Combating healthcare cost inflation with administrative measures in urban china

COMBATING HEALTHCARE COST INFLATION WITH ADMINISTRATIVE ACTION IN URBAN CHINA HE JINGWEI M.A. Public Policy & Administration, B.A. Political Science & Public Administration A THESIS SUBMITTED FOR THE DEGREE OF DOCTOR OF PHILOSOPHY IN PUBLIC POLICY LEE KUAN YEW SCHOOL OF PUBLIC POLICY NATIONAL UNIVERSITY OF SINGAPOTRE 2011 TABLE OF CONTENTS Acknowledgements Summary iii v List of Tables vii List of Figures ix List of Appendices xii List of Abbreviations xiii Chapter I Introduction 1.1. Background and research questions 1.2. Central thesis and contribution 1.3. Review of theoretical literature 1 Chapter II Policy Background 2.1. Chinese healthcare system: problems and causes 2.2. Containing cost inflation: proposals and evidence 2.3. Political dimension: institutional problems and the health bureaucracy 2.4. Summary 17 17 31 34 39 Chapter III Research Design and Methodology 3.1. Research design 3.2. Analytical strategy 3.3. Data collection and case analytical methods 3.4. Limitations 42 42 52 55 60 Chapter IV Reform Context and Policy Design 4.1. Overview of healthcare system of Fujian Province 4.2. Policy-making process 4.3. Health bureaucracy versus health facilities 4.4. Initial policy design 4.5. Summary 61 61 68 90 92 95 Chapter V Policy Implementation and Outcome 5.1. How is policy implemented? 5.2. Institutions and policy instruments 97 98 105 i 5.3. Overall policy outcome 5.4. Summary 122 135 Chapter VI Dynamics at Hospital Level: Explanation and Evaluation 6.1. Case I: Fujian Medical University First Affiliated Hospital 6.2. Case II: Fuzhou No. Municipal Hospital 6.3. Case III: Xiamen Sun Yat-sen Hospital 6.4. Quantitative analysis 6.5. Operation models and implications 6.6. Summary 137 137 147 156 163 179 186 Chapter VII Fujian and Beyond: Discussion and Implications 7.1. Health policy process and health bureaucracy 7.2. Hospital behaviors under administrative cost-containment constraints 189 189 198 Chapter VIII Conclusion 8.1. Main conclusions 8.2. Implications for ongoing national healthcare reform 8.3. Policy implications 205 205 209 215 Bibliography 217 Appendices 229 ii ACKNOWLEGEMENTS The decision to be made in April 2007 was truly a critical one. I was at the crossroads of defining the path for my future. Among several offers, I had to choose from Hong Kong, Canada, and Singapore for an adventure in my PhD studies. Fortunately, I made the right choice. The Lee Kuan Yew School of Public Policy has offered me an environment enriched with academic depth, multi-disciplinary breadth and cultural diversity that hardly exists anywhere else in Asia. The past four years have been a fascinating journey towards my intellectual maturity and academic competency, with Prof. Phua Kai Hong being the guide. Prof. Phua has not only steered my exploration in the field of health policy, but also enriched my understanding with a much broader realm of knowledge in public health as well as social policy. In the entire process of my PhD endeavor, Prof. Phua has been a consistently available and helpful source of expertise, critical comments and encouragement. I thank him sincerely. I am so fortunate for having an excellent advisory committee—consisting of a seasoned healthcare scholar, a renowned public administration teacher, and one of the sharpest policy experts whom I have ever known—to guide my research. Other than Prof. Phua as my supervisor, Prof. Scott Fritzen has given me strong support since the very beginning. He has contributed a great deal of constructive comments that are truly valuable to my thesis. His expertise in public administration and management has greatly strengthened this thesis on various aspects. Prof. Wu Xun was the only Chinese professor in the School four years ago, and naturally I had more opportunities to interact with him. His brilliance and diligence have inspired me all along the way. I feel more than fortunate for being one of his students in the module on research methods which immensely enhanced my training in methodology. Several research projects that I had collaborated with him also gave me precious first-hand experience in conducting empirical research. Two other faculty members also deserve my special thanks: - Prof. M. Ramesh and Prof. Darryl Jarvis. Prof. Ramesh‘s eminent academic achievement in public policy theory and social policy research has been a well from which the water of knowledge is always inexhaustible to me. After he has moved to Hong Kong, he still takes good care of me. I owe him a debt of gratitude. I would also like to thank Prof. Darryl Jarvis, Chair of the PhD Committee, who has always been a wonderful mentor. His warmth and generosity have encouraged me throughout the past years. In addition, I have also benefited intellectually from a couple of other faculty members and research iii staff of whom I am very appreciative - Prof. Mukul Asher, Dr. Eduardo Araral, Dr. Boyd Fuller, Dr. Qian Jiwei, and Dr. Tam Wai-keung. My thanks also go to my fellow PhD Candidates and friends in the Lee Kuan Yew School Allen Lai, Leong Ching, Seck Tan, Savita Shankar, Maura Dayashankar, Michael Raska, Tan Teck Boon, Azad Singh Bali, Nicola Pocock, Jan Seifert, Tania Ng, and many others. Thanks to all for sharing their invaluable friendship and inspiration. I would also like to express my gratitude to the outstanding administrative support team of the Lee Kuan Yew School. Ruth Choe, Dorine Ong, Yvonne Loh, Sung Lee, and other colleagues have carved the ―Singapore Experience‖ into a Chinese student‘s mind as mine in a most tangible manner. Their professionalism, responsiveness and efficiency have truly impressed me. Mr. Chen Jingde, one of my best friends, saved me from needless knocking on every door in the bureaucracy and being rejected. His key post in the Fujian Provincial Government and his wide network of guanxi facilitated my entire fieldwork in China, and enabled many key informants and data sources to be made available. Without him, the fieldwork for this research would have been almost impossible. I would like to take this opportunity to express my deepest gratitude to him. I am extremely grateful to Dr. Yu Wenxuan at the Nanyang Technological University, who was my former lecturer in Xiamen University from 2001 to 2002. He was the mentor who broadened my outlook and encouraged me to pursue a more exciting academic adventure abroad. Without him, my academic life would have been certainly different. Last but yet most importantly, I would like to express my deepest gratitude and love to my parents, Mr. He Ping and Ms. Ren Qinglan, and my wife Amy Yang Shudi. They have been a perpetual source of love, support and encouragement, inspiring me to go farther. Dad and Mom began to cultivate my interest in history and humanities when I was only three years old. The Chinese-style paternalism is never present in my family. We interact with friendship, mutual learning, knowledge and love. It is like magic that the naughty boy playing in his mother‘s hospital has grown up to become a young scholar studying health policy. Mom has witnessed all these developments. Finally, I am deeply indebted to my wife Amy, whose kindness, sincerity and affection would always motivate my endeavors. iv SUMMARY This doctoral thesis studies a critical health policy issue that many national governments around the world are grappling with—rapid inflation in healthcare costs. It specifically focuses on urban China which has been experiencing double-digit percentage in cost escalation for two decades. Its central thesis is that cost inflation in healthcare could be contained in the short run by concerted administrative action, but are contingent upon a set of conditions, which are often not present, thus undermining the effectiveness of the administrative action. The thesis supplements the popular policy prescription that cost containment would hardly be achieved unless fundamental economic incentives are realigned such that supplier-induced demand in healthcare is effectively curbed, coupled with appropriate cost-sharing mechanisms on the demandside. In examining the case of China, this thesis reveals that while a systemic and holistic approach to healthcare reforms is undoubtedly desirable, the real-world policy environment is however, not often conducive, making it imperative for the health bureaucracy to take action to address cost inflation, along with a multitude of resultant social problems. This thesis investigates a healthcare reform program committed to cost containment in Fujian Province, which had been the only Chinese province using administrative measures to combat cost inflation, without involvement of other government bodies or substantive realignment of economic incentives such as payment arrangements. Integrating various qualitative, quantitative and case study methods, the thesis provides a strong account for the driving forces, rationale, dynamics, strengths and weaknesses of administrative cost-containment policies within the context of urban China. The thesis sheds fresh light on the literature as well as relevant policy debates, with the central argument that concerted administrative action could be an effective means in cost containment provided that five conditions are fulfilled sufficiently, which are: 1) strong political v support from government, as well as policy determination of the health bureaucracy; 2) coherent and targeted alignment of policy instruments at the disposal of the health bureaucracy; 3) clear anticipation of providers‘ potential opportunistic behaviors and development of related countermeasures; 4) effective provision of adequate incentives to providers that encourage cost-saving behaviors; and 5) proactive regulation on a wider spectrum of provider behaviors rather than simple management of indicators. These conditions require strong government capacities, and therefore containing healthcare cost inflation with administrative action is not as easy as might be understood. Concurring with the perspective that the potential of administrative action in containing healthcare costs has been arguably underplayed, the thesis also reveals that this type of policy intervention also suffers from its inherent limitations which make healthcare providers‘ opportunistic behaviors possible. The analysis unveils a battery of behavioral patterns and responses on the part of public hospitals, most of which are undesirable. As such, although administrative interventions may have the potential of arresting the trend of continuous cost rise, its real effectiveness should not be overstated. This thesis draws some crucial implications for the ongoing national healthcare reforms in China, which has recently recognized the importance of administrative tools in the combat against unbridled cost escalation. It informs policy-makers that the administrative cost-containment approach is of a transitional and temporary nature, and its long-term effect must be supported by the revision of the economic incentive structure. As such, the true value of reform lies in reassertion of the health authorities‘ statutory role in healthcare administration, and restoration of collapsed accountability mechanisms in the Chinese healthcare system. In the long-run, these should be directed towards a sustainable and integrative framework of cost-containment in China, in close collaboration with other important complementary reforms, including provider payment methods, third-party controls and pricing policies. vi LIST OF TABLES Table 1-1 Comparison of major provider payment methods Table 3-1 Characteristics of hospitals selected for case study, as at 2009 Table 3-2 List of interviews Table 4-1 Major efficiency indicators of public hospitals, 2008 Table 4-2 Medical cost in provincial hospitals in Fujian, 2001 Table 4-3 Per capita consumption spending and healthcare spending in Fujian, 1998-2005 Table 4-4 Key indicators in healthcare cost-containment policy in Fujian Table 5-1 Control targets, inflation rates and per capita disposable incomes Table 5-2 Evaluation system of new government subsidization scheme in Fujian provincial hospitals Table 5-3 Cost increase rates by using different algorithms (outpatient care) Table 5-4 Cost increase rates by using different algorithms (inpatient care) Table 5-5 Changing rates of average cost for outpatient care in provincial and municipal public hospitals of Fujian Province and national average level, 1999-2009 Table 5-6 Changing rates of average cost for inpatient care in provincial and municipal public hospitals of Fujian Province and national average level, 1999-2009 Table 5-7 Key characteristics of comparison group Table 6-1 Average expenses per outpatient visit and average expenses per inpatient stay, Fujian Medical University First Affiliated Hospital, 2004-2009 Table 6-2 Share of drug cost in total medical cost, Fujian Medical University First Affiliated Hospital, 2002-2009 Table 6-3 Drug cost and diagnosis & treatment cost per outpatient visit and per inpatient stay, Fuzhou No. Hospital, 2001-2009 vii Table 6-4 Length of stay and inpatient cost per day, Fuzhou No. Hospital, 2003-2010 Table 6-5 Patient volume and total costs of extra-catalogue items in Fuzhou No. Hospital, 20012009 Table 6-6 Characteristics and variables of panel database Table 6-7 Variable description of panel database Table 6-8 Average expenses per outpatient visit and average expenses per inpatient stay in sample, by hospital type and grade Table 6-9 Regression results of using fixed effect model Table 6-10 Regression results of using random effect model Table 6-11 Regression results of testing inter-sectoral and inter-period cost shifting viii LIST OF FIGURES Figure 1-1 Key determinants of changes in organizational behavior Figure 1-2 Determinants of hospital behavior Figure 2-1 Composition of health expenditure in China, 1978-2009 Figure 2-2 Total health expenditure (as its share in GDP) and government health expenditure in China, 1990-2009 Figure 2-3 Sources of income for government-funded hospitals, 1998-2008 Figure 2-4 Sources of healthcare financing in China, 1989 Figure 2-5 Sources of healthcare insurance coverage in China, 2003 Figure 3-1 Geographic location of Fujian Province Figure 3-2 Average medical cost profiles of Fujian and the national average, 1993-2000 Figure 3-3 Geographic location of Fuzhou and Xiamen Figure 4-1 Number of hospital beds and GDP per capita in Chinese provinces, 2008 Figure 4-2 Number of health professionals and GDP per capita in Chinese provinces, 2008 Figure 4-3 Government subsidies as share of health facility income in Chinese provincial administrative divisions, 2009 Figure 4-4 Medical expenses and per capita disposal income, 1993-2004 Figure 4-5 Fiscal revenue, expenditure and budgetary expenditure on health, Fujian Province, 1997-2008 Figure 4-6 A simplified illustration of provincial political system in China Figure 4-7 Major central government agencies involved in health affairs Figure 4-8 Bureaucratic relationships of labor, health and finance authorities in urban China Figure 4-9 Health policy-making arenas at provincial level and paths for policy legitimation ix Combating Healthcare Cost Inflation with Administrative Action in Urban China He Jingwei Appendix VII (in Chinese) Fujian sheng weisheng ting guanyu jinyibu jiaqiang yiyao feiyong kongzhi de tongzhi [The Opinions of Fujian Provincial Health Bureau on Further Curbing Healthcare Cost Inflation], 3/9/2010. 福建省卫生厅关于进一步加强医药费用控制的通知 闽卫财函〔2010〕862 号 各设区市卫生局，厅直属各医疗单位，福建医大、中医药大学各附属医院： 2010 年是全面推进医药卫生体制改革承上启下的关键一年，控制医药费用工作的重要性更加 凸显。一是《福建省 2010 年深化医药卫生体制改革实施方案》明确提出医药费用―年增长幅度力 争不超过 3.5％‖的任务目标；二是今年每门诊人次收费水帄、出院者帄均医药费用两项指标列入 了政府绩效考核指标体系。但是目前各设区市、各单位开展控制医药费用工作还不帄衡。为了确 保实现医改目标任务，提高医疗服务质量，降低成本，减少浪费，切实减轻患者医药费用负担， 现就进一步加强医院控制医药费用工作提出如下意见： 一、统一思想，提高认识 控制医药费用是医疗卫生系统的一项长期而艰巨的工作任务，是医改的重要任务，是医院管 理的重要内容，是医院管理水帄、技术水帄、医德医风和为群众服务水帄的综合体现，各医院要 进一步统一思想,加强管理，细化措施,抓好落实。 二、迅速行动，采取措施 各单位要立即行动起来，进行再动员、再部署，医院院长是控费工作第一责任人，要亲自抓 控制医药费用工作，责任到人，措施到位。医院要跟踪每个科室、每个医生的工作动态情况，及 时分析原因，采取有效措施，重点是加强合理用药、合理检查和规范收费的管理和监督，务必完 成控制费用目标。 三、落实奖惩，强化管理 为了进一步加大控制医药费用工作力度，强化政府部门管理职能，省卫生厅提出四项措施： 1、严格落实超收上缴工作。超控医院要按照卫生行政部门核定的超控金额，扣除药品成本后 全额上缴同级卫生行政部门。对不能及时落实超控上缴的市县和医院将进行通报批评。 - 239 - Combating Healthcare Cost Inflation with Administrative Action in Urban China He Jingwei 2、将超控医院名单（视情节严重程度）和处理结果向社会公布。 3、在医药费用超控期间，对超控医院暂缓审批乙类大型医用设备，暂停向卫生部转报甲类大 型医用设备配置申请。 4、对年度医药费用超控的医院，暂停医院及其领导班子成员申报评先评优。 二○一○年九月三日 - 240 - Combating Healthcare Cost Inflation with Administrative Action in Urban China He Jingwei Appendix VIII (in Chinese) Fujian sheng weisheng ting guanyu kaizhan kongzhi yiyao feiyong pinggu gongzuo de tongzhi [The Opinions of Fujian Provincial Health Bureau on the Initiation of Assessments of Cost Containment Work], 22/11/2005. 福建省卫生厅关于开展控制医药费用评估工作的通知 闽卫〔2005〕函 576 号 各设区市卫生局，厅直属各医疗单位，福建医大、中医学院各附属医院： 为落实《福建省卫生厅关于进一步开展医疗机构开展医药费用增长工作的意见》，经研究决 定，每年初对控制医药费用工作进行评估，重点检查医院控制医药费用工作的落实情况，分析取 得的成效和存在的问题。现将有关事项通知如下： 一、评估目的 维护广大人民群众根本利益，围绕开展控制医药费用增长和―医院管理年‖活动，评估各医院 控制医药费用工作贯彻落实情况，力求通过合理用药、合理检查、规范收费等综合措施来达到控 制不合理费用支出，缓解―看病贵‖矛盾，减轻群众看病负担的目的。 二、评估范围 控制费用工作实行分级负责，省卫生厅负责对三级乙等以上医院（含三级乙等）进行评估， 设区市卫生局负责对辖区内三级乙等以下医院进行评估。 三、评估内容和方法 评估内容包括加强组织领导、强化医院管理、规范医疗行为等。具体分为四个部分，即合理 用药、合理检查情况；医药费用指标控制情况；规范医疗服务价格项目收费情况；药品及耗材集 中招标采购执行情况。详细的评估内容、评分标准见附件。评估采取现场查阅资料与随机抽查相 结合等方法。 二○○五年十一月二十二日 - 241 - Combating Healthcare Cost Inflation with Administrative Action in Urban China He Jingwei 附件 合理检查、合理用药情况检查表 一、开展医院管理年活动和控制医药费用情况（20 分） 1、医院管理年实施方案（5 分） 2、定期专门研究提高医疗质量和医疗安全情况（5 分） 3、医务人员对医疗质量和医疗安全核心制度的知晓情况（5 分） 4、医院控费措施（5 分） 1、 有具体的实施方案得 分，没有实施方案不得分，方案过于简单的不得分或酌情扣分。 2、 有定期专门研究提高医疗质量和医疗安全工作的得分 分，检查前三个月没专门研究过 次的不给分，不是专门研究的酌情扣分。 3、 随机抽查院领导 人，科主任 人和医生 人，核心制度掌握较好的给 分，1 人掌握不 好的扣 分。 4、 有控制医药费用措施的给 分，没有的不得分。 二、医院合理检查、合理用药制度（10 分） 1、合理检查制度的制订和落实（4 分） 2、建立健全抗菌药物临床应用的管理制度（4 分） 3、处方管理情况（2 分） 1、 有制度、有检查、有改进的得 分；没有制度，没有检查的不得分；有制度，没有检查 的得 分。 2、 有抗菌药物分级使用制度并有检查和改进的得 分；没有制度，也没有检查的不得分； 有制度，没有检查的得 分。 3、 有处方管理的制度并有检查改进的得 分；没有制度也没有检查的不得分；有制度，没 有检查的得 分。 三、大型设备检查的阳性率（20 分） 随机抽取检查前两个月的 CT（或 MRI）检查报告 100 份（20 分） - 242 - Combating Healthcare Cost Inflation with Administrative Action in Urban China He Jingwei 阳性率≥70%的得 20 分；在 69～60%之间，每下降 个百分点扣 分；＜60%的不得分。 四、门诊处方合格率（10 分） 随机抽取检查今年 月以来的门诊处方 100 份（20 分） 处方合格率≥95%的得 10 分；在 94～85%之间，每下降 个百分点扣 分；＜85%的不得分。 五、抗菌药物合理运用情况（40 分） 随机抽取检查前 个月归档手术和非手术病例各 10 份，按抗菌药物合理应用检查表和手术病 人应用抗菌药检查表检查。（各 20 分） 1、 手术病人应用抗菌药物抽查合格率≥95%的得 20 分；合格率 90%的得 16 分；80%的得 12 分；70%的得 分：60%的得 分；低于 60%的不得分。 2、 非手术病人应用抗菌药物抽查合格率≥95%的得 20 分；合格率 90%的得 16 分；80%的得 12 分；70%的得 分；60%的得 分；低于 60%的不得分。 附件 福建省控制医药费用检查评估表（控制费用指标） 一、按《意见》要求制定控制医药费用的相关措施、落实责任制，定期或不定期组织自查情 况（20 分） 1、制定控制医药费用的相关措施（查看相关文件资料）（5 分） 2、落实控制医药费用责任制（查看相关文件资料）（5 分） 3、定期或不定期组织自查情况（查看自查记录）（10 分） 1、有具体措施得 分，否则不得分，措施过于简单的不得分或酌情扣分。 2、有责任制得 分，否则不得分，流于形式的不得分或酌情扣分。 3、有定期或不定期组织自查且有详细材料的得 10 分，否则不得分，自查没有记录的酌情扣 分。 二、工作量统计情况（20 分） - 243 - Combating Healthcare Cost Inflation with Administrative Action in Urban China He Jingwei 检查门急诊人次、出院人数等工作量统计是否严格按照规定的统计口径、统计数据是否准确； 工作量大幅度增长的单位，应书面说明原因（查对有关财务、统计资料）。（20 分） 门急诊人次、出院人数等工作量统计准确的各得 10 分，弄虚作假的不得分，属于统计差错的， 每项扣 分 三、各项收入核算情况（20 分） 检查各项收入核算是否严格执行《医院财务制度》和《医院会计制度》和有关规定（查阅会 计账簿，必要时查相关凭证）（20 分） 核算正确的得 20 分，未正确进行收入核算（包括未按权责发生制进行收入核算、未正确核算 健康体检收入等）或隐瞒收入的不得分，属于差错的，扣 分 四、控制指标完成情况（40 分） 1、每门诊人次收费水帄完成情况（15 分） 2、出院者帄均医药费用完成情况（25 分） 1、每门诊人次收费水帄≤控制数的得 15 分，每超过 1％的扣 分，超过 5％的不得分 2、出院者帄均医药费用≤控制数的得 25 分，每超过 1％的扣 分，超过 12％的不得分 附件 福建省控制医药费用检查评估表（价格管理） 一、加强医疗服务价格管理领导，建立健全价格监督管理机制（5 分） 1、加强领导，成立医疗服务价格管理组织机构，落实责任制 （1 分） 2、建立医疗服务价格管理制度、公示制度、查询制度、奖惩办法以及治理乱收费措施并认真 组织实施。（3 分） 3、按规定执行医疗服务价格，价格管理程序是否加密（1 分） 如无制定相关制度或措施等，每缺 项扣 分 二、执行医疗费用一日清单制度（10 分） 1、门诊费用清单是否按规定根据门诊患者要求免费提供（3 分） - 244 - Combating Healthcare Cost Inflation with Administrative Action in Urban China He Jingwei 2、住院费用日清单是否按规定每日向住院患者免费提供（5 分） 3、住院费用汇总清单是否在出院时免费提供（2 分） 门诊抽查 10 个病人，住院抽查 20 个病人，不提供或未按规定格式提供清单，每违反 项相 应分值不得分 三、门诊医疗服务价格执行情况（20 分） 检查价格库执行情况，检查擅自立项和分解收费情况。随机抽查门诊病人收费清单（三甲医 院抽 15 个科室，各 份共 30 份;三甲以下医院抽 10 个科室，各 份共 20 份） 违反医疗服务价格规定 项扣 分 四、住院医疗服务价格执行情况（30 分） 检查价格库执行情况，检查擅自立项和分解收费情况。随机抽查出院病人费用汇总清单与病 历（三甲医院抽 15 个病区，各 份共 30 份;三甲以下医院抽 10 个病区，各 份共 20 份） 违反医疗服务价格规定 项扣 分 五、医用耗材价格执行情况（15 分） 随机抽查 15 种医用耗材收费执行情况 不按规定或超过规定加成率收取材料费，每违反 项扣 分 六、查处违规收费情况（10 分） 1、对病人投诉医疗服务价格问题是否及时调查、核实、处理（须有相应记录）（5 分） 2、每年至少组织一次医疗服务价格自查（5 分） 每缺 项相应项目分值均不得分 七、价格公示情况（10 分） 按规定在医技和临床收费科室悬挂价格本，在醒目位置通过电子触摸屏，电子显示屏或公示 栏等形式公布医疗服务价格，自觉接受群众监督。 检查醒目位置、抽查 10 个病区，每缺 项扣 分 - 245 - Combating Healthcare Cost Inflation with Administrative Action in Urban China He Jingwei Appendix IX (in Chinese) Fujian sheng weisheng ting guanyu jianli sanji yideng yishang yiyuan yiyao feiyong gongshi zhidu de tongzhi [The Opinions of Fujian Provincial Health Bureau on Establishing Medical Cost Information Disclosure System], 25/10/2005 福建省卫生厅关于建立三级乙等以上医院医药费用公示制度的通知 闽卫〔2005〕函 531 号 各设区市卫生局，各有关医疗单位： 根据―福建省卫生厅关于进一步开展医疗机构控制医药费用增长工作的意见‖（闽卫财〔2005〕 90 号）的精神，为促进各医疗单位及时分析、查找医药费用控制的薄弱环节，以采取措施，强化 管理，降低成本，减轻群众医疗费用负担，自觉接受社会和群众的监督。经研究决定，对全省三 级乙等以上公立医院建立医药费用公示制度。现将有关事项通知如下： 一、从 2005 年 10 月起，我厅将于每月下旬在―福建卫生信息网‖上公布―三级乙等以上医院医 药费用控制比较表‖（附件 1）。各医疗机构应于每月 15 日前将纸质报表随同财务报表上报我厅 （计财处），并附软盘或发送邮件至：lh@mail.fjphb.gov.cn 或 xyq@mail.fjphb.gov.cn，同时抄送 所在地的设区市卫生局。2005 年 月报表请于 11 月 日前报送。对未按时报送上述资料、影响 信息公示的单位，我厅将一并公示单位名单。 二、各医疗机构应严格执行《医院财务制度》、《医院会计制度》及卫生部对工作量统计的 有关规定，完善财务资料的收集、整理、分析和工作量的统计归集工作，指定专人，及时、准确、 完整、真实地填报有关报表。 三、各设区市卫生局应对辖区内的三级乙等以上医院报送的报表进行审核，如发现问题，要 求医院立即更正，并及时反馈给我厅（计财处）。 二○○五年十月二十五日 - 246 - Combating Healthcare Cost Inflation with Administrative Action in Urban China He Jingwei Appendix X (in Chinese) Fujian sheng weisheng ting guanyu yinfa “Fujian shengshu yiliao jigou kongzhi feiyong gongzuo jiangli banfa”de tongzhi [Cost Containment Reward System for Fujian Provincial Hospitals], 11/1/2007. 福建省卫生厅关于印发《福建省属医疗机构控制费用工作奖励办法》的通知 闽卫财〔2007〕4 号 厅直属各医疗单位，福建医大、中医学院各附属医院： 根据―福建省卫生厅关于进一步开展医疗机构控制医药费用增长工作的意见‖（闽卫财〔2005〕 90 号）及―福建省卫生厅关于开展控制医药费用评估工作的通知‖（闽卫〔2005〕函 576 号），为 促进各单位持续有效的开展控制费用工作，特制定了《福建省省属医疗机构控制费用工作奖励办 法》，现印发给你们，请遵照执行。 二○○七年一月十一日 福建省省属医疗机构控制费用工作奖励办法 根据―福建省卫生厅关于进一步开展医疗机构控制医药费用增长工作的意见‖（闽卫财〔2005〕 90 号）及―福建省卫生厅关于开展控制医药费用评估工作的通知‖（闽卫〔2005〕函 576 号），为 促进各单位持续有效的开展控制费用工作，特制定了本办法。 一、适用范围 本办法适用于厅直属各医疗机构，福建医大、中医学院各附属医院。 二、考核指标及考核标准 1、合理用药抽查合格率≥95％； 2、大型仪器检查的阳性率≥70％； 3、医疗服务价格项目收费抽查准确率≥95％； 4、门诊、住院费用水帄不高于控制指标； - 247 - Combating Healthcare Cost Inflation with Administrative Action in Urban China He Jingwei 5、门诊、住院工作量。 根据单位实际情况不设病床的单位，出院者帄均医药费用、住院工作量及大型仪器检查阳性 率指标不考核、不得分。 三、考核年度 年度计算时间：2005 年度考核时间从 2005 年 月 日到 2006 年 月 30 日；2006 年度考核 时间从 2006 年 月 日到 2007 年 月 30 日。以后年度的考核计算时间同年度控制增长指标一起 下达。 四、考核方法 采用综合评分法对指标的执行情况进行评分，总分共 100 分。评分方法如下： （1）合理用药抽查合格率（共 15 分）：通过现场抽查病历得出合理用药合格率。合格率达 到 95％以上（含 95％）得 15 分，每下降 个百分点扣 分，扣完为止。 （2）大型仪器检查的阳性率（共 15 分）：通过检查病历或大型仪器检查资料，计算出合理 检查阳性率。阳性率达到 70％以上（含 70％）得 15 分，每下降 个百分点扣 分，扣完为止。 （3）医疗服务价格项目收费抽查准确率：通过抽查病历计算出准确率。如准确率达到 95％ 以上（含 95％）得 10 分，每下降 个百分点扣 分，扣完为止。 上述（1）－（3）项目考核数据精确到 1％。 （4）费用控制情况（共 30 分） ①门诊费用控制情况（共 10 分） 通过核查，每门诊人次收费水帄超过控制指标的该项不得分。未超过控制指标的单位中， 2005～2006 年度每门诊人次收费水帄下降幅度最大的得 10 分，其次得 分，依此类推。2007 年 度起，门诊费用未超过控制指标的，该项得满分。 ②住院费用控制情况（共 20 分） 通过核查，出院者帄均医药费用超过控制指标的该项不得分。未超过控制指标的单位中， 2005～2006 年出院者帄均医药费用下降幅度最大的得 20 分，其次得 18 分，依此类推。2007 年度 起，住院费用未超过控制指标的，该项得满分。 ③指标计算方法 每门诊人次收费水帄下降幅度＝︱（核查年度实际数－控制数）÷控制数︱ 出院者帄均医药费用下降幅度＝︱（核查年度实际数－控制数）÷控制数︱ - 248 - Combating Healthcare Cost Inflation with Administrative Action in Urban China He Jingwei （5）门诊及住院工作量（共 30 分） ①门诊工作量（共 10 分）：通过核查，门急诊人次最多的单位得 10 分，其次得 分，依次 类推。该指标至少得 分。 ②出院人数（共 20 分）：通过核查，出院人数最多的单位得 20 分，其次得 18 分，依次类推。 该指标至少得 分。 四、奖励办法 从省级卫生专项预算中安排一定数额的经费，按照以奖代补的原则，结合控制费用工作开展 情况，通过综合评分，评出各医疗机构的考核分数，以考核结果安排各医疗机构补助经费。该补 助经费不宜用于发放奖金。各医疗机构分配的补助金额计算方法如下： 某医疗机构分配的补助金额＝医疗机构每得 分的补助金额×某医疗机构考核分数 其中：医疗机构每得 分的补助金额＝补助资金总额÷各医疗机构考核分数综合 各地市可参照本办法，结合实际情况，制定相应的奖励办法。 - 249 - Combating Healthcare Cost Inflation with Administrative Action in Urban China He Jingwei Appendix XI (in Chinese) Fujian sheng weisheng ting guanyu kaizhan 2010 nian kongzhi yiliao feiyong youguan gongzuo de tongzhi [The Opinions of Fujian Provincial Health Bureau on Cost Containment Work in 2010], 26/4/2010. 福建省卫生厅关于开展 2010 年控制医药费用有关工作的通知 闽卫财函〔2010〕334 号 各设区市卫生局，厅直属各医疗单位，福建医大、中医学院各附属医院： 根据《福建省人民政府关于印发福建省 2010 年深化医药卫生体制改革实施方案的通知》 （闽政文〔2010〕50 号）的精神，我省将进一步采取措施缓解群众―看病难、看病贵‖问题，并持 续开展控制医药费用工作。现将 2010 年控制医药费用增长工作有关事项通知如下： 一、继续开展县及县以上医疗机构医药费用控制工作，年增长幅度不超过 3.5％。《福建省人 民政府关于印发福建省 2010 年深化医药卫生体制改革实施方案的通知》明确规定了控制医药费用 的目标任务，即―年增长幅度力争不超过 3.5％‖。从今年起，每门诊人次收费水帄、出院者帄均医 药费用两项指标还列入了各设区市政府绩效考核指标体系。要求各设区市卫生行政部门和各医疗 机构要进一步加强监督与管理，确保每门诊人次收费水帄、出院者帄均医药费用指标实现增幅不 超过 3.5％的目标，低于全省城镇居民人均可支配收入和农民人均纯收入实际增幅。 二、加强医院管理，切实采取措施控制医药费用。一是加强合理用药、合理检查、合理治疗 监管（以下简称―三合理‖），推进医院加强―三合理‖管理，控制医药费用不合理增长；二是推行 临床路径管理，规范诊疗行为。我省现已启动了全省三级医院临床路径试点工作，在试点的基础 上逐步推开；三是开展单病种付费试点，探索医疗付费模式改革。省卫生厅、物价局、人力资源 和社会保障厅联合下发了《关于印发福建省单病种付费试点工作方案的通知》，启动单病种付费 试点工作。今年在部分医院已开展老年性白内障、结节性甲状腺肿、计划性剖腹产等 个单病种 试行按病种收费方式改革试点工作，今后将逐步扩大；四是要求各医院定期对控制医药费用实施 的情况进行动态管理并分析原因。对超控比较严重的单位，卫生行政部门可采取约谈、通报等方 式，督促限期整改。 - 250 - Combating Healthcare Cost Inflation with Administrative Action in Urban China He Jingwei 三、分级核定，进一步完善指标体系。省卫生厅负责核定省属医疗机构的费用控制指标；设 区市卫生局负责核定所辖行政区域内的市级和县（市、区）级医疗机构的控制指标。各级卫生行 政部门必须按照卫生厅统一的指标口径及计算方法核定医疗机构两项费用控制指标，并在此基础 上计算出全市所辖行政区域内的县及县以上医疗机构两项费用指标的总体费用控制水帄（增幅不 超过 3.5％），并向我厅报备。 四、开展控费核查，落实奖惩措施。省卫生厅负责核查省属医疗机构及 2007 年以来新审批的 三级医院；其他医疗机构由设区市卫生局负责核查或设区市之间联合核查、互查。2009 年度控制 费用的核查工作分三个阶段进行：第一阶段，4 月下旬为医疗机构自查阶段；第二阶段，5 月起为 各级卫生行政部门核查阶段；第三阶段，6 月上旬为核查结果汇总分析通报阶段。为了全面反映 控制费用工作开展情况，各级卫生行政部门组织人员和抽调医学专家，对―合理用药抽查合格率‖、 ―大型仪器检查的阳性率‖指标落实情况进行检查。各设区市卫生局于 月 30 日前将核查结果报送 省卫生厅，并按照核查结果，参照《福建省属医疗机构控制费用工作奖励办法》（闽卫财〔2007〕 号），落实兑现奖惩措施。 二○一○年四月二十六日 - 251 - Combating Healthcare Cost Inflation with Administrative Action in Urban China He Jingwei Appendix XII (in Chinese) Fujian sheng difang dangzheng lingdao banzi he lingdao ganbu kaohe pingjia banfa [Local Government and Cadre Evaluation Methods of Fujian Province], 2010. 福建省地方党政领导班子和领导干部考核评价办法 中共福建省委、福建省人民政府 二○一○年四月二十六日 考核内容 类别 经 济 发 展 内 容 1、经济总量（经济总量增长率、人均经济总量及增长率） 2、财政发展（地方财政收入增长率、地方税收收入增长率） 3、固定资产投资（全社会固定资产投资增长率、制造业固定资产投资占投资比 重） 4、社会消费（社会消费品零售额增长率） 5、产业结构调整（三次产业比重、高新技术产业发展） 6、工业发展（规模以上工业增加值增长率、经济效益指数） 7、外经外贸（实际利用外资增长率、进出口额增长率） 8、新农村建设（投入增长率、农村安全饮用水普及率、农村卫生厕所普及率、新 型农村合作医疗覆盖率及参合率等） 9、城镇化（城镇化水帄） 10、城乡居民收入（城镇居民人均可支配收入增长率、农民人均纯收入增长率） 1、教育发展（生均占地与校舍面积、初中生保留率、高中阶段毛入学率、增加教 育经费达到―三个增长‖） 2、社会保障（城镇基本养老保险、城镇职工失业保险参保率和发放率；城镇居 民、职工基本医疗保险，新型农村社会养老保险，城镇职工工伤、生育保险参保 率，居民最低生活保障执行情况，住房保障） 3、医疗卫生（乡镇卫生院建设、甲乙类传染病发病率、每千人拥有卫生技术人员 数、每千人拥有医院或卫生院病床数、疾病控制、财政卫生事业经费投入增长率） 社 会 发 展 方 法 4、文体事业发展（文化站、图书馆、健身场所建设，农民健身工程点计划完成 数） 率，国民体质合格率，体育人口指标，万人拥有公共卫生文化设施数，财政文体事 业经费投入增长率） 5、就业（大中专毕业生就业，城镇登记失业率，农村剩余劳动力转移） 具体指标根据 不同区域的实 际和年度目标 由上级效能 办、统计调查 机构以及相关 部门设置，并 提供数据和评 价意见进行考 评。 6、社会稳定（社会治安综合治理领导责任制考评结果，含省直部门专项考评、检 查组实地考评、公众安全感测评三方面） 7、安全生产（安全生产工作目标：安全生产制度建设、体系建设及资金投入，安 全生产控制指标：较大生产安全事故，五类生产安全事故死亡人数、亿元生产总值 生产安全事故死亡率、10 万人口生产安全事故死亡率） 8、信访工作（落实信访工作领导责任制、健全信访工作领导体制、加强信访部门 领导班子和领导干部队伍建设、进京非正常上访、集体上访人次占常住人口比重、 到省集体上访人次占常住人口比重） - 252 - Combating Healthcare Cost Inflation with Administrative Action in Urban China 可 持 续 发 展 He Jingwei 1、环境保护与治理（环境事件处理、城乡环境基础建设、重点行业领域整治、城 市规划实施情况） 2、节能减排（单位 GDP 能耗、主要减排指标任务完成情况） 3、生态建设与资源、江河保护（生态市、县区、乡镇、村创建工作，流域整治， 水源保护） 4、人口与计划生育（出生人口政策符合率、出生人口性别比、群众满意率） 5、科技投入与创新（规模以上工业 R＆D 经费投入占规模以上工业增加值比重、 财政科技投入增长率、科技投入经费比重） 6、人才发展（人才资源总量增长、高技能人才占技能劳动者比例、主要劳动人口 受高等教育比例、人力资本投资占地区生产总值比例） 1、思想政治建设(政治方向、思想作风、理论学习、学习型党组织建设、执行民主 集中制等) 党 的 建 设 2、领导班子和干部队伍建设（选人用人、推进干部人事制度改革等） 3、人才队伍建设（人才机制创新、高层次人才培养引进使用、闽台人才交流合作 等） 4、基层党组织建设（落实基层党建工作责任情况、基层党组织创先争优、健全党 内激励帮扶关怀机制等） 5、反腐倡廉建设（执行党风廉政责任制、惩治预防腐败体系建设等） 领 导 水 帄 由纪委、组织 部、宣传部等 相关部门提供 意见进行考核 1、贯彻落实科学发展观（贯彻落实科学发展观的自觉性和坚定性、联系本地实际 贯彻落实能力等） 2、决策水帄（依法决策、民主决策、科学决策水帄等） 3、执政能力（领导科学发展能力、依法行政能力、统揽全局能力、维护稳定能力 特别是处理复杂事件和应急管理能力、务实创新能力等） 1、落实中央惠农政策（用于农村民生投入增长率、惠农政策群众知晓率） 2、完善社会保障体系（居民最低生活保险、医疗救助、―五保‖供养情况，城镇基 本养老保险、城镇职工失业保险参保和发放情况；城镇居民、职工基本医疗保险， 新型农村社会养老保险，城镇职工工伤、生育保险情况） 3、促进就业（大中专毕业生就业、城乡就业困难对象就业再就业情况） 民 生 改 善 4、医疗卫生（县及县以上医疗机构人均门诊费用，县及县以上医疗机构人均住院 费用，每万人口床位数和工技人员数，公共卫生体系建设及重大疫情防范情况） 5、子女就学（就学难解决情况、就学公帄情况、主要劳动力帄均受教育程度） 6、交通出行（城市交通情况‗每万人口拥有公共汽车量数等） 7、社会治安状况（党委政府重视率、群众知晓率、治安满意率等） 由统计调查机 构、效能办及 相关部门提供 数据和评价意 见进行考核 8、解决食品药品安全问题（市场销售食品药品抽查合格率） 9、文化娱乐健身设施建设（文化馆、站建设，城镇、农村居民人均文化娱乐费支 出，农民健身工程点） 10、居住环境（城乡绿化、―农村家园清洁行动‖开展情况） 完成 重点 目标 任务 1、省委、省政府部署的重点或专项工作的执行及完成情况 2、同级党委全委会、人代会年初确定的目标任务的执行及完成情况 3、为民办实事的落实情况 由相关部门提 供数据和意见 进行考核 - 253 - Combating Healthcare Cost Inflation with Administrative Action in Urban China He Jingwei 地方党政领导班子民意调查内容 类别 民 生 改 善 社会 和谐 党 风 政 风 内 容 1、落实中央惠农政策 2、健全社会保障体系 3、促进就业 4、医疗卫生 5、子女就学 6、交通出行 7、解决食品药品安全问题 8、文化娱乐健身设施建设 9、居住环境 10、加强社区管理 11、社会治安状况 12、安全生产 13、领导班子整体形象 14、党务（政务）信息公开 15、机关工作人员办事效率（服务质量、工作作风） 16、选人用人公信度 方 法 根据各地实 际，参考调查 内容，确定具 体调查项目， 开展民意调查 - 254 - [...]... assistance schemes taking over the coverage This financing system has helped Singapore achieve spectacular success in healthcare but with minimum costs (World Health Organization 2000, Ramesh 2008) Inspired by Singapore‘s achievement in cost containment, China -9- Combating Healthcare Cost Inflation with Administrative Action in Urban China He Jingwei also launched its own MSA on a pilot basis in 1990s and... most healthcare systems, cost inflation means more spending, which in turn imposes heavier economic burdens to households -7- Combating Healthcare Cost Inflation with Administrative Action in Urban China He Jingwei Cost inflation has been translated into a multitude of acute social problems in many countries, including the United States, South Korea and China, and has increasingly made it politically... of financing arrangements (Ramesh and Wu 2009) - 10 - Combating Healthcare Cost Inflation with Administrative Action in Urban China He Jingwei Cost containment is certainly the most important requirement for any payment method, and galloping increases in healthcare costs are a main motivator of people‘s efforts to develop good payment methods Among the payment methods now in use, FFS is the worst in. .. analyze the dynamics of an administrative costcontainment policy, the study must answer an intermediate set of questions: -2- Combating Healthcare Cost Inflation with Administrative Action in Urban China He Jingwei Is the Chinese health bureaucracy incompetent to tackle difficult health policy issues— cost inflation in particular? What are the sources of its authority, resource, and instruments? What is... constraint Special Economic Zone State-owned enterprise Traditional Chinese Medicine Target Management Contract Urban Employee Basic Health Insurance Scheme Urban Resident Basic Health Insurance Scheme xiii Combating Healthcare Cost Inflation with Administrative Action in Urban China He Jingwei CHAPTER I INTRODUCTION 1.1 Background and research questions The continuous rise in healthcare spending is... between the percentage of elderly persons in a nation‘s population and national healthcare spending (OECD 2003, Reinhardt 2003) - 20 - Combating Healthcare Cost Inflation with Administrative Action in Urban China He Jingwei increase (Bloom 2004) All these factors have jointly contributed to long-term implications for healthcare spending in China Although population ageing and the epidemiological transition... modest costs (World Bank 1994) The same health system however, has shocked the world by its  Part of the contents contained in this chapter appeared in the author‘s article China s Ongoing Healthcare Reform: Reversing the Perverse Incentive Scheme‖, East Asian Policy, vol 2, no 3, 2010 - 17 - Combating Healthcare Cost Inflation with Administrative Action in Urban China He Jingwei fast deterioration since... metaphor of ―three big mountains‖ was first coined by the communist party referring to the three ―enemy classes‖ in the revolutionary period before it came to power in 1949 - 18 - Combating Healthcare Cost Inflation with Administrative Action in Urban China He Jingwei Nowadays, the average bill of a single hospital admission in China is almost equivalent to its annual income per head, and is more than... privatization - 14 - Combating Healthcare Cost Inflation with Administrative Action in Urban China He Jingwei becomes a logical solution This has been the central rationale to privatizing the vast SOE sectors in China, Vietnam and Eastern European countries (Cao, Qian and Weingast 1999, Lin and Li 2008) While this theory is instructive in analyzing the relationship between budget constraint and the economic... hospitals‘ internal institutions that determine physicians‘ behaviors - 16 - Combating Healthcare Cost Inflation with Administrative Action in Urban China He Jingwei CHAPTER II POLICY BACKGROUND This chapter reviews the applied literature, mainly policy studies, related to the research topic and presents a critical analysis on the macro policy background in China s healthcare development Consisting of . UEBHIS Urban Employee Basic Health Insurance Scheme URBHIS Urban Resident Basic Health Insurance Scheme Combating Healthcare Cost Inflation with Administrative Action in Urban China He Jingwei. of an administrative cost- containment policy, the study must answer an intermediate set of questions: Combating Healthcare Cost Inflation with Administrative Action in Urban China He Jingwei. market transition have largely failed to keep cost inflation at Combating Healthcare Cost Inflation with Administrative Action in Urban China He Jingwei - 2 - acceptable levels (Liu and