Some people introduce me as an expert and professor. I say I am nothing. This is not because I am modest, but because I seek truth from facts. I graduated from a normal school and don’t have much theory. I am just the actual operator of Sanming medical reform, at most a "construction team leader". I put my energy into establishing Sanming medical reform, and I also established the Fujian Provincial Medical Insurance Office. Recently, the state has conveyed a lot of information about the Sanming medical reform experience. From the notice issued by the National Medical Insurance Bureau, the National Health Commission and other five ministries and commissions, to the National Medical Insurance Bureau’s release of documents in May, to the recent press conference held by the National Health Commission, stating that the Sanming medical reform experience will be implemented nationwide within 5 years...

On September 27, I just received a joint document from the National Medical Insurance Bureau, the National Health Commission and the Drug Administration, requiring the supervision of medical behavior to be changed from the past medical institutions, pharmacies, and pharmaceutical companies to the specific personnel of these units. In fact, the Fujian Provincial Medical Insurance Office issued a notice on October 18, 2016 to implement the medical insurance physician code management system. Therefore, Director Zhang Ke (Director of the National Medical Insurance Administration) mentioned that "the experience of Sanming's medical reform has been partially elevated to national policy", this statement is not a problem. A comrade from the Central Reform Office came to Sanming and said at the symposium that the experience of Sanming's medical reform has been fully affirmed by the highest level and the highest leaders of the Party Central Committee and the State Council, and its correctness is beyond doubt. But some comrades are still on the sidelines and even skeptical about Sanming's medical reform...

On March 23, 2021, General Secretary Xi Jinping came to the General Hospital of Shaxian District, Sanming City for inspection and pointed out that "Sanming's medical reform embodies the awareness and responsibility of daring to be the first, putting people first, and putting life first", which is a very high evaluation. He also said that I know that there are bottlenecks in promoting the experience of Sanming's medical reform, and the central government will focus on solving them in the next step. Subsequently, relevant departments will study how to open up and solve the bottlenecks and come to Sanming for research. On July 15 this year, the Third Plenary Session of the 20th CPC Central Committee opened. At 1 p.m., Xinhua News Agency launched the "Leading the New Journey" released by the Central Propaganda Department system on the entire network. It is 44 minutes long. The film talks about four parts: economic revitalization, ecological protection, opening up to the outside world, and people's livelihood construction. Sanming's medical reform is in the "people's livelihood construction" part, which is about 10 minutes. I suggest that you can go back and watch it. Today I want to discuss with you why Sanming's medical reform has been repeatedly reported and affirmed by the Party Central Committee, the State Council, and especially General Secretary Xi, what is the overall underlying logic and reform goals of Sanming's medical reform, and what is the context of the reform.

As comrades in the medical insurance department, we need to be responsible and pay attention not only to the reimbursement ratio, but also to the medical expenses borne by the people per capita. I would like to share with you the use of medical resources and health benefits in Sanming: In 2023, the annual per capita medical expenses in Sanming City will be 2,336 yuan; the average personal out-of-pocket expenses will be 945 yuan, of which urban employees will bear 1,663 yuan per capita and urban and rural residents will bear 789 yuan per capita. Everyone should be able to understand the "gold content" behind this number. As early as 2020, the average life expectancy in Sanming exceeded 80 years, and the total per capita medical expenses were only 1/3 of the national average. The growth of medical expenses is inevitable, but the growth rate must be consistent with the growth rate of the national economy and finance and the disposable income of the people. This is the consideration of the design of Sanming's medical reform system. At present, the average annual cost growth rate in Sanming is about 7.3%, and before the reform, there were even years when the growth rate reached 28%. The people cannot accept it, and the finance cannot afford it. I served as the deputy director of the Fujian Provincial Drug Administration for more than ten years, and served as a member of the Provincial Medical Reform Leading Group, Deputy Director of the Medical Reform Office, and a member of the Provincial Drug Bidding Leading Group. On August 15, 2011, I returned to Sanming as deputy mayor. In daily research and supervision, we found that Sanming's medical chaos was very serious.

Before the reform, Sanming's drug expenses usually accounted for more than 46%, consumables accounted for 12%, and the total of non-charged drugs and consumables usually accounted for 65%-70%. How much space is there for the waste of medical resources? Judging from the results of several rounds of volume-based procurement by the National Medical Insurance Administration, the average reduction is almost above 50%. The Sanming team was considering that if the money wasted on medical resources could be "squeezed out", we could squeeze out about 500 million yuan a year. On November 1, 2013, Sanming established its own procurement platform and no longer cooperated with the provincial platform. The standard for purchasing drugs is 16 words - purchase for use, clinical reporting, real prices, and remove gray. Of course, it is a war without gunpowder to implement these 16 words. At present, the centralized procurement led by Sanming has developed into an alliance platform. After the Central Deep Reform Commission confirmed it, more than a dozen provinces and dozens of cities across the country have joined.

Our reform has led to changes in the income structure of medical institutions (drugs and consumables, examinations and tests, and medical income). The proportion of drugs and consumables has dropped from 60%-70% before the reform to 30%, while medical income (diagnosis, nursing, and surgical treatment) has increased from 18% before the reform to 46%. Our goal is to increase medical income to 50%. When the 50% target was first proposed, many people opposed it and thought it was impossible to achieve. At present, the average medical income of medical institutions across the country accounts for less than 30%. However, if the surplus medical insurance funds under the annual agreement are taken into account, then Sanming's medical income has actually reached the target last year.

From the perspective of examination fees, it currently accounts for more than 20% of the income of medical institutions, which is still relatively high. There was a joke during the reform period in Sanming that some hospitals' color ultrasound machines were purchased by employees. Since it was purchased by employees, they would definitely seek returns. A colleague from the Ministry of Finance went to Sanming for research, and I asked him a question: Is the current accounting system of the hospital tangible depreciation or intangible depreciation? If it is intangible depreciation, it will inevitably lead to "big inspections and big tests" (Editor's note: Intangible depreciation requires hospitals to recover costs within the effective use period of the equipment, and hospitals may increase income by providing more inspection services). From the current situation, the accounting system of our public hospitals needs to be further improved.

Just now, it was mentioned that the waste of medical expenses may exceed 50%, including excessive and incorrect medical treatment. Is this waste caused by the dean and doctors? No. Hospitals operate according to documents from government departments. Their mechanism comes from the government's management system and system design, and the system design comes from the management concept. Since the 1990s, the government has misplaced its characterization of medical care: it regards medical care as an ordinary commodity and consumption, and hopes that people will vote for hospitals, doctors, disease treatment methods and medications. After the qualitative misalignment, the government's handling responsibility is absent, hospitals are pushed to the market, and the "piecework system" is implemented. The dean becomes the factory director and the department director becomes the workshop director. Generally speaking, the dean needs to consider three major functions. The first is medical quality, the second is medical safety, and the third is the patient's perception and satisfaction. But now, the core functions of the deans have been lost, and how to make money and run medical institutions occupies 80% of their energy.

Medical staff have always been the main force of medical reform. If our reform design ignores medical staff, the reform will not be successful.
Here, I will talk about the reform of the doctor's salary system. If the salary system is not reformed, there will be no return to the public welfare of medical care, and it is even more impossible to build a "health-centered" medical service system.
In Sanming, from the hospital director to doctors and nurses, everyone wanted to have as many patients as possible, so that medical income and salary income would be high. Now, the overall concept of medical care has shifted to "let the people get sick less, get serious diseases later, and preferably not get serious diseases at all."
Starting from February 1, 2013, Sanming cancelled all drug markups, including Chinese herbal medicines, and adjusted the prices of 80 medical services at the same time, and implemented a target annual salary system.

The secretary and dean of a tertiary hospital are 500,000 yuan, and the design standard is calculated according to 2 times the highest salary of the local leaders of the same level, and the chief physician is calculated according to 5 times the local social position salary. This system was designed in 2021, when the average social position salary was 60,000 yuan. Therefore, the basic annual salary of the chief physician is 300,000 yuan, the deputy director is 250,000 yuan, the attending physician is 200,000 yuan, and the resident physician is 150,000 yuan. Medical technology and pharmacy are 80% of the equivalent titles of clinical doctors, nursing is 70%, and logistics is no more than 50%. This is the total amount that the government has given to the 12 general hospitals in Sanming. Instead of giving this money directly to each person, the specific amount falls on the individual, and the hospital needs to conduct an assessment and calculate it based on work points. The annual salary is calculated based on the work point system, which has changed the previous performance commission system and has been fully affirmed by the senior leaders of the central government. What I want to say is that General Secretary Xi mentioned that we should adapt to local conditions. If we implement salary reform in Gansu today, we need to determine the salary based on the local economy and average income, so we cannot copy the data of Sanming. In addition to the basic annual salary, the doctor's performance is divided into three parts: 10% of the total surplus of the medical insurance fund, 10% of the pure medical income (medical income), and 10% of the total surplus of the medical insurance fund. Director Zhang Ke went to Sanming for research and found that the deans of the general hospitals were very concerned about the use of the medical insurance fund. This is the reason. For irregular medical behavior, we rely entirely on administrative means to crack down on it. Our administrative costs are too high. We must adjust the system concept and make the policy force specific to people.

In a previous media interview, I was asked whether I was a government or market person. I am not a member of any group. The essence of Sanming's medical reform is to unswervingly implement General Secretary Xi Jinping's people-centered thinking, practice the concept of people first and life first, and design the system with health as the center and carry out the reform of the three medical linkages. Since the second half of 2016, the goal of Sanming's medical reform has risen from "medical security" to "health security", which requires all medical resources, including medical care, medical insurance, and pharmaceuticals, to develop and govern in a coordinated manner, especially the medical and health departments and medical insurance departments, to become class brothers, not class enemies. Last week, Sanming just issued Document No. 8, pointing out that the next step of reform is to build four systems: one is the government-run medical responsibility system; the second is the medical security service system; the third is the health management organization system; and the fourth is the health benefit evaluation and supervision system. In the future, performance indicators that reflect health, such as life expectancy per capita, resident health level, and per capita medical expenses, will be included in the evaluation indicators and used to determine the total annual salary of the general hospital. The overall goal is to build a new era of universal health security system.

The ultimate goal of the medical reform system design must be to change medical staff from "hoping for as many patients as possible" to "hoping for as few patients as possible". The healthier the people are, the more income the medical staff will earn, thus truly realizing health-centered, value-added medical care, value-added medical insurance, and value-added medicine, and providing basic health protection for all people.

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