According to media reports, several major research groups that were recently commissioned to study the four key tasks of the 2014 medical reform jointly held a debriefing meeting in Beijing, including public hospitals and state-owned enterprises and institutions' hospital reforms. According to the high-level deployment, the National Health and Family Planning Commission, together with the SASAC and other selected pilot units, will come up with a guiding principle this year.
According to the key tasks of the 2014 medical reform work, it is necessary to promote the pilot reform of government-run hospitals and the pilot reform of state-owned enterprise hospitals, and strive to make breakthroughs in adjusting stocks and innovating institutional mechanisms.
Based on the analysis of the living environment of the enterprise hospital in the year, Du Chuang, deputy director of the Public Policy Research Center of the Institute of Economics of the Chinese Academy of Social Sciences, believes that due to the irreversibility of the reform of state-owned enterprises, the overall health care system of enterprises with the characteristics of a planned economy collapsed For most corporate hospitals, the various problems they face cannot be solved through "requiring policies" and "requiring fair treatment." The way out is to reform the system.
Although this article is not the latest published, the analysis and recommendations in the text are still time-sensitive for the task of medical reform.
——The enterprise three-level medical and health network, the labor insurance medical system, and the welfare nature of state-owned enterprises are the three elements that constitute the enterprise's medical and health system during the planned economy period. The three complement each other and form a positive feedback system.
——The fundamental reason for the reform of corporate hospitals is that the corporate health system with a planned economy has completely disintegrated, and the external environment for state-owned enterprises to run hospitals has disappeared. Under the impetus, the actual driving force for the system reform is to reduce the burden on state-owned enterprises. The slight deviation between the two makes the corporate hospital restructuring, although the overall direction is correct, many problems are exposed in the specific implementation.
——In the new medical reform, we should adhere to the direction of corporate hospital reform, improve supporting policies, and expand social capital participation.
In this article, "enterprise hospital" refers specifically to hospitals run by state-owned enterprises. During the planned economy period in China, state-owned enterprises in petroleum and petrochemical, metallurgical, aerospace, aviation, railway, coal, electric power, textile, heavy machinery, transportation and other industries all set up hospitals, which played an important historical role in maintaining the life and health of their employees. According to the China Health Statistics Yearbook, in 2002, before the large-scale restructuring of corporate hospitals, there were 17,844 hospitals in China, of which 5,432 were corporate-owned hospitals, one of which is one-third of the world.
Despite the huge number and once prominent status, in the new round of medical and health system reforms launched in 2009, corporate hospitals have always been in an "embarrassing" position. The policy encourages social capital to participate in the reform of corporate hospitals, making it possible to become an entry point for social capital to run medical services and a breakthrough in the reform of public hospitals during the 12th Five-Year Plan; The improvement and the unsuccessful restructuring of some corporate hospitals have made many corporate hospitals see the benefits of staying in the system and identifying the identity of public hospitals. Where to go from here? The corporate hospital stood at the crossroads again. Today, it is necessary to comprehensively review the origin, logic, problems faced by China's enterprise medical and health system, and the reform process of the past ten years, and use this as a basis to analyze the path of the new round of enterprise hospital reform.
Logic: Enterprise Healthcare System in the Planned Economy Period
The prevalence and good operation of corporate hospitals during the planned economy period are not an isolated phenomenon, but a series of institutional factors that complement them, forming a positive feedback system that integrates corporate medical and medical insurance operations and is coordinated with the external environment.
First, corporate hospitals and local government-run hospitals are two systems. Most of the relatively large-scale state-owned enterprises have formed three-level medical and health networks. Among them, the enterprise health clinic and factory health station are primary. The medical and health unit at this level assumes the primary health care tasks of the employees and their families in the factory, and takes the medical prevention work in the area as the main form. When encountering difficult and urgent patients, they can ask the higher-level hospital to take Various forms of assistance in diagnosis and treatment, or sent for consultation, or referral to hospital. The enterprise staff hospital is a second-level hospital, which is a link between the past and the present. This level of medical and health units mainly assists primary medical units to solve problems in medical prevention, and then transfers them to higher-level hospitals for assistance. The company's central hospital is three-level and faces the entire enterprise. Its main tasks are: focus on handling difficult and urgent patients, and do a good job of medical, teaching, and scientific research; the main responsibilities are to assist the lower-level hospital in the diagnosis and treatment of difficult and urgent patients. , Or receive inpatient treatment, or go to a basic hospital for consultation and surgery; second, to help medical staff in lower hospitals improve their technical level, or receive further education, or send experts and backbones to carry out training.
Second, the labor insurance medical system. China's enterprise labor insurance medical system was established when the Labor Insurance Regulations of the People's Republic of China was promulgated and implemented in the early 1950s. This is a free medical model similar to public health care, but it is also a self-contained system. Lack of social mutual aid. The enterprise raises funds by itself, and the medical expenses of employees are reimbursed by the enterprise and the medical expenses of their immediate family members are reimbursed by half.
Third, external conditions. During the planned economy period, state-owned enterprises were welfare units rather than profit-making units, and implemented a compensation system featuring weak incentives and low wages. The financial appropriation for state-owned enterprises included appropriations for corporate hospitals. At that time, state-owned enterprises were generally responsible for running social functions, not only hospitals, but also schools, internal unit management of retired employees, and so on. These do not constitute a burden on state-owned enterprises under the planning system, because the entire social economy is dominated by state-owned and collective public-owned enterprises, competition pressure is not obvious, and profit maximization is not the operating goal of state-owned enterprises; more importantly, the fiscal The appropriation system for state-owned enterprises naturally includes funds for running social functions such as hospitals and schools.
The above three factors are complementary and mutually supportive. For example, for enterprise employees, labor insurance medical is a free medical system, and individuals do not need to bear the costs, so how to control expenses is a big problem. The need for fee control has led to the development of enterprise medical units in the direction of "small and comprehensive", and formulated some restrictive measures during the transfer process-eventually forming a three-level medical health network within the enterprise. If an employee is ill, he or she must first go to a primary health institution, such as a health center or a factory health station, and refer to the patient for further referrals. The primary medical institutions within these enterprises assume the role of gatekeeper. However, if there is only a primary medical and health institution and no large hospital, then the "gatekeeper" can play a certain role, and it is still difficult to control the cost of medical treatment for employees in the hospital. Therefore, a "small but complete" three-level network is necessary.
Of course, the establishment of a large three-level medical and health system within an enterprise does not necessarily conform to the principle of economic efficiency. However, because state-owned enterprises are welfare units rather than profit-making units under the planning system, fiscal appropriations for state-owned enterprises include appropriations for corporate hospitals, and state-owned enterprises do not need to worry about economic benefits. On the contrary, within the scope of the system, hospitals can run well. The bigger the state-owned enterprise, the more disbursed it will be. However, a problem that comes with it is that within the huge welfare unit, the enterprise's medical and health institutions are only in a subordinate position (a branch of the logistics support department), so it is impossible to count on their medical facilities, physicians' technical level and local professionalism. Medical institutions shoulder to shoulder. This weakness is just offset by the weak incentives and low wage system: the generally low income of state-owned enterprise employees has not released the multi-level demand for medical care, and low-level medical security can basically meet the demand; and weak incentives, The low-wage system makes the enterprise hospital, although it is only a logistical guarantee unit for state-owned enterprises, the salary gap with front-line employees of the enterprise is not large, and it will not affect the enthusiasm of doctors.
Despite the above interactions, the overall efficiency of corporate healthcare systems is still low, providing only a low level of medical security. In addition, the labor insurance medical system is mainly based on self-protection by the unit. The degree of social mutual assistance for employee medical expenses is low. There is a lack of co-ordinated medical expenses among new and old enterprises and between different industries.
Problem: The collapse of corporate healthcare systems since reform and opening up
Since the reform and opening up, with the gradual progress of the reform of state-owned enterprises, the external conditions on which the enterprise's medical and health system has existed have undergone tremendous changes. The internal adaptability of the original enterprise's medical and health system has been destroyed, and a series of problems have arisen from this. The inevitable choice for most corporate hospitals.
First, state-owned enterprises have changed from welfare units to profit-making units. Strong incentive mechanisms have been introduced, and the government no longer directly allocates funds to state-owned enterprises. Since then, corporate hospitals have become a part of the cost of state-owned enterprises, that is, “policy burden”. State-owned enterprises need to consider the scale of their hospitals and even the issue of staying from the perspective of maximizing profits. This has led to the development of corporate hospitals being more directly constrained by the operating conditions of the enterprise, but not closely related to their own performance. Corporate hospitals generally have low-level and backward mechanisms in terms of development positioning, scientific research, talent, and incentive mechanism construction. In addition, because corporate hospitals belong to the logistics support department in the enterprise, companies generally adopt total salary management for their personnel funding, which not only limits the development of corporate hospitals, but also prevents them from attracting talents and establishing incentive systems. More importantly, due to the closed state funding channel for state-owned enterprises, it has also made it difficult for their medical institutions to enjoy the state's relevant policies on public health institutions. For example, corporate hospitals, like community health service agencies, have undertaken some basic medical and public health services for people in the territories, but they have not received the same government subsidies as local community health service agencies. Since the new medical reform in 2009, The adjustment of inspection costs has a direct impact on the income of enterprises' primary medical and health institutions, and it is difficult to obtain corresponding local financial subsidies. Moreover, the low-wage system for employees in state-owned enterprises no longer continues. As the income of employees increases, the multi-level demand for medical care is also released, and the internal medical and health institutions within the company can no longer meet their needs.
Secondly, the labor insurance medical system was abolished and replaced by a localized urban employee medical security system. As mentioned earlier, the health care system divided between enterprises and localities and the medical security system divided between enterprises and localities are mutually compatible. With the universal establishment and territorialization of the urban employee medical insurance system, the medical insurance system split between the enterprise and the local area is gradually becoming unified; however, the enterprise medical health system and the local medical health system are still separated. The medical insurance system and the medical health system The incompatibility makes the development of corporate hospitals face difficulties. For example, many second-tier and below corporate hospitals are discriminated against when they are included in the medical insurance fixed point. Some places even explicitly prohibit basic medical insurance and new rural cooperative medical patients from seeking medical treatment in corporate hospitals. Otherwise, they will not be reimbursed. As a result, corporate hospitals will lose their service radius. , Competitiveness is reduced, and even unable to survive.
Third, with the gradual establishment of a new community health service system in urban areas, primary health institutions, such as health clinics and health stations, have been gradually included or marginalized, and the three-level medical health network within the enterprise has also ceased to function. Role, the "gatekeeper" disappeared, the division of labor no longer exists.
Deviation: the root cause and actual motivation of the restructuring
In 2002, the former State Economic and Trade Commission and six other ministries and commissions jointly issued the "Opinions on Further Promoting the Social Function of State-owned Enterprises Separated from the Office" (State Economic and Trade Enterprise Reform  No. 267 Document), and the work of separating hospitals to run hospitals has started on a large scale . By 2008, before the start of the new medical reform, the number of hospitals run by state-owned enterprises had halved.
Based on the analysis above, the fundamental reason for the need for corporate hospital restructuring is that the corporate healthcare system with the characteristics of a planned economy has completely disintegrated, and the external environment for state-owned enterprises to run hospitals has disappeared. However, the restructuring of corporate hospitals from 2002 to 2008 was mainly driven by the state-owned enterprise sponsors. The actual driving force for the restructuring was to reduce the burden on state-owned enterprises and eliminate the policy burden on state-owned enterprises. The two are essentially the same, but there are slight deviations; this makes the corporate hospital restructuring in this period of time although the overall direction is correct, but many problems are exposed in the specific implementation.
First, one of the driving forces for local governments to reduce the burden on state-owned enterprises is to reduce the local financial burden, which is also the driving force for the large-scale reform of local state-owned enterprises during the same period. However, a considerable amount of corporate hospital restructuring is achieved through the transfer to local governments, or the restructuring system is transferred, incorporated into the establishment, or is hosted and subsidized by the local government, which is also the most desirable reform method of corporate hospitals. However, if this method is implemented conscientiously, it is nothing more than moving the government's financial burden from the left to the right, or (for the hospitals run by central enterprises) from the central government to the local government. The prevailing local financial pressure makes the actual implementation result often "institutional and enterprise-oriented operation", and the hospital spontaneously dies.
Second, in order to smoothly and quickly realize the reform of the hospitals under their jurisdiction, some enterprises have adopted the shareholding system reform based on employee shareholding, leaving behind the aftermath. Every employee has shares. Although there are fewer conflicts during the restructuring, the daily management after the restructuring will be difficult, and it will be difficult to form a unified decision, which will ultimately affect the development of the hospital. Today, these restructured corporate hospitals generally have the problem of "secondary restructuring".
Third, since the main promoters of the restructuring are state-owned enterprise authorities, fewer supporting policies have been issued by the health administrative organs, which has affected the effect of privatization reforms (employees holding shares and social capital participation in reforms). After the privatization of corporate hospitals, corporate hospitals appeared in the medical market in the form of private non-enterprise units, and had to bear the “pain” of other private medical institutions: the market was monopolized by public hospitals, discriminatory treatment at fixed points of medical insurance, non-profit profit Tangled, and so on.
Ideas: adhere to the direction of reform, improve supporting policies, and expand social capital participation
In 2010, five ministries and commissions, including the National Development and Reform Commission, Opinions on Further Encouraging and Guiding Social Capital to Host Medical Institutions, put forward: "Encourage social capital to participate in the reform of public hospitals. The reform of public hospitals can take precedence in public hospital reform pilot areas and hospitals run by some state-owned enterprises. Pilot. "However, there is still a lack of comprehensive and systematic policy ideas for corporate hospital restructuring. According to the previous analysis, the author believes that corporate hospitals should adhere to the direction of system reform, improve supporting policies, and expand social capital participation.
Due to the irreversibility of the reform of state-owned enterprises and the overall disintegration of the enterprise medical and health system with a planned economy, for most corporate hospitals, various problems (including those that occurred during the initial reform) cannot be passed through "requirements". 2. The solution to "the need for fair treatment" lies in reform (secondary reform). Of course, due to the need for confidentiality in special strategic industries, a small number of hospitals should continue to remain inside the enterprise; for large industrial and mining areas that are far from cities and towns, their service targets are relatively single and can be transferred to the mining area government. For other secondary and above corporate hospitals that need to be restructured, priority should be given to absorbing social capital participation.
The new round of reform should learn the lessons of the first reform, strengthen the communication between the state-owned enterprise authorities and the health administrative departments, and improve related supporting policies. For example, in the evaluation of state-owned assets, the issue of land use rights in hospitals, personnel placement, and for-profit and non-profit policies in hospitals, the relevant policies should be detailed and operational.
(The author is deputy director, associate researcher, and Ph.D. of the Center for Public Policy Research, Institute of Economics, Chinese Academy of Social Sciences; this article was published on December 31, 2012)
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