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Although there is policy support, in the actual implementation, the model of the medical association has two problems. First, there is limited substantive promotion of the service capabilities of primary medical institutions. The second is that it is difficult to reflect the effect of sinking the patient and controlling the cost.
First, as a part of the large hospital enclosure movement, the medical association helps to absorb more patients for large hospitals through grassroots networks, especially in specialists, sinking quality experts to the grassroots level to help more patients. . Because the primary medical institutions' services are insufficient in the cooperation of the hardware and the overall treatment team, the patients who ultimately need treatment will turn to the big hospitals. Therefore, the first benefit of the medical association is the large hospitals, not the grassroots.
In the doctor's multi-point practice, the grassroots institutions have indeed obtained a certain number of customers from the famous doctors in the big hospitals, but these patients are still rushing to the reasons of not being able to hang on the big institutions and want to see famous doctors. User loyalty. It is toward a famous doctor, not an institution. Therefore, as long as the famous doctor moves to where the patient will follow, there is no substantial improvement in the ability of the grassroots to attract patients.
At the mutual recognition of inspection reports and the integration of information services such as remote readings and expert consultations by some medical associations, the grassroots have indeed achieved some improvement in their ability. However, in the training of talents, highly qualified primary doctors have been trained in large hospitals. Or the opportunity to practise, will not hesitate to leave the grassroots. For large hospitals, going to the grassroots to teach also helped them to find some talents, especially in the cooperation between tertiary hospitals and some secondary specialized hospitals. Some excellent secondary hospital specialists were absorbed into tertiary hospitals. Talents are also very active in moving upwards, so in essence, good talents still cannot stay at the grassroots level.
From the above three points, the first profit in the medical joint mode is still the big hospital, which has little effect on the substantial improvement of grassroots strength.
Second, how much the medical association has in the sense of actual control fees has always been a controversial issue. At present, the strong base level with the medical association as the core has played a role in improving the service capacity and control fees of the grassroots. Now, no clear data can be seen. However, although the medical data of the Chinese market is still unclear, in the US market, there is an ACO (Responsible Medical Organization) similar to the China Medical Association. Recently, relevant research reports have shown its effect on the improvement of efficacy and the role of control fees. Not strong, its main value is still concentrated outside the hospital, not the largest part of the hospital for medical expenses.
ACO is short for "Accountable Care Organization". The main mission of the responsible medical organization is to combine hospitals and doctors at all levels, including specialists, family doctors, rehabilitation doctors, and other health care professionals. The integrated medical organization that synergizes medical services to improve the quality of care and the patient's efficacy and ultimately achieve the goal of control. ACO mainly consists of two types: ACO with only basic medical (general + specialist clinic), and ACO with large hospital plus clinic.
ACO is primarily targeted at retirees under the federal insurance program (Medicare users), and the Medicare Shared Savings Program (MSSP) program requires ACOs to participate in multi-level collaborations with participating healthcare organizations, thereby reducing medical costs. MSSP will give direct rewards to ACOs with well-controlled medical expenses and fines for ACOs that fail to meet the requirements. From the specific situation of implementation, only the ACO of basic medical care has a certain ability to control fees, but the ACO with the participation of large hospitals is not successful.
According to a recent report by Harvard Medical School released by Health Affairs, ACO's fees are not ideal. In the three years of 2012-2014, the hospitalization rate of ACO participating in MSSP did not decrease significantly. The hospitalization rate decreased by 1.6% and 0.7% in 2012 and 2013, respectively, but increased by 0 in 2014. .3%. The report shows that ACO's savings are mainly from low-risk patients rather than high-risk patients, which is contrary to the original intention of the project. Since the main medical expenses are used by high-risk patients, ACO would have liked to Save more on high-risk patients. In fact, ACO's savings are more focused on reducing the use of higher-priced out-of-hospital services, including a reduction in the use of SNF (Skilled Nursing Facilities), outpatient services, and home care.
Although there is no reduction in hospitalization rates, ACO still has value, especially in out-of-hospital services, which reduces costs but improves service quality. However, there is still a big gap between the goals set and the ACO. The ACO needs to make appropriate adjustments to encourage the hospital to work with all types of institutions to better manage high-risk patients.
From the perspective of the development of ACO in the United States, the medical cooperation organization's ability to control fees is not strong, its effectiveness is mainly concentrated outside the hospital rather than the hospital, but the core expenditure of medical services is still concentrated in the hospital, the cost savings outside the hospital is very limited, The core of the development outside the hospital is to reduce the expenses in the hospital. Therefore, from the perspective of control fees, the future development of the medical association still needs to be accompanied by effective measures and tools.
Judging from the current development practice, the value of the medical association is not great. If it is to reduce the cost of the hospital, DRG can be effectively promoted, as long as the payer changes the payment rules. If it is to be promoted in out-of-hospital services, the core is still focused on providing post-operative health management for discharged patients, reducing the rate of readmission and improving the patient's health, which requires payment policies to lean toward rehabilitation and care. Fundamentally, the bulk of medical expenses is still in hospital. The core control measures should focus on this part, relying mainly on payment policies to guide the transformation of service models, and encourage hospitals and doctors to take the initiative to manage patients.
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