Why Is Accessing Healthcare So Difficult? How Should Tiered Diagnosis and Treatment Proceed? National Health Commission Speaks Out

From the patient’s perspective, the so-called “difficulty in seeking medical care” essentially refers to the challenges of accessing tertiary hospitals and renowned specialists, whereas visiting primary care facilities and consulting general practitioners is not particularly difficult. However, due to a lack of trust in the capabilities of primary healthcare institutions, patients strive to seek expert care at major hospitals regardless of the difficulties involved. This irrational healthcare-seeking behavior not only increases individual medical costs but also leads to the wastage of high-quality medical resources, preventing scarce expert resources from being allocated where they are most needed. Addressing this issue requires a combined approach of guidance and regulation.

Difficulties in accessing medical care can be categorized into two types. The first is absolute difficulty, which arises from an absolute shortage of medical resources, leading to an inability to meet basic healthcare needs due to a lack of medical personnel and medicines. This type is currently prevalent in remote rural areas of central and western China, characterized by economic underdevelopment, poor transportation infrastructure, vast territories, and sparse populations. The second is relative difficulty, which results from the insufficiency of high-quality medical resources relative to residents’ demand, causing challenges for patients in seeking specialist care at large hospitals. This represents the primary manifestation and characteristic of the current difficulties in accessing medical care.

The practice of patients seeking care at major hospitals for minor ailments leads to underutilization of primary healthcare resources on the one hand, and overcrowding at large hospitals, which remain in a perpetual state of emergency, on the other.

Large hospitals are positioned to treat complex diseases, conduct scientific research, and train medical professionals. If chronic overcrowding remains unaddressed, these institutions will be unable to leverage their advantages or fulfill their intended roles. Amidst the growing healthcare demands of the public, some large hospitals have even embarked on the misguided path of disorderly expansion, competing with county-level hospitals, community health service centers, and township health personnel for patient volume, thereby compromising the assurance of medical quality.

Statistics show that 80% of high-quality medical resources across society are currently concentrated in major cities, and within these cities, 80% of such resources are further clustered in a few top-tier hospitals. This high concentration of medical resources is a significant contributor to the difficulty patients face in accessing care. If the expansion of top-tier hospitals continues, new high-quality resources will become even more concentrated in these large urban institutions, creating a "siphon effect." Major city hospitals will not only siphon highly skilled physicians from primary care facilities but also draw away patients, thereby further weakening grassroots healthcare services and exacerbating the challenge of accessing medical care.

It is commonly believed that large hospitals boast superior clinical expertise, more advanced medical equipment, and better nursing care, thereby providing greater peace of mind for patients and their families. However, it is important to note that the “overload” situation—characterized by daily addition of beds in corridors and round-the-clock overtime work by medical staff—can overwhelm these major institutions. Consequently, the quality of services available to patients is inevitably compromised, and the overcrowding may further increase the risk of nosocomial infections. Meanwhile, some primary healthcare facilities remain underutilized. Over time, this creates a vicious cycle: large hospitals continue to grow stronger, while grassroots institutions suffer from brain drain and stagnant development. As a result, the challenges of difficult and expensive access to medical care for the general public will be further exacerbated.

In fact, a significant proportion of patients seeking care at large hospitals suffer from common conditions that do not necessitate tertiary-level care. This trend has, to some extent, exacerbated the difficulties and high costs associated with accessing medical services at these institutions. Reflect for a moment: have you ever rushed to an overcrowded major hospital for minor ailments such as a cold, fever, or upset stomach? Indeed, flocking to large hospitals for common illnesses is truly a thankless and inefficient endeavor.

First, seeking medical care at large hospitals incurs significantly higher costs than at primary care facilities. This is because the regulated prices for registration fees, nursing care, hospital beds, and medications are substantially higher than those at community health centers. Furthermore, under the tiered reimbursement policy of the basic medical insurance system, where reimbursement rates vary by facility level, it is easy to understand why patients end up spending unnecessarily more money at large hospitals for treating common minor ailments.

Case:

Due to her child’s weak immune system, which led to several respiratory infections every autumn and winter, Ms. Zhang from Jinan, Shandong Province, took her child to multiple hospitals of varying tiers in the provincial capital. As an attentive mother, Ms. Zhang compared her child’s medical records from different hospitals and found that the treatment methods and procedures for the same common condition were basically consistent across these institutions, with prescribed medications being largely similar as well. However, there was a significant disparity in treatment costs: for intravenous infusion therapy for pediatric bronchitis, the average daily cost exceeded 300 yuan at a tertiary Grade A hospital, amounted to over 200 yuan at a secondary hospital, and was less than 150 yuan at a community hospital near her home.

Secondly, seeking medical care at large hospitals is time-consuming and labor-intensive, resulting in high time costs. Many people are familiar with the “spectacle” of long queues for registration at major hospitals. Even after successfully securing an appointment, patients must wait in line at every stage—consultation, examination, medication pickup, and payment. The cumulative waiting time often far exceeds the actual duration of diagnosis and treatment, with a single outpatient visit frequently consuming an entire day. In contrast, seeking care at primary healthcare institutions, such as community health service centers and township health centers, significantly reduces time costs and spares patients considerable hassle.

Another point worth mentioning is that the risk of cross-infection increases significantly when seeking medical care at large hospitals. Many Grade A tertiary hospitals handle over 10,000 outpatient visits per day on average. Especially during peak seasons for infectious diseases such as influenza, it is easy to “catch something” even with protective measures in place, given the crowded environments filled predominantly with patients. Imagine going in for gastrointestinal issues but ending up with a cold due to accidental transmission; this would truly be a case of the cure being worse than the disease.

Many patients flock directly to large hospitals when seeking medical care, even for minor ailments such as headaches and colds, preferring to travel far rather than receive treatment at primary care facilities. There are several reasons for this trend: the public has gained a renewed appreciation for the value of health, recognizing that health is priceless and feeling reassured only by visiting major hospitals even for minor illnesses; there is a significant gap in service quality and professional standards between primary healthcare institutions and large hospitals, leading to a lack of public trust; policy publicity is inadequate—for instance, many people are unaware that reimbursement rates under basic medical insurance or the New Rural Cooperative Medical Scheme are higher at community health service centers or township health centers; and primary healthcare institutions have a limited formulary, making it difficult for many patients with chronic diseases to obtain commonly prescribed medications at the grassroots level.

A key factor is the persistent lack of trust in primary care capabilities. The weakness of China’s primary healthcare system has long been a stubborn problem affecting the public. Primary care general practitioners (GPs) are often described as the “gatekeepers” of residents’ health. In countries such as the United Kingdom and Australia, which have fully implemented GP systems supported by universal health coverage, residents must first consult a GP; only when deemed necessary and upon referral can they see specialists. Although the Chinese government has paid considerable attention to strengthening primary care during its healthcare reform efforts, it has yet to establish primary care as the first point of contact for patients. Neither the introduction of tiered diagnosis and treatment, the creation of medical consortia, nor the implementation of multi-site practice has been able to change the dominance of tertiary A hospitals, which continue to attract patients with all types of conditions.

The root cause of the public’s lack of trust in primary care capabilities lies in the scarcity of excellent primary care physicians, with even a shortage of qualified ones. Furthermore, the persistent market absence of general practice clinics that boast a unified brand and high-quality service is a significant factor contributing to patients’ distrust in primary care. The reasons for this distrust cannot be simply attributed to the lack of good doctors in primary care institutions. Upon closer reflection, do minor illnesses really require consultation with the best doctors? The answer is clearly no; even when visiting large hospitals, diagnoses are often made by ordinary physicians. So why have primary care institutions ultimately been reduced to mere venues for elderly patients to obtain prescriptions, rather than truly serving as gatekeepers of the healthcare system? It can be argued that for most minor ailments, physicians’ technical expertise does not need to be exceptionally high; what matters more is a positive service attitude and a standardized diagnostic and treatment framework. Through enhanced services and standardized systems, primary care can rebuild its brand image.

Case:

Taiyuan: General Practitioners to Be Fully Staffed at Primary Care Level by Year-End

The Implementation Opinions on Establishing a General Practitioner System, issued by the Taiyuan Municipal People’s Government of Shanxi Province, stipulate that all community health service institutions and township health centers in the city must be fully staffed with general practitioners by the end of this year. By 2020, Taiyuan plans to train an additional 600 general practitioners, ensuring that there are at least two qualified general practitioners per 10,000 residents in both urban and rural areas.

Taiyuan City plans to gradually establish a standardized training system for general practitioners. Individuals with a bachelor’s degree or higher in clinical medicine from a five-year program who successfully complete the standardized training for general practitioners and meet the national degree requirements will be awarded a professional degree in Clinical Medicine (General Practice track).

To address the current shortage of general practitioners, Taiyuan City will vigorously promote job-transfer training for incumbent primary care physicians. Personnel in urban and rural primary healthcare institutions in Taiyuan who meet the eligibility requirements for licensed (including assistant) physicians may, upon completing one year of job-transfer training and passing a unified examination to obtain a Certificate of Completion for General Practitioner Job-Transfer Training, register as general practitioners or assistant general practitioners.

Various regions have successively introduced two-way referral systems to rationally triage patients. However, in practice, these referrals have become “one-sided,” with upward referrals being easy while downward referrals remain difficult. The sluggishness of downward referrals can be primarily attributed to three managerial factors.

First, the two-way referral system involves the distribution of benefits between large hospitals and primary care institutions, which leads to reluctance among some large hospitals to transfer patients who have stabilized to primary care facilities for rehabilitation. Second, insufficient “green light” measures have been implemented for downward referrals. Due to inadequate policy incentives, patients transferred from large hospitals to primary care institutions for rehabilitation do not perceive tangible benefits from such transfers. Third, there is no sound mechanism for supervision, inspection, and penalties related to two-way referrals. In some regions, health administrative departments merely issue documents without further follow-up on two-way referrals, failing to conduct regular inspections at large hospitals and primary care institutions or to carry out periodic public opinion surveys among residents.

To facilitate the downward referral of patients, all regions should establish and improve standardized protocols for two-way referrals, strictly implement referral procedures, supervision, inspection, and penalty measures, and formulate more favorable preferential policies for patients referred to lower-level institutions. In addition, efforts should be made to increase publicity on two-way referrals through various channels such as newspapers, television, radio, and community health education programs.

To address the aforementioned issues, implementing a tiered diagnosis and treatment system offers a viable solution. Establishing such a system means guiding patients away from disordered medical seeking behaviors; instead, they should visit appropriate hospitals and consult suitable physicians based on the severity of their conditions. The goal is to retain patients with common and frequently occurring diseases at primary healthcare institutions, refer those with special, complex, or critical conditions to large hospitals for treatment, and transfer them back to primary care facilities during the rehabilitation phase.

Over the past six years, the government has introduced numerous measures for primary healthcare, ranging from tiered diagnosis and treatment to medical consortia, with the aim of having large hospitals drive the development of smaller ones. However, evidence has shown that these initiatives have failed to stimulate the growth of primary healthcare; indeed, other policies (such as the separation of prescribing from dispensing) have even triggered a reverse flow of patients. Whether through tiered diagnosis and treatment or medical consortia, the fundamental objective remains to strengthen primary healthcare.

However, patients vote with their feet, still flocking to tertiary Grade A hospitals even for minor ailments. Some argue that while the tiered diagnosis and treatment system is well-designed in theory, its implementation faces significant challenges. The root cause lies in the fact that most primary care physicians have limited clinical expertise, and primary healthcare institutions suffer from outdated equipment, making it difficult to retain patients. Therefore, unless the shortcomings in primary healthcare service capacity are addressed, the tiered diagnosis and treatment system will remain an unattainable ideal.

During the 2015 National “Two Sessions,” Ma Xiaowei, Deputy Director of the National Health and Family Planning Commission, responded to questions from committee members at a joint discussion group for the medical and health sectors of the Chinese People’s Political Consultative Conference (CPPCC). He stated that the key to implementing a tiered diagnosis and treatment system lies in gaining patients’ trust in primary care physicians. “Whether ordinary people choose to seek care at the grassroots level depends primarily on the doctors themselves, not on financial considerations, nor can it be resolved through administrative orders. That is precisely where the challenge lies.”

To achieve the goal of making primary care institutions the first point of contact for patients, it is essential to enhance the medical capabilities of grassroots healthcare facilities. This requires a more equitable distribution of medical resources and the presence of numerous highly qualified general practitioners at the primary care level. Achieving this objective is, of course, a gradual process that demands coordinated efforts across multiple departments. For instance, in terms of planning, the allocation of medical resources should be adjusted to promote the downward flow of talent, equipment, and infrastructure development. Regarding fiscal investment, resources should be increasingly directed toward the grassroots level to improve the compensation and benefits of primary care healthcare workers. In terms of talent cultivation, enrollment scales for undergraduate clinical medicine programs targeted at grassroots service should be expanded, and standardized residency training and general practitioner training systems should be refined. Furthermore, accelerating personnel system reforms to facilitate multi-site practice for physicians will encourage the mobility of high-quality doctors, thereby amplifying the impact of premium medical resources.

Medical insurance should also serve as a regulatory lever for the tiered diagnosis and treatment system by widening the reimbursement rate differentials among hospitals of different tiers. If medical costs at county-level hospitals and township health centers are significantly lower than those at tertiary hospitals, it will help guide patient flow. Furthermore, medical insurance policies should incentivize large hospitals to admit more patients with complex, critical, and severe conditions.

Furthermore, many patients are reluctant to seek care at primary healthcare institutions due to the incomplete range of available medications. To address this issue, policies should be introduced to optimize the formulary structure for chronic disease management, including hypertension and diabetes, ensuring that medications available in tertiary hospitals are also accessible in community health centers.

In fact, since the implementation of healthcare reform over six years ago, the development of primary healthcare service systems in both urban and rural areas has received unprecedented attention and investment, achieving significant progress. Many residents may have noticed that community health service centers (stations) or township health centers (village clinics) are now within a 10-minute walk from home, making medical consultations more convenient; new outpatient and inpatient buildings have been constructed at the community and township levels, improving the medical environment; medical equipment has been updated and upgraded, allowing basic examinations that previously required visits to large hospitals to be performed locally; thanks to various policies facilitating collaboration between primary healthcare institutions and major hospitals, patients with difficult or complex conditions that cannot be managed at the primary level can now have their appointments with specialists and hospital beds at tertiary hospitals arranged through their local facilities. The ultimate goal of all these reforms is to save time, reduce worry, and lower costs for the general public.

Various regions have undertaken a series of initiatives to strengthen the soft power of primary healthcare institutions. An increasing number of localities have achieved the dual downward flow of high-quality medical talent and resources by establishing medical consortiums, and through large hospitals taking over management or providing assistance to primary healthcare facilities. This has also created opportunities for primary care staff to receive training and further education at higher-level hospitals. Meanwhile, in accordance with national deployments, regions across the country are exploring targeted, tuition-free training programs to attract clinical medicine graduates to work in central and western regions and at primary healthcare institutions. Measures such as retraining programs for general practitioners and pilot special-post plans are being implemented to enhance internal capacity building and improve the quality of primary healthcare personnel. These reforms and explorations aim to ensure that common and frequently occurring diseases among the public can be treated conveniently and promptly.

Case:

Yunnan: Enhancing Village Doctors’ Service Capacity Through a “One In, One Out” Approach

Yunnan Province will further enhance the service capabilities of village doctors through a "one in, one out" approach. This strategy entails strictly controlling the entry requirements for village doctors and improving policies regarding their departure from posts. Henceforth, any new village doctor practicing in a village clinic must hold at least a secondary vocational school diploma or higher and pass the assessment and approval by the county-level health administrative department. Meanwhile, efforts will be made to address the livelihood difficulties of village doctors who have left their posts, with prefecture (city) governments assuming primary responsibility and allocating special fiscal funds to provide them with living subsidies after departure. In principle, each locality should select and hire village doctors based on a standard of no fewer than one village doctor per 1,000 people served. Measures such as public construction with private operation and government subsidies will be adopted to support infrastructure development and equipment procurement for village clinics. Free training and full-time advanced studies will be provided for village doctors, with opportunities offered to those holding associate degrees or higher to receive training at major provincial (or municipal) hospitals. In principle, approximately 55% of basic public health service tasks should be assigned to village doctors.

However, for a long time, the composition of primary care physicians in China has been relatively complex, with varying capabilities and levels in providing medical services. Qualified general practitioners are scarce, whether in township health centers in rural areas or community health service institutions in urban areas.

In fact, China’s efforts to develop general practice and strengthen primary healthcare services began long ago. In 2000, the former Ministry of Health issued the “Opinions on Developing General Practice Education,” initiating post-specific training for general practitioners in large and medium-sized cities, with a focus on transitioning in-service personnel, and gradually promoting postgraduate general practice education. Since the launch of the new round of healthcare reform in 2009, greater emphasis has been placed on the development of general practice.

At present, China has established over a thousand clinical training bases and primary-care practice sites, systematically strengthening the standardized training of general practitioners (GPs) in a planned manner and continuously expanding the number of trainees. The vision of “basically achieving 2–3 qualified GPs per 10,000 residents in both urban and rural areas by 2020” is now within reach.

Not long ago, six departments, including the Ministry of Education and the National Health and Family Planning Commission, jointly issued the “Opinions on Deepening the Reform of Clinical Medical Talent Training through Medical-Educational Collaboration,” proposing to strengthen the construction of primary healthcare workforce with a focus on general practitioners and introducing numerous preferential policies. Many experts believe that this is a fundamental solution to address the shortage of medical talent at the primary level and to build public trust in grassroots doctors. Currently, some provinces have issued documents specifying that rural-oriented medical graduates starting from 2015 should undergo standardized residency training. This means that in the future, there will be an increasing number of trustworthy primary care physicians around us who have completed standardized training.

Of course, we must also clearly recognize that both the cultivation of grassroots healthcare talent and the enhancement of primary care service capacity are gradual processes. Currently, various regions have increased the reimbursement rates for initial visits at primary healthcare institutions, aiming to use economic incentives to guide the public to seek initial care at the grassroots level. Meanwhile, is it not also necessary for us to change our healthcare-seeking habit of “visiting large hospitals even for minor ailments,” thereby granting primary healthcare institutions greater opportunity and trust? In fact, this ultimately serves our own interest in accessing more convenient and cost-effective diagnosis and treatment services.