What is the policy background of chronic disease management?

The policies related to the management of chronic diseases in our country are essentially issued under the dual motivations of "the skyrocketing burden of chronic diseases has forced medical insurance to control fees + the public health system to make up for its shortcomings and find breakthroughs for the implementation of hierarchical diagnosis and treatment." Since the new medical reform in 2009 first included chronic disease management into the scope of basic public health services, the entire policy system has been continuously adjusted and improved in accordance with actual implementation issues.

To be honest, the growth rate of chronic diseases in our country in the past ten years has indeed exceeded expectations. There are now more than 300 million patients with chronic diseases, more than 80% of deaths, and more than 70% of medical insurance expenditures are linked to chronic diseases. I conducted research at the medical insurance bureau of a county in Hubei two years ago and found that almost 40% of the local medical insurance co-ordination fund in a year was spent on diabetes complications, hypertension and stroke. Regarding hospitalization cases that could have been prevented and controlled in advance, there was a 70-year-old man with diabetes who had never tested his blood sugar regularly for many years. When his foot rotted and he needed amputation, he spent 120,000 yuan on hospitalization, and the medical insurance reimbursed him more than 90,000 yuan. If the community had kept an eye on him to control his blood sugar three to five years earlier, he might have spent hundreds of yuan a year on medicines to stabilize his condition. It would have been a sure profit for both the patient and the medical insurance.

It is precisely because of this calculation that when the new medical reform was implemented in 2009, free follow-up and health guidance for patients with hypertension and diabetes were included in the first batch of basic public health service projects. At first, they only assigned tasks to the grassroots. Later, in 2015, hierarchical diagnosis and treatment was to be promoted. We really couldn’t find a suitable incision. We can’t let seriously ill patients go to the community first, right? Chronic diseases have become the most convenient choice - after all, chronic diseases do not require complicated treatment. The main thing is long-term follow-up and medication adjustment. The community can fully handle it, and it can also reduce the pressure on outpatient clinics in large hospitals. At that time, policies in various places were basically focused on "how to keep chronic disease patients at the grassroots level." For example, the reimbursement rate for chronic diseases in the community was 10% to 20% higher than that in large hospitals.

However, it is not that there have been pitfalls during the implementation process. Now there are two different voices in the industry. Some people think that the early policies focused too much on assessment indicators, such as requiring grassroots to follow up patients with chronic diseases four times a year. In order to complete the task, many community doctors just call and ask casual questions and they do not really care about how well the patients' blood pressure and blood sugar are controlled. Instead, they do a lot of useless work.； Some people also feel that the previous incentive mechanism has not kept up. The public health subsidy for a community doctor to take care of a chronically ill patient is only thirty or forty yuan a year. If the patient does not answer the phone and the follow-up is unsuccessful, money will be deducted. No one has the motivation to really spend their energy on taking care of the patient.

In fact, these problems have been quickly caught on the policy side. The policies in the past five or six years have obviously been in the direction of "promoting incentives and emphasizing practical results." For example, starting in 2021, long-term prescriptions for chronic diseases will be promoted nationwide, and medicines can be prescribed for up to 12 weeks, without patients having to go to the hospital every week for prescriptions.； There is also a capitation payment system for chronic diseases piloted in Zhejiang, Guangdong and other places. The annual medical insurance limit of a certain chronic disease patient is contracted to the community in advance. If the community controls the patient well and has not been hospitalized for a year, the remaining money will be used as performance by the community. I have been in contact with a certain patient in Hangzhou before. A family doctor in the community manages more than 200 patients with high blood pressure. Last year, because the control rate reached the standard, he received more than 20,000 yuan more for the performance of chronic diseases alone. Now he takes the initiative to call patients with poor control every week to adjust medicines. His enthusiasm is completely different.

To put it bluntly, these policy adjustments are never made out of head, but are developed step by step based on actual implementation problems. The core purpose has never changed - to install a pre-filter for the National Health and Medical Insurance Fund, so as not to wait for minor illnesses to become serious ones before plugging leaks, and to contain risks in advance, which is much more cost-effective.