The 9th Anniversary Test of the Founding of the University of Hong Kong Shenzhen Hospital: Medical Reform Sample or Utopia?

The 9th Anniversary Test of the Founding of the University of Hong Kong Shenzhen Hospital: Medical Reform Sample or Utopia?

No matter how you look at it, the Hong Kong University Shenzhen Hospital, which has just celebrated its 9th anniversary, is an outlier in the medical system in Mainland China.

In the early stage of operation, the 100 yuan registration fee was criticized as an “aristocratic hospital”. What made the patients even more incomprehensible was that they went home without prescribing medicine after paying for treatment at the hospital. Nine years ago, when the sunshine salary of most mainland doctors was no more than 100,000 to 200,000, the Hong Kong University Shenzhen Hospital was able to provide the attending doctor with an annual salary of up to 500,000 to 600,000.

As the first public hospital in the country that has no establishment, the purpose of high salaries in Hong Kong University Shenzhen Hospital is to maintain integrity-to eliminate red envelopes and drug consumables rebates, to refuse large prescriptions and excessive diagnosis and treatment. But this newborn hospital, in the first few years that it has been unable to make a profit, was reported by the media that it lost more than one billion in two years . It was once considered to rely on blood transfusions from the wealthy Shenzhen government, and could not be self-financing and operating independently. .

As a medical reform pilot, the Hong Kong University Shenzhen Hospital carries the important task of exploring a new path for public hospitals in China. Nine years have passed. Is it a medical reform sample or a utopian story that cannot be replicated?

High salary to raise honesty, what kind of honesty can be raised?

The Hong Kong University Shenzhen Hospital was born in 2012, not long after the launch of the new medical reform. At that time, China’s medical environment was in the era of red envelopes, large prescriptions, and excessive medical treatment. The problem of “difficult and expensive medical treatment” has become prominent. The public complains about the medical system, and all kinds of contradictions have accumulated to the apex. Its extreme manifestation is violent wounded doctors.

At the same time, the price of medical services that measure the value of doctors is appallingly low. The number of outpatient surgeries, examinations, and prescriptions of doctors are directly linked to personal salaries, which is also related to the expansion and development of public hospitals.

The sunshine income of doctors and hospitals is not high, and they can only rely on a series of “gray income” to feed back, which has become an open secret of the hospital. The face income may only account for 30% of the salary. The rest is mainly based on “bonuses.” Many doctors in public hospitals prescribe more medicines, prescribe more examinations, and perform more operations to increase their income.

“This method is very low-level. It’s like screwing a screw. How much money is for screwing one, and you will not be paid for less work.” Zhuang Yiqiang, director of Guangzhou Alibaba Hospital Management Research Center, believes that the current performance assessment of some hospitals is based on income. Reduce expenditures, treat doctors as piecework, and doctors and hospitals are still happy.

The health care reform operators have always hoped to curb the chronic diseases of using medicines to nourish doctors. They hope to squeeze out the intermediate moisture of medicines and consumables, increase the price of medical services, allow doctors to obtain higher income from the sun, and solve the problem of expensive and difficult medical treatment. Against this background, policy makers have adopted many reforms, hoping that a batch of model hospitals will emerge.

For the University of Hong Kong, its medical school is world-famous, but it cannot have its own affiliated hospital. The size of the population space in Hong Kong determines its limited number of patients, which is not conducive to the long-term development of medical schools. In several dialogues between Deng Huiqiong, then chairman of the Faculty Committee of the Faculty of Medicine of the University of Hong Kong, and Huang Jiefu, then Deputy Minister of Health, the idea of ​​the two sides to cooperate in medical treatment came across unexpectedly.

In 2012, the Shenzhen Hospital of the University of Hong Kong, which was funded by Shenzhen to build a hospital and introduced Hong Kong’s hospital management model, came into being. Deng Huiqiong served as the first dean.

Since the establishment of the hospital, the Hong Kong University Shenzhen Hospital has decided to take an unusual path. It is the first public hospital in the country without an establishment. The average salary of doctors is 690,000, and consultants and senior consultants (similar to the director) can reach 1.15 million. 2 million. At the same time, a fixed salary of 70% and a performance of 30% are implemented, and the number of patients received and income generation are not used as evaluation indicators.

This is not a decision made on an impulse. At that time, all walks of life had done a lot of research on the reform of public hospitals. The root causes of large prescriptions and over-examinations are hospitals’ self-financing and struggling to generate income, and doctors’ salaries are linked to the volume of business. Many scholars generally believe that increasing the salaries of doctors is useful to curb the use of medicines to support doctors.

Every doctor who came from the hospital has described this scene more or less—a half-day outpatient clinic, a doctor must see nearly a hundred patients within 4 hours, leaving only 2 to 5 minutes for each patient.

In the original hospital, the door to the clinic is always open, and Wang Yaokai, a gynecological oncologist, wants to ask the patient about menstruation, sex life, childbirth, and miscarriage. These questions and answers can be heard by the patients in the next room and the long queue at the door. The patients have no secrets.

It is not difficult for the people in it to understand that every few seconds of opening and closing the door is precious time for consultation. Wang Yaokai was also thinking about why he used to be so busy and didn’t feel hard, because the amount of outpatient visits and performance are linked, but now, as long as he is a good doctor and optimistic about the disease, he feels a lot easier without the potential pressure.

After arriving at the Hong Kong University Shenzhen Hospital, the pace of work has slowed down significantly. There are about 30 patients a day to ensure that there is enough time to communicate with the patients. For a surgical plan, you must explain the reason for the plan, the operation process, and the postoperative impact in detail with the patient.

He must give up some things-traditional title status, stable and guaranteed establishment, a steady stream of diseases, and the incomprehension of people around him. Choosing to try and grow under a new system means that we must give up the advantages of the traditional medical system.

Because of the implementation of the appointment registration system, the Hong Kong University Shenzhen Hospital has well controlled the number of patients, and the door is closed to ensure patient privacy. Being in this azure modern hospital will not be as noisy as most hospitals. It is more like being in a high-end shopping mall in the city center. Everything is proceeding in an orderly manner. The doctors patiently answer questions and answer questions. A patient rushed in for stoppering.

One patient praised the experience of the University of Hong Kong for medical treatment. The doctors of the University of Hong Kong will explain the basis of judgment very patiently. However, she will only consider going to the University of Hong Kong when she has a minor illness. For serious illnesses, she will still go to Shenzhen hospitals or even Guangzhou and other provincial capital cities.

With the patient as the center, it did. As a result, both patients will even complain that the treatment at the Hong Kong University Shenzhen Hospital is too conservative. A patient with lung cancer took the same film and went to different hospitals to see a doctor. All doctors advised him to operate as soon as possible. Only the Hong Kong University Shenzhen Hospital asked to continue the observation.

Zhuang Yiqiang pointed out that in order to generate income, many hospitals basically operate on the principle of “don’t miss when you pass by”. Do everything you can and do what you can’t, and even think, “Why don’t you come to the hospital for surgery?”

Where is the standard line of surgery, they have different opinions. If it is a benign tumor, Hong Kong doctors will advise patients to follow-up regularly and consider resection when it develops into a malignant tumor. Mainland doctors will remind patients that benign tumors may develop into malignant tumors, and they are advised to remove them early.

In general, the Hong Kong University Shenzhen Hospital hopes to reduce costs as much as possible on the premise of curing the patients. This concept is increasingly recognized. In the early days of its opening, the average daily outpatient visits of the Hong Kong University Shenzhen Hospital remained at around 3,000. Today, a few years later, the average daily outpatient visits at the Hong Kong University Shenzhen Hospital reached 8,000 to 10,000, with an annual outpatient capacity of more than 1.7 million, which is comparable to hospitals of the same level.

However, many interviewees commented that the level of medical care and the amount of diagnosis and treatment in the Hong Kong University Shenzhen Hospital is at a medium level in Shenzhen. Zhuang Yiqiang pointed out that the level of doctors in Hong Kong is good, but their investment in the Mainland is limited. Some people in the medical circle compare it to the construction of branches of tertiary hospitals. Although it is well-known that the director performs rounds, the number of patients is actually limited. The branch that has changed its sign is still the original team immediately.

However, the medical reform experiments in recent years have explored deeper meanings. Lu Chongmao, the dean of the Shenzhen Hospital of the University of Hong Kong, once told the Hong Kong media that he had only helped a few thousand people since he graduated 33 years ago, but if the reform is successful, it will not only affect the 20 million people in Shenzhen, but the 110 million permanent residents of Guangdong as a whole. .

However, Hong Kong doctors who break through the differences between the two places, endure the hardships of the journey, and are willing to give up their high salaries, are after all a minority. Therefore, most doctors in Hong Kong have a tenure system, and the completion of the “task” is like flowing water from one term to another, which is not conducive to the long-term training of medicine. Experienced doctors in the Mainland may not be willing to come.

A chief surgeon in a tertiary hospital in Shenzhen receives a call from the Shenzhen Hospital of Hong Kong University every few years and was dug up by this hospital three times before and after. When he was still the attending physician, the high salary offered by the Hong Kong University Shenzhen Hospital made him temporarily tempted, but in the end he remained on the platform with greater development opportunities.

Last time, he was already a well-known young backbone in his discipline. The Hong Kong University Shenzhen Hospital offered him a million-year salary to hire him as a consultant. The salary was very good, but he refused. The reason was: “I stayed in the municipal hospital well. Yes, all kinds of income add up to the same amount, and there is a system to guarantee future retirement. Why go to a strange place?”

Personnel mobility is a sensitive word that hospitals do not want to talk about. As Shenzhen has vigorously built new hospitals in recent years, frequent flow between hospitals of the same level is quite common. A scholar who has systematically studied the Hong Kong University Shenzhen Hospital commented that the high salary of the University of Hong Kong is not very attractive today, but there is such a hospital that pursues the concept of green medical care, so that people who are willing to try provide another kind of minority. Is it bad for people to choose?

A hospital made with money?

A relatively relaxed working atmosphere, standardized Hong Kong-style diagnosis and treatment, significant numbers of sunshine income, and no need to bear the pressure of performance appraisal. Behind these beautiful pictures, there is always an unavoidable problem. Has the Hong Kong University Shenzhen Hospital achieved a balance of income and expenditure?

Some people believe that the successful operation of the Hong Kong University Shenzhen Hospital is nothing but government funds. If Shenzhen was originally a wealthy family, the birth of the Hong Kong University Shenzhen Hospital was like the sudden addition of a young son to the family, which was dominated by parents.

One fact is that, according to the departmental budget released by the Shenzhen Municipal Health and Family Planning Commission in 2013, the budget project expenditure of Shenzhen public hospitals was 1.187 billion yuan, of which the Hong Kong University Shenzhen Hospital accounted for 1.05 billion yuan. In addition to the 3.5 billion yuan invested in the early stage, the Shenzhen Municipal Government has also promised to subsidize the operating expenses of the Hong Kong University Shenzhen Hospital in the first five years, which will be 100% before the opening of the hospital, and will be reduced to 70%, 50%, and 30% year by year after the opening.

A report in “China News Weekly” shows that in 2015, the Shenzhen Municipal Government’s financial allocation accounted for 30% of the total income of the Hong Kong University Shenzhen Hospital. Li Chuang, Director of the System Reform and Grassroots Division of the Shenzhen Municipal Health Commission, said that for a newly opened public hospital, its medical and health service income capacity is relatively low, and the government needs to increase subsidies to support its initial operations. Business development. When the hospital is on the right track, the Shenzhen Municipal Government will provide subsidies in the form of “fixed fees, purchase services, and special subsidies”.

However, since the beginning of the establishment of the hospital, the hospital reached an agreement with the local government. Five years later, the Hong Kong University Shenzhen Hospital no longer enjoys special financial subsidies. After all, the youngest son has to be self-reliant.

The five-year limit, which is the temporary beginning of 2017, the financial data disclosed by the Hong Kong University Shenzhen Hospital shows that the financial investment in 2017 was 169 million yuan, which was greatly reduced compared with previous years, and was only 1/3 of the 514 million financial subsidies in 2016. According to the financial data disclosed on the official website of the Hong Kong University Shenzhen Hospital, the hospital’s revenue and expenditure balance in 2017 was negative 50.16 million yuan. However, in 2018, the hospital began to turn losses into profits, achieving a balance of 100 million yuan.

The development of Hong Kong University Shenzhen Hospital relies on “increasing income and reducing expenditure”:

The first is to develop an international medical center to make up for the lack of funds for basic medical care through high-end medical income to ensure high-quality and low- cost public hospital services. Some scholars said that this is the “prescription” for compensation that the University of Hong Kong came up with after worrying about the reduction in financial investment, and that this path can be worked out because the government gave the green light. When the new medical reform in 2009 stipulated that public hospitals should carry out special needs no more than 10%, the Hong Kong University Shenzhen Hospital allowed 30% to be oriented independently. In 2021, the hospital’s special needs medical income is expected to account for 14-15%, and the income will be more than 300 million.

Another innovative package fee is an important lever for the Hong Kong University Shenzhen Hospital to adjust fees. Four package fees, 100 yuan for outpatient registration fee, 255 yuan per day for hospitalization, 200 yuan for general practice, and fees for surgery according to the type of disease, so that Hong Kong University Shenzhen Hospital has more balance.

This means transparent fees for patients. The 200 yuan for general outpatient clinics covers examination and 7-day drug fees, and the hospitalization package fee of 255 yuan ensures a stable expenditure for daily expenses. The surgical package fee allows patients to know about it when they are admitted to the hospital. There is no need to worry about the time and cost of hospitalization, major inspections, excessive medical treatment, and additional treatment costs due to infections and complications.

This system encountered frequent obstacles in the beginning. The package fee for general outpatient clinics is 200 yuan, which is calculated by the Hong Kong University Shenzhen Hospital based on various expenditures. This figure was once reduced to 130 yuan by the Shenzhen Municipal Price Bureau. It was discovered that the hospital was actually losing money, and only agreed to increase the fee to 200 yuan.

Xu Xiaoping, Secretary of the Party Committee of Hong Kong University Shenzhen Hospital, introduced in a speech hosted by Shanghai Chuangqi Health Development Research Institute in June 2021 that Hong Kong University Shenzhen Hospital has 67 types of surgery for packaged charges. In addition to the average price of 255 yuan per day for hospitalization, The price of packaged surgery is about 30% off that of other municipal hospitals. Taking laparoscopic cholecystectomy as an example, the price of Hong Kong University Shenzhen Hospital is 14,100 yuan, the average price in Guangdong Province is 19,000 yuan, and the hospital saves 35%. If the project charges more than 9,000 yuan, the hospital can still make a surplus of 35%, saving 28%.

Unlike other hospitals desperately generating income, the Hong Kong University Shenzhen Hospital is taking a new path to reduce costs. Hong Kong University Shenzhen Hospital’s medicine accounted for 19.98%, and its medicines accounted for less than 20.7% of Shenzhen’s when the volume of diagnosis and treatment was lower than that of hospitals at the same level. The income from sanitary materials is only 12.1%, which is lower than the 16% of other hospitals.

In Xu Xiaoping’s words, in this Mahjong match, the government, medical insurance, patients, and hospitals all won in the arena, and only the suppliers hidden under the table made less money.

Packing fees proves the possibility of reducing costs to adjust the structure. However, some interviewees said that the way out by saving money is ultimately unsustainable. “If it is necessary to use high-end to make up, it means that this road has not worked.”

However, some people in the medical community believe that packaged fees are feasible today, but as the number of intractable diseases and elderly patients increases, the subsequent increase in the cost of basic disease management and complication treatment may lead to losses in the future. Following this path, packaging costs must rise.

Medical reform test island?

The policy implementation process is like a funnel. Amidst layers of screening and elimination and coincidences, it happens that every layer has people who want to do things and can do things, and that makes the change happen. In a sense, it can only happen in Shenzhen, and even only this hospital has done it.

Why did it happen in Shenzhen? It has the geographical advantage of being separated by a river. It is the first batch of 16 public hospital reform cities. Everything here is young and has the soil for fostering innovation.

Shenzhen is an absolute top student in medical and health investment. The proportion of national direct financial investment in public hospitals in total expenditure is just over 10%, while Shenzhen’s figure is 32%, ranking first in the country. The construction of a new hospital requires a large amount of early investment. Not every place has economic strength and is willing to continue to pay this money.

Why is there only Hong Kong University Shenzhen Hospital? It happens to happen in the context of relying on medicines to support doctors. The basis of high salaries and honesty is the financial allocation to ensure the survival of the hospital and give the hospital great room for independent innovation. Everything this hospital does has people who abide by the ideals and are guided by the Hong Kong model. This road can be passed because of the green light on special needs medical care, but this approach does not meet the positioning of public hospitals.

Such success may not be easy to replicate. The advancement of medical reform is not a straight road with a certain direction, but with constant obstacles and trial and error, one to the left and another to the right, only swinging can ensure that you keep walking on the road.

The de-organization, high salary, and cost reduction of the Hong Kong University Shenzhen Hospital are also the epitome and prototype of Shenzhen’s medical reform. In 2015, Shenzhen took the lead in the country to completely abolish all newly-built public hospitals and implement employment by post and salary by post. This kind of salary structure adjustment is more meaningful in the context of today’s centralized procurement of medicines and consumables. The gray income squeezed out should eventually be backfilled to the doctor’s income.

However, with the emphasis on the public welfare of public hospitals and the strengthening of the establishment, the de-organization reform of the Hong Kong University Shenzhen Hospital has suddenly become somewhat outdated. At the beginning of this year, the National Health Commission clearly strengthened the establishment of public hospitals. This move made the “medical marketization” reform path pause. The opening of this “green channel” can be seen from the fact that the doctors who aided Hubei broke the rules after returning. Strengthening the establishment means increasing financial investment, but where does this money come from?

In the eyes of almost all interviewees, the Hong Kong University Shenzhen Hospital is more like a small experimental field. The reform experience needs to be summarized. Will golden wheat waves grow in the wheat fields? You will not know until the harvest season.

An alternative medical system is transplanted to the soil in the mainland, and perhaps a flower will survive, but the story of southern orange and northern orange is not uncommon. Obviously, this experience cannot be replicated in its entirety, but on the other hand, if there is only such a hospital in the end, wouldn’t the reform be a failure?

When the external environment forces all public hospitals to pursue efficiency, will the relaxed, patient-centered working environment that attracted doctors in the first place change its taste? Whether in public speeches or academic surveys, the management of the Hong Kong University Shenzhen Hospital also stated that they have begun to attach importance to efficiency and pursue a balance between Hong Kong’s quality and mainland efficiency. On the contrary, the hidden worry of the aforementioned scholars is whether the Hong Kong University Shenzhen Hospital will be assimilated by the mainland medical system.

It is always good to have such a pattern, just like different flowers bloom in the soil, but over time, will the flowers eventually flourish and multiply, or will they gradually wither?

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