Telemedicine is not a new concept, and it has long existed. In terms of definition, it is a kind of medical behavior, so it is impossible to equate services such as light consultation with it, and the provider of telemedicine must be a medical institution with relevant qualifications, not an individual.
Telemedicine is not just a new type of medical model. Behind it, it also hides a huge industrial chain connecting medical care, medical insurance and medicine. It is an extremely important part of this chain. If divided by role, this chain can be simplified as: medical insurance - large hospitals - telemedicine - primary medical institutions - pharmacies - pharmaceutical companies. It can be seen that telemedicine can not only connect medical resources upstream and downstream, but also connect pharmacies with medical institutions. But to truly form this chain, the problems to be solved will be multifaceted.
Difficulties: Primary care and medical associations
The purpose of telemedicine is to grade medical treatment, which is to sink high-quality medical resources to the grassroots. The government promotes graded medical treatment and hopes that the visiting population will return to the grassroots. However, the key to improving the service capacity of primary medical institutions is talent cultivation. Telemedicine is a decentralized model, which is a kind of resource recombination of the patient population released by the top three hospitals after the graded diagnosis and treatment.
This is really hard. Primary medical institutions often only have policy tasks for telemedicine, and in most cases, companies use pure sales models to sell products to hospitals. After the hospital got the product, the task was basically completed. After the acceptance, it is difficult to continue to use it. Over time, it will be ineffective.
This situation is not unsolvable, and the result depends on the way companies work with primary care institutions. The remote vision company is a good example. First, they provide free inspection equipment such as fundus cameras for institutions that lack equipment. Secondly, they provide remote system software and hardware services for free. Finally, the experts from the large hospitals help them. Support and improve the medical level of medical institutions. The costs of inspections, remote services and surgery generated during the period will be divided proportionally with the primary hospitals.
In addition, with the increase in medical investment in China, such as the implementation of favorable policies such as the new rural cooperative medical policy, the profitability of primary medical institutions has greatly improved. In the past, county-level hospitals with annual incomes of only 10 million to 20 million have now earned more than 100 million yuan, and they have the strength to purchase more medical equipment. Coupled with the decline in the cost of purchasing medical equipment, the penetration rate of medical equipment in primary medical institutions has steadily increased. Therefore, the foundation of telemedicine in primary medical institutions has matured.
Compared with the traditional software sales model, this model makes the primary medical institutions more engaged and more willing to cooperate. However, it only verifies a feasibility. In order to form a chain of graded diagnosis and treatment, it is necessary to establish a large-scale medical alliance between a large hospital and primary care, similar to the organization of the medical association.
Take the remote vision as an example. According to the specialties, the remote vision has successively cooperated with the hospitals to form various special leagues such as the Asia Pacific Remote Ophthalmology Alliance, the National Gynecology Telemedicine Alliance, and the National Cancer Medical Alliance.
The current medical association includes grassroots community medical institutions, county hospitals, municipal comprehensive hospitals, and regional cooperation assistance. There are two types of construction methods, one is a compact medical association, and the other is loose. Type of medical union.
Taking Sichuan Province as an example, the close-type medical association is managed by the hospital for county-level hospitals. The county-level hospitals enjoy the brand use rights of Sichuan Provincial People's Hospital, and the managed hospitals become the branch of Sichuan Provincial People's Hospital. The loose medical association is composed of hospitals and hospitals in various levels. The hospitals of all levels use the Sichuan Academy of Medical Sciences and the Sichuan Provincial People's Hospital (Group) Hospital.
Regional cooperation means that the hospital signs regional cooperation agreements with local governments or medical and health authorities, and assists and cooperates with different medical institutions in the region through medical joint forms. However, the loose medical modality model is subject to many restrictions on human, financial and material interoperability. Therefore, Sichuan Province adopts the model of medical association trusteeship.
Whether it is a medical association or a specialist alliance, only by forming a large-scale and intensive industrial operation can we effectively integrate medical resources and truly bring telemedicine operations to the medical level.
Difficult two: choose which mode to cut into
If classified by business model, telemedicine can be divided into four categories:
Remote diagnosis: refers to the experts or doctors of higher-level hospitals to provide diagnostic opinions to the basic clinical staff, including remote imaging diagnosis and remote pathological diagnosis.
Remote consultation: mainly the higher-level doctors through the remote consultation system, directly to the primary level patients for consultation, and give advice to the primary doctors, such as remote video consultation.
Remote monitoring: the use of home medical devices to collect vital signs of patients, and transmission to the monitoring center through the network, medical staff to monitor and disease management services for home patients, such as remote home monitoring, remote disease management.
Distance education: refers to continuing education and training for primary health care personnel.
At present, most telemedicine enterprises are concentrated in the first two categories, and the choice is to cut in from the big and all, but the effect is not good, not only in the hospital side is difficult to make profits, but also on the patient side. Although the use of telemedicine can solve some medical problems, telemedicine still has a certain gap compared with the face-to-face communication diagnosis between doctors and patients. It cannot completely replace traditional doctors to examine patients. Therefore, telemedicine is more suitable for a follow-up than the first visit.
Under such market logic, the telemedicine, which is mainly oriented to the B-end of the technology category, is the first to develop, and the small and light mode of ECG is the first breakthrough. Modes such as remote imaging and telepathology are currently not developing fast because of the need for a heavier offline layout.
Therefore, not all patients are suitable for telemedicine. At this stage, telemedicine really needs to focus on starting from suitable specialist diseases, such as gynecology, heart disease, and cancer. Moreover, such patients often have extremely strong needs for experts and large hospitals. Due to the long-term nature of disease management, it is not only in the follow-up, but also in patients after surgery.
Difficulties 3: The power of big hospitals and doctors
Although the country is currently vigorously promoting the grading diagnosis and treatment policy and telemedicine, the effect is not satisfactory. The phenomenon of “take all-in†in the top three hospitals in the industry is still very serious – that is, patients, medical expenses, and medical insurance funds. From the data point of view, the proportion of inpatients in the top three hospitals in Beijing, Shanghai and other big cities has increased from 70% in the past to 70%. In some coastal cities, the number of hospitalizations in tertiary hospitals even accounts for 85%.
Is there a conflict between the prescription outflow caused by telemedicine and the top three hospitals? actually not. Graded diagnosis and treatment is to divert patients from large hospitals. Partial loss of patients is not the reluctance of large hospitals. In contrast, patients who really need to enter the top three hospitals have more expert resources available, and let the experts see more patients with real needs, which is the true efficiency. Release. Therefore, the top three hospitals and experts are actually not exclusive to telemedicine, but they are happy to see it.
The zero mark rate of drugs is a must to break the "medication by medicine", which is not directly related to telemedicine. According to the assumption of the zero rate of medicines, the more expensive the medicines opened by the hospital, the more the workload of the pharmacy and the management cost of the hospital will increase. It will not benefit the increase in doctors' income and hospital income, and will eventually promote the separation of medicines and prescription outflows. Implemented.
The key point of the hospital's unwillingness to let go of the prescription outflow is not "medical", but in the "medicine", this point should be conceptually clear. Therefore, telemedicine is only a natural result, not a cause, for taking out prescriptions. As a result of the development, the competition between the hospital and the hospital has shifted from the number of large prescriptions to its own medical level and brand, so that the improvement of the treatment rate and model innovation has become the primary choice of the top three hospitals.
Since the trend of breaking medicines and medicines is irreversible, for doctors, telemedicine, even if it has lost the benefits of medicines, will increase its extra workload to a certain extent, but in terms of income, It is a compensatory measure. Moreover, with the implementation of graded diagnosis and treatment, the siphon effect of the top three hospitals is controlled, the patients in the offline clinics are continuously diluted, and the precise patients brought by telemedicine will be more and more.
Difficult four: electronic cases need regional information support
The definition of medical records, China's "medical institutions medical records management regulations 2013 edition", Article 2 clearly stipulates that medical records refer to the integration of texts, symbols, charts, image slices and other data formed by medical personnel in medical activities. In other words, as long as the various forms of information formed during the diagnosis and treatment process should be medical records.
The integrity and accuracy of patient medical records and imaging data have a great impact on the results of telemedicine consultation. However, the general status of electronic medical records in China is that not only hospitals and hospitals have their own affairs, information is difficult to transmit, but also within hospitals. Due to the inconsistency of interfaces and standards between information systems such as HIS and PACS, information islands are clustered. Therefore, the transmission of electronic medical records is a technical problem in telemedicine.
With the acceleration of the construction of national regional information, more and more cities have completed the migration from hospital informationization to regional informationization. Take Wuxi City as an example. Up to now, all hospitals and municipal hospitals in Wuxi City, including community clinics, have implemented electronic medical records. Among them, the utilization rate of Wuxi Second Hospital even reached 95%. Such high usage rates have made telemedicine information sharing a reality.
In November this year, Sichuan, which has been active in telemedicine, has also issued relevant policies on electronic medical records: telemedicine relies on the Sichuan e-government extranet and e-government cloud platform to integrate the entire population, residents' electronic health records, and electronic medical records. the three major databases, fully completed interoperability provincial, city and county health information platform for three people, improve and promote data exchange, collaborative sharing, security, technical service standards, supporting cross-agency, cross-regional, cross-sectoral new Network medical health services.
The advancement of telemedicine cannot be supported by the shared data of regional electronic medical records, but this is a phased evolution, and the lack of time.
Difficult five: How retail pharmacies undertake prescription outflows
There are two points in the retail pharmacy's ability to undertake prescription outflows: one is how the retail pharmacy's own ability to undertake is established; the other is how the relationship chain of prescription outflows is formed and controlled.
Telemedicine is one of the sources of e-prescribing. Why do you want to put e-prescriptions together with retail pharmacies for two reasons: First, retail pharmacies can directly serve as accessors for telemedicine; second, retail pharmacies are undertaking The main channel for hospital telemedicine and prescription outflows. Therefore, the pharmacy's own pharmacy service ability and medication professionalism are inevitable capabilities. Especially for new special drugs for tumors, the guidance of professional pharmacists is the key to solving the "last mile" of prescriptions. Here, we are optimistic about the DTP pharmacy model.
In the traditional sense, the prescription outflow is mostly caused by the patient taking the prescription out of the hospital's natural outflow, and the use of the prescription natural outflow for the drug sales business is called prescription drug retail. In this mode, retail pharmacies can only passively guide the flow of prescriptions from marketing, and cannot form a peer-to-peer relationship with medical institutions.
The other is called the externalization of the prescription hospital. This model is based on the deep cooperation between hospitals and retail pharmacies. After clinical promotion and telemedicine, the hospital will continue to introduce the doctor's prescription to the professional pharmacy outside the hospital, and then the licensed pharmacist will conduct the prescription and sell the product to the patient (or provide the drug delivery service), and give the patient follow-up medication. Consultation or disease management.
However, in this mode, high-quality medical resources and retailers tend to be less-to-many, and hospitals have absolute right to speak, so pharmaceutical companies will inevitably give benefits to hospitals, which means that prescription flows and drug “dividends†are still Medical institutions are bundled together, so the country’s original intention to achieve drug separation through prescription outflows is difficult to achieve.
The biggest difference between electronic prescriptions and electronic medical records is the extremely strong "medicine" attribute of electronic prescriptions. And drugs are the core of the interests of all parties, and because of this, the value of prescriptions is infinitely magnified. So, how to control the flow of hospital electronic prescriptions? This involves whether the electronic prescription can be separated from the large prescriptions in the hospital. It is necessary not only to use DRGS to control the payment of inducing medical expenses, but also to use the big data medical insurance control fee to check and supervise the hospital income, from the perspective of income and expenditure. To work at the same time.
Of course, this involves the transfer of benefits. The outflow of prescriptions means the release of additional income from hospitals and doctors. Therefore, there will be resistance in the implementation process, so that electronic prescriptions will flow out from the hospital channels. A third-party data management and sharing platform is needed. This is directly connected with patients. The telemedicine company has become the most suitable target.
By cooperating with pharmacies, telemedicine companies can not only directly supplement the benefits of drug zero rate in large hospitals from the diagnosis and treatment stage, but also realize the patient follow-up management and chronic disease management that are difficult for hospitals through pharmacies, thus forming a more equal The partnership, while also allowing the hospital to break away from the black hole of drug benefits.
The formation of this relationship will inevitably lead to the reorganization of the staffing of hospitals and pharmacies. In the future hospital, the final reservation may be clinical pharmacy staff, not pharmacists. Clinical pharmacists guide the clinical work and clinical application of patients. And simple pharmacy personnel will return to retail pharmacies, which is the future trend.
Difficult point six: the formation of medical insurance payers
In the past, telemedicine was not included in the scope of medical insurance, and the hospitals were priced differently. Because of the unclear understanding of telemedicine and the sensitivity to price, the enthusiasm is not high. In August 2016, China's telemedicine took the lead in ushered in the dawn of Guizhou Province. Guizhou Province decided to include the telemedicine service project in the payment of the basic medical insurance fund. It will be implemented on August 1, 2016, and the trial time will be one year.
According to the “Notice on the Relevant Issues Concerning the Payment of Telemedicine Services into the Basic Medical Insurance Fund†issued by the Ministry of Human Resources and Social Security of Guizhou Province, the scope of payment to the basic medical insurance fund includes: remote single-disciplinary consultation, remote multidisciplinary consultation, and remote Chinese medicine practitioners. 9 items including syndrome differentiation and consultation, and simultaneous remote pathology consultation.
Following Guizhou, in October 2016, Sichuan Province also issued the “Notice on the Pricing of Internet Medical Service Projects†and the “Guiding Opinions on Accelerating Internet + Medical Health Servicesâ€.
According to the "Notice on the Pricing of Internet Medical Service Projects", Sichuan hopes to expand the capacity of medical institutions by integrating regional medical resources to promote the sinking of quality medical resources. At the same time, the "Price List of Internet Medical Service Projects of Provincial Public Medical Institutions in Sichuan Province" was formulated to implement government-guided prices, remote monitoring and other price implementations for remote medical consultation, remote diagnosis and remote examination of public medical institutions. Market adjustment price.
The successive test of water in Guizhou and Sichuan has undoubtedly given great promotion to telemedicine from the payment link. With the policy provisions and the support of medical insurance, the hospital and patients will be more motivated, and the implementation of graded diagnosis and treatment will really fall. Real place.
Difficult point seven: how to introduce medical insurance control fees for telemedicine
The telemedicine model is destined to make it difficult to directly become a payment method for the payer, and can only be used as a part of improving medical efficiency and improving basic medical services. In order to co-ordinate the formation of a fee-control mechanism in the chain of medical insurance, large hospitals, telemedicine, primary medical institutions, pharmacies, and pharmaceutical companies, a global fee-control model is needed. PBM is a kind of Very good means.
PBM, translated as drug welfare management, originated from the United States and is a third-party organization specializing in the management of medical expenses. The institutions that provide this service are generally supervised, managed, and coordinated between payers (commercial insurance agencies, employers, etc.), pharmaceutical manufacturers, hospitals, and pharmacies in the market. PBM manages and guides the entire medical service process based on the collection and analysis of patient visit data, drug prescription review, etc., so as to achieve effective supervision of medical services, control medical expenses, and promote therapeutic effects.
The first to introduce this model in China is Haihong Holdings. Since 2009, Haihong Holdings has cooperated with ESI in the United States to develop medical welfare management business.
From the perspective of the operation of Hangzhou, Haihong's PBM model saves the government at least 10% of the medical insurance expenditure every year. For the whole country, it means that the country saves hundreds of billions of dollars a year. The interview twice reported the huge loopholes in medical insurance. Under the background of tight local finances, the demand for medical reform by local governments and even public opinion is very urgent.
In addition to the control fees, the key point is that PBM is more like the top management mechanism in the industry chain, connecting medical insurance (commercial insurance), large hospitals, primary medical institutions, pharmacies, and pharmaceutical companies in tandem to form a community of interests. It also controls the effectiveness and benefits of telemedicine from the source. Therefore, the introduction of PBM is both natural and inevitable.
The most fundamental problem is still the game of the interests of all parties.
After writing a long article, we will put the telemedicine into the final industry chain, and simply summarize it into these four categories: basic construction, business model, benefit distribution and policy basis. It can be said that the development and challenge of telemedicine in China is not only the formulation of standards, but how the various stakeholders can finally form a coordinated division of labor under the policy and market game is the real problem.
From a big trend, the decentralization of medical resources, corporate mergers and acquisitions, and everything, all indicate that medicine is moving toward a more efficient form. Telemedicine, by virtue of its role as a technology connector, is becoming an integral part of this new ecosystem.
Tuna Loin,Frozen Tuna Loin,Fresh Tuna Loin,Yellowfin Tuna Loin
ZHEJIANG RETRONX FOODSTUFF INDUSTRY CO.,LTD , https://www.retronxfoods.com