In this year's government work report, it is clearly stated that the medical and health care strengthening project should be implemented (hereinafter referred to as the "medical 'fucking project'"). The most important tool for the medical "strengthening foundation project" is to build a close county-level medical community. Unlike loose urban medical alliances and specialist alliances, county medical communities emphasize the closeness of "bundling" between medical institutions, connect the upper and lower levels, and lead the township with counties.

As a pioneer in medical reform, Sanming City is also at the forefront of the country in the construction of county-level medical communities. In 2017, all 12 counties (cities and districts) in Sanming City established the Medical Community General Hospital, with county hospitals as the leading hospital and township health centers as member units, integrating all three-level medical institutions at the county, township and village levels into one.

In 2012, Zhan Jifu took the lead in launching medical reform as the deputy mayor of Sanming City. Since then, he has served as deputy director of the Fujian Provincial Medical Insurance Committee, director of the Fujian Provincial Medical Insurance Bureau, and director of the Sanming Municipal People's Congress Standing Committee. In his opinion, the construction of a close county-level medical community is a key turning point after Sanming's medical reform moves to a deep water zone. It is from here that Sanming's medical reform has truly achieved the transformation from "treatment as the center" to "health as the center".

In an exclusive interview with China Newsweek, Zhan Jifu, now vice president of the Fujian Provincial Medical and Health System Reform Research Association, repeatedly emphasized that the ultimate goal of medical reform is to improve people's health benefits and make the people less sick and not sick. "However, many counties have not yet figured out who they are building, why and how they are building."

Zhan Jifu. (Data picture)

Become a "family"

"China News Weekly": In 2017, when Sanming City launched the reform of a close county-level medical community, six years have passed since the start of Sanming's medical reform. At this time, why did Sanming City decide to shift the focus of medical reform to the grassroots level?

Zhan Jifu: Sanming medical reform is mainly divided into three stages. The first stage is to rectify the "money-making" and cure medical kickbacks and medical chaos. At present, medical reform in most parts of the country is still in this stage; the second stage is to "treatment as the center", by decoupling the salary of medical staff from medical income, by 2016, Sanming doctors had returned to the role of seeing a doctor. Despite this, the hospital still hopes that there will be more patients, because there will be more patients, and the hospital's income will increase.

This year, General Secretary Xi Jinping proposed at the National Health and Health Conference to transform the treatment-centered treatment into the people’s health-centered. This also means that hospitals can no longer operate according to the original logic, and the people will become healthier and the number of patients will naturally decrease. From then on, I began to think: For Sanming, can there be a better operating model that can not only protect the health of the people, but also maintain the normal operation of the hospital? Therefore, since 2016, Sanming Medical Reform has officially entered the third stage of "health-centered" and proposed to build a close-knit county-level medical community.

In Sanming City, Fujian, people are preparing to go to Youxi County General Hospital for medical treatment. Picture/China News Service

"China Newsweek": How to understand "close type"? Why can we achieve the "health-centered" reform goal only by breaking through the barriers between county, township and village three-level medical institutions and thoroughly integrating medical resources?

Zhan Jifu: Before the reform of the close-knit county medical community, the management of China's county medical and health service system had been fragmented for a long time, and hospitals at different levels were in a competitive relationship. Horizontal, county-level hospitals are all in their own right, blindly expanding their scale, vicious competition, competing for talents, funds, equipment and disease sources, resulting in low-level duplicate construction of disciplines; vertically, county-level medical institutions compete with each other, and county-level hospitals have a strong siphon effect. Although the National Health Commission has issued many documents to promote the sinking of high-quality medical resources, due to the existence of this competitive relationship, most policies are only on slogans, and it is difficult to really implement them. Sanming City also faces the same dilemma.

Sanming City is located in a mountainous area, with more than 60% of the permanent population distributed in townships (towns) and villages, but the distribution of medical resources is an "inverted triangle". Before the construction of the medical community, 80% of the resources were concentrated at the municipal and county levels, and the gap between the medical and health service level in townships and county towns was widening. If this situation is not changed, the hospitals at the doorstep of the people, that is, township health centers, will always be in a state of "no grass grows under the big tree", rather than "there is a cool place under the big tree", and it will be difficult for grassroots people to obtain fair and accessible medical services nearby. Therefore, the primary problem that needs to be solved in grassroots medical reform is how to change competition into close cooperation between superiors and subordinate medical institutions and become "a family".

After years of practice, I have found that in order to build a close-range county-level medical community and achieve county-level and rural integration, the most important thing is to achieve "three unifications": the unity of people, finance and material resources, the unity of legal representatives and financial appropriations, and the unity of salary. This is the core of the "close type". Especially the unity of legal representatives must be "one-stop" from the very beginning. There is only the only legal representative of the member units of the medical community, namely the president of the general hospital. If the legal representatives are not unified, it will be difficult to form a community of interests and a community of responsibility among medical institutions at different levels.

After becoming a "family", under the medical community model, the general hospital must be responsible for the medical affairs of the whole county. If the doctors in the township health center are unsure of their decisions during diagnosis, they can directly connect to the county hospital through the remote consultation platform specially set up by the general hospital. If necessary, the general hospital will immediately send an ambulance to pick up the patients, which truly realizes the connection between the upper and lower levels and tiered diagnosis and treatment. Without a close county-level medical community, the tiered diagnosis and treatment system will be difficult to implement.

"China Newsweek": How difficult is resource integration?

Zhan Jifu: There is an important prerequisite for the reform of the medical community, and it must be fully authorized by the government. The essence of resource integration is the reallocation of interests. If the general hospital does not have sufficient management and scheduling authority in the preparation and use, personnel arrangements, performance allocation, and the use of medical insurance funds, integration is empty talk. These powers are scattered in different government functional departments and are difficult to mobilize by the health and health department alone. Therefore, the construction of the medical community must make the government "turn inward" and encourage relevant functional departments to delegate power. To achieve this, the "top leader" of the local government needs to promote it and take the initiative to assume the responsibility for reform.

In 2012, at the beginning of medical reform, Sanming City established a leading group for deepening the reform of the medical system (hereinafter referred to as the "Medical Reform Group"), with members including the heads of relevant departments such as the city's finance, development and reform, health, medical insurance, and drug supervision. At that time, I was the deputy mayor of Sanming City and also served as the leader of the medical reform group. The Municipal Party Secretary and Mayor fully authorized the medical reform team. Medical reform involves the game of interest between various departments. Someone once joked that if the meeting discussed above, there will be only 3 pages left for the 5-page reform plan. The guiding ideology in the front and the organization guarantee in the back will be cut off in the middle. After 2016, the head of the Sanming Medical Reform Group was the secretary of the Municipal Party Committee.

The reason why Sanming City can successfully promote medical reform at all stages is because of the existence of the medical reform group mechanism. It is not a simple deliberative and coordination agency, but an institution that truly has the power to make decisions, command and dispatch. During the reform of the medical community, the medical reform team directly ordered the county-level organization, personnel, finance, performance, medical insurance and other relevant departments to delegate the autonomy of running medical care to the general hospital. While delegating power, the medical reform team must also effectively supervise the medical community to ensure that the overall reform direction remains unchanged. The medical reform team must assess the president of the general hospital every year. If the assessment results are not good, they can be dismissed on the spot. In the past few years, we have removed several deans.

"China News Weekly": You mentioned that reform must be "one-stop" but Sanming only issued the "Opinions on Deepening the Management of Staff in Close County Medical Community" in 2023, which clearly proposed to open up the "last mile" of the coordinated use of personnel and open up the staffing boundaries between general hospitals and primary medical institutions. Does this mean that before this, the overall authority of the Sanming Township Health Center was not fully received by the General Hospital? At present, many other pilot areas for medical community reform also have the same problems. Although the county-level hospitals are horizontally "bound" and the vertical integration of township health centers has encountered many difficulties and resistance. What suggestions do you have for this?

Zhan Jifu: In terms of staffing, Sanming City did encounter many challenges in the early stages of reform. The core crux of the problem is that township and health centers in many areas, including Sanming City, still implement "two lines of income and expenditure". They belong to public welfare institutions in the first category, and are fully allocated by the finance department, while county hospitals are public welfare institutions in the second category, which belong to public welfare institutions with different funding. The two are of different natures and are difficult to move and connect with each other.

Under such premise, employees of township health centers cannot be transferred to county hospitals, and transferring personnel of county hospitals to township health centers is a "reverse transfer", that is, from the difference unit to the full unit, it is also subject to policy restrictions. But I think that a true "family" must truly integrate the personnel of the third-level medical institution, and the people above can go down, and the people below can also come up, and everyone can eat at the same table to be united. During the reform process, we found that if the finance and staffing are not unified, township health centers will be "disobedient" and will weaken the leadership of the general hospital.

After the new staffing policy was introduced, Sanming City, on the basis of maintaining the unchanging nature of the existing grassroots medical and health institutions, the general hospital can coordinate the staffing of the medical community within the approved total staffing, recruit grassroots medical and health talents in a unified manner, and implement "county-managed townships, township recruitment and village use", which is equivalent to putting personnel and funds into a pool for accounting and allocation. But this kind of reform is still limited, and it is a "patch". I suggest that in the future, we can consider combining township health centers in public welfare and county hospitals in public welfare and county hospitals in public welfare and into "medical and health institutions", that is, a special staffing can be set up for public medical institutions, so as to fundamentally solve the staffing and financial problems of medical community reform.

The medical insurance service station of Sanming Sha County General Hospital. Photo/Visual China

The complete "change of the salary system"

"China Newsweek": In the construction of the medical community, salary performance reform is a key tool. Sanming City’s salary system reform is drastic and is at the forefront of the country. As early as 2015, it has begun to implement the target annual salary system for all employees. Since 2021, it has been further upgraded to the annual salary system for all employees. What is the difference between the two? What is the significance of the reform of the salary system to the reform of the medical community?

Zhan Jifu: After building the basic framework of the General Hospital of the Medical Community - branch, compensation performance reform must be carried out in a supporting manner. If the salary system remains unchanged, it is impossible to achieve the transformation of the "health-centered" medical system. In the past, the departments of the hospital were managed according to the piece-based commission method, that is, the salary was calculated based on the amount of income. Under this assessment method, the more sick the people get, the more money the hospital makes, and the higher the salary of doctors; but now, we hope that the people get less sick, get serious illness late, and don’t get serious illness. So, as the number of patients decreases, how can we ensure that the income of medical staff does not decrease or even continue to increase?

The Sanming Medical Reform first abolished the salary distribution system that links performance wages to pharmaceutical consumables and medical income, and implemented the target annual salary system for all employees under the total salary. Moreover, the annual salary of medical staff is no longer distinguished from hospital level. Whether it is a county hospital or a township health center, as long as it is a chief physician, the annual salary is 300,000 yuan, which is reduced in turn according to the title level, with deputy directors of 250,000 yuan, attending physicians of 200,000 yuan, and 150,000 yuan in resident physicians, and the annual salary of village doctors also reached 100,000 yuan. This equalized salary design has greatly stimulated the vitality of primary medical institutions.

After 2021, Sanming City began to implement an annual salary system for all employees. A core change compared with the past is: Previously, although the salary assessment of medical staff weakened medical income, it was still linked to the number of jobs to a certain extent. After the reform, the assessment mainly emphasized work quality and job responsibilities. There is an essential difference between the two. This is a complete "change" of the salary system.

For example, in the past, fewer patients would be deducted points, but now it would be extra points, because this means that residents in the jurisdiction would suffer less illness. After the reform, the health benefits of the people will increase, which is the most important job responsibility of doctors. Moreover, if you fail to complete your job responsibilities, you will also lose your annual salary. There was no such regulation in the past. At the beginning, many hospitals were not adapted to this change. Major general hospitals often argued that they were red-faced when they were arguing about how to allocate their assessment work points. So many years have passed, and some hospitals are still arguing about this issue.

Outside the general hospital, in order to further guide public medical institutions to transform to "health-centered", the medical reform team conducts health benefits assessments on the general hospital every year, and includes performance indicators that reflect health such as life expectancy, residents' health level, and per capita medical expenses in the evaluation indicators. Through these reforms, Sanming has promoted the medical community to a "Healthy Community".

On November 24, 2020, staff of Sanming Medical Insurance Fund Center (center) explained to residents the issue of medical insurance fund collection and payment. Photo/Xinhua

"China News Weekly": Except for Sanming City, although most areas where medical communities reform have also implemented salary system reform, basically only the president and vice presidents of the general hospital and branch office can achieve the annual salary system. Ordinary medical staff still cannot do this. The overall logic of performance reform is "more work and more income, better performance and better rewards". What consequences may this bring?

Zhan Jifu: If only the upper-level hospital reforms, the salary of ordinary medical staff will still be linked to medical income, and there will still be "treatment of minor illnesses" and excessive medical treatment. At the same time, it will cause psychological imbalance between medical staff and the waste of medical resources cannot be fundamentally curbed.

The problem now is that the national medical reform is not synchronized. Even if we carry out reforms in small areas ourselves, if the entire external medical environment is still "the bigger the hospital, the more medical income, and the more money the doctors make", talents will continue to flock to large hospitals, rather than staying down to the grassroots level. This is why the medical community has been reforming for many years and has always said that it is necessary to strengthen the grassroots, but the situation where talents "cannot enter counties or townships" cannot be fundamentally solved.

"Spend your own money to do your own business"

"China Newsweek": In recent years, the National Health Commission has repeatedly emphasized the need to give full play to the leverage role of medical insurance payment methods and implement an incentive mechanism for "total prepayment and balance retention" for close-knit county medical communities. Sanming City has been "packaging" payment of county medical insurance funds since 2017. What is the significance of this reform? How to "package" correctly?

Zhan Jifu: Through the construction of a close-knit medical community, we have formed a grassroots medical system that integrates counties, villages and villages, and have created a "car to health" that shares responsibilities and benefits. However, the car still cannot drive without oil and engines. The medical insurance fund is equivalent to the engine of this car, and it is a lever used to leverage the integration of medical and defense.

What is total prepayment and balance retention? Every year, the medical insurance fund is packaged to the general hospitals of each county by head. For example, there are 200,000 insured persons in a certain county, and there is only one medical community in the county. After the medical insurance fund collected from the cap in the county is kept with a certain proportion of the risk fund, it will be "packaged" and distributed to the general hospital of the county as a whole. This is the "contracting the county" method. This "packaging" method of "money follows people" can maximize the benefits of using medical insurance funds.

If there is a balance in the medical insurance fund that year, the medical community can retain it themselves. This money is an important source of performance. The total salary of jobs in the 12 county general hospitals in Sanming City, a very important part of which is withdrawn from 10% of the remaining balances of the medical insurance fund in the previous year. Under such an incentive mechanism, the hospital will force itself to transform from treatment to prevention as soon as possible, and reduce medical expenses as much as possible. I hope that the people will not get sick, and it is impossible for them to "something is said to be sick" or "small illness is said to be serious" because once they get sick, they will spend their own money.

Of course, there is an important prerequisite for implementing this kind of medical insurance "packaged" payment reform, that is, the medical insurance department can no longer settle with individual hospitals separately, but can directly settle with the general hospitals of third-level medical institutions. In other words, the reform of the medical community is the prerequisite for medical insurance to "contract to the county". If the construction of the medical community is not carried out through the grid management of all insured objects in the city and districts according to the county, "packaged" payment will not be operable and the ultimate goal of "saving health" cannot be achieved.

"China News Weekly": Many counties did not simultaneously carry out the "packaged" payment reform of medical insurance when building medical communities. What problems will this bring?

Zhan Jifu: I am worried that this reform will cause greater harm to the people. A close-knit medical community may be alienated into a community of "coordination between the upper and lower levels and making money together". We must be wary of this potential consequence. I have always believed that to achieve the "health-centered" medical community reform, the concept of using medical insurance funds must be changed, and its core must shift from "purchasing medical care" to "purchasing health", and from "basic medical insurance" to "basic medical insurance" to "basic medical insurance" and then rise to "basic health insurance".

In order to achieve this, the allocation of medical insurance funds must be coordinated at the municipal level and divided into counties and districts, because only by "spend your own money to do your own business" will the hospital think about saving funds, otherwise the waste of medical insurance funds will be inevitable. Nationally, the reform of payment by disease group and disease type score (DRG/DIP), which is the top priority in the reform of medical insurance payment methods, has been carried out in all coordinated areas in 2024. This is a stage that my country's medical reform must go through. However, the DRG/DIP reform is essentially "centered on treating diseases."

In fact, there are only three situations for the use of medical resources: the first is waste, the second is not waste, and the third is to maximize the health benefits. The last one is the ultimate goal of our medical community reform. I have always suggested that provinces should announce their per capita annual medical expenses, as well as the structural ratio of medical service income of public hospitals in various provinces and cities, drug consumables income and inspection and testing income.

If each province can publish all these data and compare them together, you can immediately discover the differences in medical service levels and the degree of waste of medical resources in various places. Why does the medical insurance funds and reimbursement ratio increase year by year, while the medical expenses borne by individuals still increase year by year? Once the pool water is released, there will be clear where there are loopholes, which will force provinces to "chase each other" in reform, rather than "heavy medical reforms for many years," like now, and "thunder loudly and little raindrops."

On November 18, 2020, staff of the Medical Insurance Office of Sanming First Hospital (right) explained the relevant policies to residents who came to consult about drug reimbursement. Photo/Xinhua

"China Newsweek": Many reform counties in medical communities hope to implement "packaged" payment for medical insurance, but because medical insurance funds are coordinated at the municipal level, some municipal medical insurance departments are more conservative about this, mainly worrying that they will not be able to control the safety of medical insurance funds after "packaging". What do you think about this?

Zhan Jifu: This is indeed the case. Because of the overall adjustment of medical insurance funds, the overall system design is based on prefectures and cities, while building a close-knit medical community is based on counties. If only the county is carrying out reforms but the city does not, then the county level reforms will be difficult to promote. Judging from the experience of Sanming’s medical reform, it is best to push the reform of the medical community down from the municipal level, so that a lot of work will be easier to do and more in line with China’s national conditions.

In addition, some medical insurance departments are mainly concerned that their power will be reduced after the funds are not in their hands. But in fact, after "contracting the county", the main responsibilities of the medical insurance department will also change accordingly. In the past, it was mainly to supervise the safety of funds and prevent excessive medical treatment. In the future, it can turn to prevent hospitals from insufficient medical care and declining medical service quality in order to increase surpluses.

"China News Weekly": Sanming's medical reform has been going on for 14 years, and the National Health Commission has repeatedly proposed to "learn Sanming" to "learn the country." But there are still voices of doubt. How can Sanming medical reform truly move from local to national?

Zhan Jifu: My response to these doubts is that in a prefecture-level city like Sanming with relatively weak economic conditions, we can embark on a path to allow the people to obtain the greatest health benefits through reform. Can we not do other places with better economic conditions?

I think there is no place in the country that cannot carry out reforms. The key is whether the local government is "willing, daring, or not thinking." The Sanming model is not the only model of medical reform. Local governments need to adapt to local conditions, but there is a basic principle of reform that will never change, that is, it must move from "treatment as the center" to "health as the center". All localities should be clear about whether it is reforming for the health goals of the people or to complete the tasks assigned by superiors. Medical reform involves thousands of households. Reform is an offensive thing, the system and mechanism are changed, and vested interests are acted upon. It is impossible to do it without realizing the sword and gun.

[Editor in charge: Sun Hui]