Can the Family Doctor System Serve as a Catalyst for China's New Healthcare Reform?

Source: Beijing Times

For most Chinese families, family doctor services remain an unfamiliar concept. On June 6, the Guiding Opinions on Promoting Family Doctor Contract Services, jointly formulated by seven departments including the State Council’s Office of Healthcare Reform and the National Health and Family Planning Commission, was officially released. The opinions propose that by 2017, the coverage rate of family doctor contract services should exceed 30%, with contract service coverage for key populations reaching over 60%. By 2020, efforts will be made to expand family doctor contract services to the entire population, establish long-term and stable contractual service relationships, and basically achieve full coverage of the family doctor service system.

Prior to the joint issuance of documents by seven ministries and commissions, the Central Leading Group for Comprehensively Deepening Reforms had already formulated quite specific guiding principles and an action roadmap for advancing family doctor contract services. From the launch of pilot family doctor service programs in 2011 to the current rollout of comprehensive implementation opinions, this follows the traditional “playbook” of steadily yet decisively advancing reforms in key areas. This signifies that family doctor services have been elevated to a national-level strategy and constitute an important component of the new round of healthcare system reform. So, what exactly are family doctor services? Can they shoulder the heavy responsibilities of the new round of healthcare reform? Can many of the contradictions in the public healthcare sector be alleviated as a result? How can the general public feel the benefits of these reforms? These “indicators” will determine the pace of advancement for family doctor services, as well as the progress and efficiency of healthcare reform.

What Are the Components of Family Doctor Services?

When it comes to family doctor services, Chinese families unfamiliar with the concept often draw comparisons to the private family physicians depicted in foreign films and television dramas. In reality, pilot experiences from regions such as Shandong, Shanxi, Beijing, and Shanghai demonstrate that the two models are distinct. In Shanghai alone, over the four-year period from 2011 to 2015, 10.273 million permanent residents in pilot areas signed contracts for family doctor services, achieving a coverage rate of approximately 44%. However, signing such a contract does not entitle residents to home visits by a private family physician. In fact, even with a contract, medical consultations generally require prior appointments, and family doctors typically do not provide home-based services.

In terms of composition, the main body of family doctors consists of general practitioners in primary healthcare institutions, capable township health center physicians, and retired clinical doctors from public hospitals. In terms of service recipients, the key populations served by family doctors are infants and young children, pregnant and postpartum women, patients with chronic diseases, and the elderly. In terms of medical services, family doctors primarily provide prevention and basic medical care for common diseases. In other words, the management of primary and common conditions, along with basic preventive and therapeutic services, constitutes the core offerings of family doctors.

So, what are the benefits of family doctors? From the perspective of enrolled residents, since family doctors serve a relatively fixed population, they maintain comprehensive medical records and have a thorough understanding of patients’ conditions. This enables them to provide more precise prevention and treatment plans, reduce the waste of medical resources caused by repeated consultations and redundant tests when patients see different doctors, and avoid delays in treatment resulting from blind choices of hospitals and physicians. In terms of rational allocation of medical resources, the current lack of distinction between primary care resources and resources for serious diseases leads most people to seek care at large hospitals. This has resulted in overcrowding at major hospitals and persistent difficulties and high costs in accessing medical care. Moreover, excessive workloads force doctors to treat both minor and major illnesses, diverting medical resources that should be concentrated on severe cases and thereby lowering the overall standard of care. Furthermore, amid tense doctor-patient relationships, some doctors, driven by financial interests or self-protection, either engage in overtreatment—such as treating non-existent conditions or overtreating minor ailments—or refuse to accept patients with complex conditions, further exacerbating doctor-patient conflicts and leading to irrational use of health insurance funds. The family doctor system allows minor illnesses to be addressed at primary healthcare institutions, playing a role in the rational allocation and channeling of medical resources. At the same time, it helps prevent overtreatment at its source, establishing an additional safeguard for controlling health insurance expenditures.

It can be said that the value-added nature of the family doctor system is manifested in multiple aspects: enrolled residents can address their needs for the prevention and treatment of basic diseases at close range, purchasing whole-process health management services through market mechanisms; primary healthcare institutions can fulfill their role in preventing and treating primary and common diseases, effectively implementing the health policy of prioritizing prevention, while simultaneously improving income, benefits, and work motivation to prevent brain drain; medical resources in large hospitals can be allocated more rationally, alleviating excessive work pressure and allowing them to focus on the treatment of serious illnesses, thereby enhancing advanced medical capabilities. This tiered diagnosis and treatment pattern expands the pathways for the new round of healthcare reform.

Can the Family Doctor System Leverage the New Healthcare Reform?

Healthcare system reform is a complex, multi-layered endeavor. Underlying the two core issues of healthcare administration and pharmaceutical production and distribution management lie critical questions regarding how to define the public versus market-oriented nature of healthcare institutions, as well as challenges related to drug R&D, circulation, and pricing mechanisms. Consequently, this gives rise to a spectrum of topics ranging from macro-level to micro-level concerns, such as what truly constitutes the “public” character of public hospitals and whether private hospitals can serve as constructive participants in healthy competition.

In this context, the proposed tiered diagnosis and treatment model—characterized by “initial consultation at the community level, two-way referrals, separate management of acute and chronic conditions, and coordinated care between primary and tertiary institutions”—aims to reconcile various contradictions in the healthcare sector, optimize the environment for healthcare reform, and create favorable conditions for deepening the next round of reforms. The implementation of the family physician system, the establishment of a tiered diagnosis and treatment framework, and the promotion of the new round of healthcare reform clearly outline the step-by-step approach adopted by policymakers. It can be said that implementing the family physician system is the first step in the new round of healthcare reform and a prerequisite that must be established.

Can the family doctor system play the expected role in leveraging healthcare reform? First, it is necessary to assess whether the family doctor system has sufficient human resources to drive public healthcare. Currently, there are more than 2.8 million registered physicians in China. Based on the number of doctors per 1,000 population, this figure reached 2.06 in 2013. While this ratio is lower than that of the United States and the European Union, it is not low compared to the global average. According to statistics from the Chinese Medical Doctor Association, the number has been growing at an annual rate of 4.4% in recent years. This indicates that the basic conditions for implementing the family doctor system are in place. However, since family doctors primarily manage primary and basic diseases, requiring general practice skills rather than specialized expertise, the proportion of general practitioners (GPs) is a key factor. In the past, insufficient emphasis was placed on GP training, resulting in a significant shortage. Against the target of having 2–3 GPs per 10,000 people by 2020, the current shortfall stands at approximately 100,000 to 300,000, highlighting an urgent need to strengthen workforce development.

Secondly, it is essential to assess whether the family doctor system can mobilize and aggregate medical teams to actively participate. The "Guiding Opinions on Promoting Family Doctor Contract Services" have introduced numerous incentive measures that facilitate the engagement of medical teams, thereby addressing the growing demand for family doctor staffing.

Most critically, it is essential to examine what kind of pricing mechanism is established for the family doctor system. According to the guiding opinions, in order to promote family doctor contract services and optimize the substance of these services, differentiated and diversified service models are encouraged. This implies that family doctors should have a long-term, stable baseline price for their services, with fees charged on a tiered basis according to the type and quality of service provided. However, there is a lack of comparable benchmarks for the pricing mechanism of family doctors. If local income levels are used as the basis, it will be difficult to implement family doctor services in poorer regions, potentially causing medical resources to skew further toward wealthier areas and exacerbating imbalances. Conversely, if pricing is set according to the standards of affluent regions, the number of resident physicians may decline. Therefore, a more detailed and comprehensive design is required.

Once issues related to resources and pricing are resolved, the family physician system has the potential to inject new momentum into the next round of healthcare reform by establishing a tiered diagnosis and treatment framework.

Need to draw on international experience to manage and control unexpected negative effects

Despite the multifaceted potential benefits of the family physician system, it must be acknowledged that in practice, well-intentioned policies may be misimplemented, and favorable policy expectations may fall short. The windows for such unintended consequences primarily lie in the following three areas.

First, how to balance the public nature of healthcare institutions with the partial market orientation of family doctors. The costs of family doctor services are jointly borne by the medical insurance fund, basic public health service funding, and contracted residents. Although this alleviates the financial burden on contracted residents, the principle that higher prices secure higher-quality services means that households with stronger financial standing will have the opportunity to engage more prestigious and highly qualified medical teams. This could further exacerbate the imbalance in medical resource distribution, leading to a phenomenon where top-tier physicians primarily serve the wealthy.

Second, the level of diagnosis and treatment fails to meet the needs of contracted residents. Although the primary functions of family doctors are disease prevention, management of minor ailments, and chronic disease care, their practice ultimately relies on support from general medical expertise. If sufficient trust is not established between physicians and patients, disagreements and conflicts may arise in key areas such as determining treatment plans, deciding whether specialist referral is necessary, and selecting appropriate hospitals.

Third, who should oversee the evaluation of family doctors’ clinical practice? Although policy guidelines grant contracted residents the right to designate and switch their family doctors, due to the specialized nature of medical care, residents can only assess service attitude and find it difficult to accurately evaluate the quality of clinical treatment. This creates potential for mutual misunderstandings between both parties and opens the door for individual doctors to engage in rent-seeking behavior. Therefore, healthcare institutions that deploy family doctors must assume regulatory responsibilities. In cases of serious medical incidents, judicial intervention is also warranted based on clear legal grounds. Currently, institutional frameworks in these areas remain largely absent.

As an emerging strategy awaiting broader adoption, the family doctor system requires adjustments during implementation and can draw lessons from international experience. Currently, more than 60 countries and regions worldwide have fully implemented family doctor systems. Taking the United States, which has relatively extensive practical experience, as an example, a series of mature mechanisms are in place to prevent the family doctor system from becoming unmanageable. For low-income populations, the U.S. offers specialized Health Maintenance Organization (HMO) insurance plans, under which insurers assign physicians to provide services, thereby ensuring the inclusiveness of the family doctor system. For uninsured individuals, hospitals are required to provide emergency care unconditionally, with the resulting costs borne by state finances. Households with greater financial means can opt for relatively more expensive insurance plans to meet differentiated service needs. The evaluation of family doctors primarily relies on third-party assessments conducted by insurers and social organizations. Although practices such as overtreating patients cannot be entirely avoided, this relatively independent and objective evaluation system helps constrain family doctors’ behavior. While national conditions differ, the experience of leveraging market forces to promote the family doctor system and utilizing social resources to establish management mechanisms is worthy of reference.

The Family Doctor System Cannot Be Advanced in Isolation

In a certain sense, the implementation of the family doctor system addresses practical contradictions in the healthcare sector from a relatively micro-level perspective, while simultaneously accumulating momentum to drive the next round of healthcare reform. Previous healthcare reforms have achieved significant phased results, such as the expansion of health insurance coverage, substantial reduction in the medical cost burden for both urban and rural residents, the abandonment of the model of subsidizing healthcare through drug profits, and the optimization of drug pricing and distribution mechanisms. However, overall, there is still a considerable distance to go before healthcare reform completes the “last mile.” As one of the initiators of the new round of healthcare reform, the family doctor system is still halfway through its promotion process.

Currently, to accelerate the implementation of the family doctor system, measures such as the comprehensive rollout of standardized residency training, mobilizing general practitioners to transition into multi-site practice, and offering free, directed enrollment and training for rural medical students have been introduced. However, from the perspective of the ultimate objective of the new healthcare reform—which the family doctor system is tasked with addressing—it is insufficient to merely create a favorable environment for the family doctor system to advance in isolation, thereby causing the core agenda of healthcare reform to stagnate. Only by fostering a dynamic where the family doctor system and the core objectives of healthcare reform mutually reinforce and resonate with each other can the positive effects of the family doctor system be maximized.

Therefore, while optimizing the micro-environment of the family doctor system, it is necessary to simultaneously optimize other environments of the new healthcare reform.

According to the "Key Tasks for Deepening the Reform of the Medical and Healthcare System in 2016" issued by the General Office of the State Council, this year’s priorities—equally important as the implementation of the family doctor system—include accelerating the reform of public hospitals; establishing a traceability mechanism for ex-factory drug pricing information to streamline intermediate links and reduce artificially inflated prices; and expediting the nationwide networking of basic medical insurance and the settlement of cross-regional medical expenses, including the establishment and improvement of a national-level platform for cross-regional medical expense settlement. If the family doctor system primarily aims to address issues in primary medical care, then other reform agendas to be implemented concurrently involve defining the nature of public hospitals, determining whether drug prices can be reduced, and resolving issues related to cross-regional reimbursement. These aspects are closely intertwined with the family doctor system. For instance, if the institutional nature of public hospitals remains ambiguous, family doctors, who largely originate from public hospitals, will face a dilemma in balancing their diverse roles: providing health management services to enrolled residents while ensuring that public hospitals maintain their capacity for public service delivery. Furthermore, as population aging intensifies, many elderly individuals reside with their children away from their home regions, while their medical insurance affiliations remain localized. Since the elderly are the primary recipients of family doctor services, failure to resolve the challenges of cross-regional reimbursement will inevitably significantly undermine the effective coverage of family doctor services.

More broadly, advancing other healthcare reform tasks in tandem with the implementation of the family doctor system is also essential for deepening the new round of healthcare reform. Only when a “trickle-down effect” of reform is generated across all subfields can the new healthcare reform coalesce into a powerful momentum, accelerating progress toward the “last mile” and moving closer to core objectives such as strengthening the basic medical security system, initially establishing the national essential medicines system, improving the grassroots medical and health service system, and promoting the gradual equalization of basic public health services.