Struggle and innovation in China's medical situation

drug additions and the introduction of a two-vote system, have not yet disappeared. In mid-2018, the National Health Care Commission and the National Medical Security Bureau made their grand appearances. After its establishment, the Medical Insurance Bureau immediately and vigorously promoted the "4+7 volume purchase", and the knife saw blood, and the evolution direction of my country's new stage of the medical industry became clearer. In the past, the intricate mechanism of the Chinese medical system is still deeply rooted in the hearts of the people. How do the old diseases and the new medical reform main line form a wave of new trends? How many possible opportunities are left to the market in the midst of policy turmoil? These are issues worthy of our consideration.

However, medical services are only the tip of the iceberg of the entire medical industry. At the same time, the particularity of the medical industry lies in the close relationship between the various sectors. It takes the whole body to move, looking at a subdivided field is tantamount to blind people touching the elephant, and often makes mistakes. Judgment.

When pharmaceutical companies, distribution companies, and non-public medical services are under pressure, what are the possible opportunities on the other side of the pressure? Opportunities and pressures show the industry's own laws. Where does the motivation behind the laws come from?

In this article, we hope to show the core features of the current medical system, as well as the main lines of possible industry trends in the future, and sort out the accompanying opportunities.

We can roughly divide time into three stages:

1. The two decades of "1990-2009" as the first stage are also the main shaping stages of the characteristics of the medical system that we now feel;

2. As a new round of medical reform, the "2010-2019" decade began the transition phase of exploring new directions. There have been attempts and iterations;

3. From "2020--", the new main line has been clarified, the effects of various trends will gradually appear, and promote the formation of a new medical ecology.

The following will also be divided into two parts to talk about the distortions and struggles formed in the first stage of the medical industry, and the second part will discuss the trend of the beginning of the transition period and how it will affect the future. This article focuses on the first stage of the medical industry.

Before embarking on the following, the first thing to explain is that no matter how many problems there are, China's medical achievements are still far greater than the problems that have arisen. However, due to the limited space, we will focus on the problems we face. Secondly, although the following discussion will criticize the behavior of each subject, we all know that most things in the system are not shifted by personal will. We only talk about trends, not about right and wrong.

Service side, pay side and product side

We divide the medical industry into three major entities: medical service providers dominated by public hospitals, payers dominated by medical insurance, and product providers dominated by medicines and devices. This is also consistent with the classification of medical, medical and medical insurance described in the current policy. The policy thinking is the main line of the medical industry. The policy is adjusted according to the general trend, and the next round of general trend is created.

Obviously, the Chinese medical industry does not belong to a market-dominated field, which requires a clear understanding. However, the relationship between government dominance and market law is not a completely opposite relationship. Policy determines the direction, and supply and demand in the market are used to verify its feasibility and shape it, whether it is healthy or deformed.

The relationship between the three major entities well defines the first stage (1990-2009) of the first characteristic of the medical industry: the service side is strong, the payment side is weak, and the product side becomes a vassal of the service side.

Let’s talk about the payer first: the service party (hospital) should serve the demand side (large number of patients), and the patient itself lacks medical knowledge and is in an asymmetric information position. Second, the patient group is relatively scattered and does not have direct feedback Ability and position; therefore, the payer (medical insurance) is to some extent the spokesperson of the demander (large number of patients), on the one hand, it needs to strive for higher quality services for patients, on the other hand, it needs to strive for more reasonable and cheaper the price of.

The product side (pharmaceutical enterprise) refers to the supply side of medicines and devices, and is also an important value part of the service side (hospital) in addition to services provided to patients. The situation in China is very clear. For a long time in the past, the medical insurance party mainly assumed the role of a financial supporter and a guaranteeer. From the perspective of financial support, it completed the task well and covered the vast majority of the population. It has made a solid guarantee for the people's well-being. However, the role of "demand spokesperson" is basically blank, and there are no excessive demands on the public. In recent years, although the implementation of total prepayment and major prescription supervision, etc., it can only cause public gangsters in individual directions. 'S attention is far from the chamber resistance.

Let’s talk about the service side: Public hospitals have achieved rapid development in the past few decades. The good side is to lay a solid resource foundation for the construction of China’s medical and health care; the bad side is that the scale is greatly expanded, and the top three siphon Part of the resources and patients, while the goals are distorted, established their own circle and logic from top to bottom, basically at a stage of lack of game, guidance, and free expansion according to their own needs.

At this stage, the top three public institutions at the top of the food chain have obtained the support of the government, medical schools, land finance and the rigid needs of the vast number of patients. They have obtained huge resources. If some resources are invested in patients, their goals are also consistent with their own interests. Direction, such as "building a building, buying equipment, opening a department", as we often say, such as a better pursuit of "advanced technology, high-end treatment", but rarely made in terms of efficiency improvement and cost control, customer service Great investment.

Finally, the product side: The overall price set by the government is low, and the price of the service is obviously low. This has caused medical institutions to rely on "excess" "drugs and materials" to balance the balance of hospitals and increase personal income. On the surface, public hospitals and pharmaceutical companies can achieve a win-win situation. Public hospitals will increase the amount of use and strive for higher prices. Both will benefit, and the phenomenon that has been shown for a long time is basically the same.

At a deeper level, pharmaceutical companies are also a vulnerable group contained in public hospitals under such a system, and become a vassal parasitic on the unreasonable public three-dimensional system and the phenomenon of over-prescription, causing pharmaceutical companies to rebate a lot of energy and money. In the form of flowing into public hospitals, it also lacks the vitality and innovation ability for the benefit of patients, which is not conducive to the long-term development of the enterprise.

To sum up, we can see that a vicious cycle has occurred in the medical system, the patients are weak, the medical insurance is weak, and the public is strong. However, due to price controls, the strong public has embarked on the path of supporting medicine and prescribing medicine in excess. Going forward, the greater the public resources, the siphon effect produced makes the efficiency of the entire medical system more uneven, less oriented to efficiency and cost-effectiveness, and also makes patients more vulnerable, and sometimes the public can actually threaten patients with medical insurance. In a moral depression, the product side is surrounded by public profits.

Consortium

The second feature is: "Government-institution establishment-medical schools-public hospitals-medical insurance" as a chain of interests. This “public party”-led benefit chain declares that the absolute resource highlands and absolute barriers in the medical field are on the public side, and that the barriers are not established by a single subject, but by multiple subjects.

Under the policy supervision and relatively strict access policy, the public as a whole is under the excellent welfare prepared by the public institution and the unique teaching and research promotion rules, under the mutual benefit and coexistence of the medical school to the public, the public hospital itself has a strong Under the human resources, under the tilt of medical insurance as the core payer to the public, the barriers are erected high, whether it is a single commercial insurance or HMO integrated medical model that is hard at the payment level, and an individual outstanding at the doctor level. Doctor groups, private hospitals that work hard at the hospital level, or light online consultations that work at the customer level, can't shake the original system alone, and it is not easy to form a new ecosystem.

It is precisely for this reason that several well-developed sectors in the past medical industry are attached to this system and can bring common benefits, including: pharmaceutical companies (which have earned a lot in the past, recent Subject to some inhibitions, this will be mentioned below), medical device companies (the interests of hospitals as a whole are completely consistent, and the government unilaterally manages the symptoms of large-scale equipment without a cure), pharmaceutical distribution companies (large and small pharmaceutical distribution companies in the above In the circulation, because it is with a strong party, it can follow the public to obtain benefits. At present, the channel is squeezed and the pharmaceutical companies are squeezed. There is a similar reason, which will also be mentioned below).

Next are a few subdivisions that are struggling: medical services.

The service model with the supply chain as the core: Among the medical services, the first to be successfully verified is Phoenix Medical (now China Resources Phoenix): medical service + IOT hosting + supply chain model. The basic idea is to make a fuss around the supply chain. It does not prove the success of the medical service's own model.

General hospitals and clinics: Next, let's look at the general hospitals and clinics. From the target group's spending power, we can distinguish them by high-end medical treatment, mid-end medical treatment, and general medical treatment.

For high-end medical services, we can see United Family, whose target customers are foreign customers and high-end crowds. After more than 20 years of operation, United Family Beijing Campus has become a model of high-end medical success in China, but her several overseas expansions have not As expected, other first-tier cities also have projects that target high-end other brands, but to some extent, they are not currently successful.

This shows that the high-end foreign market is a relatively separate market. In theory, the high-end market can do its own market segmentation without competing with the public or relying on medical insurance. The success of United Family has verified this. However, the size of Beijing United Family is only 100 beds. With the gradual lack of growth in foreign demand, the local high-end population still needs public experts, and the extra value of the international process cannot be fully realized. What is the room for the high-end medical market? It is still unknown how to replicate more advanced high-end international hospitals everywhere.

Mid-range healthcare can be defined as advocating "value healthcare". In the face of out-of-pocket patients, pre-commercial insurance payments are the mainstay, hoping to use "value healthcare and quality services" to break the publicly formed strange circle of medicine-based healthcare and to Patients provide a new medical experience. The ideal is beautiful, but in reality, the "new public" that is benchmarked with mid-range hospitals (such as the relocation of public hospital branches or main hospitals built in the past 5 years or under construction, or several large social offices for the majority of medical insurance patients Medical institutions, such as Peking University International, Tsinghua Changgeng, Shulan Hospital, etc.).

"New public" has already surpassed the so-called mid-range hospitals that provide value-based medical care in terms of geographic location, human resources, and even environmental hardware and information technology. When medical insurance is lacking and higher-end mid-range medical care is desired, the quality of medical care actually provided is lower than the "new public" average level, and the market competitiveness is obviously insufficient. At the same time, it is not easy to host a “new public” standard hospital through social forces. It requires a lot of medical resources and local government blessings. It is not enough to cooperate with one or two medical institutions. At the same time, the non-profit nature of hospitals is often It is a necessary condition for medical resource support and government blessing.

Mid-end clinics: For mid-end clinics that generally locate self-paying and insurance customers, they face the following problems:

First, there is no medical insurance payment;

Second, in the absence of public support, can the team of doctors form a team from core experts to attending, and at the same time can cover all core specialties;

Third, how can we gain the trust of customers without public medical consortium and brand output; how to implement referrals at higher and lower levels.

Fourth, compared with community hospitals, where rents are high, staff costs are high, and there is no medical insurance, how to compete.

In response to these problems, mid-range clinics should gain advantages in the following directions:

First, despite the positioning of mid-range customers, the payment side should still be based on medical insurance. At the same time, innovative value-added self-financed projects, commercial insurance are short-term desserts in China in the short term and cannot support chain clinics. Some high-end clinics have room to survive, but the market space will not be so large that a city can accommodate several chain clinics in a short time (those who locate high-end white-collar workers in high-end business districts can consider commercial insurance and high pricing, and some cases have also been successful. It takes a certain amount of time to cultivate, and at the same time, the supply in a region cannot be excessive, and it may not be able to replicate, just like high-end hospitals.

Second, there must be a team, which reflects the reason why some chain clinics are doing well in one area, but they cannot expand. If you want to expand here, you need the support of medical schools, public institutions, and self-organized training systems. Another approach is to establish a set of partners that can attract teams.

Third, strive for the network system that can enter the public medical consortium, which will have the advantages of brand and expert visits, up and down referrals, and multi-point surgery.

Fourth, in order to highlight its own convenience and value medical advantages, it can be considered to be located in the core business district or a new urban area lacking supporting medical care, rather than the general community. If it is a first-tier CBD area, if the brand is good, the company upstairs may purchase the clinic's services as employee benefits.

To cover a larger mainstream market, clinics should be able to win with convenience, while providing high-quality services at a lower price. It is very difficult for operators to have very strong operational capabilities and low-cost access to medical resources. Some regional entrepreneurs with resources can meet this standard in the region, but it is difficult to replicate across cities. At present, although there are a lot of clinic entrepreneurs, the resources are not abundant, but the profitability is not ideal. The average return on investment is about 5%-15%, and there are also many losses, which are difficult to reproduce by blood.

In short, no matter whether it is a mid-range hospital or a mid-range clinic, because it cannot avoid direct competition with the public, it is still constrained by the system of "government-public institution-medical school-public hospital-medical insurance", which makes the operation of mid-range medical care difficult. .

Finally, in the face of the general public's general hospitals, there is basically no advantage compared with the public. The general clinics basically need to be able to form a differentiated positioning with the public, or have their own unique business, can form a clear profit model and can be replicated on a large scale. It is also very rare. I will not repeat them here.

Specialist medical: the ones that can achieve good results in the medical service sector are generally specialized medical institutions in specific specialty fields. Specialties can be divided into two categories. One type of specialty is consumer medical specialties, such as stomatology, medical beauty, and physical examination. , Obstetrics and gynecology, ophthalmology. The first category is the specialty that is just needed, such as heart, oncology, brain, pediatrics, and rehabilitation.

Basically, the consumer medical category belongs to the nature of natural medicine is relatively small, because of the low proportion of medicines, lack of high-value consumables, long operation and treatment time, and more self-funded items in the project. Favorable, relatively marginal department. In terms of non-public institutions, it belongs to the disciplines with different public strengths, low dependence on medical insurance, and low dependence on experts in ophthalmology, obstetrics and gynecology, medical beauty, and physical examination.

It can be seen in the successful cases in this category of specialists that they need to make excellent efforts on both the supply and demand sides to succeed. In addition to their own medical facilities