The first step (2008~20 10): determine the budget and framework.
The first step can be to formulate a health law and determine the proportion of government investment and the proportion of governments at all levels; Accelerate the construction of the current compound medical insurance system and increase government investment. By the end of 2008, the new rural cooperative medical system will basically cover all rural areas.
(1) Formulate the health law, and determine the proportion of government investment and the proportion of governments at all levels. Education has legislation, and the proportion of government budget and other inputs to GDP has been determined in the document. Health involves everyone, and the investment should be more. It can be clearly increased from the current government budget of 0.85% to 5% of GDP.
(2) Accelerate the construction of the current compound medical insurance system and increase government investment. By the end of 2008, the new rural cooperative medical system will basically cover all rural areas. By the end of 20 10, the basic medical insurance for urban workers, the basic medical insurance for urban residents and the medical assistance system will cover all urban residents (instead of "fully pushing" the basic medical insurance for urban residents now). At present, the focus of the new rural cooperative medical system should shift from expanding coverage to increasing the proportion of government payment and reimbursement. Otherwise, farmers, especially poor farmers, will greatly reduce their enthusiasm for participating in the new rural cooperative medical system, and the new rural cooperative medical system initially established in recent years is at risk. Similarly, more subsidies should be given to the demanders of urban communities, and the initially established community medical institutions and equipment should not be left idle. As long as there are patients, it is ok to make up less suppliers. These reforms can be solved by national debt, central government transfer payment and local government supporting measures, and the lowest line can be delineated. Where conditions are good, more subsidies can be given, and where conditions are poor, subsidies can reach the basic line.
(2) The public health system should verify the staffing and projects, realize the full financial allocation, make full use of the central and provincial transfer payments, and realize the free system for some projects, such as production, some chronic diseases, major diseases and infectious diseases.
(three) the people's congresses at all levels set up specialized medical institutions management committee, the management of public hospitals in the region. The leadership and finance of public hospitals are decided by the Committee and are responsible to the NPC Standing Committee. Health administrative institutions at all levels have changed their functions and strengthened their supervisory responsibilities. The financial allocation of non-profit medical institutions is no longer through health administrative institutions or investors, and a hearing system for medical service price adjustment has been established.
(4) Reform the tax system, increase the proportion of direct tax to local finance, and reduce the proportion of indirect tax. That is to reduce the local government's dependence on the turnover tax of a large number of pharmaceutical enterprises, guide them to pay attention to the profits of enterprises, and then fundamentally integrate the pharmaceutical enterprises with an extraordinary number but low efficiency and insufficient innovation.
(5) At this stage, the basic drug system, the assessment system of non-profit hospitals and the adjustment and restraint mechanism of medical insurance payment should also be gradually established or deepened.
(6) Reduce direct government pricing and procurement, and reform the current system of fixed-point production of essential drugs and unified procurement of medical devices. In 2007, the US Food and Drug Administration designated enterprises to produce "essential drugs for urban communities and rural areas", and the health department withdrew the right to purchase medical devices. However, this system may not have a good effect. On the one hand, even if the enterprise is willing to produce because of the preferential price set by the government, the high cost of unified distribution will inevitably lead to the absence of these essential drugs in many places, so the prices of other drugs may rise further, and if the price is too low, these essential drugs will be produced less and less; On the other hand, it is difficult for the government to unify cost standards and identify manufacturers, and market fairness may be broken. In addition, it seems that the health administrative department should take back the right to purchase medical devices to cope with the high kickback and disorder in the market. In fact, it is likely to aggravate the random procurement of public hospitals (because they basically apply for procurement), increase the cost of medical procurement, and transfer more practical benefits to the health department managed by the industry, thus making the responsibility more unclear and difficult to separate management from management. These will aggravate the institutional obstacles of medical reform.
In fact, the production of essential drugs can completely encourage enterprises with production approval numbers to compete, rather than fixed-point production. At the same time, it can gradually increase the proportion of medical insurance payment for basic drugs. In addition to centralized procurement, the industry supervision of medical devices is more important to rationally allocate regional health resources and reform the financial system of public hospitals. These government departments in charge of industry should not be allowed to interfere with enterprise and market behavior at will, otherwise, even the best wishes are likely to bring bigger and more complicated problems. The government is responsible for procurement decision-making and supervision; Entrust enterprises and institutions to implement. Government officials are not allowed to participate in the implementation to prevent abuse of power for personal gain.
Step 2 (20 1 1~20 13): open the market and improve the law.
(1) While continuing to strengthen the capital investment in the composite medical insurance system, the government strongly encourages the participation of various social insurance institutions, and strives to make the proportion of the total health expenditure shared by the government, society and individuals reach 25%, 35% and 40% (currently 18%, 30% and 52%). In particular, we will vigorously increase the proportion of government investment in the protection of unemployed urban residents and rural residents in the central and western regions.
(2) Reform the publicly-funded medical care system, appropriately reduce the proportion of government contributions to the demand side, and increase individual contributions. Change the current government health budget 1/4 for public health care, so that it will be partially over-consumed. The reduced capital contribution is used for the above part.
(3) Professionals from people's congresses at all levels make plans for health resources according to regional integration, and initially define the proportion of existing public hospitals, such as 70% reserved and converted into non-profit hospitals, 15% converted into community health institutions, and 15% allowed social capital to merge and integrate. And confirm the minimum financial input of governments at all levels and local governments to these non-profit hospitals by laws and regulations, and ensure the annual growth.
(4) The advance payment system and total amount control shall be implemented for non-profit medical institutions, and the scale of hospital revenue and expenditure shall be scientifically verified under the leadership of the management committees of specialized medical institutions of people's congresses at all levels, not just the two lines of revenue and expenditure under government supervision. For tertiary hospitals with excessive revenue and expenditure scale, the approved budget revenue and expenditure of their business revenue and expenditure scale should be reduced at the beginning of the year; For community health service centers and service stations with small scale of revenue and expenditure, the approved budget revenue and expenditure of their business revenue and expenditure scale should be expanded at the beginning of the year; For secondary hospitals, it is necessary to transform according to the Huimin hospital model. Second-level hospitals that accept the transformation can approve larger business expenses and smaller business income, and the approved balance of income and expenditure is subsidized by the government budget.
If the actual business income is greater than the approved business income, the excess shall be turned over to the state treasury; If the actual business income is less than the approved business income, the government has no responsibility for subsidies; If the actual business income is equal to or less than the approved business income and the actual business expenditure is less than the approved business expenditure, it is reasonable to check the linkage between revenue and expenditure, and the reduced expenses need not be turned over to the hospital for use.
(5) realize the free system of major public health projects.
Joint point: "the devil is in the details"
Determine the proportion of public health and basic medical expenses that governments at all levels should bear in a certain period of time in legal form to prevent softening in the implementation process. If only multi-department documents are issued, and the documents are different ideas of different interest departments, the final documents may be "tailor-made"
In the current work and the suggestions we mentioned above, there are some common points that must be paid attention to:
1. At present, there are still about 400 million urban and rural residents who are not included in the medical insurance system. At present, while insisting on expanding coverage, we must speed up government investment and reduce the proportion of personal burden, otherwise the initially established urban and rural medical insurance system will face crisis.
2. Although some achievements have been made in the new rural cooperative medical system and community health construction in the past few years, the "crowding out" effect on health resources is limited, and it is urgent to make efforts to reform the system step by step.
3 through the reform of departmental budgeting system, promote the separation of government and enterprise, management and office. Some explorations are being carried out all over the country to separate the personnel rights and financial rights of public hospitals from the health administrative institutions. The fundamental solution is not to appoint the leaders of public hospitals through health administrative agencies and get financial allocations through them. At present, we should deepen the departmental budget system and separate this part of the funds from the budget of the health administrative department. At present, in some pilot projects of separating management from office, the hospital management company and the health department are actually two tables and one team, and the effect of this practice is debatable.
4 for routine projects such as planned immunization, maternal and child health care, health supervision and health education, the budget can be prepared according to the number of clients; For unexpected projects such as infectious diseases, special reserve funds can be established to support them, such as medical assistance funds and public health risk prevention reserves. Change from "supporting people by things" to "supporting people by things", reduce the cost of providing public health medical services and maximize the efficiency of funds.
5. Determine the proportion of public health and basic medical expenses that governments at all levels should bear in a certain period of time in legal form to prevent softening in the implementation process. It is reported that the representatives of the "two sessions" have repeatedly suggested that it be determined through NPC procedures as soon as possible. If only multi-departmental documents are issued, and the documents are different ideas of different interest departments, and the departments coordinate policy compromises, the final documents may be "cut to fit the needs".
Several relevant documents of the Central Committee 1997 and 2000 and the spirit of the Seventh Plenary Session of the Sixteenth Central Committee and the Seventeenth National Congress are the basis for formulating the health law, including how to provide medical services, what system, what kind of hospital structure, what kind of relationship between the structures, what kind of competition between them and what kind of referral system is. It also includes how to raise funds, who will handle basic medical insurance and commercial insurance, what regulations are there, and what powers and responsibilities each department has. In particular, the proportion of responsibilities and financing burdens between governments at all levels needs to be implemented in legal form.
6. There is an urgent need to deepen the reform of the public finance system and the financial system below the provincial level. The results of raising health funds in different provinces are very uneven, which is related to the current tax system. The tax system with indirect tax as the main body has nothing to do with residents' income, but is closely related to residents' consumption level. The ability to raise funds is directly affected by the level and quantity of consumption in various places. Therefore, although the absolute amount of health expenditure of poor families is not as good as that of rich families, the proportion in family income is much higher. From this perspective, the local tax system must gradually change from indirect tax to direct tax. On the other hand, after the tax-sharing reform of 1994, the financial system below the provincial level basically continued the previous contract system, and the number of tasks was directly affected by the higher-level government, which not only caused economic contradictions between the central and local governments, but also often refused to undertake their own functions of providing public goods because of different responsibilities and rights. In some places, GDP and fiscal revenue have even increased, while the per capita growth of public goods has declined.
7. It is inevitable to raise the medical price appropriately, but the premise should be to basically complete the distorted institutional reform and state institutional reform, otherwise it will be difficult to implement it like some places, or it will eventually fail to achieve the goal of solving the problem of difficult and expensive medical treatment.
8. The medical and health industry is highly professional. The experience of developed countries shows that even with strong government supervision, it is not easy to control the rapid growth of expenses. Various forms of medical and health industry associations should better play the role of checks and balances and self-discipline. Judging from the debate on the medical reform plan, the role of trade associations is still very limited.
Can medical reform become the breakthrough of new economic growth mode?
In 2008, under the environment of global economic uncertainty and increasing economic uncertainty in China, although the resistance to reform still exists, the reform of medical and health system must be deepened, which can also become the driving force and breakthrough for the transformation of economic growth mode and the enhancement of public goods in China in the new period.
The current medical and health system reform has advantages and disadvantages. The advantage is that the financial funds are relatively sufficient, and they have formed a certain understanding of medical reform, and the leaders also have a calm and full understanding. The disadvantages lie in the trend of solidification and differentiation of interests of various departments and strata, poor social expression mechanism, excessive exaggeration of irrational voices and lack of ability to maintain policy continuity and coordination.
People's good wishes are naturally that the more government subsidies the better. However, it is difficult to significantly increase the growth rate of short-term subsidies. Second, subsidies are not free lunches. There must be costs and sources of funds, which will eventually become people's wealth. Therefore, we should not only pay attention to the distribution of health expenses, but also fundamentally change the economic growth mode and distribution pattern of China as soon as possible, and reverse the current bad way of exchanging high profits by reducing the price cost of labor, capital and resources, so as to rely more on export and investment for growth. Increasing the share of national income distribution flowing to the people can also change the investment system that relies too much on government funds, promote industrial upgrading, and pave the way for the government to invest more financial funds in public goods such as health. This is basically consistent with the central government's strategy of Scientific Outlook on Development and changing the mode of economic growth.
In essence, the long-term shortage of medical and health supply in China is also closely related to the above-mentioned economic development mode. Not only is the fiscal expenditure biased towards industrial investment, for example, many of our national debt projects are also biased towards investing a lot of money in backward infrastructure such as transportation and energy. This is a realistic choice, and the achievements are not small, but on the one hand, these fields have long-term clear benefits, which can be completed through market-oriented or socialized operation, on the other hand, they lead to a serious shortage of investment in social undertakings such as health and education. In fact, health and education are the most profitable areas of a country, which can greatly promote a country's domestic demand and social development, and the people's right to health care and education is also the basic responsibility of the government.
Medical reform is a worldwide problem, and it is difficult to find an ideal model, which is bound to be a long-term and gradual process. From another perspective, medical reform is actually a part of China government's administrative system, public finance system and the establishment of a complete social policy system. At present, the primary problems are: first, the government clearly assumes public responsibility through law; Second, the government supports and formulates the "market function expansion policy"; Third, try to avoid departmental interests and increase coordination and transparency mechanisms. At present, the direction and basic path of medical reform have been fixed or continued. What needs more attention is whether the scheme can be reconsidered and demonstrated and whether more rational and in-depth opinions can be added. Second, the specific policy direction of government departments after the "two sessions" in 2008, sometimes details determine success or failure.
In 2008, with the increasing uncertainty of the global economy and China's economy, although the resistance to reform still exists, we have reason to believe that the reform of the medical and health system must be deepened, and it can also become the driving force and breakthrough for the transformation of China's economic growth mode and the enhancement of public goods in the new period. We don't hope for a package solution, but it is undeniable that with the existing material, manpower and wisdom and a highly responsible attitude towards history and people, we should be able to make the right direction, make overall plans, adopt appropriate strategies, or take small steps or make great strides without hesitation.