The Model of Public-Private Joint Ownership of Chinese Medical Institutions and its Development and Prospects
The Health Management College of Harbin Medical University
Professor Du Le Xun
Summary：
nThis paper is entitled “The Model of Public-Private Joint Ownership of Chinese Medical Institutions and its Development and Prospects ”. The institution implemented system reforming could adopt the model of public-private joint ownership, so does that without system reforming. The reorganization could accelerate the cooperation; and the cooperation without reorganization also could expedite the restructuring. The reorganization is the mean by which we would achieve the goal of the public-private cooperation and the socialization, and attain the aim of good health promoting.
Summary：
nChinese public hospitals should carry out the transformation even if fail to reform its system. While the private hospital also need transforming. The transformation of hospitals is one of the prerequisites for unhampered development of public-private joint ownership and hospital socialization. The task of hospital transforming consists in reforming the old hospital that without clearly identified property rights into modern hospital that have clearly established ownership, which means clarifying the original ownership into the property right of investors and the legal persons’.
nResolving the contradictions between the original ownership of public-private and the socialization and internationalization of hospitals.
What Means Public? and What Means Private?
nTo study public-private cooperation, we must first define the meaning of public and private? The definitions are as follows:
n“Public ” is “the government” and “the functionary”; While “Private” is “non-government” and “the populace”.
n“Public ” is the public ownership，“Private” is private ownership.
n“Public ” is for non-profit, “Private” is for profit.
n“Public ” is the public company such as listed company; “Private” is the unlisted company, of which legal persons indiscriminately labeled as private legal persons regardless of the ownership of your investors belonging to public or private capital.
“Jinling Pharmaceutical” Annexed Suqian Town Hospital
n“Jinling Pharmaceutical” is a listed company, which was originally established by the army, later transferred to local unit and then to be listed. He has controlled the share and annexed Suqian Town Hospital with a total investment of RMB 70 millions in conformity with the views of Jiangsu Provincial Committee.
nAccording to the first definition it is the cooperation venture of public and private: the government cooperated with the non-government; According to the second definition it is the public and public joint ownership: state-owned enterprises cooperated with public hospitals; According to the third definition it is the cooperation of public and private: non-profit hospitals cooperated with profitable enterprises; According to the fourth definition it is another kind of public and private cooperation: the cooperation of listed company “Jinling Pharmaceutical” and private company “State-owned Assets Supervision and Administration Commission of Suqian City”
Privatization or Communization？
nThe merger of unlisted Suqian Town Hospital by “Jinling Pharmaceutical”, which is a China listed company owned by the whole people; the merge of unlisted Xinxiang Town Hospital by “Worldbest Life”, another China listed company owned by the whole people－both two cases suspected by Health Department are privatization or communization? Is it a failure or a great progress of reformation?
nIs it a positive approach of achieving public-private ownership to smash up the monopoly of public hospital or a failure reform of marketization and profitable?
The Decisions of the Central Committee of the Communist Party of China:
nThe public ownership could be and must be achieved by a variety of means;
nThe joint-stock system, namely the mixed public-private ownership of joint, partnership, cooperation venture is the primary means of achieving public ownership.
nI realized from the decisions of the Central Committee of the Communist Party of China and international experience that the mixed ownership, namely the public-private ownership of joint, partnership and cooperation venture was a bright road for the development of public hospitals.
Could the profitable company establish the public welfare hospital?
nInternational Experience：
nAmerican Hospital Management Company has already established a number of public welfare hospital；
nThe profitable company in American established some non-profit hospitals by raising charity funds.
Could the profitable company establish the public welfare hospital?
nDomestic Experience ：
nFormosa Plastics Group established Chang Gung Hospital for the public welfares ;
nThe profitable Daqing Petrol Develop Group established Daqing Oilfield General Hospital Group for the public welfares;
nWorldbest Group and Jinling Pharmaceutical established hospital group for the public welfares；
nThe Regulatory Commission of Tianjin Teda Development Area established Teda International Cardiovascular Hospital for the public welfares ；
nThe state-owned hospital is under Zhong Mei Hua Yi Investment & Management Co.,Ltd. trusteeship.
The Cooperation Bond Between Profitable and Non-Profit Organization
nThe Pattern of Capital Operating and the Approach of Quick Return of Investment：
nThe shareholding system: the public hospital obtained the dividends from investing in profitable hospital.
nTrusteeship Operation: the public hospital acquired admin fee by means of entrusting profitable hospital; the profitable enterprises acquired admin fee by means of entrusting non-profit hospital;
nFinance Leasing: the profitable company collect rents from lease business with the public hospital.
The Cooperation Bond Between Profitable and Non-Profit Organization
nThe Pattern of Capital Operating and the Measure of Return of Investment：
nFranchise Operation: the profitable company or public hospital acquired admin fee from entrusting profitable or non-profit hospital with franchise operation.
nMembership System: the membership system is a system of cooperation, of which all members qualify for a small amount of bonus.
nFinancing: the cash flow of public hospital could be the internal bank of hospital group. The non-profit Chang Gung Hospital gained the interest from making loans to profitable Formosa Plastics Group; the profitable Formosa Plastics Group could receive preferential low-interest loans with lenient time limit.
Public Institutional Units Establish the Profitable Hospital
nDomestic Experience：
nMerger Model:
nShanghai Hua Shan Public Hospital invested in profitable hospitals；
nBeijing Tongren Public Hospital controlled the share and invested in Nanjing and Kunming Tongren Hospital；
nTrusteeship Model:
nThe government entrusted various hospitals to the hospital management center of Wuxi and Shanghai；
nJinling Pharmaceutical Group entrusted Suqian People’s Hospital to Nanjing Drum Tower Public Hospital.
Sino-Foreign Public-Private Cooperative Hospital
nModel Cases：
nOur government encourage overseas Chinese and foreign capital and fund to invest in profitable and non-profit hospital in China. The foreign capital and fund could control 70% share and find a partner in china.
nZhe Jiang University together with overseas Chinese entrepreneurs established Sir Run Run Shaw Hospital；
nShanghai Hua Shan Hospital together with foreign business establish profitable medical organization “Shanghai Hua Shan Health Company” ；
nThe foreign business together with Chinese Academy of Medical Sciences established United Family Hospitals and Clinics；
nTongguan Tung Wah Hospital founded by Hong Kong businesses.
The Prospect of Development of Public-Private Ownership and the Sino-Foreign Cooperative Hospital: the Purpose of Cooperation
nSmash up the monopoly of public hospitals in Health Department:
Forcing the public hospital to carry out the reformation and transformation; Building free competition situation of Chinese medical treatment market; Extricating from the hardship of Difficult medical services and expensive medical cost; Developing the comfortable relationship between doctors and patients.
nHelp the reformation and transformation of public hospitals with capital and fund investment：
Taking on basic medical and health service by establishing veritable public hospital;
Taking on medical care insurance service by establishing veritable public hospital;
Taking on particular medical service by establishing veritable public hospital;
nModernizing the governance structure from helping public hospital clarifying the ownership.
nFulfilling the reformation of admin system by helping the government separating the administration from business.
The Prospect of Development of Public-Private Ownership and the Sino-Foreign Cooperative Hospital: The Model
nThe Medical Group of Limited Liability Company：
n such as Jinling Pharmaceutical; Worldbest Life; Daqing Medical;
nThe Medical Group of Unlimited Liability Centre：
n such as Wuxi Medical Centre; Shanghai Medical Centre;
nThe Medical Group that Centered on Public Hospitals：
n such as Drum Tower Hospital Group; Hua Shan Hospital Group；
nThe Medical Group that Centered on Foreign-funded Limited Liability Company:
n such as United Family Hospitals and Clinics
The Prospect of Development of Public-Private Ownership and the Sino-Foreign Cooperative Hospital: the Art of Financing
nThe Art of Mergers and Acquisitions：Worldbest Group; Phoenix Group
nThe Art of Trusteeship Operation：Drum Tower Hospital Group
nThe Art of Finance Leasing：Zhejiang Financial Leasing Company
nThe Art of Management Buy Out：Zhong Mei Group
nThe Art of Strategic Investor：Zhong Mei Group
nThe Art of Franchise Chain Operation：Tongren Hospital Group
nThe Art of Commonweal Funds Endowment ：Sir Run Run Shaw Hospital
nThe Art of Commonweal Funds Investment：the model of Chang Gung Hospital of Formosa Plastics Group
The Driving Force:
nOverseas Finance Corporations and Foundations ；
nForeign Banks；
nThe Capital of Overseas Chinese and Foreign Citizen of Chinese Origin；
nOverseas Hospital Investment and Management Companies；
nOverseas Hospitals；
The Operating Public Capital Absolutely Could Establish the Non-Profit Hospitals
The operating public capital could absolutely establish the non-profit hospitals, Daqing Hospitals Group for example, Jinling Pharmaceutical and Worldbest Life later joining in.
The operating private capital also could absolutely establish the non-profit hospitals, Yanshan Petrol Hospital and Tianjing Teda Hospital for example, the profitable Formosa Plastics Group established Chang Gung Hospital for the public good.
If the operating public assets that converted from non-profit public assets was under the centralized management of State-owned Assets Supervision and Administration Commission, it could fully establish non-government non-profit hospitals. It was reported that the assets of public hospital that adhere to Shanghai Hospital Management Center was under the centralized management of State-owned Assets Supervision and Administration Commission of Shanghai.
Placing hopes on:
n1. State-owned Assets Supervision and Administration Commission network especially including the listed companies:
nSuch as State-owned Assets Supervision and Administration Commission of Shanghai；
nWorldbest Life Group；
nJinling Pharmaceutical Group；
n999 Group.
n2. The Investment Bank and the Foundation
nIn the status of strategic investor
nSupporting Chinese high quality physicians group achieving Management Buy Out；
nPromoting the development by financing from listing shares abroad.
明晰产权改造公立医院
<中国国有医院产权制度研究>课题组负责人杜乐勋:明晰产权改造公立医院
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离开医院,任何医疗体制改革都不会从根本上解决问题。
现阶段,公立医院面临的主要问题是公益性淡化,私益性强化。根本问题仍是体制问题。
改革旧有的医疗体制,必须破除垄断,培育公平竞争的医疗市场。而公立医院改革的目标选择是,建立产权明晰的现代医院制度。
医改纷争背后的实质是什么?对于花甲之年的杜乐勋来说,或许很有发言权。
24年前,杜乐勋创建中国第一个卫生经济学教研室,开启了从经济角度研究卫生事业的先河;他带领的团队,帮助卫生部测算了我国第一个"全国卫生总费用"的数额。
公立医院如何改革?是新医改方案中一个绕不开的命题,也是改革最深、最难的环节。
杜乐勋的理解是,必须改革旧有的医疗体制,破除垄断,培育公平竞争的医疗市场。而公立医院改革的目标选择是,建立产权明晰的现代医院制度。
问题不能归咎于公立医院改制
<21世纪>:有一种观点是,由公立医院改制为核心的"市场化医改"不成功,并引发了去年开始的医改大讨论。你怎么看待各地公立医院改制?
杜乐勋:先要定义什么是公立医院。我认为,公立医院是指政府举办的纳入财政预算管理的医院。到目前为止,我们谁都没有读到一份由国务院正式公布的文件,明确规定如何进行公立医院改制改造的政策措施办法。
卫生部组织相关专家,也对全国医院产权改制的全面情况进行了"摸底"调查,调查显示,全国医院改制率不到2%,并没有出现大规模的改制现象。这种情况下,怎么能说所谓"医改不成功"是由公立医院改制带来的呢?
现在,各地都有公立医院改制改造的案例,大多属于地方政府的改革探索和研究。
<21世纪>:目前医改方案讨论热烈,集中在政府财政投入"补需方"还是"补供方"。你持何种观点?
杜乐勋:八路方案其实只有三路。卫生一路、社保一路,财政一路。
卫生医改路,权且称为政府主导路。政府主导基本公共卫生服务提供、基本医疗服务提供、基本药物提供。政府加大对政府主导的基本公共卫生服务提供方、基本医疗服务提供方、基本药物提供方的财政投入。经费实行收支两条线管理,收大于支结余上缴"财政小金库",收小于支超支部分"财政小金库"兜底。这是轻车熟路。
社会保险路,权且称为大病统筹路。主张政府主导下利用市场机制。政府主导全民多层次基本医疗保险筹资,政府财政为政府主导的全民多层次基本医疗保险筹资兜底。政府主导下鼓励竞争,公私合伙多渠道多形式办医。
公共财政路,权且称为有限责任路。公共财政对卫生工作承担的有限责任就是公共卫生服务和弱势人口基本医疗和医疗救助。运行机制就是政府转移支付和政府购买产品和服务。政府要加大财政卫生投入,但是,加大投入必须有依据,这个依据就是区域卫生规划。
我赞成"补需方",即赞成政府通过医疗保险局,补助城市居民参加基本医疗保险,在居民生了大病时医疗保险局替居民支付医院医疗费。我也赞成"补供方",即赞成政府通过<公共卫生项目>、<疾病控制项目>、<健康促进项目>、<健康管理项目>支持各类卫生机构发展。但是,不赞成那种"大锅饭、不核算、一刀切、独家办"的"补供方"。
"恢复公益性"逻辑不通
<21世纪>:有观点认为,取消以药养医机制,加大对公立医院投入,恢复其公益性,就会解决目前医药领域的诸多问题。你赞同吗?
杜乐勋:这个观点是处于垄断地位的伪公立医院对政府施加的压力。这种观点的逻辑是,"你不加大投入,我就不能改变以药养医机制,我不能改变以药养医机制,我就不能恢复公益性,医药领域的诸多问题解决不了就不要赖我。"
政府不是没有钱,不是不愿意加大投入,问题是你效率这么低行不行。企业医院,民营医院如果技术效率和分配效率高,政府同样加大投入。
<21世纪>:以宿迁医改为代表的公立医院改革模式曾受到质疑,如何评价宿迁医改模式?
杜乐勋:我本人1998年从国家科技部接受软科学项目<中国医院产权制度改革>以来到今年已经8年了。
经过8年的探索,我发现医疗机构的改制,具体情况太复杂。改制必须划出界限,但又不能一刀切。各地发展不均衡,很难用统一标准衡量。因此,怎么改制并不是关键问题。关键是什么医院可以改制,什么医院不能改制,这是新医改中要首先明确界定的。
我对宿迁医改模式的评价如下:
我国农村卫生改革出现过三次遭遇非议的事件。一个是温州模式;一个是辽宁海城模式;再一个是江苏宿迁模式。三次事件都毫无例外地触及农村三级医疗网的网底。
合作医疗解体了,村卫生室个体承包了,现在,卫生院也要卖了。于是乎"不能一卖了之" "国有资产流失"等观点满天飞。
对宿迁医改的评价不应该把基点放在"批判"上,应该立足于正确引导和帮助上。首先,应该肯定基层政府部门改革的动机是为了发展卫生事业,而不是破坏卫生事业不是为了牟利;其次,要帮助基层认识政府的公共卫生责任;第三,要派遣工作组鼓励帮助基层把改革引导到符合区域卫生规划的方向。
据统计,2002年中国农村有44992家乡镇卫生院,其中有26399家以上的卫生院面临改制。我们认为,政府加强县公立医院和村卫生中心建设,乡卫生院走公共卫生派出所道路的宿迁模式前途光明。
<21世纪>:公立医院目前存在什么问题?改革的方向到底是什么?
杜乐勋:公立医院的主要问题是公益性淡化,私益性强化。不能正确处理公共利益和私人利益之间的关系。把私人利益伪装成为部门和单位利益。在部门和单位利益的伪装下偷卖私货,成为腐败的温床。
根本问题是体制问题。公立医院必须明晰产权,就是明晰出资人产权和法人产权。出资人产权必须到位和法人产权面对面进行扁平化管理。现在的公立医院名义上叫公有制,其实已经变为职工所有制,就是因为出资人不到位。所以公立医院管办分离、政事分开,成立代表出资人利益的医院管理委员会或医院管理中心,是解决公立医院问题的出路。这就叫做公立医院改造。
民营医院是培育对象
<21世纪>:有观点认为,民营医院是赢利性的,不能像公立医院那样承担公共卫生服务,社会资本和公益性一定相矛盾?民营医院是否能办成非营利性的?
杜乐勋:我不认为民营医院都是营利性的。将来,民营医院的大多数可能是非营利性的,如享受免税待遇,承担公共卫生服务、扶贫救助服务。
有的民营医院可以办成营利性医院,但是,他们纳税收作出了贡献。比一不纳税、二不减轻病人负担、三要政府加大投入,并且十分霸道蛮不讲理的假公立医院强多了。
当然,我国许多民营医院处于资本原始积累阶段。如同当年温州的民营资本走的路,走假冒伪劣路。打一枪换一个地方。我相信真金不怕火炼,经过医疗市场的筛选,一批优秀的民营医院精英会脱颖而出。
<21世纪>:在目前的医改讨论中,民营医院群体成为"沉默的一员"。您认为,未来的中国医疗市场,民营医院和公立医院是什么定位?
杜乐勋:在目前的医改讨论中,民营医院群体成为"沉默的一员"是正常的。公益性淡化,需要改造的是公立医院,而民营医院不是改造对象而是培育对象。
1992年全国共有医院17844家,其中政府办的公立医院9221家,非政府办的民营医院8623家。构成比是公立医院51.67%,营利性民营医院10.04%,非营利民营医院38.28%。
我预计,将来公立医院的比重可能下降到30%左右;营利性医院的比重不会增加很多,如果有税收优惠,其比重也不可能超过20%。公立医院的比重下降主要原因是公立医院职能转变,相当一部分公立医院转型为社区卫生服务指导中心。会有一些公立非传染病专科医院改制,数量不会很多。三级大医院的数量会减少。
公立医院今后走惠民医院道路,而民营营利性医院走特需医疗服务道路,民营非营利性医院走基本医疗保险的道路。
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