How to implement PPP project in public hospitals is a problem that puzzles investors and local governments at present. Do you know the hospital PPP model? If you don't understand, please look below with me!
As far as local governments are concerned, most public hospitals have some problems, such as poor medical environment, outdated medical equipment, serious medical problems in hospitals, and medical income cannot make ends meet. It is urgent to improve the local medical service level by moving, updating equipment and improving management. Therefore, the desire of social capital to participate in public hospital services is very strong.
For social capital, hospitals and medical services belong to monopoly resources. With the aggravation of social aging, health problems will be paid more and more attention by the society. With the increase of income and the improvement of quality of life, more people are willing and able to spend more money on health. Due to the public welfare nature, tax incentives and good brand effect of public hospitals, social capital is optimistic about the development prospects of hospitals, especially public hospitals, and also very much hopes to participate in the investment and operation of public hospitals.
PPP model, as a public-private cooperation model encouraged and strongly advocated by the government at present, seems to open a door for the cooperation between the government and social capital in running medical services. As a public welfare undertaking, public hospitals belong to public affairs that the government can cooperate in PPP projects. The core of PPP mode is to improve the efficiency of public affairs through social capital participation without changing the public welfare of public affairs. Therefore, from the principle of PPP, it is completely suitable for the practical needs of government and social capital cooperation in the above-mentioned hospital projects.
Representative model
It is not new for social capital to participate in the operation of public hospitals. If there is demand and interest, there will be people involved. In recent ten years, various forms of social capital participation in public hospital investment have emerged in various places, including shareholding system reform, trusteeship (public and private) and so on.
shareholding system
The typical case of shareholding system reform is Tongzhou District People's Hospital in Nantong City, Jiangsu Province, which was implemented in 2004. At that time, Tongzhou Municipal Party Committee and Municipal Government implemented the shareholding system reform of People's Hospital, and introduced Jiangsu Dafuhao Beer Co., Ltd. as the major shareholder of the hospital through public bidding. The shares were held by state-owned capital and employees, accounting for 30% and 25% respectively. During 10, the construction area of this hospital increased from 40,000 square meters to over 654.38+10,000 square meters, and the number of beds increased from less than 400 to over 1600. The rate of maintaining and increasing the value of state-owned assets controlled by the company reached 132%.
Despite this, doubts about this restructuring have never stopped. Some people think? People's hospital? With what? People? But the signboard is private and cannot guarantee fairness. The conflict between the shareholding system and the public welfare status of public hospitals seems to be an irreconcilable contradiction for social capital to invest in public hospitals.
Because the shareholding system reform has changed the nature of public hospitals, it seems that the hospitals after the shareholding system cannot be accommodated in the new development plan of public hospitals. In 2009, the new medical reform plan was promulgated, requiring? Will the government set up 1-2 county-level hospitals (including Chinese medicine hospitals) in each county (city)? As a result, many local governments have to buy back the shares of the original public hospitals from private capital, so that joint-stock hospitals can return to the ranks of public hospitals.
The case of Tongzhou People's Hospital in Jiangsu Province represents an attempt ten years ago. Since then, market-oriented restructuring has been questioned or even denied. The new medical reform emphasizes government investment, and social capital was once silent.
Since 20 13 national policy explicitly encouraged social capital to participate in the medical industry, the reform of public hospitals has ushered in a new capital boom. The latest sample is the joint-stock reform of public hospitals in Shanwei and CITIC Medical in Guangdong. The way of cooperation is that the Shanwei Municipal Government and CITIC Medical * * * jointly invested to form a joint venture company, and the company's capital was valued by the net assets of three hospitals, and then CITIC Medical invested in cash according to the equity ratio of 60%, occupying a controlling position. The non-profit and institution attributes of the three hospitals remain unchanged.
trusteeship
Public hospital trusteeship is also a common mode for social capital to participate in hospital management. There are many forms of custody, including asset custody, custody management and custody operation. The overall hospital trusteeship is more thorough. At present, it is more popular to set up a hospital management group to manage a number of hospitals, both public and private.
The Blue Book of Private Hospitals: Report on the Development of Private Hospitals in China (20 13), jointly published by the Private Hospital Management Branch of China Hospital Association, Changce Think Tank and Social Science Literature Publishing House, holds that social capital (state-owned and private) is an effective way to manage public hospitals.
The biggest feature of public hospital trusteeship model is that it does not involve the transfer of ownership of public hospitals, that is, investors do not acquire the property rights of hospitals, but only obtain hospital management fees and supply chain management profits through entrusted operation.
The representative of social capital in custody is phoenix medical Group, and its IOT (Investment-Operation-Transfer) hospital custody model has been implemented in many public hospitals. The so-called IOT model is simply to exchange investment for operation rights. The IOT model has not changed the ownership and non-profit of hospitals. By investing in hospitals, phoenix medical Group improves the level of medical facilities and diagnosis and treatment services, in exchange for the right to manage and operate hospitals within a period of 65,438+09-48 years, collecting hospital management fees and supplying medicines, instruments and consumables for hospitals.
Policy orientation
Since the promulgation of the medical reform plan in 2009, the government has invested a lot of support and financial resources in basic medical services, clarified the government's responsibility for running medical services, and emphasized that basic medical services belong to public products to ensure that their public welfare and people's basic health needs are met.
The recent key implementation plan of medical and health system reform released in 2009 clearly stated that the purpose of the reform is to fundamentally change the long-standing situation that some urban and rural residents have no medical security and public medical and health services are weak, and to reverse the profit-seeking behavior of public medical institutions and make them truly return to public welfare.
The Opinions of the State Council on Promoting the Development of Health Service Industry issued on 20 13 stipulates that the government's responsibility for running medical services should be effectively implemented, regional health planning and medical institution establishment planning should be rationally formulated, the number, scale and layout of public medical institutions should be clarified, and the leading position of public medical institutions in providing basic medical services for urban and rural residents should be adhered to.
2065438+April 2005, the newly issued "Implementation Opinions of General Office of the State Council on Comprehensively Pushing Forward the Comprehensive Reform of County-level Public Hospitals" further clarified the direction of comprehensive reform of county-level public hospitals.
Judging from the trend represented by the above policies, in the direction of public hospital reform, the government tends to keep the nature of public hospitals unchanged to ensure that the basic medical needs of the people are guaranteed. This has also led to a comprehensive reform of public hospitals under the premise of unchanged ownership, and improved the efficiency and service level of medical services through specific management changes such as separation of medical treatment from office, performance appraisal, personnel system and salary system. Only when the number of public hospitals is sufficient and the people's basic medical needs can be met from public hospitals can some surplus public hospitals be reformed into non-public hospitals.
relevant issues
1, the shareholding system reform cannot be used as the mainstream model of PPP in public hospitals.
It can be seen from the above-mentioned policies of public hospitals that the government will not allow the change of the dominant position of public hospitals just because it wants to ensure the provision of public basic medical services.
From the operation of PPP itself, it is generally believed that equity cooperation is also a way of PPP. However, the legal basis of equity cooperation is corporate operation, and the company must aim at profit, so the shareholding system reform is really incompatible with the public welfare and career of public hospitals themselves.
The project of CITIC Medical in Shanwei, Guangdong Province seems to have adopted a flexible way, that is, the government and CITIC set up a joint venture company, the government injected hospital assets into the joint venture company, CITIC invested in cash, and the joint venture company managed the investment of the hospital, and the cause and public welfare of the hospital remained unchanged. But after adopting this model, the owner of the hospital has become a joint venture company, that is, social capital. Strictly speaking, hospitals are not public hospitals, but non-profit hospitals established by social capital. Due to the government's requirements for the number of public hospitals, it is difficult to implement this model in some places where the number of public hospitals is not surplus.
2. If IOT is adopted, will T be paid?
The aforementioned IOT model of phoenix medical Group is worth further discussion. The foundation of this model is custody, but investors need to provide some upfront investment in exchange for custody rights. The initial investment is finally transformed into hospital buildings, facilities and medical equipment, so who owns these assets invested by investors? At the end of the custody period, when the relevant facilities are completely owned and operated by the government, does the government need to pay some consideration to investors? These questions are difficult for the government and investors to answer. For the government, if the custody period ends, the government needs to buy back the facilities invested by investors, which is equivalent to an extended BT. Will the government have enough financial resources to buy back by then? Should this repurchase be treated as government debt? For investors, if it was transferred to the government for free at that time, can investors recover their investment during the custody period? Due to the pressure of investment, will investors try their best to break through the boundaries of hospital public welfare to generate income during the custody period? If it is repurchased by the government at that time, investors will still be worried about whether the government can afford it at that time.
3. How to charge the custody fee? How to allocate the operating profit and loss of the hospital during the trusteeship period?
As far as social capital is concerned, the purpose of taking trusteeship to intervene in the management of public hospitals is still to obtain benefits from management behavior. The management behavior provided is still a commercial behavior. Similarly, in the hospital restructuring project in Shanwei, Guangdong Province, China Resources also participated in the bidding for this project, but the model proposed by China Resources is trusteeship, which requires the local government to pay a certain management fee to China Resources every year. This model was rejected by the local government on the grounds that the purpose of hospital reform was to reduce the burden on the government. If the government has to pay a fixed management fee every year after the reform, it will increase the burden on the government.
Therefore, how to collect management fees under trusteeship is an important issue for social capital to consider. Judging from the current situation, it seems not feasible for social capital to charge a fixed management fee to ensure drought and flood protection. The acceptable way for local governments is that social capital takes a fixed proportion of hospital income as management fee without loss. This condition is actually equivalent to the need for social capital to ensure that the hospital has enough income, otherwise it can not maintain its management costs, which has a certain conflict with the public welfare of the hospital.
It is worth mentioning that in the custody fee clause, can it be agreed that all the benefits of the hospital will be enjoyed by the custodian? I don't think such a rule is appropriate. If the income belongs to the trustee, then the loss must be borne by the trustee, which is equivalent to the trustee completely contracting the hospital. Due to the private profit-seeking nature of the trustee, this model obviously violates the public welfare of the hospital.
4. How to generate income reasonably on the premise of ensuring public welfare?
Although the trusteeship model is compatible with the identity and public welfare nature of public hospitals, how to make social capital manage public welfare hospitals through trusteeship is still profitable, which is the key to promote the trusteeship model. Especially when social capital needs to provide a large amount of investment funds in advance in exchange for custody rights, the problem becomes more prominent.
Based on the scarcity of hospital resources and the brand effect of public hospitals, many social capital investors are not so worried about this in reality, but think that as long as they can get the exclusive right to operate hospitals, they will naturally find corresponding ways to make money.
What needs special attention is that in order to ensure that public hospitals do not distort their public welfare nature, the government has drawn many red lines for the operation of public hospitals, which greatly limits the income-generating channels that social capital hopes when hosting public hospitals.
For example, it was clearly stipulated in the Implementation Opinions on Classified Management of Urban Medical Institutions issued in 2000? Non-profit medical institutions run by the government shall not invest in joint ventures or cooperate with other organizations to establish non-independent legal persons for profit? Department? 、? Ward? 、? Project? . Have you invested in joint ventures and cooperation with other organizations for profit? Department? 、? Ward? 、? Project? , should be closed or approved by the administrative department of health and finance to become an independent legal person. ?
20 13 the health planning commission also issued "strengthening the construction of medical and health work style? Nine are not allowed ",in order to prevent the hospital from being driven by interests to destroy the medical style.
Moreover, in the future, the government may introduce new regulations to ensure the public welfare nature of hospitals, which may make the business activities created by social capital that were not prohibited at the time of signing the contract unable to continue because of violating the new regulations. Even if the custody contract may contain legal change clauses to avoid the risks of such new regulations, the government can explain that these are not legal changes, but are for the explanation and clarification of hospital public welfare. Since the social capital party promises that the public welfare of the hospital will remain unchanged, it should not engage in these business activities.
5. How do centralized procurement and services cooperate with government bidding?
Another source of income for social capital to participate in hosting public hospitals is the purchase price difference. For example, phoenix medical Group buys medicines, instruments and consumables at the prices agreed by suppliers, and then resells them to its hospitals at the bidding prices set by the government to earn the difference. Because phoenix medical Group has a network of 12 hospitals and 28 clinics, its bargaining power is high. In 20 13, the management service income of Phoenix Hospital was 480 million yuan, accounting for 48.4 1% of the income, and the gross profit10 million yuan, accounting for 47.23% of the gross profit, with a gross profit rate of 20.94%.
This business seems to be profitable, but due to the centralized procurement of drugs in public hospitals, the profit margin may be continuously compressed. On the other hand, to have high bargaining power, the resource control ability of social capital itself is also very important.
The Guiding Opinions on Improving Centralized Drug Purchase in Public Hospitals issued by the General Office of the State Council on 20 15 clearly stipulates that? All drugs used in hospitals (except Chinese herbal pieces) should be purchased through the provincial centralized drug procurement platform. ? With the effective implementation of the government procurement platform, the bidding price of drugs may be closer and closer to the bargaining price of social capital, resulting in social capital being unable to obtain differential income from this piece.
To sum up, there are still many problems in the development of PPP in public hospitals, but as mentioned above, from the principle of PPP, it should be completely applicable to public hospitals. My suggestion is not to stick to the nature of ownership, but to establish detailed public welfare indicators of public welfare hospitals, and take the indicators as an assessment to see whether they meet the needs of basic medical security services and whether they are in the public interest. In the newly issued Notice of the General Office of the State Council on Printing and Distributing the Work Summary and Key Tasks of Deepening the Reform of Medical and Health System in 20 14 and 20 15, it has been mentioned that the implementation plan of comprehensive reform effect evaluation of county-level public hospitals should be printed and distributed. If there is a detailed performance evaluation standard, as long as it meets the performance evaluation standard, it can be recognized as public welfare, and the government can give subsidies or rewards according to the specific situation, regardless of its ownership nature. In this way, the government and social capital will have more choices and space in PPP projects in public hospitals.
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