Insights from Sichuan: Four Experts Address Seven Core Issues in Western China's Primary Healthcare Capacity Building

On May 17, the “2017 China Primary Healthcare Innovation Practice Forum” was grandly held in Chengdu. During the morning’s roundtable discussion, Mr. Ding Zhigang (Moderator), Deputy Director of the Sichuan Provincial Health and Family Planning Information Center; Mr. Luo Honglin, Director of the Cooperation Community Health Service Center in Chengdu High-Tech Zone; Mr. Xue Gang, General Manager of Sichuan Kuaiyi Technology Co., Ltd.; and Mr. Xing Yong, Deputy General Manager of Chengdu Shulian Yikang Technology Co., Ltd., jointly shared their insights on “Practices in Building Primary Healthcare Service Capacity in Western China: A Sichuan Perspective.” VCBeat (WeChat ID: vcbeat) promptly compiled a summary of the discussion.

Sichuan is located in western China. According to the 2015 statistical data from the National Bureau of Statistics, it had a population of 82.04 million. It is a multi-ethnic region, home to the second-largest Tibetan area and the largest Yi ethnic area in China. The eastern part consists of plains, while the western part features high mountains, covering a vast territory.

Just as its terrain is complex and varied, Sichuan’s economic development is highly uneven. The central region has developed relatively rapidly, while the Qinba Mountainous Area remains significantly impoverished. Viewed from a broader geographical perspective, Sichuan serves as a microcosm of China’s rapid development. Analyzing Sichuan’s experiences in grassroots healthcare and health informatization offers valuable insights for the rest of the country.

Luo Honglin, Director of the Hezuo Community Health Service Center in Chengdu High-Tech Zone, previously participated in grassroots visits organized by the Sichuan Provincial Health and Family Planning Commission, traveling to Ngawa Prefecture. He believes that there is a significant gap between the capacity of primary healthcare services in remote areas of Sichuan and that in the developed city of Chengdu.

In rural areas, many township health centers have at most one licensed physician and lack adequate equipment. Even where hardware is relatively good, power supply is often unavailable, and primary care staff lack the skills to operate the equipment. In contrast, Chengdu has achieved a high level of informatization. Consequently, the service capacity of primary healthcare institutions in Sichuan Province is highly uneven.

Luo Honglin shared his personal experiences regarding the issues and challenges facing primary healthcare.He believes that retaining talent is the most difficult issue.. Many services require human involvement. For instance, during visits to five counties in the Aba Prefecture, we observed a severe shortage of physicians and unusable medical equipment. Although grassroots doctors battle diseases daily, under current policies and resource constraints, it is virtually impossible to retain personnel.

However,The current trend shows that many remote devices are beginning to enter medical facilities. Informatization is an effective means of overcoming geographical and transportation barriers, thereby alleviating the shortage of physicians.The Cooperative Community Health Service Center in Chengdu High-Tech Zone has established remote outpatient services with West China Hospital. This information-based approach can help address certain issues, yielding rapid short-term results.

According to Luo Honglin, they are collaborating with social security agencies on medical insurance projects to expand the accessibility of healthcare for the general public. They have also undertaken other exploratory initiatives; for instance, regarding door-to-door physician services where payment mechanisms are lacking, they considered integrating POS terminals. Consequently, their medical team has prepared to equip these services with card-swiping devices. This serves as an entry point and represents an attempt aligned with China’s national advocacy for the coordinated development of medical care, health insurance, and pharmaceuticals (the “Three-Medical Linkage”). The goal is to make purchasing medication as convenient as ordinary shopping for the public in the future, including home delivery, thereby bridging the significant gap in traditional healthcare.

To accelerate the enhancement of primary healthcare service capabilities, the state issued official supporting documents in March of this year. During the 13th Five-Year Plan period, deepening healthcare reform involved numerous key tasks related to primary healthcare.

However, the investment in primary care talent is indeed a shortcoming, which can be addressed through multi-channel training.A relatively effective solution is to leverage information technology to support primary healthcare institutions in carrying out tasks within their capacity.。

Xue Gang, General Manager of Sichuan Kuaiyi Technology Co., Ltd., stated that in recent years, Kuaiyi has leveraged the “Internet Plus” model to advance informatization, providing patients with convenient digital services through healthcare institutions.

How Can Healthcare IT Improve the Quality of Primary Care Services? Kuaiyi Company Has Undertaken Extensive Practical Initiatives to Adapt to Information Technology Platforms. For Instance, Its Recently Launched Product, Bashu Kuaiyi, Is Highly Targeted Toward Tiered Diagnosis and Treatment and Family Doctor Contracting.

“Bashu Kuaiyi” integrates resource pools from hospitals, enterprises, experts, and medical teams to establish a “one-click access” online platform for doctor-patient interaction and clinical diagnosis and treatment. Patients can access “Bashu Kuaiyi” via WeChat Service Accounts, mobile apps, or digital TV, enabling a new “Internet + Healthcare” service model characterized by multi-level coordination among homes, communities, and tertiary hospitals, as well as seamless online-offline integration.

The implementation approach of Kuaiyi is “empowerment.” This is specifically manifested by enhancing the service capacity at the primary care level from two perspectives: empowering the two key stakeholders in this sector, namely primary care physicians and healthcare institutions themselves.

First, regarding primary care physicians, the main issue is the lack of supportive tools—both for enhancing their own learning capabilities and for managing various other workflows—due to the absence of effective solutions.

Second, medical institutions lack an effective information system, particularly in the current "Internet Plus" environment, where there is a shortage of proven mobile-based management and diagnostic tools.

Big data processing, currently a major trend, offers significant benefits in enhancing physicians' clinical decision support and competency training.

Regarding big data, Xing Yong, Deputy General Manager of Chengdu Shulian Yikang Technology Co., Ltd., stated that the company’s primary focus is leveraging big data technologies to control health insurance expenditures.

Its core business involves providing medical insurance claims auditing, big data-driven regulatory oversight for medical insurance, and intelligent healthcare and decision support systems to local Human Resources and Social Security Bureaus, Health and Family Planning Commissions, commercial health insurance companies, and medical institutions.

In the formulation of medical insurance policies, there are currently many issues with medical insurance. The more concerning ones include slow payments, cumbersome processes, and capitation-based fees. Whether the new payment methods have an impact on grassroots healthcare remains uncertain.

Shulian Yikang’s competitive advantage lies in its solutions, which were successfully developed by refining hundreds of millions of business data records and independently developing hundreds of big data algorithmic models tailored for medical insurance.. For instance, it can provide data support to different medical institutions, helping them better achieve interoperability among these devices.

In Sichuan, Shulian Yikang has collaborated closely with the Health and Family Planning Commission to advance informatization initiatives, extending beyond grassroots community settings to include pilot projects in hospitals. Xing Yong revealed that during a prior collaboration with a Grade 3A hospital, they discovered that data could be represented in potentially thousands of different formats. Consequently, substantial time was devoted to data cleaning to lay a solid foundation for subsequent technical analysis.

For example, big data analysis can be conducted on the pathogenic factors of gestational diabetes mellitus.These analyses can be provided to primary healthcare institutions. As the two-way referral system facilitates the decentralization of diagnosis and treatment for common and chronic diseases to the primary care level, these tools assist physicians in clinical decision-making. In the future, such approaches will continue to be essential for steadily enhancing the service capacity of primary healthcare institutions.。

Signing up with family doctors is also a crucial step in advancing primary healthcare. Luo Honglin stated that the public needs time to gradually accept and recognize the value of signing up with family doctors. The Chengdu High-Tech Zone has a population of over 170,000, and the Sichuan Provincial Health and Family Planning Commission requires 30,000 sign-ups. This task is indeed challenging and must be supported by information technology solutions.

Furthermore, public awareness of contracted primary healthcare services is low, standing at less than 15%. There is even a prevalent negative perception characterized by complaints about high drug prices and poor service attitudes. It is essential to strengthen publicity efforts to foster public recognition and trust in community health services.

How can this be achieved? One approach is to establish a remote healthcare system within the jurisdiction, encompassing schools, government agencies, enterprise infirmaries, and even local police stations, by leveraging internet-based technologies. Luo Honglin revealed that they are developing new service models, such as WeChat-based contract signing. Currently, most institutional contracts are executed on paper, which is inconvenient. By adopting WeChat for contract signing and enabling direct digital submission, the completion rate for family doctor services would certainly reach 30%.

It is evident that the extensive application of information technology in family doctor contracting brings significant convenience to the public and enhances their acceptance. In this regard, what initiatives has Bashu Kuaiyi undertaken in family doctor contracting, and what services has it provided for primary care and chronic disease management?

Xue Gang stated that Bashu Kuaiyi was officially launched in August 2016. From the perspective of product development, it was divided into three phases:

In the first phase, the priority was to facilitate interactions between patients and doctors through the product, enabling them to meet and establish connections. The Kuaiyi team has been dedicated to this initiative since last August, and this phase has now been completed, garnering significant favor from both doctors and patients.

The second stage involves normalizing physician-patient services after the initial connection has been established, essentially outlining a model for gradual escalation. This is the initiative currently being implemented by Kuaiyi.

Phase Three: Integrating medical resources to establish a collaborative model between primary care institutions and tertiary Grade A hospitals, akin to a medical consortium. An interactive mechanism must be established among medical institutions and physicians. This is currently in the testing phase at Bashu Kuaiyi, representing the current three-step strategy of Bashu Kuaiyi.

Xue Gang believes that family doctor contracting services can be delivered via a mobile app. Given the substantial demand for chronic disease management in the context of primary care physicians’ daily practice, Kuai Yisheng provides robust tools on the provider side to support chronic disease management.

Certainly, during the implementation of primary healthcare services, some existing issues have indeed been identified. Xue Gang has outlined two core pain points:

First, under the government-led model, the most critical issue for commercial companies is how to establish a viable business model. The implementation of physician contracting has already begun and is being put into use. However, there is a general perception that enthusiasm remains insufficient. Upon analysis, the reasons are primarily attributable to inadequate efforts in promoting free practice among physicians and the need for greater flexibility and refinement in business models.

The second issue is that the pace and planning vary across different grassroots regions, with each operating independently; we anticipate a more unified model.

At the national level, supporting policies for primary care family doctor contract services are gradually being introduced. However, as health insurance remains the fundamental payment mechanism, robust and effective oversight is essential. How can regulatory frameworks help medical institutions avoid unnecessary compliance burdens, and what preparations should primary care institutions make?

Xing Yong, Deputy General Manager of Chengdu Shulian Yikang Technology Co., Ltd., stated that the company has been engaged in medical insurance cost containment for three years. Through extensive interactions with the Medical Insurance Bureau, they have identified certain underlying patterns.

Regarding payment methods, the state is seeking ways to incentivize payers. Currently, expenditures related to insurance fraud and deceptive practices within medical funds account for 30% of total healthcare spending—a remarkably high figure. Only by curbing this proportion can we create greater flexibility for further adjustments.

Furthermore, we have observed proactive efforts by the basic medical insurance system to explore innovative solutions. Currently, critical illness insurance programs are being fully opened to commercial insurers for administration, representing a foundational attempt to enhance fund management and provide policy guidance, thereby effectively unlocking the vitality of medical insurance funds.

In the United States, commercial insurance companies play a dominant role, and the pharmaceutical management sector is highly developed, featuring unicorn companies valued at hundreds of billions of dollars. Greater involvement of commercial entities would enable more substantial resource mobilization.

When the health insurance fund is profitable, healthcare institutions should actively engage in disease prevention and management.For instance, whether prescribing practices comply with medical standards may not appear cost-effective from a payment perspective; while it can help control costs in the long run, standardized management of clinical practices is critically important. Therefore, within this broader context, primary healthcare institutions in China need to make preparations in this area, including advancing health information technology infrastructure.

Luo Honglin shared a set of data: China’s healthcare expenditure accounts for 5% of its GDP, compared to over 10% in the United States, while the average for most countries stands at 8%. Given that our spending is already so low, how can we further control costs? What kind of health products should we provide to the public—low-end or high-quality ones? Obtaining the best products at the lowest price is not easily achievable from a purely payment-based perspective.

Health insurance funds wield significant power. In terms of cost containment, reliance must be placed on primary healthcare institutions, as commercial insurers have limited cost-control capabilities, fail to provide high-value medical services, and consequently struggle to attract enrollees.

In China, health insurance is mandatory and the social security system operates as a monopoly. Under these circumstances, effective cost containment requires holding family doctors truly accountable and focusing on disease prevention to keep the population healthy.Therefore, if everyone signs up with a family doctor, our family doctors will shift from treating diseases to preventing them, thereby controlling costs.

Indeed, cost containment in China’s basic medical insurance is not the end goal; the ultimate objective is to reduce societal healthcare expenditures by keeping the population healthy and minimizing disease incidence.

Xing Yong also agrees with a prevention-first approach, incorporating measures that can reduce incidence rates into insurance reimbursement coverage. This represents a major difference between government-led and commercially led models.

Luo Honglin is full of expectations for what the ideal state of primary healthcare should look like. First and foremost, it is essential to ensure that the quality of services provided by primary care physicians is homogeneous with that of doctors in general hospitals. Society must recognize primary care physicians; the misconception that they are inherently less competent needs to be changed. If community health service centers can achieve full automation in the future, including automated registration and medication dispensing, the public will still be willing to seek medical care at the primary level.