公立医院改革下一步 The next step reform of public hospitals

　　公立大医院集纳着全国最优质的医疗资源，堪称医改的“国家队”，它们为何会在此番改革中呈现“作壁上观”的态势？公立医院改革这盘棋究竟会怎么走？

Public hospitals market offer most high-quality medical resources across the country,Of health care"The national team",Why they will appear in this reform"On the sidelines"The situation?Reform of public hospitals, this game will turn out to be?

　　3年前即已吹响的改革号角，似乎仍未穿破公立医院的重重迷雾。

Three years ago that has blown reform horn,Seems still not wear out in public hospitals in the heavy fog.

　　全国政协委员、中华医学会副会长吴明江向《瞭望》新闻周刊评论说：“公立医院改革试点到现在，没有取得实质性突破。”

The CPPCC national committee/The Chinese medical association, vice President of Wu Mingjiang to[outlook]The weekly news magazine:"Trial reform of public hospitals to now,No substantive breakthrough."

　　全国政协委员、北京大学口腔医学院副院长林野赞同这一观点。他说，公立医院改革目前还没有明确的方向，也没有触及核心问题，现在进行的诸如优质护理服务、预约挂号、控制医疗费用不合理增长等，还仅是公立医院的正常工作。

The CPPCC national committee/Oral medical school of Peking University, vice President of woodlands agree with this view.He said,The direction of the reform of public hospitals is not yet clear,No touch the core problems,Such as high quality nursing service now/Make an appointment/Control unreasonable medical expenses growth, etc,Also is only the normal work of the public hospital.

　　对此，全国政协委员、国务院医改办主任孙志刚给出解释：医改进行到现在，主要是围绕基层医疗机构做文章，医改还没有改到公立大医院。

For this,The CPPCC national committee/Sun zhigang, director of the reform of the state council for an explanation:In the reform,Mainly around the grass-roots medical institutions,Reform has not yet been transferred to public hospitals.

　　而公立大医院集纳着全国最优质的医疗资源，堪称医改的“国家队”，公立医院改革这盘棋究竟会怎么走？

And large public hospital market offer most high-quality medical resources across the country,Of health care"The national team",Reform of public hospitals, this game will turn out to be?

　　

投入不足 Investment insufficient

　　也有观点认为，在2010年公立医院改革试点启动之后，公立大医院并非全无变化。

Also has a view,After in 2010 launched a trial reform of public hospitals,Not all public hospitals without change.

　　全国政协委员、北京大学第一医院院长刘玉村以其所在医院为例说，医改3年多来，医院大楼起来了，设施设备到位了，工作效率提高了，服务水平增强了，并且医院的效益没比原来差。“我是一步一步看到自己医院的变化，我觉得大家还是要对公立大医院的进步给予充分肯定。”

The CPPCC national committee/Dean of Peking University first hospital LiuYuCun said in their hospital, for example,Health care reform for more than three years,Hospital buildings,Facilities in place,Work efficiency is improved,The increasing service level,And the benefit of the hospital didn't poor than the original."I see myself is a step by step changes in the hospital,I think we still need to give full affirmation the progress of public hospitals."

　　刘玉村打比方说，解决问题的办法通常有3种：一种是“佯攻”，看似挺热闹，其实不真打，但可能这架势把里面的人吓破了胆，也就真解决了问题；第二种是“围而不攻”，即长期围着你，逼着你去解决问题；最后一种是真正的攻坚克难，强行解决问题。“公立医院改革已经经过了佯攻的阶段，现在是围而不攻，各种力量正在角力。”

LiuYuCun for example,Usually there are three kinds of solution to the problem:One kind is"feint",Seems quite busy,Don't really play,But may be this posture to the inside of the people terrified,Is really solved the problem;The second is"Wai not attack",That is around you for a long time,Force you to solve problems;The last one is the real overcome difficult,To solve the problem."The reform of public hospitals have been feint stage,Now is not,All kinds of forces are wrangling."

　　刘玉村认为，公立大医院办得越好，基层医疗机构的患者就会越少，但公立大医院的院长又绝无理由将自己的医院越办越差：“公立医院改革的主力军是大医院，因为医疗人才的培养是有周期的，基层医疗机构人才的到位要靠时间、要靠等待，这是谁都没有办法改变的客观规律。这个时间大概会是10年到15年，那么在此期间，甭管外面怎么变，公立大医院还是要努力，要沉下心把自己的医院办好。”

LiuYuCun think,Public hospitals for the better,Patients with grassroots medical institutions will be less,But the director of the public hospitals and no reason to turn their hospital is getting worse:"The main force of public hospital reform is a big hospital,Because the cultivation of medical talents is a cycle,Grassroots medical institutions in place of talent depends on time/Want to rely on wait,This is who all have no way to change the objective laws.This time will probably be 10 to 15 years,So during this period,Regardless of how to get outside,Public hospitals or effort,To heavy to do a good job in your hospital."

　　办好公立医院，离不开财政的支持。

Do a good job in public hospitals,Without financial support.

　　中国卫生部部长陈竺在2012年的夏季达沃斯论坛上表示，中国的卫生费用占GDP比重仅为5.1%，不但低于高收入国家的平均数值8.1%，而且低于低收入国家的平均数值6.2%，与中国同在金砖国家中的巴西和印度则分别达到9%和8.9%。

China's ministry of health minister Chen zhu said at the 2012 summer davos BBS,China's health costs as a proportion of GDP is only 5.1%,Not only numerical values by an average of 8.1% less than in high-income countries,And values by an average of 6.2% less than in low-income countries,With China's bric countries of Brazil and India are 9% and 8.9% respectively.

　　全国政协委员、首都医科大学北京宣武医院神经外科主任凌锋说，卫生一般和教育相对比，2012年，中央财政共安排医疗卫生支出2048亿元，与此同时，中央政府向教育安排投入3700多亿元；2013年，中央财政教育支出4132亿元，卫生则为2600亿元。“从投入比例的增加幅度看，卫生最高，为27%，但从绝对数值看，卫生比教育获得的财政支持还是相差很远。”

The CPPCC national committee/Beijing xuanwu hospital, capital medical university, director of neurosurgery LingFeng said,Health and education are relatively better than in general,In 2012,,The central government has spent 204.8 billion yuan on medical and health care,At the same time,The central government to education investment of more than 3700 one hundred million yuan;In 2013,,The central fiscal education expenditure of 413.2 billion yuan,Health is 260 billion yuan."Look from the investment proportion of the increase amplitude,Health top,Of 27%,But look from the absolute value,Health education than to get financial support or far."

　　据凌锋计算，在2600亿元的医疗卫生投入中，仅新农合从240元提高到280元这一项，就要花去500多亿元，那么，倘若把剩余的2100亿元资金分摊到现存的18000所公立医院，则平均每家医院只能获得1100多万元投入。“对一个三级甲等医院来说，这笔钱只占其运转费用的约10%，显然非常不足。”

According to LingFeng calculation,In the 260 billion yuan investment in medical and health care,Only new farming increased from 240 yuan to 240 yuan (us $,They're spending more than 500 one hundred million yuan,then,If the rest of the 210 billion yuan of capital contribution to the existing 18000 public hospitals,On average every hospital can only get into more than 1100 1100 yuan."For a level of first-class hospital,The money accounts for only around 10% of its operating costs,Obviously very inadequate."

　　此外，即使是这个相对较低的卫生费用投入，能否得到合理、科学的分配也有待验证。

In addition,Even this relatively low pay for the health,Can be reasonable/Scientific allocation also needs to be verified.

　　作为一名老政协委员，凌锋回忆说，在过去的5年中，医卫界政协委员不断要求增加国家对卫生的投入，“大家要求了5年，现在也的确上涨了27%，但投入总量还是偏低。”

As a veteran CPPCC member,LingFeng recalls,In the past five years,YiWeiJie asked CPPCC increasing state spending on health,"You ask for five years,It's also true that also rose 27%,But in total on the low side."

　　接下来的问题是，在财政投入严重不足的情况下，公立医院改革将向何处去？

The next question is,In the case of serious shortages of financial investment,Reform of public hospitals will be where to go?

　　

确保钱用在刀刃上 To ensure that the money used on the blade

　　凌锋的答案是，用一个精妙的顶层设计，确保钱用在刀刃上，而不是去撒胡椒面。

The answer is LingFeng,With a subtle top-level design,To ensure that the money used on the blade,Instead of black pepper.

　　在她的设想里，这个顶层设计应当以完善公立医院法人治理结构为突破口，以调动全体医务人员积极性为主要手段，最终达到深化公立医院体制机制改革的目标。

In her idea,The top design shall be based on the perfect public hospital corporate governance structure as the breakthrough point,To arouse the enthusiasm of the medical personnel as the main means,Finally reached the target of deepening the reform of public hospital system and mechanism.

　　全国政协委员、卫生部副部长黄洁夫也是顶层设计的倡议者。他表示，公立医院的弊病就是带有垄断性质、缺乏竞争，缺少进一步改革的动力。为此，他提出一个类似教育部“211”工程的建议，即遴选3000家左右的各级公立医院，由政府“包”下来，其他医院则松绑、放开，允许社会资本参与。

The CPPCC national committee/Deputy health minister huang jiefu also advocates the top-level design.He said,Public hospital's ills is with monopoly nature/The lack of competition,Little incentive to further reform.To do this,He put forward a similar to the ministry of education"211"Project proposal,Namely the selection of the 3000 or so in public hospitals at all levels,By the government"package"down,Other hospitals are loosening/Let go of,Allow the social capital to participate in.

　　本刊记者获悉，目前中国共有2万多所医院，其中绝大多数是公立医院。在这些公立医院中，政府投入约为医院收入的7%～15%，剩下的运营费用要靠医院自己解决。“如果一直这样下去，这个结就还是解不开。”黄洁夫说。

This reporter learned that,China is now more than 20000 hospital,Most of them in public hospitals.In the public hospital,Government spending is about 7% ~ 15% of hospital income,The rest of the operating expenses depend on hospital."If always like this,This knot or solution doesn't open."Huang Jiefu said.

　　按照黄洁夫的想法，“2、1、1”分别代表2000所左右的县级水平的医院、1000所左右的省市级医院和100所左右的国家级医院，这个评定应该公开、透明，让人民群众，特别是医务人员广泛参与，而不是由官方来评定是否入选。“为了创建这3000来家‘211’医院，各级医院都会动起来，医院就会拿出让人民群众满意的措施来。”

According to the Huang Jiefu ideas,"2/1/1"Represent the 2000 or so of county level hospital/About 1000 or so provincial hospitals and 100 national hospital,This evaluation should be public/transparent,Let the people,Especially widely participate in medical staff,Rather than to assess whether or not to be included by the authorities."In order to create this to 3000‘211’The hospital,Hospitals at all levels will move,Hospital will take the steps to transfer the people satisfied."

　　比如，县级医院包括县中医院、县人民医院等，数量很多，如果是一个好的评定机制，那就可以调动县级医院的积极性。而这2000家县级医院应该能够覆盖70%的农民，为其提供基本医疗服务，同时，地方财政也能够支持得起。

Such as the,County hospitals including the county hospital/County people's hospital, etc,A lot number,If it is a good assessment mechanism,It can arouse the enthusiasm of county-level hospitals.And this 2000 county-level hospitals should be able to cover 70% of the farmers,To provide basic medical services,At the same time,Local governments can support also.

　　再如，挑选100所左右的国家级重点医院，这些医院代表国家的医疗水平，也能够提供一些特殊服务，如外交需要等。“当前公立医院几乎垄断全部医疗资源，越大的医院垄断的资源就越多，排的队也越长，它们缺乏竞争，没有进一步改革的动力。但在一个好的评定机制下，它也必须有所动作。”

Again, such as,Pick up about 100 national key hospitals,These hospitals on behalf of the state health level,Can also provide some special service,Such as foreign need, etc."The current public hospital almost monopolized all medical resources,The greater the monopoly of the resources, the more hospitals,The longer the team also,They lack of competition,No further reform.But under a good evaluation mechanism,It must also be action."

　　黄洁夫说：“‘211’只是一个大概的数字，但这不是随便想出来的，而是我和卫生部负责医改的马晓伟副部长几经探讨、根据政府财力测算出来的。”

Huang Jiefu said:"‘211’Just a ballpark figure,But it is not easy,But the deputy minister of the ministry of health is responsible for the health of Mr. Ma and I discussed several times/According to the government financial resources is calculated out."

　　凌锋表示，决策者一定要想清楚，公立医院改革究竟是需要“小岗村”还是需要顶层设计。“如果是需要‘小岗村’，那么在全国各试点城市中找一个典范推开即可。但似乎对医疗来说没有这么简单，公立医院改革一定是一个多部门合作的事情。”

LingFeng said,Decision makers must want to clear,The reform of public hospitals is needed"Xiaogang has"Still need to the top-level design."If it is need to‘Xiaogang has’,So looking for a model in each pilot city in the country away.But it seems not so simple for medical,Reform of public hospitals must be a multi-sectoral cooperation."

　　

“借鸡下蛋”与“杀鸡取卵” "Borrow chickens lay eggs"With the"Kill the goose that lays golden eggs"

　　公立医院改革的另一个关键，在于社会究竟以何种态度对待民营资本。

Another key to reform of public hospitals,Is to society what to what kind of attitude towards private capital.

　　“国家既然没有太多资金投入医疗卫生，没有办法养太多医院，那我想就要‘借鸡下蛋’，把市场向民营资本开放。”全国政协委员、阜外心血管病医院心内科教授张澍说。

"Since countries don't have much money into health care,There is no way to keep too many hospitals,I think will be‘Borrow chickens lay eggs’,The market opened up to private capital."The CPPCC national committee/Fuwai cardiovascular hospital professor of cardiology Zhang Shu said.

　　黄洁夫表示，社会着力建立一个以医生自由执业为基础的医生人力资源市场和一批高水平的非营利性民营医院，才能解决在市场经济规律下的中国医疗体制问题。通过医院体制改革，建立以私人诊所或合伙人医疗中心为主体的竞争性全科医生社区“守门人”制度，才能有效解决城乡居民“看病难、看病贵”的问题，也才能有效控制医疗费用过快增长，保障国家财政中的医保资金得到合理使用。

Huang Jiefu said,Strive to build a society based on doctor free practice doctor human resources markets and a high level of non-profit private hospitals,To solve it in a market economy under the rule of China's medical system problem.Through the reform of hospital system,Establish a private clinic or partner competitive general practitioner community medical center as the main body"The gatekeeper"system,To be effective to solve the urban and rural residents"The doctor is difficult/See a doctor expensive"The problem of,To be effective for controlling the excessively rapid growth of medical expenses,Safeguard national finance in health care get rational use of funds.

　　然而，现行制度与之颇有抵牾。“有的制度不仅不是在‘借鸡下蛋’，根本就是在‘杀鸡取卵’。”张澍说。

however,The current system there is quite a discount with them."Some system not only isn't in‘Borrow chickens lay eggs’,Is in the‘Kill the goose that lays golden eggs’."Zhang Shu said.

　　张澍分析说，“杀鸡取卵”的现象之一，就是医生的劳动强度、劳动时间等大大超过一般职业。“比如有的医院说他们要保证患者就诊当天即可全部看完，可医生数量与之并不匹配，那么医生就要加班加点，劳动强度很大，待遇却不是很好，导致医生队伍人才流失的情况越来越普遍。”

Zhang Shu analysis said,"Kill the goose that lays golden eggs"One of the phenomenon of,Is the doctor's labor intensity/Far more than general professional labor time, etc."Such as some hospitals said they make sure can finish all the day to the patient,Can the doctor number does not match with them,So the doctor is going to work overtime,The intensity of labor is very big,The treatment is not very good,Cause the doctor team the brain drain situation is becoming more common."

　　张澍说，中国用仅占世界医疗资源3%的医疗总费用，维护了占世界总人口22%的人群健康。在这背后，并不完全是中国的设备、器材等比国外落后，一个很重要的原因是中国的医生和护士平均收入很低。由于对医疗服务存在不合理的价格管制，大部分医疗服务定价并未考虑人力成本，医生的劳动价值得不到合理体现。

Zhang Shu said,China use only 3% of the world medical resources of medical cost,Maintain the crowd health accounted for 22% of the total population in the world.Behind this,Equipment is not in China/Geometric foreign countries lag behind,One important reason is that doctors and nurses, the average income in China is very low.Due to the price control for medical service is unreasonable,Most of the medical service pricing does not take into account the human cost,The doctor's labor value is not reasonable.

　　“杀鸡取卵”的现象之二，则是现行医师职称晋升考评中存在的重论文科研、轻临床实践的导向。全国政协委员、解放军总医院副院长范利认为，这种导向已经暴露出两大弊端：

"Kill the goose that lays golden eggs"The second phenomenon of the,Is the current physician title promotion existing in the evaluation of scientific research papers/Light guide clinical practice.The CPPCC national committee/The people's liberation army general hospital, vice President of Fan Li think,This guide has exposed two big drawbacks:

　　其一，医生临床水平明显滑坡，医疗安全形势严峻。范利说，一个人的精力总是有限的，要求大多数医生既能为患者看好病又能在科研上不断出成果，成为一个复合型医生是不客观、不现实的。面对晋升时众多考试、科研和论文的要求，医师只能缩减对病人进行观察和管理的精力，有的甚至拿出80%的时间去搞科研，而医生没有足够心思和精力对患者精心诊疗、人文关怀，极易导致医患间出现矛盾。

The first,Doctors clinical levels decline,Medical security situation grim.Fan Li said,A person's energy is always limited,Require most doctors can watch the disease for the patient, as well as continuously the achievement in scientific research,To be a composite doctor is not objective/Not realistic.Many test when it came to promotion/Scientific research and paper requirement,Physicians can only be reduced to the patient carries on the observation and management of energy,Some even took out 80% of the time to do research,The doctor didn't have enough idea and effort careful diagnosis and treatment of patients/Humanistic care,Easy to lead to conflict between doctor and patient.

　　其二，医学科研脱离临床，学术腐败触目惊心。范利表示，医师晋升职称标准中对科研课题、奖项和SCI论文数量的过高要求，导致一些科研一味追求高、新、尖，不注重临床需要和实用，在成果鉴定之时，就是成果寿终正寝之日。更难容忍的是，由此导致的学术浮躁、论文抄袭、科研造假现象愈演愈烈。“当所有医生都一窝蜂地去生产论文的时候，买卖版面、剽窃抄袭也就粉墨登场。”

The second,From clinical medical research,Academic corruption.Fan Li said,Physicians, promotion of scientific research subject in title standard/Awards and SCI papers number too high requirements,Lead to some scientific research devotion to high/The new/tip,Does not pay attention to the clinical needs and practical,At the time of the achievements appraisal,Is the end date.Is more difficult to tolerate,The resulting academic fickleness/plagiarism/Fraud phenomenon intensified."When all the doctor paper rush to go to production,Buying and selling page/Plagiarism is copying it."

　　凌锋认为，如果说“看得上病”的问题已经通过基本医疗保障制度不断扩大覆盖面、提高支付能力有所缓解，那么眼前迫切的问题就是解决“看得好病”的问题。“说白了，医院的运行机制一定要保障医务人员的合理收入，调动他们的工作积极性，如果医生没有积极性，好看病是做不到的。与此同时，医生自己也要修德，要以大医精诚的态度对待病人，追求仁心仁术。”(《瞭望》新闻周刊记者 张冉燃)

LingFeng think,If there is"Value disease"Problem has been by expanding coverage of basic medical security system/Improve the ability to pay,So the urgent problem is solved"See good doctor"The problem of."To put it bluntly,Hospital operation mechanism must be reasonable income security staff,Arouse the enthusiasm of their work,If a doctor without enthusiasm,Good to see the doctor is made.At the same time,The doctor himself to strive for virtues,To treat patients with large medical sincere attitude,The pursuit of er."([outlook]Newsweek reporter zhang ran)