Payment reform aids primary healthcare

The National Healthcare Security Administration said on Monday that the first batch of conditions suitable for primary care have been selected as part of a medical insurance payment reform aimed at encouraging patients with common and chronic illnesses to seek care at grassroots hospitals.

The reform's core policy is "same disease, same payment". Within a local insurance pooling area, a primary-level disease type, such as hypertension or diabetes, will carry the same payment standard regardless of the level of hospital treating it.

However, a similar insurance payment standard does not mean the same out-of-pocket cost for patients. This is largely because primary-level hospitals generally have lower deductibles and higher reimbursement rates, so patients can pay less when they choose a grassroots facility.

The system is designed not to restrict patients' choices, but to encourage them to seek primary care through payment leverage, according to the administration.

Xu Na, deputy director of the administration's medical services management department, said primary care conditions are common and frequently occurring diseases, as well as some chronic conditions, that are suitable for treatment at qualified secondary and lower-level medical institutions. Such institutions should have sufficient capacity and mature clinical expertise to treat these conditions.

The reform aims to promote tiered diagnosis and treatment, make medical care more convenient, curb overtreatment and ensure the safe and efficient use of medical insurance funds, said Ren Jing, a researcher at the China National Health Development Research Center.

Ren said the policy targets a long-standing mismatch between supply and demand in China's healthcare system.

"Large numbers of patients with common and frequently occurring diseases that could be safely and effectively handled at the grassroots level have flowed to high-level urban hospitals because of doubts about grassroots capacity," she said.

As a result, outpatient and inpatient resources at tertiary-level hospitals are being consumed by common ailments, leaving less capacity for complex and critical cases. At the same time, primary-level institutions miss opportunities to gain valuable experience and improve their services. For patients, seeking treatment for minor illnesses can result in long-distance travels and longer waiting periods, Ren said.

While primary healthcare has been steadily strengthened, challenges remain.

This requires further improvement of the quality of primary healthcare, while simultaneous efforts are made to raise public awareness of its role and functions. Establishing an orderly pattern in which common and frequently occurring diseases are first treated at the primary level will require sustained and coordinated efforts from all departments, she said.

Regarding implementation, the administration said provincial pooling areas should not simply copy the national recommendations. Instead, they are expected to draw up their own primary-level disease types based on local disease patterns and the service capacity of primary-level institutions.

"Pooling areas can include common and chronic conditions they can genuinely handle, and exclude conditions for which local grassroots institutions do not yet have diagnostic or treatment capabilities," Ren said.

Xu said localities may refer to the national recommendations and adjust them according to local conditions. The administration pledged to guide local authorities in refining their primary-level disease types after the first batch is formally issued.

The administration also stressed that the types of conditions suitable for primary care is a payment management tool, rather than a rule governing which hospitals can treat particular diseases.

The recommendation does not affect a hospital's right to decide whether to admit patients, nor does it restrict patients from choosing a preferred medical facility.