China Promotes Chronic Disease Joint Clinics Nationwide; Shandong's Digital Chronic Care Consortium Emerges as National Model
Recently, the General Office of the Central Committee of the Communist Party of China and the General Office of the State Council issued the “Opinions on Further Improving the Medical and Health Service System” (hereinafter referred to as the “Opinions”). The document proposes establishing an integrated medical and health service system, with specific measures including “exploring the establishment of joint outpatient clinics for chronic diseases by primary healthcare institutions and higher-level medical institutions to carry out treatment, prevention, and rehabilitation of common chronic diseases,” and explicitly “supporting privately-run medical institutions in leading or participating in the formation of medical consortia.” This represents a significant step in China’s efforts to further improve its medical and health service system based on the new development stage and centered on people’s health, providing clear guidance for localities to explore chronic disease management models.
Data from the National Bureau of Statistics indicates that by 2025, China’s population aged 60 and above is projected to reach 300 million, classifying the country as having a super-aged society. The overall healthcare demand among residents, particularly for chronic and geriatric diseases, will continue to rise. Leveraging hierarchical diagnosis and treatment reforms characterized by regional coordination and vertical integration between primary and tertiary care providers, and fully capitalizing on the advantages of digital platforms operated by social institutions, an efficient chronic disease management system has been established within medical consortia. This approach aims to achieve breakthroughs through comprehensive, end-to-end chronic disease management, thereby forming an all-encompassing, full-cycle integrated healthcare service system. Currently, the Digital Chronic Disease Medical Consortium being promoted across Shandong Province has once again attracted attention from media and industry stakeholders due to its close alignment with the planning outlined in the “Guiding Opinions.”
In 2021, among the ten municipal-level process reengineering reform cases submitted by Shandong Province to the Central Office for Comprehensive Deepening Reforms, “The Taian Model of ‘Internet + Medical Insurance + Healthcare + Pharmaceuticals’ for Tri-Medical Coordination” garnered widespread attention for its remarkable achievements in achieving “two increases and one decrease”: improved healthcare management services for chronic diseases, enhanced health indices among chronic disease populations, and reduced medical cost burdens. This model pioneered a focus on chronic disease management, led by private healthcare institutions in building digital medical consortia, thereby exploring and establishing the digital chronic disease medical consortium model.
Health News once reported on this model under the headline “Digital Health Management and Care Takes Shape,” suggesting that the exploration of digital chronic disease medical consortia has formed the雏形 of a Chinese-style health maintenance system. Professor Li Shixue, a member of the expert guidance group for the construction of national pilot zones for comprehensive primary healthcare, stated that this model represents another major innovation in the coordinated reform of medical care, health insurance, and pharmaceutical supply (“Three-Medical Linkage”), following the “Sanming Healthcare Reform.”
Reportedly, the Tai’an Digital Chronic Disease Medical Consortium is led by WeDoctor Taishan Chronic Disease Internet Hospital and connects 15 secondary-and-above medical institutions in Tai’an. It integrates offline chronic disease specialty management at these 15 member hospitals with online internet hospital services, providing continuous, integrated care for chronic disease patients across the city through a combination of in-hospital and out-of-hospital, as well as online and offline services. Data show that the consortium serves 236,000 outpatient chronic disease patients citywide, alleviating more than 20% of hospital outpatient pressure; it has established 15 chronic disease service centers throughout the city, reducing patient visit and medication pickup time from the previous 2–3 hours to just 20–30 minutes.
WeDoctor Taishan Internet Hospital for Chronic Diseases is China’s first internet hospital dedicated to chronic disease management, jointly established by the Tai’an Municipal Government and WeDoctor, the country’s largest digital health platform. In introducing the “Tai’an Model,” the Tai’an Municipal Healthcare Security Administration stated that the Tai’an model of coordinated reform across healthcare, medical insurance, and pharmaceutical services has reengineered medical insurance service processes through “delegation, regulation, and service” reforms in the medical insurance sector. In particular, the development of a digital consortium for chronic disease care has reshaped online-to-offline service workflows, representing an innovative achievement driven by government leadership, multi-stakeholder participation, and market-oriented operations.
Building on Tai’an’s successful experience, Shandong Province has promoted the digital chronic disease medical consortium model across all 16 prefecture-level cities in the province. On January 11, 2020, the Shandong Provincial Committee of the Communist Party of China and the Shandong Provincial People’s Government issued implementation guidelines to carry out the “Opinions of the Central Committee of the Communist Party of China and the State Council on Deepening the Reform of the Medical Security System,” calling for “promoting specialized management of chronic diseases in large medical institutions and developing integrated online-offline diagnosis and treatment as well as home medication delivery services.” Currently, leveraging the Shandong Internet Health Platform, the province has established more than 40 chronic disease service centers in cities such as Jinan, Tai’an, Dezhou, and Weifang, serving over 4.5 million visits among patients with chronic conditions.
It is worth noting that the Shandong Internet Health Platform is China’s first open, comprehensive service platform operating under a model of “government support, state-controlled ownership, integration of advantageous resources, and market-oriented operations.” The development of this digital platform has fully mobilized social forces, with WeDoctor participating in its construction and responsible for service operations. The platform serves the elderly, individuals with disabilities or partial disabilities, and patients with chronic diseases across the province, providing assisted services such as follow-up consultations and prescription issuance, medical insurance payment, home delivery of medications, and in-home nursing care.
“Previously, getting prescriptions filled required registering and queuing at the outpatient clinic, which would take up most of the day with back-and-forth trips. Now, it can be done in just a few minutes using a smartphone.” This reflects how patients with chronic diseases have tangibly experienced greater convenience in accessing medical care following media reports on Shandong’s innovative development of digital medical consortia for chronic disease management.
Behind the convenient services lies the Digital Chronic Disease Medical Consortium, which leverages a “cloud platform” to enable data interoperability, facilitating coordination among healthcare providers, prescriptions, pharmaceuticals, and insurance. This achieves an integrated online-offline model for the entire continuum of chronic disease care, including follow-up visits and medication dispensing. Patients can schedule follow-up appointments in the dedicated chronic disease sections of their designated hospitals online, with support for direct online settlement via medical insurance; alternatively, they may receive follow-up care at primary healthcare institutions, enjoying medication regimens and health management plans consistent in quality with those offered by tertiary hospitals. This digital empowerment initiative addresses the most significant pain point in the previous tiered diagnosis and treatment system for chronic diseases, effectively enhancing primary care capabilities and encouraging patients to proactively seek follow-up care closer to home or through online channels.
Beyond the integration of online and offline services, the Digital Chronic Disease Medical Consortium also addresses the challenge of continuous management from in-hospital to out-of-hospital settings. The consortium has developed health management tools tailored for both patients and physicians. After online follow-up consultations, patients can seamlessly enroll in health management programs, upload daily monitoring data for health indicators such as blood glucose and blood pressure, record daily dietary and exercise data, and submit periodic follow-up examination reports and prescriptions. Physicians prescribe personalized health management plans based on individual patient conditions, providing guidance on daily health monitoring, diet, and exercise, and formulating follow-up and re-examination schedules. By implementing a “three-provider co-management” service mechanism involving specialists, general practitioners, and health managers, the consortium achieves comprehensive “in-hospital plus out-of-hospital” full-course management. This approach significantly improves patient adherence and promotes the integration of treatment and prevention.
Leveraging digital platforms that enable data interoperability and the application of artificial intelligence, rural grassroots areas with weak medical equipment and service capabilities can now access homogeneous healthcare services. Relying on internet hospital platforms, the Digital Chronic Disease Medical Consortium has developed a “Mobile Hospital” model by integrating digital health service vehicles, cloud-based mobile clinic kits, and medical-health workstations. This model provides a comprehensive healthcare service system covering examination, testing, diagnosis, prescription, and medication delivery. It supports grassroots institutions in delivering online consultations, remote specialist consultations, two-way referrals, online prescribing, and medication distribution, as well as public health services, family doctor contract services, and disease control emergency response services. By simultaneously addressing weaknesses in clinical care, public health, and disease prevention and control, this approach accelerates the formation of a high-quality, efficient, integrated grassroots healthcare delivery system.
The “Opinions” proposed establishing a family doctor contract service model that uses primary healthcare institutions as the main platform, features general practitioners as the core, ensures effective collaboration between general and specialist care, and integrates medical services with public health prevention, thereby providing comprehensive and continuous public health, basic medical, and health management services. It also suggested that regions with appropriate conditions may explore capitation-based payments of the outpatient pooling fund from basic medical insurance for contracted residents to primary healthcare institutions or family doctor teams. These measures are regarded as a key aspect demonstrating strong support for digital chronic disease medical consortia.
The Digital Chronic Disease Medical Consortium has also transformed offline services that have long occupied outpatient resources at large hospitals. By establishing dedicated chronic disease service zones within member institutions of the consortium and reengineering processes, it has separated consultation and prescription renewal services for outpatients with chronic diseases from the routine outpatient operations of physical medical facilities. This enables “single-zone processing, one-stop service, and single-bill settlement” for registration, appointment scheduling, consultation, prescription issuance, payment, and medication pickup. This approach not only addresses the pain point of “three longs and one short” (long waiting times for registration, long waiting times for consultation, long waiting times for medication pickup, and short consultation times) faced by patients with chronic diseases, significantly enhancing their sense of convenience in accessing medical care, but also alleviates outpatient pressure at large hospitals and effectively supports the expansion of high-quality medical resources.
Upgrading intelligent health insurance monitoring is also a key component in the construction of digital medical consortiums for chronic disease management. By reengineering the implementation processes of intelligent health insurance monitoring, information interoperability and sharing among health insurance bureaus, healthcare institutions, and pharmaceutical service providers are achieved. This enables full-process supervision, including pre-event reminders, intra-event warnings, and post-event audits, covering various aspects such as physicians’ order entry, prescription issuance, and ordering of diagnostic tests. Such measures effectively reduce the prevalence of excessive prescriptions and unnecessary examinations, and maximally prevent fraudulent and abusive claims against health insurance funds.
Health insurance plays a core leveraging role in the rational allocation and scientific utilization of medical and pharmaceutical resources. The "Opinions" propose advancing reforms in health insurance payment methods, improving diversified and composite payment systems; exploring global budgeting for closely integrated medical consortia, strengthening supervision and assessment, and implementing policies that allow retention of surpluses and shared responsibility for reasonable overspending. The successful exploration by digital chronic disease medical consortia in enhancing health insurance regulatory capabilities has created the technical conditions for implementing global budgeting reforms in closely integrated medical consortia.
Industry analysts note that, in pursuit of the dual objectives of enhancing the quality of chronic disease health management and achieving cost containment within the basic medical insurance system, various regions across China are accelerating reforms to medical insurance payment methods. The core of this shift is moving from the traditional fee-for-service model to a value-based payment approach centered on diagnosis-related groups (DRGs) or capitation. Against this backdrop, and aligned with the goals of an integrated healthcare delivery system, the development of chronic disease medical consortia has evolved beyond its initial aim of implementing tiered diagnosis and treatment. It now places new demands on the interoperability of data among medical care, health insurance, and pharmaceutical sectors (“three-medical” data), as well as on the deep integration of services. The digital chronic disease medical consortium model has emerged as a pioneering, directional template, offering referenceable and replicable case models for various regions exploring joint chronic disease outpatient clinics, while also unlocking new opportunities for the upward trajectory of regional digital health industries.