A small county’s medical reform as the Example of China

Since 2012, many experts and public opinion have begun to think that the reform of public hospitals is lagging behind or not in place, which is offsetting or eroding the effect of the total medical policy. Therefore, various localities have launched a series of medical reforms to solve this problem. Whether it is the promotion of settlement in different places or the pilot of graded diagnosis and treatment, it is one of the key measures to promote medical modernization and explore the "Chinese model" of medical treatment in China. However, the reform of public hospitals, which is the most important part of medical reform, has made limited progress. Although the so-called "XX model" emerges one after another, it is either a minor repair of the original system, or "a lot of thunder and a little rain", with little real progress. However, Sanming City, as a pilot area of public medical reform, has achieved great success in the field of medical reform because of the huge loss of medical funds, the sharp increase of medical expenses and frequent occurrence of medical corruption.

Sanming is a small county town, located in the middle of Fujian, and its economic development level is relatively backward. Before carrying out the medical reform, Sanming, like many other areas in China, also had problems of unbalanced distribution and unsmooth flow of medical resources; especially the phenomenon that it was difficult, expensive and unreasonable for grassroots people to get a instant treatment. People generally do not want to stay in the city to see a doctor, complaining a lot about Sanming The First Hospital and Sanming Hospital of Integrated Chinese and Western Medicine (The Third Hospital), and the contradiction between doctors and patients is prominent. It can be said that Sanming before the medical reform was almost a "negative case" of the whole country under the situation of low economic level and lack of medical resources. Specifically, the coordination of medical resources, expensive drugs and low income of medical staff and rigid medical insurance system are the "stubborn diseases" of Sanming Medical.

Since Sanming began to implement medical reform in 2010, it had achieved a real transformation in just ten years. It can be said that its medical reform is facing a series of severe situations, such as huge medical insurance fund losses and serious medical corruption, and it is a "reform standing on the edge of a cliff". To explore his experience, the most important thing is to reduce the starting point of "expensive medical treatment." Sanming's medical reform is called "the reform starting from anti-corruption". After integrating county and municipal resources, relevant departments in Sanming started with "three doctors", namely medical treatment, medicine and medical insurance, and made efforts to reduce people's medical expenses.

In the overall planning of medical resources, after setting up several county-level general hospitals, Sanming City achieved "sunshine income" by expanding the autonomy of county-level hospitals and setting up special funds. Through the implementation of the "annual salary system" for deans, doctors and technicians, we strive to eradicate the phenomenon that doctors "prescribe expensive drugs and earn kickbacks", and even force Sanming City to coordinate the development of urban and rural medical standards and "prevent diseases" through primary medical care. This reform has greatly reduced the "profit-centered" orientation in hospitals in the past, and changed from "treatment-centered" to "health-centered". As the person who direct this reform, Zhan Jifusaid, “it promoted the increase in the balance of county-level hospitals and the increase in the income of medical talents. From 2010 to 2019, the salary of medical service personnel in Sanming City almost tripled.”

Drug prices and supervision are strictly controlled. All public hospitals above the second level implement the sales of drugs with zero difference rate, and the reduced income is mainly compensated by finance and adjustment of medical service price. Unite many provinces to form "Sanming Alliance", which aims to organize the price reduction of medicinal materials by prefecture-level cities alone, and form a "low-price plain" of drug prices. In other words, we should reform and standardize the purchasing mechanism of medicines and consumables to squeeze out moisture and corruption in circulation.

Innovate the payment method of medical insurance. In June 2017, the former State Health Planning Commission listed Sanming City as a pilot city for the reform of C-DRG (Diagnosis Related Groups, DRGs) in China. From November 1, 2017, it was put into practice in public hospitals above Grade II in Sanming City, and it was fully rolled out on January 1, 2018 . In short, the C-DRG model means that medical insurance institutions pay a fixed amount to hospitals according to the disease diagnosis grouping standards of patients, "pricing first, then paying". According to the principle of "the same disease, the same treatment, the same quality and the same price", all hospitalized cases are divided into 800 disease groups, and the price is charged according to the group. For the first time, the medical insurance and the fixed settlement of patients and hospitals according to the disease are realized, so that the masses can see the doctor clearly and reduce the risks caused by doctor-patient disputes.

By 2018, the per capita medical expenses in Sanming City were 1,403 yuan, far lower than the national average. For a time, Sanming became a star in the medical industry. In the coming third decade of the 21st century, the whole country is working towards the goal of "healthy China". Sanming's medical reform needs to provide experience for the reform of the national medical system: the experience of local medical resources co-ordination is actually a local exploration of "graded diagnosis and treatment", with the aim of starting from the grassroots level, changing the bad competition mechanism between higher and lower levels and giving play to local initiative. The solution of expensive drugs refers to the problem of unified "bargaining" at the municipal level, how to use and supervise it. The reform of medical system focuses on innovation of payment methods and clear pricing.

No matter Sanming or the whole country, medical reform is still on the way. How to solve the problem of "expensive medical treatment" for people? The most important thing is to find the crux of the problem and make precise governance strategies according to local conditions.

This commentary reflects the author’s personal opinion and does not necessarily reflect the opinion of the Global Engagement Academy Shandong University (Weihai).

Zhu Yimin, undergradute student of School of Politics and Public Administration, Qingdao University; special research fellow of Youth Think Tank of Glory Diplomacy.

朱翊民，青岛大学政治与公共管理学院本科生；大外交青年智库特约研究员