Analysis on the model of the combination of medical and health care from the perspective of aging

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By the end of 2018, data released by the National Bureau of Statistics of China showed that 249.49 million people were 60 years old or above, accounting for 17.9 percent of the total population. Among them, there were 166.58 million people aged 65 or above, accounting for 11.9% of the total population. In 2018, the total population increased by 5.3 million. But there was an increase of 8.59 million over the age of 60 and 8.27 million over the age of 65.

It is estimated that China’s elderly population will peak at 487 million around 2050, accounting for 34.9 percent of the total population. At the same time, the prevalence rate of chronic diseases in the elderly reached 52.7 percent [1], bringing long-term severe pressure on the elderly, medical care and social security. The economy in China is not yet developed when China entered the aging society.

For such an aging process, China has formulated the policy of “home-based, community-depended, institution-supplemented, combined medical and health care”, which conforms to the basic national conditions with Chinese characteristics. This paper summarizes and analyzes the general situation and related factors of the combination of medical and health care in China, aiming at providing new solutions to the problems in the combination of medical and health care in China.

1. Combination of medical and health care

1.1. Concept: “combination of medical and health care” refers to the combination of medical resources and pension resources to maximize the use of social resources. Among them, “medical” care includes medical rehabilitation services. It contains specific medical services: health counseling, health examination, disease diagnosis and treatment and nursing care, serious illness rehabilitation services and hospice care.

“Health care” includes life care services, mental services, cultural activities services. With the development model of “integration of medical and health care”, it integrates medical treatment, rehabilitation, health maintenance and old-age care, and puts the health and medical services for the elderly at the first place. It combines the functions of old-age care institutions and hospitals, and integrates life care and rehabilitation care into a new model of old-age care service.

1.2. Classification of the elderly.

By the end of 2018, the average life expectancy in China was 77 years. In contrast to the usual international practice of defining people over the age of 65 as the elderly, China defines people over the age of 60 as the elderly. Article 2 of China’s “Law on the Protection of the Rights and Interests of the Elderly” states: “the term” elderly “as used in this law refers to citizens over the age of 60.”

Therefore, we divide the elderly into the following categories according to their ability to act:

1) healthy and active period. At this stage the elderly can travel for holidays, reemployment, etc., They need only physical examination and other health management as the general adult;

2) assisted living period. They need care from their families and communities, as well as informal medical needs such as sports, health and wellness;

3) inconvenience period. During this period the elderly need to receive formal medical treatment, including rehabilitation treatment, chronic disease management, etc., in order to return to society;

4) hospice period. At this stage the elderly need to alleviate the pain and maintain the dignity of life as the goal.

1.3. Mode: the combination of medical and health care has just started in China, and all the modes focus on “Medical” + “Health care” (Fig. 1). Taking into account financial pressures and inadequate human resources, there are four existing models.

 

Fig. 1. The combining of medical and health care mode

Рис. 1. Комбинированный медико-социальный подход

 

First model “Home care, medical care tour.”

This model adopts the way of family doctors signing contracts and medical institutions allocate medical staff to provide door-to-door service. Through the establishment of family beds, the establishment of health records, to provide medical care services for the elderly at home.

This model is suitable for the elderly in the healthy and active period and the assisted living period. The disadvantage is the limited ability to respond to emergencies.

In this model, Qingdao, Shandong province, is experienced and has become an excellent example in the home care. Shandong has a dense population and a large elderly population, so it is more difficult for institutions to provide care for the aged due to the limitation of health resources. Therefore, the mode of home-based care for the aged in Shandong is booming and Shandong is the first region to carry out “medical care tour”.

Second model “Community care, smart services.”

This model is suitable for urban and new rural communities with relatively concentrated and large population. Relying on the smart home-based care system such as the large data center for health care, the elderly residents in the community can enjoy the combination of day care, door-to-door follow-up and other medical care services.

This model is suitable for the elderly in the assisted living period and inconvenience period. The advantage is to achieve day care and quickly respond to emergencies. The disadvantage is overly dependence on medical resources. Besides, a better large data system and more abundant medical workers are needed.

The representative region of this model is Shanghai. Shanghai has very advanced big data technology, and the “Internet +” community pension model is mature. With a developed economy and a high level of per capital income, Shanghai, as the earliest pilot of the combination of medical and health care in China, initiated medical consortium services, established electronic medical records for the elderly, and Shared them among tertiary hospitals. The elderly in the community mode can not only receive daily care, but also be transferred to the tertiary hospitals for treatment in case of emergency.

This model is suitable for the elderly in inconvenience period and hospice period. Its advantage is highly safety. In the medical institutions, it can satisfy the medical needs of the elderly. And it will have an important impact for the treatment. And the drawback is also obvious because it cannot realize personalized endowment. It is a department for the aged in the hospital, which has a certain negative impact on the psychology of the elderly. In addition, the economic pressure on the family is also greater.

Shenzhen, as the youngest first-tier city in China, has great foresight. In 2017, the central hospital of Guangming new area in Shenzhen set a nursing home, realizing the concept of “the combination of medical and health care.” In June 2019, Shenzhen university general hospital and Shenzhen nursing home for the aged started in-depth cooperation.

Third model “Institutional medical care and the integration of both institutional.”

This model is suitable for medical institutions to carry out elderly care services. Make full use of the professional advantages of medical institutions, through the internal endowment institutions or social capital cooperation and other forms. The “five unification” combined medical and health care are provided with unified management and operation, unified resource allocation, unified service contents, unified standards and specifications, and unified information platform. It has gradually realized chain operation and large-scale operation. Township health centers (community health service centers) and township nursing homes (community day care centers) have built a “two-in-one” integrated institutional medical care service.

Fourth model “Intergrated medical care, multi-tiered linkage.”

This model is suitable for large — scale general hospitals. The combination of medical and health services is provided through the establishment of old-age care institutions in general hospitals. With the help of the compact medical consortium and “Internet plus”, it drives the secondary medical institutions, community health service centers and township hospitals in the medical consortium to carry out the combination of medical and nursing services. We will drive the team of family doctors to carry out the combination of home care and medical care, and build a comprehensive medical care service system that combines medical service, old-age rehabilitation, discipline construction, talent training and achievement transformation.

Comprehensive medical care model, is the latest research results in recent years, is also the future direction of the development of old-age care. With a large population base and relatively short of medical resources, China is able to realize a comprehensive medical care and multi-tiered linkage pension model, which will certainly have great positive significance for China’s aging society.

2. Problems existing in the combination mode of medical care

As a new type of old-age care model suitable for China’s national conditions, the combination of medical and health care model meets the rigid needs of old-age care service for the aged, frail, incapacitated and mentally retarded people. At present, aging is accelerating, but the mode of combining medical and health care service is still in the exploration stage. There are multiple management and poor coordination in the functional departments of the state, and the service model of combining medical and health care is fragmented. The economic difference between eastern and western regions and between urban and rural areas is significant, which restricts the development of combined medical care service mode. The contradiction between the insufficient supply of medical care services and the huge social demand; The quantity and quality of the talent reserve and the lack of staffing standards [2].

2.1. Policy barriers.

In the specific implementation of the combination of medical and health care, the government departments cross management, resulting in many policy obstacles for hospitals at different levels to participate in the combination of medical and health care. For example, if a community hospital wants to expand an endowment institution, it needs to apply for approval from the civil affairs department, but the medical institution is managed by the health department.

In China, medical insurance and endowment insurance belong to two separate systems, and there is no policy on which system the expense reimbursement channels for the combination of medical and health care belong to.

The coverage rate of medical insurance for pension institutions is also relatively low. Many pension institutions are unable to carry out medical insurance settlement, and the reimbursement ratio of covered institutions for medical insurance is not clearly specified, resulting in settlement chaos.

2.2. Lack of industry standards.

At present, the combination of medical and nursing care has been promoted on a trial basis throughout the country. But the outstanding problem is that there is no uniform industry standard. For example, there is no standard for fees. Public hospitals in China are public welfare institutions. There are relevant standards for fees, but there is no standard for the combination of medical and health care. For the elderly with chronic diseases, there is no standard for medical or health care centered. There is no standard for palliative care for cancer and other diseases, and no standard for the admission and assessment of nursing staff who are specialized in the combination of medical and health care.

2.3. Imbalance between supply and demand.

Although the combination of medical and health care has been piloted across the country, the imbalance between supply and demand has not been alleviated.

First, the combination of medical care costs more, which is still the choice of minority groups. Most households have urgent needs, but they cannot afford them. Supply and demand do not match.

Second, there are significant differences between regions and, urban and rural areas. Economically developed areas develop better.

Third, because of the increasing aging population, China’s current family structure is mostly one-child families, which has a huge demand for pension institutions. But the supply of medical-care services is far from meeting demand.

Fourth, many combine medical and health care institutions with nursing care are still traditional hospitals, which cannot meet the psychological needs of the elderly and cannot live for a long time.

2.4. Imperfect infrastructure and lack of feedback mechanism.

According to the research, some pension institutions were rebuilt from early nursing homes, and the internal facilities did not fully consider the needs of the elderly. New facilities for the elderly, entertainment centers, catering services and most of them are only suitable for the elderly in the assisted living period. There is not enough consideration for the elderly inconvenience period. At the same time, there is a lack of effective service satisfaction evaluation and feedback mechanism. There is no response or even channel for the elderly to report their concerns to the institution. There is also a lack of democratic evaluation and feedback mechanism for working service personnel [3].

2.5. Poor financing.

The combination of medical and health care institutions has a strong public welfare, which is difficult to attract investors in the external market. Institutions only rely on financing channels such as old-age service fees paid by the elderly, government funds and financial subsidies. In addition, the initial construction cost of private pension institutions is high. The residential environment for the elderly and the combination of medical and nursing services provided are also higher than those provided by public pension institutions to a certain extent. At present, the occupancy rate of private pension institutions in China is low, so it takes a long time for institutions to realize profits [3]. Financing channels are not smooth, investment payback period is long, and capital turnover difficulties, resulting in the enthusiasm of pension institutions is not high.

3. Relevant suggestions

3.1. Policy and system update.

Policy should be updated at the national level. Including but not limited to the examination and approval regulations the combination of medical and health care, division of powers and responsibilities between the health and civil affairs departments, the integration of health insurance and pension insurance, for urban and rural residents medical insurance and the specific division of urban workers medical insurance.

First, the establishment of a relatively independent long-term care insurance system. The long-term care insurance system is the payment guarantee of the combination of medical and health care for the aged and is the inevitable need of the development of the combination of medical and health care for the aged. Long-term care insurance and medical insurance, endowment insurance exist huge difference, they should not be mixed. Of course, as a result of national standard of living place limited, collect care insurance premium alone at present may increase policy-holder and the burden, insurance premium of long-term care insurance can be included by medical treatment or endowment insurance collect, but should establish special insurance fund, pay a procedure specially, avoid mix with cure or endowment insurance.

Second, reform the management system of the combination of medical and health care. The mode of the combination of medical and health care involves multiple management departments, and it is easy to fight for power and shift responsibility when the ownership is unclear. Therefore, we must improve the current management system. We need to establish a supervisory system with distinct levels and consistent powers and responsibilities. First of all, the distribution of supervision responsibility between civil affairs department and health administration department should be clarified. The civil affairs department and the health administration department are the daily supervisors of the combination of medical and health care industry. On the one hand, multiple management will lead to multiple doors and increase the operating costs of the regulated industry. On the other hand, it will lead to shirking responsibilities and different powers and responsibilities.

Third, establish a regulatory mechanism. In the future, the combination of medical care and health care industry regulations should establish a detailed regulatory catalogue for specific sectors of the industry, clarify regulatory subjects and regulatory standards, and disclose regulatory information in a timely manner. Large data platform can be used for information sharing to timely find regulatory risks.

3.2. Public ownership is dominant and financing channels are expanded.

We should uphold the government’s dominant position in public ownership, ensure the public welfare of the combination of medical and health care, increase financial input, and create diversified financing mechanism, actively encourage and attract private capital and foreign capital to participate in medical combination of industry, but through tax cuts and other ways to encourage more enterprises or individuals set up and manage non-profit foundation, to support public welfare projects.

Banks should be encouraged to provide credit support for the combination of medical and health care industry, and the government should actively seek investors for the combination of medical and health care institutions, establish a wide range of social participation mechanisms. And promote the diversified development of the combination of medical and nursing care investors and investment methods.

3.3. Establish industry standards.

Due to the great differences in medical resources, social and economic development and people’s demand for the combination of medical and health care. It is suggested that the state should explore and popularize the industry standard for the combination of medical and health care. Different standards can be applied in different areas and measures should be taken according to local conditions to meet regional or urban and rural development levels.

What is most urgent is to establish standards for the use of medical resources, elderly service and corresponding service evaluation, which should also include the feedback evaluation of the elderly on the medical care institutions, so as to help form a benign environment for the development of the industry.

3.4. Strengthen the training and management of medical and health care professionals.

At present, the combination of medical and health care market in China is in short supply. The number of professional medical care service personnel is small and the level is low. Therefore, it is urgent to strengthen the construction of geriatric specialty and train the geriatric professional personnel team. Improve the professional quality of medical and health care service personnel through pre-job training.

In universities, colleges and universities of higher learning and technical secondary schools, we should set major which is related to the combination of medical and health care for the elderly, rehabilitation medicine and old-age care, combining clinical medicine, nursing, rehabilitation and public health.

To improve the shortage of talents in the combination of medical and nursing services, we should train high-quality professionals through various ways such as college training and on-the-job training.

It is necessary to establish a unified talent access standard for medical and health care service personnel in institutions and raise the admission threshold for medical and health care personnel. Personnel shall regularly participate in training and assessment after entry. To improve salary of the staff of the combination of medical and health care services and gradually perfect the personnel system. We have established a set of recruitment, training, assessment and incentive mechanisms for medical and health care personnel.

3.5. Strengthen the construction of humanistic spirit.

First, strengthen education on the current situation of aging society, policies and regulations on aging. Guide the whole society to accept, respect, and help the elderly. Improve the elderly self-esteem, self-reliance, self-reliance of self-love awareness [4].

Second, the people-oriented service concept should be implemented in the practice of combining medical care with medical care [2]. Relying on the large data of the Internet, we provide meticulous care for the elderly, so that they can live with more dignity, quality and hope. From the elderly’s mentality, psychological, social adaptability and other aspects of all-round services.

Thirdly, to satisfy the old people’s dependence on traditional medicine. Integrate traditional Chinese medicine elements to provide elderly care services, such as acupuncture, massage, herbal bath, etc., and implement them in a symptomatic manner, so that the elderly can live comfortably in a more familiar medical care environment.

Fourth, provide social services for the elderly. Allowing older people to find peers, regardless of family background or illness, is more likely to resonate.

4. Actively absorb the experience of other countries

Many countries in the world have already had rich experience in medical and health care. Russia, the same as China, is faced with a serious aging population problem [5]. The ratio of aging population in Russia is more severe and faces greater challenges (Fig. 2). Russia is a friendly and good-neighborly country of China. Two graduate students of this paper have the honor to have a deep understanding and study on the medical care of the elderly in Russia.

 

Fig. 2. The proportion of the elderly in total population in Russia and China

Рис. 2. Доля пожилых в структуре населения России и Китая

 

The medical care for the elderly in the Russian medical system shows a high degree of humanistic care, which is very worthy of learning from China.

About the authors

Yang Chunyan

Harbin Medical University, School of Humanity and Social Sciences

Author for correspondence.
Email: catspring@126.com

first author, PhD, Research Assistant. Candidate, majoring in medical and medical humanities

China

Zhang Hanwen

Harbin Medical University, School of Humanity and Social Sciences

Email: 1021033984@qq.com

co-author, graduate student, majoring in medical and medical humanities

China

Yin Mei

Harbin Medical University, School of Humanity and Social Sciences

Email: dryinmei@163.com

corresponding author, Professor, Doctoral Supervisor, working as Chief

China

References

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