Chongqing Issues Medical Consortium Policy and Explores Global Budget Payment Model

Recently, Chongqing’s medical consortium policies have been promulgated!

To thoroughly implement the "Guiding Opinions of the General Office of the State Council on Promoting the Construction and Development of Medical Consortia" (Guo Ban Fa [2017] No. 32), accelerate the construction and development of medical consortia in Chongqing Municipality, and facilitate the establishment of a tiered diagnosis and treatment system. The launch of medical consortium (hereinafter referred to as "medical consortia") construction represents a significant step and institutional innovation in deepening the reform of the pharmaceutical and healthcare system. It is conducive to adjusting and optimizing the structural layout of medical resources, promoting the downward shift of focus and resources in healthcare services, enhancing primary care capabilities, facilitating the vertical integration of medical resources, improving the overall efficiency of the healthcare service system, and better implementing tiered diagnosis and treatment to meet the public's health needs.

How to Build Medical Consortiums Based on Local Conditions: The Chongqing Municipal Government’s Implementation Opinions

I. General Requirements

(I) Guiding Principles.Fully implement the spirit of the 18th National Congress of the Communist Party of China (CPC) and the Third, Fourth, Fifth, and Sixth Plenary Sessions of the 18th CPC Central Committee, as well as the National Conference on Health and Wellness; earnestly carry out the decision-making arrangements of the CPC Central Committee and the State Council; coordinate the overall layout of “Five-sphere Integrated Plan” and advance the strategic layout of “Four Comprehensives”; firmly establish and implement the new development philosophy; adhere to the people-centered development ideology; base our work on the actual conditions of the city’s economic, social, medical, and pharmaceutical development; focus on clarifying the functional positioning of medical institutions, enhancing primary care service capacity, and streamlining two-way referral processes; continuously improve the organizational management models, operational mechanisms, and incentive mechanisms of medical consortia; gradually establish and perfect a clear, equitable, and effective mechanism for division of labor and collaboration among medical institutions of different levels and types with clearly defined goals and responsibilities; promote the establishment of a tiered diagnosis and treatment system; and achieve a shift in the development model from being disease-centered to being health-centered.

(II) Basic Principles.

Government-led, coordinated planning.Implement the government’s primary responsibility for operating healthcare institutions and fulfill its functions in planning, guidance, coordination, regulation, and public communication. Led by high-quality medical resources, and based on the structural layout of medical resources and the health needs of the population, medical institutions shall be guided in a coordinated manner to form medical consortia, in accordance with the principles of business relevance, complementary advantages, mutual selection, and sustainable development, while taking into account previously established cooperative relationships.

Uphold Public Welfare, Innovate Mechanisms.Uphold and safeguard the public-welfare nature of basic medical and health services. Adhere to coordinated reforms across healthcare delivery, health insurance, and pharmaceuticals; innovate mechanisms; break down barriers and obstacles related to administrative divisions, fiscal investment, health insurance payment, and personnel management; optimize the structural layout of resources; and, in conjunction with the advancement of reforms such as health insurance payment methods, establish and improve mechanisms for division of labor and collaboration among medical institutions.

Decentralize Resources, Enhance Capabilities.Leverage high-quality medical resources to exert a technical radiation and driving effect on primary healthcare institutions through measures such as technical assistance and talent development. Encourage the adoption of unified management models within medical consortiums, leverage economies of scale, promote the sharing of regional medical resources, and harness the leading and supportive role of science and technology, thereby enhancing the overall service capacity and performance of the healthcare delivery system.

Convenience for the people, benefits for the public.Adhere to the people-centered approach to health, gradually achieve homogeneous management of medical quality, strengthen the role of primary healthcare institutions as “gatekeepers” of residents’ health, promote the integration of prevention, treatment, and management of chronic diseases, facilitate the alignment of medical consortium development with preventive and healthcare services, enable convenient access to nearby medical care, alleviate patients’ financial burdens, prevent poverty caused or exacerbated by illness, foster the development of the health industry and economic transformation and upgrading, and enhance the public’s sense of gain.

(III) Work Objectives.In 2017, the basic institutional framework for medical consortiums was established to promote the development of medical consortiums in various forms. All tertiary public hospitals were required to participate in the construction of medical consortiums and play a leading role. Each district and county (including autonomous counties, hereinafter referred to as districts and counties), as well as the Liangjiang New Area and Wansheng Economic and Technological Development Zone, were required to establish at least one medical consortium with demonstrable effectiveness.Exploring Division-of-Labor and Collaborative Models in Vertically Integrated Medical ConsortiaImplement Total Budget Payment for Medical Insurance, and other methods,Guide the initial formation of a relatively scientific division-of-labor and collaboration mechanism, as well as a smoother referral mechanism, within medical consortiums.

By 2020, a relatively comprehensive policy framework for medical consortiums had been established.All public hospitals at the secondary level and above, as well as government-run primary healthcare institutions, are fully integrated into medical consortia.Establish clear, well-defined, fair, and effective mechanisms for division of labor and collaboration among medical institutions of different levels and categories, along with guidance mechanisms that align responsibilities with authority, thereby transforming medical consortia into communities of service, responsibility, interest, and management. This facilitates the effective sharing of regional medical resources, further enhances primary care service capacity, and strongly promotes the formation of a tiered diagnosis and treatment model characterized by initial consultations at the primary level, two-way referrals, separate management of acute and chronic conditions, and coordinated care between upper- and lower-level institutions.

II. Main Tasks

(1) Establish medical consortium organizational models in diverse forms.All districts and counties, as well as the Liangjiang New Area and Wansheng Economic and Technological Development Zone, shall, in light of the actual progress in establishing a tiered diagnosis and treatment system within their respective administrative areas, adopt measures tailored to local conditions and provide categorized guidance. They shall fully consider factors such as the geographical distribution, functional orientation, service capacity, professional relationships, and willingness to cooperate of medical institutions; leverage the roles of local, military, and social medical resources; respect grassroots innovation; and explore regional, multi-level, and diverse forms of medical consortia to promote the flow of high-quality medical resources to primary care settings and remote, impoverished areas. Participation of privately run medical institutions in the development of medical consortia is encouraged.

1. Municipal medical institutions with the necessary conditions shall form medical groups.Led by municipal medical institutions with strong operational capabilities, and in collaboration with district- and county-level medical institutions, community health service centers, nursing homes, and specialized rehabilitation facilities, a management model characterized by resource sharing and division of labor has been established. Within the Medical Consortium, cooperation is facilitated through mechanisms such as talent sharing, technical support, mutual recognition of diagnostic test results, prescription portability, and seamless service coordination.

2. District- and county-level medical institutions establish medical consortia.Promote the integrated management of district/county, township (town), and village levels, with district- and county-level hospitals as the lead, township health centers and community health service institutions as the hub, and village clinics as the foundation, ensuring effective coordination with rural integrated management. Fully leverage the leading role of district- and county-level hospitals to establish a mechanism for division of labor and collaboration among medical and health institutions at the district/county, township (town), and village (community) levels, thereby building a three-tier linked medical and healthcare service system within districts and counties.

3. Specialized medical institutions and tertiary public general (including traditional Chinese medicine) hospitals shall establish cross-regional specialized alliances based on their advantageous specialties.Leverage the specialized resources of specialty hospitals and tertiary public general (including traditional Chinese medicine) hospitals, supported by the distinctive specialized technical capabilities of selected medical institutions, to fully utilize the role of National Regional Medical Centers and their collaborative networks. Tertiary public general (including traditional Chinese medicine) hospitals are encouraged and supported to lead the establishment of inter-regional specialty alliances, spearheaded by departments housing national-level key specialties, disciplines, and distinctive specialties, as well as departments where experts serving as chairpersons or vice-chairpersons of national-level academic associations such as the Chinese Medical Association are employed. These alliances should use specialty collaboration as a link to foster a complementary development model, with a focus on enhancing the capacity for treating major diseases.

4. Paired assistance medical institutions shall establish telemedicine collaboration networks.Medical institutions undertaking paired assistance work shall leverage the city-wide health and family planning private network to vigorously develop telemedicine collaboration networks targeting grassroots, remote, and underdeveloped areas. Public hospitals are encouraged to provide services such as telemedicine, remote teaching, and remote training to primary healthcare institutions, utilizing information technology to facilitate the vertical flow of resources, enhance the accessibility of high-quality medical resources, and improve the overall efficiency of medical services.

(II) Expand and Standardize the Organizational Models of Medical Consortia.

1. Expand Organizational Models.Urban tertiary public hospitals may serve as the lead entities to establish medical consortia, building upon existing long-term and stable counterpart support relationships. This can be achieved through various models, such as assuming trusteeship of district- and county-level hospitals within their regions. Urban tertiary public hospitals may deploy management and expert teams to these district- and county-level hospitals, with a focus on enhancing their medical service capabilities and standards. In addition to participating in local medical consortia, municipal medical institutions may establish cooperative relationships with multiple medical consortia across administrative regions (including affiliations with hospitals directly under the administration of the National Health and Family Planning Commission). This aims to form high-level medical consortia with complementary strengths, carry out innovative collaborative research, promote technical dissemination, and cultivate talent, thereby radiating influence and driving improvements in regional medical service capabilities.

2. Standardize the organizational model.In principle, health and family planning administrative departments do not assign names to medical consortium institutions. Member units of a medical consortium may, while retaining their original names, separately display signs such as “XX Medical Group Hospital,” “XX Hospital Medical Community Hospital,” “XX Specialty Alliance Hospital,” or “XX Hospital Telemedicine Collaboration Hospital” in accordance with the formation model of the medical consortium. Such names shall not be registered as secondary names for medical institutions.

(3) Improve the division of labor and collaboration mechanism within medical consortia.

1. Improve organizational management and collaboration systems.Lead institutions and member units of medical consortia shall explore the establishment of a close collaborative relationship characterized by “integrated operational management and integrated medical services.” Alternatively, cooperation may be promoted primarily through management and technical support, while maintaining the status quo regarding institutional nature, administrative affiliation, personnel status, asset ownership, and funding channels. By formulating medical consortium charters and signing cooperation agreements, the responsibilities, rights, and obligations of lead institutions and other member units shall be clearly defined, thereby improving systems such as medical quality management and enhancing managerial efficiency. Medical consortia may explore the establishment of councils at the hospital level.

2. Implement the functional positioning of medical institutions.Medical consortia should establish mechanisms for shared responsibility and benefit distribution to incentivize all member medical institutions and ensure the implementation of their designated functional roles. In accordance with the functional positioning of medical institutions at various levels as specified in the "Implementation Opinions of the General Office of the Chongqing Municipal People's Government on Promoting the Construction of a Tiered Diagnosis and Treatment System" (Yu Fu Ban Fa [2015] No. 183), tertiary hospitals shall gradually reduce the proportion of patients with common diseases, frequently occurring diseases, and chronic conditions with stable status. Primary healthcare institutions, specialized rehabilitation facilities, and nursing homes shall provide treatment, rehabilitation, and nursing services to patients with clearly diagnosed and stable chronic diseases, those in the rehabilitation phase, elderly patients with chronic conditions, and patients with advanced-stage tumors. Village clinics are encouraged to strengthen public health and health management services and carry out disease prevention and control work in response to the local population's healthcare needs.

3. Establish a quality management system.The lead institutions of medical consortiums must strengthen medical quality control and patient safety management, formulate and implement unified quality control standards, and develop technical guidance and assistance programs—such as ward rounds, outpatient consultations, lectures, and case conferences—tailored by specialty and based on the actual conditions of each medical institution within the consortium, while strengthening the management of medical technology access. They should increase guidance for key clinical specialties in member institutions, prioritizing the development of urgently needed specialties including emergency medicine, critical care medicine, obstetrics, pediatrics, general practice, and ultrasound medicine, with particular emphasis on strengthening specialties with high rates of external referrals. Leveraging their disciplinary advantages, lead institutions should guide member institutions in establishing corresponding key specialties to fully capitalize on the specialized expertise in specific diseases within the consortium. All medical consortiums should fully leverage the distinctive advantages of Traditional Chinese Medicine (TCM) to meet the public’s demand for TCM services.

4. Promote family doctor contract services.Strengthen the training of general practitioners. Focusing on chronic diseases such as hypertension and diabetes, accelerate the promotion of family doctor contract services within medical consortiums, prioritizing coverage for key populations including the elderly, pregnant and postpartum women, children, and persons with disabilities. Adopt a demand-oriented approach to substantiate family doctor contract services, and by 2017, include all impoverished individuals in the city within the scope of these contract services.

Through contracted services, residents are encouraged and guided to seek initial consultations at primary care facilities within medical consortiums. Tertiary hospitals provide contracted patients with priority services, including priority consultation, priority examination, and priority hospitalization. Efforts are being made to explore the provision of long-term prescriptions, covering no more than a two-month medication supply, for contracted patients with certain chronic diseases. Where conditions permit, localities may strengthen the coordination of medication between primary care facilities and tertiary hospitals through extended prescriptions and centralized distribution, based on the healthcare needs of patients referred through the two-way referral system, thereby facilitating patients’ access to nearby medical care and medication pickup.

5. Provide continuous diagnosis and treatment services for patients.Encourage nursing homes, specialized rehabilitation institutions, and other entities to join medical consortiums. Establish a referral mechanism within medical consortiums, with a focus on streamlining downward referrals, to ensure that patients in the recovery phase from acute illnesses, those recovering post-surgery, and patients with stabilized critical conditions are promptly referred to lower-tier medical institutions for continued treatment and rehabilitation. Strengthen the integration of healthcare services with elderly care, providing patients with integrated and convenient continuous services encompassing disease diagnosis and treatment, rehabilitation, and long-term care.

(4) Promote the vertical integration of high-quality medical resources within medical consortia.Encourage medical institutions within medical consortiums to coordinate personnel deployment, compensation distribution, and resource sharing, while maintaining their existing administrative affiliations and fiscal funding channels, thereby establishing channels and mechanisms for the vertical integration of high-quality medical resources.

1. Promote the orderly flow of human resources.Unify the allocation of medical technology and other resources to maximize the utilization efficiency of existing resources. Explore coordinated compensation distribution within medical consortia to fully mobilize the enthusiasm of medical personnel. Encourage secondary and tertiary medical institutions within medical consortia to dispatch professional technical and managerial talent to primary healthcare institutions. Within medical consortia (including cross-regional medical consortia), medical personnel practicing in medical institutions that have signed assistance or trusteeship agreements are not required to undergo procedures for changing their practice location or registering with the practice institution.

2. Enhance the capacity of primary healthcare services.Fully leverage the leading role of tertiary public hospitals. In response to the regional disease spectrum and the diagnosis and treatment needs for key diseases, deploy medical personnel to promote the sharing and downward flow of high-quality medical resources to the grassroots level through various approaches, including specialty co-construction, clinical mentoring, operational guidance, teaching ward rounds, and research and project collaboration.

3. Unified Information Platform.Strengthen planning and design to fully leverage the supportive role of information systems in medical consortiums. In conjunction with the establishment of two-tier population health information platforms at the municipal and district/county levels, coordinate the development of information platforms for hospital management and medical services within medical consortiums. This will enable continuous recording and information sharing of electronic health records (EHRs) and electronic medical records (EMRs), achieving interconnectivity of diagnosis and treatment information within the consortiums. By sharing resident health information data within the region, medical consortiums can facilitate services such as appointment scheduling, two-way referrals, health management, and telemedicine, thereby improving patient access to care and advancing medical research and technical capabilities. Leverage the role of telemedicine to bring medical resources closer to grassroots urban and rural communities, implement fee structures for telemedicine services, and promote the sustainable development of telemedicine.

4. Achieve regional resource sharing.Within a medical consortium, centralized facilities such as medical imaging centers, laboratory and diagnostic testing centers, sterile supply centers, and logistical support centers can be established to provide integrated services to all member healthcare institutions. On the basis of strengthening medical quality control, mutual recognition of laboratory and diagnostic test results among healthcare institutions within the consortium shall be implemented. Efforts should be made to explore the establishment of a unified platform for drug centralized procurement and management within the consortium, thereby forming mechanisms for prescription circulation, drug sharing, and distribution across the consortium.

III. Safeguard Measures

(1) Fulfill the primary responsibility of the government in operating healthcare institutions.Leveraging support from central government infrastructure investment, efforts will be accelerated to address weaknesses in the development of medical consortia, enhance the capacity for diagnosing and treating complex and critical diseases within the region, strengthen the comprehensive capabilities of district- and county-level hospitals, and improve the level of remote medical collaboration, thereby enabling medical consortia to play a more effective role at the primary care level. District and county people’s governments and administrative committees of development zones shall fulfill their primary responsibilities for operating healthcare institutions, implement funding policies for public hospitals, and establish a mechanism linking fiscal subsidy allocations with performance evaluation results. The ownership structure of each medical institution within the medical consortium shall remain unchanged, and fiscal subsidies shall continue to be disbursed through the original channels. Medical consortia are encouraged to attract private healthcare institutions to join and contribute by providing technical support and cultivating professional talent.

(2) Leverage the economic lever of medical insurance.Leverage the guiding role of medical insurance on both the supply and demand sides of healthcare services. Reasonably differentiate reimbursement rates among primary healthcare institutions, district- and county-level hospitals, and large urban hospitals to enhance the attractiveness of seeking care at the primary level and guide insured patients to seek medical attention in an orderly manner.Select 3–5 medical consortia to explore the implementation of various payment methods, such as global budgeting for health insurance, for division-of-labor and collaborative models like vertically integrated medical consortia.and establish corresponding assessment measures to guide the formation of a smooth referral mechanism within the medical consortium, thereby promoting the decentralization of high-quality medical resources.

(3) Improve personnel support and incentive mechanisms.In accordance with the requirement to “allow medical and health institutions to exceed the current wage control levels for public institutions, and to primarily use revenue from medical services—after deducting costs and allocating various funds as prescribed—for personnel incentives,” we shall improve performance-based pay policies compatible with Medical Consortia, and establish a sound distribution and incentive mechanism closely linked to job responsibilities, work performance, and actual contributions. We shall implement hospitals’ autonomy in personnel management, adopt a system of setting positions based on needs and hiring according to positions, and establish a flexible personnel mechanism that enables both promotion and demotion, as well as hiring and dismissal. We shall innovate human resource management systems, improve professional title promotion methods compatible with Medical Consortia, implement scientific evaluation, and expand career development opportunities for medical personnel.

(4) Establish a performance appraisal mechanism compatible with the medical consortium.Strengthen performance assessments and institutional constraints by establishing a comprehensive evaluation index system for medical consortia. The assessment should focus on the technological radiation and driving effect of the consortia, as well as the downward flow of medical resources, rather than merely evaluating service volume. Key indicators to be incorporated into the evaluation system include the extent to which tertiary hospitals channel medical resources to lower-level institutions, their collaboration with primary healthcare facilities, the proportion of diagnoses and treatments at the primary level, the rate of two-way referrals, improvements in resident health outcomes, and compliance with medical insurance policies. This approach aims to guide tertiary hospitals in fulfilling their responsibilities, improving measures, proactively supporting primary care institutions, effectively playing a leading role, and encouraging active participation from medical institutions at all levels. The results of these evaluations shall serve as an important basis for personnel appointments and dismissals, as well as for awards and recognitions, and shall be linked to medical staff’s performance-based salaries, continuing education opportunities, and professional promotions.

IV. Organization and Implementation

(I) Strengthen organizational leadership.All district and county people’s governments, administrative committees of development zones, and relevant departments of the municipal government shall further enhance their awareness, regard the establishment of medical consortiums as a key component in deepening healthcare reform and an effective measure to improve public health and well-being, strengthen organizational leadership, establish inter-departmental coordination and promotion mechanisms, refine supporting measures, and ensure the smooth implementation of related work. All district and county people’s governments and administrative committees of development zones shall promptly formulate implementation plans tailored to local conditions for the establishment of medical consortiums, clearly define objectives and timelines, and complete assigned tasks on schedule and with high quality. By the end of September 2017, all districts and counties, Liangjiang New Area, and Wansheng Economic and Technological Development Zone shall finalize their respective implementation plans for establishing medical consortiums within their jurisdictions, and all tertiary public hospitals shall take the lead in completing the formation of medical consortiums.

(II) Clarify departmental responsibilities.Relevant municipal departments must strengthen overall coordination and inter-agency collaboration, promptly issue supporting documents, leverage the synergistic effects of policies, and ensure the effective implementation of reform measures. Using the development of medical consortia as a key driver, these departments shall promote institutional innovations, including public hospital reform, health insurance payment method reform, and the establishment of a tiered diagnosis and treatment system. Health and family planning administrative departments shall strengthen oversight of medical consortium development, clarify organizational management and division-of-labor mechanisms, and take the lead in formulating relevant technical guidelines. Development and reform (pricing) departments shall improve pharmaceutical pricing policies. Science and technology departments, in conjunction with health and family planning administrative departments, shall support the establishment of national and municipal clinical medicine research centers to foster the growth of medical consortia. Finance departments shall implement fiscal subsidy policies in accordance with regulations. Human resources and social security departments shall enhance supervision of medical services under health insurance, advance reforms in health insurance payment methods, and refine performance-based wage distribution mechanisms. The comprehensive financial service advantages of developmental finance—encompassing investment, lending, bonds, leasing, and securities—shall be leveraged to support medical consortia and related infrastructure development.

(3) Strengthen supervision and evaluation.The Municipal Health and Family Planning Commission shall, in conjunction with relevant departments of the Municipal People’s Government, promptly monitor work progress through research, special inspections, and regular evaluations, so as to guide all districts and counties, Liangjiang New Area, and Wansheng Economic and Technological Development Zone in advancing the construction of medical consortia in an orderly manner and ensuring the quality and safety of medical services. Adequate space should be provided for reform exploration by all districts and counties, Liangjiang New Area, and Wansheng Economic and Technological Development Zone; beneficial experiences should be summarized and promoted in a timely manner, leveraging exemplary cases to drive progress and mobilize the enthusiasm of these localities. In collaboration with relevant municipal government departments, the Commission shall establish mechanisms for evaluating the effectiveness of medical consortia and methods for performance assessment, comprehensively assessing factors such as quality, safety, efficiency, economic benefits, and social benefits. With a focus on strengthening primary care, the responsibility system and accountability mechanism shall be strictly implemented to enhance the motivation of large hospitals to support grassroots institutions and control unreasonable medical expenses. Adhering to a problem-oriented approach, measures shall be taken to prevent and resolve issues such as the monopolization of resources by large hospitals, indiscriminate expansion (“land grabbing”), the “siphoning” of grassroots resources, and the squeezing out of space for socially run medical institutions.

(4) Strengthen publicity and training.All districts and counties, as well as the Liangjiang New Area and Wansheng Economic and Technological Development Zone, shall vigorously conduct policy training for healthcare institution administrators and medical personnel. They must effectively carry out policy interpretation for the broadest grassroots population to further unify thinking and build consensus. Full advantage should be taken of mass media and new media platforms such as Weibo and WeChat, employing diverse formats and methods to continuously strengthen publicity on tiered diagnosis and treatment and the development of medical consortia. This aims to enhance social recognition and support, guide the public in changing their healthcare-seeking concepts and habits, and gradually establish an orderly pattern of medical care utilization.