How have medical institutions responded to national healthcare reform in China?: Site investigation in pilot area of Hanbin Distrcit, Shannxi Province
By the China Policy Influence and Research Uptake (PIRU) Team
To further understand the reactions of medical institutions in light of national healthcare reform and to explore corresponding influences of payment system reform on medical behaviors of the medical staff, China FHS conducted a full-scope site investigation in the pilot area of Hanbin District, Shannxi province from 9th-11th April, 2014.
At the beginning of the event, the reps of local health authorities and health institutions management held an official bilateral meeting with the research team to introduce the overall progress of local health reform and to clarify the objectives and tasks of visiting with host agencies. Afterwards, to meet the specific research objectives with input from a variety of perspectives, the general research team was grouped into the following three sub-teams to collect qualitative and quantitative data: health policy, hospital, and grass-root health institution. A senior researcher led each sub-team, with the support of two or three junior researchers.
The health policy sub-team interviewed the local governor and policymakers in relation to health reform. This included the Director of Bureau of the Development and Research Commission (DRC), directors or managers of the Bureau of Finance, Bureau of Health, Bureau of Civil Affairs, and New Rural Cooperative Medical System (NCMS). Interviews covered the following topics: the general actions adopted and feedback about payment system reform; the involvement and inputs of different governmental stakeholders; experience and suggestions created according to local context; further reform plans etc. Moreover, all policies and documents issued by governmental agencies were collected as reference.
The hospital sub-team undertook similar semi-structured interviews at Hanbin Peoples’ hospital with hospital management and medical staff, such as reps of medical insurance office, financial office, pharmaceutical office, human resource office, physicians and nurses. Their responses provided a more practical perspective on the implementation of the reforms. To verify the qualitative findings, quantitative data containing medical costs in regard to inpatient and outpatient services were recorded for further analysis. In addition, pre-designed questionnaires were also filled out by the target population.
The grass-root health institution sub-team visited the Liushui township health center and Yugong village clinics to explore the influences of payment reform policy on the bottom of China’s three-tier rural health delivery system, in terms of institutional revenue, personal income, behavior changes, turnover of patients, etc. As was done in the hospital sub-team, the grass-root health institution sub-team investigation involved interviews, data recording and questionnaires.
Generally, the site investigation implies that Hanbin district has promoted mixed payment reform through various initiatives to deal with the complexity of conditions, such as pay for service, pay for performance, pay for clinical pathway, and pay for hospitalization day. According to initial analysis and reflection, the average medical cost and length of stay has been reduced, and utilization efficiency of medical funds has significantly improved. Meanwhile, the financial protection of patients has been strengthened, but changes in the health status of the population remains unclear based on the existing evidence. It should be noted that payment reform has been recognized by local health stakeholders as a very important leverage to trigger other reform activities in the national reform strategy, such as public basic health, the essential drug system, and hospital reform.
On the other hand, Hanbin district also faced some challenges in payment reform. Firstly, the medical fund faces financial pressure due to the increasing demand for population medical services, and requires increased government funding to improve. Secondly, the equity dimension is regularly ignored in payment reform. The balance of efficiency and equity in health reform creates a paradox for the next phase. Following the development of health reform, evidence-based decision making has become more popular and effective between policy makers, and rising problems can be solved smoothly around this principle.