Basic information on chronic disease management

The coverage base has reached the standard, there are large differences in service stratification, and there are still obvious gaps in the implementation effect. At this stage, a universal optimal implementation path has not yet been formed. Public health, medical institutions, and market-oriented service entities each have their own advantages and disadvantages, and are still being explored.

Anyone who has worked in the community public health field will understand that the registration rate of chronic disease patients at the national level is actually quite high. By the end of 2023, the standardized management rates of patients with hypertension and diabetes will exceed 70% and 65% respectively. This number is achieved by relying on community medical care from door to door. When I was stationed at a community health service center in a certain neighborhood in Jing'an, Shanghai last year, I met Dr. Li, who was in charge of chronic disease management. He was in charge of more than 1,200 hypertensive patients. He knew which household had elderly people with sequelae of cerebral infarction who were inconvenient to go out, and which household had aunts who always liked to stock up on expired antihypertensive drugs. But even such experienced doctors and nurses still have headaches: many elderly people refuse to go after receiving the free follow-up number, and when their blood pressure is high, they turn around and buy the "hypertension health tea" sold in WeChat Moments. Your earnest advice for half an hour is not as effective as "Uncle, we don't need to take medicine and there are no side effects" in the sales of health products. Uncle Zhang, who lives downstairs in my house, has been suffering from diabetes for five years. He used to buy "sugar-free biscuits" from the supermarket as snacks, and his blood sugar fluctuated. He didn't stop talking until the community doctor came to him and explained to him that the starch in sugar-free biscuits can also be converted into sugar.

Interestingly, practitioners with different backgrounds in the industry have completely different ideas regarding this core pain point of compliance. Most scholars who do public health research believe that we still have to rely on grid sinking, binding chronic disease management with community care for the elderly, the work of street grid workers, and even linking it with the property and property committees of the community. After all, chronic disease management is essentially an "anti-human" thing, and it is difficult to persist without anyone watching. The constraints of acquaintance society are much more effective than cold regulations. But Internet medical entrepreneurs don’t see it that way. They have made a calculation: a community doctor can take care of up to 1,500 patients at full time. If they rely solely on human supervision, how much more medical care will be needed for the nearly 300 million hypertensive and nearly 100 million diabetic patients in the country? They prefer to use smart devices for pre-screening, such as equipping patients with blood pressure monitors with transmission functions. Abnormal data will automatically send early warnings to medical staff. If there are no abnormalities, there is no need to waste time visiting the door, and the efficiency can be doubled several times. There are also specialist doctors from tertiary hospitals who hold a third view: the root cause of many chronic disease management problems now is "failure to manage the disease at the first visit." When patients are first diagnosed with high blood pressure, they are prescribed medicine at the tertiary outpatient clinic and leave. No one explains to them clearly how to monitor and adjust their living habits in the future. It is too late to think of contacting the community until complications occur. The chronic disease management port should be moved to specialist outpatient clinics, and management responsibilities should be implemented at the first visit. This is the root cause. Each of these three ideas has its own pilot projects, and it is not yet clear which one has the absolute advantage.

Of course, in addition to the exploration of the public system, there are also many market-oriented services that are filling the gap. There is a young girl born after 2000 who suffers from type 1 diabetes. She bought an annual card service from an Internet platform. A nutritionist helped her calculate the carbohydrate intake of each meal, and an endocrinologist followed up her blood sugar data every week. It cost more than 2,000 a year. She said that the effect of sugar control was much better than just going to the hospital for follow-up consultations before. But there are also many scammers. Last year, many institutions that claimed to be able to "reverse diabetes" were exposed. They charged tens of thousands of yuan in service fees and prescribed a bunch of "three-no" health products to patients. In the end, they pushed the patients' blood sugar even higher. There is also a very real contradiction: most market-oriented services cannot be reimbursed by medical insurance. Most of the people who are willing to pay out of their own pockets are intellectual or young patients. Those rural and low-income elderly groups who most need standardized management can still only rely on the public health system to support them.

Speaking of money, this is also the most controversial issue in the industry right now: Should all chronic disease management services be included in medical insurance reimbursement? Those who support it calculate the "long-term account": if a hypertensive patient spends several hundred yuan a year on standardized management, it can reduce more than 90% of the risk of serious illnesses such as cerebral infarction and cerebral hemorrhage. In the future, it can save hundreds of thousands of first-aid and rehabilitation expenses. It is a sure-profit deal for the medical insurance fund. But those who oppose it also have a point: Medical insurance funds in some areas are already tight. If all chronic disease management services are included at once, problems of insurance deception and service inflating will inevitably occur, which will in turn be a waste of money. The current pilot policy also balances both sides. In some areas, follow-up visits and medication costs for hypertension and diabetes are included in outpatient overall reimbursement, but additional value-added services still have to be paid for out-of-pocket.

In fact, after doing industry research for so long, I feel that chronic disease management has never been a matter that can be solved by one party. You say it relies on technology. I have seen many elderly people living alone who can’t even use their smartphones. They don’t know what to do when the APP reminder rings. ； You say it depends on people. The energy of community medical care is indeed limited. It is impossible to watch thousands of people taking medicine every day. ； You say it depends on the patient's self-awareness, let alone the elderly. There are many programmers in their 30s around me who were diagnosed with hyperlipidemia, but they stayed up late and worked overtime to eat takeout without remembering to take statins. There is no one-size-fits-all solution. What can be put into practice are "local methods" that are suitable for local conditions: for example, some places let retired medical staff in the community serve as volunteers to measure the blood pressure of neighbors, which is more effective than community doctors visiting their homes. ； Some places distribute eggs and laundry detergent to the elderly who follow up on time, and everyone's enthusiasm suddenly rises. To put it bluntly, chronic disease management is not about "diseases" but "people". It must be based on people's habits to be truly effective.