Hangzhou's Innovative General Practitioner Contracting Model: Covering 808,000 Residents with Over 1,000 Doctors

Amid an aging population, difficult and costly access to medical care has become the most pressing challenge in the healthcare industry. While tiered diagnosis and treatment systems are well-established and provide clear models abroad, China’s implementation remains in an exploratory phase. Nevertheless, pioneers inevitably emerge among the masses, offering direction for those who follow. Tiered diagnosis and treatment is a centerpiece of Hangzhou’s deepening healthcare reforms. As a frontrunner in China’s healthcare reform efforts, Hangzhou has developed a distinctive “Hangzhou Model.”

Recently, at the First National Workshop on Best Practices and Experience Sharing for Family Doctor Contract Services in Hangzhou, guided by the Department of Primary Health Care of the National Health and Family Planning Commission, He Wei, a Division-Director-Level Health and Family Planning Inspector from the Hangzhou Municipal Health and Family Planning Commission, shared Hangzhou’s experience in promoting a tiered diagnosis and treatment system through general practitioners’ family doctor contract services. The following is a summary of his insights.

Hangzhou launched its initiative to promote tiered diagnosis and treatment through general practitioner contract services as early as 2014, primarily driven by three background factors:

First, in 2013, the state successively issued work requirements related to the elderly care service industry and the health service industry. The continuous improvement of medical and health services in Hangzhou has led to a steady increase in life expectancy at birth among its residents. Zhejiang Province held a province-wide video-teleconference on healthcare reform, during which it was reported that the average life expectancy at birth across the province reached 82.08 years, reflecting the growing demand for healthcare services driven by population aging;

Second, the proportion of the population facing aging is increasing. In Hangzhou’s core urban districts, individuals aged 60 and above account for more than 20% of the population. Meanwhile, the prevalence of chronic diseases among the elderly in Hangzhou has reached approximately 78%. This places greater demands on the city’s healthcare services, with the need for accessible, nearby medical care becoming increasingly prominent.

Third, the structural system of overall medical resources is unbalanced. In 2014, outpatient and emergency visits in the main urban districts of Hangzhou accounted for only 26.8% of the total number of medical consultations nationwide. This structural imbalance has led to difficulties and frustrations in accessing medical care, with large hospitals becoming overcrowded.

Against this backdrop, the Hangzhou Municipal Health and Family Planning Commission proposed a series of measures to address the aforementioned issues, most notably the conceptual design of exploring, through practical implementation, the establishment of integrated medical, nursing, and elderly care contracted services as a key lever to build a tiered diagnosis and treatment system.

In recent years, Hangzhou has successively issued the “1+5” policy documents, wherein the “5” refers to documents jointly issued by the Hangzhou Municipal Health and Family Planning Commission and local authorities responsible for pricing, human resources and social security, finance, as well as the Hangzhou Municipal People’s Government. In 2015, Hangzhou promulgated the Measures for Promoting Integrated Smart Medical Services Combining Medical Treatment, Nursing, and Elderly Care in the form of a Mayoral Order. Corresponding district-level governments also introduced detailed implementation rules to collaboratively advance contracted services for the integration of medical treatment, nursing, and elderly care.

He Wei stated, “Policy leverage should deliver a ‘win-win’ outcome: healthcare professionals must feel a sense of gain, and the general public must also benefit.” Specific implementation measures include providing a funding allocation of 120 RMB per person per visit for contracted medical, nursing, and elderly care services, with the cost shared as follows: 25% covered by municipal funds, 65% by district-level finance, and 10% borne by individuals.

Health insurance-related policies have also been tilted in favor of patients: those referred from primary care institutions to higher-level hospitals under the New Rural Cooperative Medical Scheme (NRCMS) can enjoy the reimbursement rate applicable at the primary care level; the individual contribution standard for Urban Employee Basic Medical Insurance has been reduced by RMB 300.

Meanwhile, supporting pricing policies will be further improved. The fee for home bed establishment by family doctors will be increased from 10 yuan to 80 yuan per bed, and the fee for home visits and house calls will be set at 40 yuan per visit.

Furthermore, He Wei emphasized that the most critical priority is to strengthen the development of general practitioner teams. Currently, Hangzhou City has achieved a 97% participation rate in rotational training for general practitioners. The specific health management and home-based medical services provided include disease prevention, public health management, clinical care, health management, remote health monitoring, and health assessments.

Hangzhou began establishing a basic community health service information system in 2009, creating electronic health records for residents, connecting with large hospitals, enabling interoperability of medical information, and even allowing shared access to imaging resources across institutions at all levels. “We have developed a contracted referral system to support signed-up services and two-way referrals, which also includes a teleconsultation platform through which tertiary hospitals provide support to primary care institutions,” introduced He Wei. By integrating resources with physician workstations, a cloud-based Hospital Information System (HIS) platform has been built to connect the National Health and Family Planning Commission, hospitals, and primary healthcare institutions.

Across Hangzhou, a single medical card enables access to healthcare platforms at all levels and retrieval of patient information, turning the social security cards held by residents into a true “all-in-one healthcare card.” “This achievement is inseparable from the establishment of health information platforms at both the municipal and district levels.”

Under the leadership of the National Health and Family Planning Commission, a contracted referral platform was established to connect provincial and municipal hospitals in the Hangzhou area with community health service institutions in the main urban districts, achieving interoperability among provincial, municipal, and county-level platforms.

It is worth noting Hangzhou’s initiative to establish county-level diagnosis and treatment centers. According to available information, the referral principles of Hangzhou’s referral platform are as follows: primary healthcare institutions at the county level should, in principle, refer patients to local county-level hospitals; for complex and difficult cases at county-level hospitals, referrals are then made to major hospitals in Hangzhou through integration with the city’s appointment and referral platform.

Therefore, the Hangzhou Municipal Health and Family Planning Commission also requires counties to establish county-level referral platforms. These platforms connect with higher-level referral systems through physician workstations, enabling one-click referrals and simultaneous registration of medical insurance contracts. Furthermore, patients can even access treatment from physicians at top-tier tertiary hospitals through this platform.

Throughout the referral process, the highest priority is to ensure continuous coverage under medical insurance benefits. Furthermore, as contracted responsibility relationships are adjusted concurrently, the rotation of family doctors will lead to adjustments in basic public health service relationships; the Hangzhou Municipal Health and Family Planning Commission is also planning supporting measures for these initiatives.

He Wei emphasized, “The entire process of signing up for family doctor services cannot proceed without the support of large hospitals. The concept of ‘medical consortia’ actually relies on the support of information technology, the integration of human resources, and the integration of our related management models.”

Although it is a traditional medical service, it cannot do without the support of "Internet Plus" initiatives. As early as 2015, Hangzhou began establishing a unified public-facing health service platform, including smart healthcare apps, as well as the currently established medical-care-nursing contracted service platforms—the Hangzhou Smart Healthcare Network and the Hangzhou Health Pass app (General Practitioner Service Platform).

To promote the decentralization of high-quality medical resources, the Hangzhou Municipal Health and Family Planning Commission has facilitated close collaborative hospital management between municipal- and county-level hospitals, adopting two models—key trusteeship and comprehensive trusteeship—with corresponding financial support. In accordance with Zhejiang Province’s “Double Decentralization, Double Improvement” initiative, six municipal-level hospitals in Hangzhou have collectively assumed trusteeship over 18 county-level hospitals.

Since the launch of general practitioner contract services in 2014, a three-year evaluation has shown that the number of Hangzhou residents under family doctor contracts increased from 520,000 in 2014 to 808,000 in the main urban areas by 2017. The coverage rate of key populations with chronic diseases under contract in the main urban areas reached 64.19%, and more than 1,000 general practitioners participated in the contracting service after receiving training.

In 2016, the community-based consultation rate among contracted residents reached 64.67%, with a referral rate controlled at 12.04%. In contrast, the community-based consultation rate for non-contracted residents was only 48.50%. The effectiveness of implementing contracted services is evident from these figures: it increased consultation rates at primary healthcare institutions and facilitated the downward allocation of medical resources. The general practitioner contracting service has played a certain role in promoting the establishment of a tiered diagnosis and treatment system. While increasing the income of healthcare professionals, it also enabled the public to access better medical services through the most direct means.

According to He Wei, the Hangzhou Municipal Health and Family Planning Commission currently requires that 30% of expert resources from municipal medical institutions be made available through contracted referral platforms to primary care facilities. Main urban district and county-level hospitals were integrated into the Zhejiang Provincial Referral Platform by June 2017, enabling residents to access higher-quality, scarce specialist expertise. Meanwhile, in chronic disease management, Hangzhou has been advancing pilot programs for the supply of commonly used chronic disease medications through smart pharmacies.