三明医改：一直被质疑从未被问倒-经营战略-医院绩效咨询,医院绩效管理,医院管理咨询 -九鼎医院管理顾问

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三明医改：一直被质疑从未被问倒

提交者：jiuding发表时间：2016-5-5点击次数：2906来源:本站整理

　　“三明医改模式”到底好在哪里呢?先看看下面这一组数据吧:

　　12997万：这个数字是2015年三明市职工医保统筹基金当期结余的数字，而在2011年，这个数字是负20800多万元。三明医改不仅扭转了收不抵支的局面，医保基金可持续性增强。

　　25.74%：这是2015年三明市药品占比数字，达到国务院医改意见提出药占比下降到30%以下的标准。药占比通俗来讲就是病人看病的过程中，买药的花费占总花费的比例。2011年，三明全市的药占比是46.77%，药品费用为9亿。

　　148元：老百姓医疗费用大幅下降，全市22家县级以上医院住院平均费用仅为5174.3元，平均住院天数8.34天，药占比为25.74%，门诊平均费用仅为147.94元。

　　50%：三明市实行了医生目标年薪制，参照国际上医生收入一般为社会平均收入3~5倍的惯例。在工资总额下，向一线人员倾斜，医生、护士和行政后勤团队分别占50%、40%和10%。

　　这些闪亮的医改成绩单，不得不让人惊叹：三明医改成功地实现了患者、医生、医院、政府的“多赢”!但这种“多赢”并不是被所有人都认可，三明医改模式面临肯定与质疑。今天我们就带着这些疑问和不同的声音采访了福建三明市委常委、宣传部长、市医改领导小组组长詹积富，一起看看他是如何解读这些质疑的!

　　詹积富是三明市委常委、宣传部长、市医改领导小组组长，是三明医改的领军人物。

　　按照三明市政府领导分工的传统做法，教科文卫与社会保障及社会救助分别由两位市领导分管，具体的管理职能则分散到卫生局、人事局、发改委和财政局等。改革开始后，三明将有关“三医”的政府职能部门都集中归口给了时任副市长的詹积富分管，给予充分授权，具体事务上其他领导都不干预。三明市医改领导小组出台的90多份文件，全部由他一人签发。

　　一问：政府主导医改是否有违背“简政放权”的方针？

　　有人认为，三明医改是通过强势政府、铁腕改革来解决，并不是通过市场化来解决的。三明医改模式对于当前医疗问题——医疗市场垄断、医生不能自由执业、医疗服务可靠性差等问题，并不能解决，甚至政府强力推进的改革导致政府扩权，在市场开放等问题上会开倒车。而这与国家提倡的“简政放权”相违背。

　　在詹积富看来，“三明医改中政府是从为老百姓提供基本医疗保障的目标出发，而非强权政策，这与习总书记说的政府要承担领导改革的责任，提供保障责任是统一的。

　　政府是为人民服务的，而且政府本身必须承担一定的保障责任，比如，为老百姓提供基本的教育、基本的公共安全保障，基本的医疗保障，甚至是基本的住房保障等。

　　都说医改难，难在哪里？难在九龙治水。各部门之间利益难以打破，互相推诿。所以，三明医改的第一步就是制度改革。詹积富强调，“三明市首先理顺了领导体制，将涉及医疗、医保、医药等领域的事情归由一人管理，打破多头共管的局面，真正做到三医联动。然后，理顺政府部门与公立医院之间的权责。政府部门应该将医院围墙内的权力交还给院长，由政府承担的责任，政府必须担起来。”

　　“三明医改是以公立医院为主体，不能完全走市场路线，那么老百姓的看病费用或许更高。而政府引导医改在这里起到的是保障作用和功能，为老百姓提供基础医疗保障。因为医疗医药是个特殊行业，医患关系是性命相托的关系，所以，不是简单的商品买卖，不能按市场路线走，要保持公立医院的公益性。

　　据詹积富介绍，三明市公立医院的基本建设和设备购置、重点学科发展、公共卫生服务的投入均由政府负责。对改革前的公立医院历史债务问题，经调查后，统一纳入政府性债务统一管理。

　　而对于公立医院的人事任命、日常运营等事宜，詹积富认为应该归还给公立医院，政府在其中可以发挥管理与监督功能。三明市将医改工作纳入各级政府绩效考核，建立了院长绩效评价体系。政府积极承担相应职责，而公立医院则可以回归公益性。

　　当然，在公立医院改革的内部，比如医生薪酬制度、药品采购，我们都是放手给市场的，根据市场供需关系来定价。”詹积富介绍道。

　　二问：很多医护因年薪制分配不公平、打消积极性而流失？

　　对于网上流传的三明市医护人员流失严重、医生抱怨薪酬制度不公平等情况，詹积富自信地说：“2011年三明医改前，22家公立医院工资总额是3.8亿元，人均是4万元左右，而2015年医生工资总额是8.95亿，平均工资近9万元，这个工资可能跟北京、上海没办法比，但是对三明当地来说，已经是有很大变化了。其实医护人员的流动很正常，也是一直都存在的问题，有这种担忧是正常的，但我可以肯定得说，三明医改之后，流入的医生远多于流失的医生。我这里有一个详细的数据，从2013年至2015年，三明市直医疗卫生单位人才流失共计96人，而这三年里，分别招聘进来502人、421人和406人，共计1329人，这些流入的人才数字就是一个很好的说明。”

　　医生薪酬制度改革是医改的重要一环，因为医院的主体是医务人员，如果无法保障他们的薪酬待遇，又如何能调动他们的积极性？

　　“医改需要建立新机制，建立有激励、有约束的公益性运行机制，使控制成本、提高质量、改善服务成为公立医院院长和医务人员的内在动力，从根本上解决医务人员的激励问题。”詹积富说。

　　因此，三明市推行院长、医务人员目标年薪制，院长年薪由财政拨付，不与医院收入挂钩。对院长，主要考核次均费用、药占比、住院率等体现办院方向的指标，医务人员则考核工作量、医德医风。

　　“以前公立医院院长的权利太大，基本上一个人说了算，购买医疗器械拿回扣，灰色收入很多，但下面的医生薪水都是与科室创收相关，只有多开药多做检查增加科室收入，才能多拿奖金，拿药品回扣等等，这就让医生失去了看病的本质，比如现在的医生动不动就开抗生素，动不动就打吊瓶，出现了多少的抗生素耐药？这些都是非常可怕的。”

　　“现在通过取消药品加成、整顿用药秩序和增加医务人员合法收入，扭转了医务人员激励机制。现在让医生以前的灰色收入变成阳光工资，工资略有增长，就能让医生一心看病，回归看病角色。”詹积富介绍，现在医院的收入与医生薪酬无关，医生薪水实行工分制，不同岗位工分数不一样，可以缩小各科室的薪水差距。这是按照市场机制来做的。

　　三问：患者买不到廉价药，是药品限价采购带来的副作用？

　　在三明医改的成绩单上，我们看到患者的医疗费用明显降低，按理说，患者应该是最满意的一方，但是由于药品限价采购，事实上很多常用的好药并不能在医院买到，因此，患者也存在很多抱怨。

　　说起药价改革，詹积富认为，药品回扣问题不单纯是药品加成的问题，实质上应该是药品流通领域的问题。“90年代的时候，药品交易费顶多是一条毛巾、一件小家电;现在，药品流通领域充满了违法行为。”詹积富强调，由于可以过票、洗钱，滋生出了药品灰色收入的空间。

　　对于廉价药的断供和缺失，詹积富认为，其实廉价药的缺失并不是现在才有的，是一直都有，也并不是因为廉价才消失，而是因为药品质量与价格相关系数低于0.5，医药代表觉得没有利润可图，也不积极推销。

　　此外，很多廉价药医生无回扣可拿，所以在医生处方中开出较少，导致市场销售量很低，药企批量生产后浪费量很大，所以，廉价药逐渐消失，医生都去开高价药了。

　　三明医改很重要的一环就是打破以药养医的格局，撬动药品灰色利益链条，降低虚高的药价。“之所以药品水分那么多，是因为药品招标采购过程中大多是药代公司，并不是直接跟药企公司对接，医药代表在中间中转的利润非常大，他们还要给医生药品回扣，让医生无法专心治病，乱开高价药;而药企生产的一些廉价药以出厂价给他们，利润空间很低，药代也不愿意多推广，医生拿的回扣少，也不愿意开这类药，所以，廉价药越来越少。做药代的这些人都是有医学背景的，挤占他们的利润空间，让他们无利润可图，让这个行业净化，甚至消失，或许能让这些人回归医生职位。”詹积富坦言。

　　四问：有药企对于三明医改中的药品限价采购怨声载道，甚至放弃三明市场？

　　三明医改领导小组组长詹积富认为：“改革是整个利益的调整，这是非常困难的”，“医改难的不是投入，不是方案，而是决心”。

　　三明医改究竟动了谁的奶酪？这其中既有卫生部门与人社部门争夺医保管理权力的持久战，也有要医药定价权的战争，同时还触动了医药公司、医生灰色收入等多重利益。

　　三明要做的就是挤掉这中间的水分。所以，三明想出了药品限价采购的做法。改革后，医药费用得到有效控制，医药总费用从2006年-2011年年均19.4%的增长速度，下降到了8.7%，次均门(诊)费用增长5.89%，低于全国17.8%平均增速。出院者平均医药费用实现负增长，实现了总药品费和次均药品费双降。

　　这样大刀阔斧的改革药价，挤占药品利润空间，使得一些药商有意绕开三明市场，造成部分药品无药可配。三明市医管中心数据显示，有54种药在2015年第一季度缺货无法配送的情况超过20次。有的药商还利用各种关系给政府施加压力。

　　詹积富对此很无奈，“如果在福建降价，其他省份必然也会来压低价格。医药代表为了维护全国的高价，不会轻易在福建省降价。”詹积富说，三明的用药费仅占福建全省的3.28%，而福建只占全国的3.25%，因此对药商而言，三明是一个可以放弃的市场，甚至福建市场也可以放弃。

　　因此，詹积富希望能够有更多城市联合三明一起，做药品限价采购，目前，已经有乌海、宁波、玉溪、珠海等四个城市参与其中，只有这样才能形成较大的市场，举全国之力去议价，才能真正降低药品价格，才能真正让老百姓受益。

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Configure Command	cscript /nologo configure.js "--enable-snapshot-build" "--enable-debug-pack" "--disable-zts" "--disable-isapi" "--disable-nsapi" "--without-mssql" "--without-pdo-mssql" "--without-pi3web" "--with-pdo-oci=c:\php-sdk\oracle\x64\instantclient_12_1\sdk,shared" "--with-oci8-12c=c:\php-sdk\oracle\x64\instantclient_12_1\sdk,shared" "--with-enchant=shared" "--enable-object-out-dir=../obj/" "--enable-com-dotnet=shared" "--with-mcrypt=static" "--without-analyzer" "--with-pgo"
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Virtual Directory Support	disabled
Configuration File (php.ini) Path	C:\Windows
Loaded Configuration File	D:\PHPWEB\php\php.ini
Scan this dir for additional .ini files	(none)
Additional .ini files parsed	(none)
PHP API	20131106
PHP Extension	20131226
Zend Extension	220131226
Zend Extension Build	API220131226,NTS,VC11
PHP Extension Build	API20131226,NTS,VC11
Debug Build	no
Thread Safety	disabled
Zend Signal Handling	disabled
Zend Memory Manager	enabled
Zend Multibyte Support	provided by mbstring
IPv6 Support	enabled
DTrace Support	disabled
Registered PHP Streams	php, file, glob, data, http, ftp, zip, compress.zlib, compress.bzip2, https, ftps, phar
Registered Stream Socket Transports	tcp, udp, ssl, sslv3, tls, tlsv1.0, tlsv1.1, tlsv1.2
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Features
AsynchDNS	Yes
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Host	x86_64-pc-win32
SSL Version	OpenSSL/1.0.2q
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libSSH Version	libssh2/1.8.0

date/time support	enabled
"Olson" Timezone Database Version	2016.10
Timezone Database	internal
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DOM/XML	enabled
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JPEG Support	enabled
libJPEG Version	9 compatible
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WebP Support	enabled

iconv support	enabled
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OpenSSL support	enabled
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Openssl default config	c:/usr/local/ssl/openssl.cnf

PCRE (Perl Compatible Regular Expressions) Support	enabled
PCRE Library Version	8.38 2015-11-23

PDO Driver for PostgreSQL	enabled
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json support	enabled
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PostgreSQL Support	enabled
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Directive	Local Value	Master Value
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pgsql.max_links	Unlimited	Unlimited
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gzip compression	enabled
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ALLUSERSPROFILE	C:\ProgramData
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APP_POOL_CONFIG	C:\inetpub\temp\apppools\wwwroot\wwwroot.config
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CommonProgramFiles	C:\Program Files\Common Files
CommonProgramFiles(x86)	C:\Program Files (x86)\Common Files
CommonProgramW6432	C:\Program Files\Common Files
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OS	Windows_NT
Path	C:\Windows\system32;C:\Windows;C:\Windows\System32\Wbem;C:\Windows\System32\WindowsPowerShell\v1.0\;D:\Program Files\Microsoft SQL Server\110\DTS\Binn\;D:\Program Files (x86)\Microsoft SQL Server\110\Tools\Binn\;D:\Program Files\Microsoft SQL Server\110\Tools\Binn\;D:\Program Files (x86)\Microsoft SQL Server\110\Tools\Binn\ManagementStudio\;C:\Program Files (x86)\Microsoft Visual Studio 10.0\Common7\IDE\PrivateAssemblies\;D:\Program Files (x86)\Microsoft SQL Server\110\DTS\Binn\;C:\sslctlw;C:\Windows\system32\config\systemprofile\AppData\Local\Microsoft\WindowsApps
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TMP	C:\Windows\TEMP
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_SERVER["ProgramData"]	C:\ProgramData
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_SERVER["SystemRoot"]	C:\Windows
_SERVER["TEMP"]	C:\Windows\TEMP
_SERVER["TMP"]	C:\Windows\TEMP
_SERVER["USERDOMAIN"]	WORKGROUP
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_SERVER["windir"]	C:\Windows
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_SERVER["HTTPS_KEYSIZE"]	256
_SERVER["HTTPS"]	on
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_SERVER["CERT_COOKIE"]	no value
_SERVER["AUTH_USER"]	no value
_SERVER["AUTH_PASSWORD"]	no value
_SERVER["AUTH_TYPE"]	no value
_SERVER["APPL_PHYSICAL_PATH"]	D:\wwwroot\yyjg.net\wwwroot\
_SERVER["APPL_MD_PATH"]	/LM/W3SVC/1/ROOT
_SERVER["IIS_UrlRewriteModule"]	7.1.0871.0
_SERVER["HTTP_USER_AGENT"]	Mozilla/5.0 AppleWebKit/537.36 (KHTML, like Gecko; compatible; ClaudeBot/1.0; +claudebot@anthropic.com)
_SERVER["HTTP_HOST"]	www.yyjg.net
_SERVER["HTTP_COOKIE"]	PHPSESSID=l7e32724aqgacdm4pgeepkrjj1
_SERVER["HTTP_ACCEPT_ENCODING"]	gzip, br, zstd, deflate
_SERVER["HTTP_ACCEPT"]	/
_SERVER["HTTP_CONNECTION"]	close
_SERVER["FCGI_ROLE"]	RESPONDER
_SERVER["PHP_SELF"]	/admin.php/index/view/aid/10492.html
_SERVER["REQUEST_TIME_FLOAT"]	1789709600.2359
_SERVER["REQUEST_TIME"]	1789709600

PHP Authors
Contribution	Authors
Zend Scripting Language Engine	Andi Gutmans, Zeev Suraski, Stanislav Malyshev, Marcus Boerger, Dmitry Stogov, Xinchen Hui, Nikita Popov
Extension Module API	Andi Gutmans, Zeev Suraski, Andrei Zmievski
UNIX Build and Modularization	Stig Bakken, Sascha Schumann, Jani Taskinen
Windows Port	Shane Caraveo, Zeev Suraski, Wez Furlong, Pierre-Alain Joye, Anatol Belski
Server API (SAPI) Abstraction Layer	Andi Gutmans, Shane Caraveo, Zeev Suraski
Streams Abstraction Layer	Wez Furlong, Sara Golemon
PHP Data Objects Layer	Wez Furlong, Marcus Boerger, Sterling Hughes, George Schlossnagle, Ilia Alshanetsky
Output Handler	Zeev Suraski, Thies C. Arntzen, Marcus Boerger, Michael Wallner

SAPI Modules
Contribution	Authors
AOLserver	Sascha Schumann
Apache 1.3 (apache_hooks)	Rasmus Lerdorf, Zeev Suraski, Stig Bakken, David Sklar, George Schlossnagle, Lukas Schroeder
Apache 1.3	Rasmus Lerdorf, Zeev Suraski, Stig Bakken, David Sklar
Apache 2.0 Filter	Sascha Schumann, Aaron Bannert
Apache 2.0 Handler	Ian Holsman, Justin Erenkrantz (based on Apache 2.0 Filter code)
Caudium / Roxen	David Hedbor
CGI / FastCGI	Rasmus Lerdorf, Stig Bakken, Shane Caraveo, Dmitry Stogov
CLI	Edin Kadribasic, Marcus Boerger, Johannes Schlueter, Moriyoshi Koizumi, Xinchen Hui
Continuity	Alex Leigh (based on nsapi code)
Embed	Edin Kadribasic
FastCGI Process Manager	Andrei Nigmatulin, dreamcat4, Antony Dovgal, Jerome Loyet
ISAPI	Andi Gutmans, Zeev Suraski
litespeed	George Wang
NSAPI	Jayakumar Muthukumarasamy, Uwe Schindler
phpdbg	Felipe Pena, Joe Watkins, Bob Weinand
phttpd	Thies C. Arntzen
pi3web	Holger Zimmermann
Sendmail Milter	Harald Radi
thttpd	Sascha Schumann
tux	Sascha Schumann
WebJames	Alex Waugh

Module Authors
Module	Authors
BC Math	Andi Gutmans
Bzip2	Sterling Hughes
Calendar	Shane Caraveo, Colin Viebrock, Hartmut Holzgraefe, Wez Furlong
COM and .Net	Wez Furlong
ctype	Hartmut Holzgraefe
cURL	Sterling Hughes
Date/Time Support	Derick Rethans
DB-LIB (MS SQL, Sybase)	Wez Furlong, Frank M. Kromann
DBA	Sascha Schumann, Marcus Boerger
DOM	Christian Stocker, Rob Richards, Marcus Boerger
enchant	Pierre-Alain Joye, Ilia Alshanetsky
ereg	Rasmus Lerdorf, Jim Winstead, Jaakko Hyvätti
EXIF	Rasmus Lerdorf, Marcus Boerger
fileinfo	Ilia Alshanetsky, Pierre Alain Joye, Scott MacVicar, Derick Rethans
Firebird driver for PDO	Ard Biesheuvel
FTP	Stefan Esser, Andrew Skalski
GD imaging	Rasmus Lerdorf, Stig Bakken, Jim Winstead, Jouni Ahto, Ilia Alshanetsky, Pierre-Alain Joye, Marcus Boerger
GetText	Alex Plotnick
GNU GMP support	Stanislav Malyshev
Iconv	Rui Hirokawa, Stig Bakken, Moriyoshi Koizumi
IMAP	Rex Logan, Mark Musone, Brian Wang, Kaj-Michael Lang, Antoni Pamies Olive, Rasmus Lerdorf, Andrew Skalski, Chuck Hagenbuch, Daniel R Kalowsky
Input Filter	Rasmus Lerdorf, Derick Rethans, Pierre-Alain Joye, Ilia Alshanetsky
InterBase	Jouni Ahto, Andrew Avdeev, Ard Biesheuvel
Internationalization	Ed Batutis, Vladimir Iordanov, Dmitry Lakhtyuk, Stanislav Malyshev, Vadim Savchuk, Kirti Velankar
JSON	Omar Kilani, Scott MacVicar
LDAP	Amitay Isaacs, Eric Warnke, Rasmus Lerdorf, Gerrit Thomson, Stig Venaas
LIBXML	Christian Stocker, Rob Richards, Marcus Boerger, Wez Furlong, Shane Caraveo
mcrypt	Sascha Schumann, Derick Rethans
MS SQL	Frank M. Kromann
Multibyte String Functions	Tsukada Takuya, Rui Hirokawa
MySQL driver for PDO	George Schlossnagle, Wez Furlong, Ilia Alshanetsky, Johannes Schlueter
MySQL	Zeev Suraski, Zak Greant, Georg Richter, Andrey Hristov
MySQLi	Zak Greant, Georg Richter, Andrey Hristov, Ulf Wendel
MySQLnd	Andrey Hristov, Ulf Wendel, Georg Richter, Johannes Schlüter
OCI8	Stig Bakken, Thies C. Arntzen, Andy Sautins, David Benson, Maxim Maletsky, Harald Radi, Antony Dovgal, Andi Gutmans, Wez Furlong, Christopher Jones, Oracle Corporation
ODBC driver for PDO	Wez Furlong
ODBC	Stig Bakken, Andreas Karajannis, Frank M. Kromann, Daniel R. Kalowsky
OpenSSL	Stig Venaas, Wez Furlong, Sascha Kettler, Scott MacVicar
Oracle (OCI) driver for PDO	Wez Furlong
pcntl	Jason Greene, Arnaud Le Blanc
Perl Compatible Regexps	Andrei Zmievski
PHP Archive	Gregory Beaver, Marcus Boerger
PHP Data Objects	Wez Furlong, Marcus Boerger, Sterling Hughes, George Schlossnagle, Ilia Alshanetsky
PHP hash	Sara Golemon, Rasmus Lerdorf, Stefan Esser, Michael Wallner, Scott MacVicar
Posix	Kristian Koehntopp
PostgreSQL driver for PDO	Edin Kadribasic, Ilia Alshanetsky
PostgreSQL	Jouni Ahto, Zeev Suraski, Yasuo Ohgaki, Chris Kings-Lynne
Pspell	Vlad Krupin
Readline	Thies C. Arntzen
Recode	Kristian Koehntopp
Reflection	Marcus Boerger, Timm Friebe, George Schlossnagle, Andrei Zmievski, Johannes Schlueter
Sessions	Sascha Schumann, Andrei Zmievski
Shared Memory Operations	Slava Poliakov, Ilia Alshanetsky
SimpleXML	Sterling Hughes, Marcus Boerger, Rob Richards
SNMP	Rasmus Lerdorf, Harrie Hazewinkel, Mike Jackson, Steven Lawrance, Johann Hanne, Boris Lytochkin
SOAP	Brad Lafountain, Shane Caraveo, Dmitry Stogov
Sockets	Chris Vandomelen, Sterling Hughes, Daniel Beulshausen, Jason Greene
SPL	Marcus Boerger, Etienne Kneuss
SQLite 3.x driver for PDO	Wez Furlong
SQLite3	Scott MacVicar, Ilia Alshanetsky, Brad Dewar
Sybase-CT	Zeev Suraski, Tom May, Timm Friebe
System V Message based IPC	Wez Furlong
System V Semaphores	Tom May
System V Shared Memory	Christian Cartus
tidy	John Coggeshall, Ilia Alshanetsky
tokenizer	Andrei Zmievski, Johannes Schlueter
WDDX	Andrei Zmievski
XML	Stig Bakken, Thies C. Arntzen, Sterling Hughes
XMLReader	Rob Richards
xmlrpc	Dan Libby
XMLWriter	Rob Richards, Pierre-Alain Joye
XSL	Christian Stocker, Rob Richards
Zip	Pierre-Alain Joye, Remi Collet
Zlib	Rasmus Lerdorf, Stefan Roehrich, Zeev Suraski, Jade Nicoletti, Michael Wallner

PHP Documentation
Authors	Mehdi Achour, Friedhelm Betz, Antony Dovgal, Nuno Lopes, Hannes Magnusson, Georg Richter, Damien Seguy, Jakub Vrana, Adam Harvey, Peter Cowburn
Editor	Philip Olson
User Note Maintainers	Daniel P. Brown, Thiago Henrique Pojda
Other Contributors	Previously active authors, editors and other contributors are listed in the manual.

Websites and Infrastructure team
PHP Websites Team	Rasmus Lerdorf, Hannes Magnusson, Philip Olson, Lukas Kahwe Smith, Pierre-Alain Joye, Kalle Sommer Nielsen, Peter Cowburn, Adam Harvey, Ferenc Kovacs, Levi Morrison
Event Maintainers	Damien Seguy, Daniel P. Brown
Network Infrastructure	Daniel P. Brown
Windows Infrastructure	Alex Schoenmaker