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Improving Treatment

Despite the government’s best efforts, and willingness shown by nursing home providers, incorporating medical services into the elder care system has not been easy

By NewsChina Updated Jan.1

Liu Zhongyun, 86, felt lucky to be one of the beneficiaries of the new policy that incorporates medical services into the elder care system. After her husband passed away in 2015, Liu entered the Golden Heights Home for the Elderly in her residential community in Beijing. She is delighted by the services there, especially the medical care provided by the community hospital connected to the nursing home. 
“We can get our prescriptions filled right at our front door,” Liu told NewsChina. 
Golden Heights built the independent community hospital in 2014, a year after the “incorporation” policy was launched. In 2015, the Chinese government issued a guidance document on setting up pilot nursing homes under the policy, and pledged to extend the new elder care system nationwide by 2020. 
Driven by such strong encouragement, many cities set up new nursing homes that provide medical care in various ways. Some are doing well, like Golden Heights. Many others face numerous difficulties, such as funding, hiring qualified staff and government bureaucracy, not to mention worries over potential risks. 

Ways of ‘Incorporation’ 

Covering an area of 13,000 square meters, Golden Heights accommodates 283 seniors whose average age is 86. Thanks to the incorporation policy, its parent company invested over 40 million yuan (US$6.2m) in 2014 to develop the attached hospital. It now leads the nation in the way it treats seniors in and around the nearby residential communities. 
“The medical service here is five-star,” Liu said. Suffering from a serious heart disease, Liu has to take five different medications daily, four of which are available in the nursing home’s hospital and are covered by medical insurance. Before, she had to ask her son to bring them from a large hospital far away. 
“Our hospital has also greatly facilitated emergency services,” said Zhao Ting, Golden Heights’ president. “In an emergency, we send the patient straight to our hospital through the corridor connecting the clinic and the home. In many cases, we’ve dealt with all the hospitalization formalities before the patient’s family even arrives.” 
There are 61 doctors and 22 nurses at Golden Heights. Given the small range of patients, the medical staff has more time to listen to the patients and treats them in a more friendly and patient way than in big hospitals. 
“The doctors here even bend down to listen to hearing-impaired seniors, which is impossible in big hospitals where doctors are generally too busy to listen to anyone,” Xiong Douyin, a 91-year-old Golden Heights resident told NewsChina. “Last year, I got pneumonia and it only took me nine days to get over it in the community hospital. Living here is much better than at home.” 
So more seniors can access such convenient medical services, the Chinese government in 2015 issued a guidance document, proposing four ways to implement the incorporation policy. Besides establishing an independent hospital like Golden Heights, nursing homes are allowed to set up an internal clinic or cooperate with nearby hospitals. The government also encouraged hospitals to launch nursing services for seniors or send family doctors to make house calls. 
In June 2016, the government appointed 50 cities or districts as the first pilot sites for the incorporation policy, and two months later, the list was enlarged to 90.
Now, many cities have set up models. The Hospital Group of the First Affiliated Hospital of Chongqing Medical University, a first-tier hospital in Chongqing, set up an elder care facility that can provide medical care, rehabilitation and daily nursing care. An apartment complex for seniors in Xingtai, Hebei Province took over a community clinic as a way of purchasing services from the government and contracted with another 40 communities to provide services for each other. As early as 2011, Shanghai launched a pilot system of family doctors which now covers all residential communities and has a network of 10,000 users in the community. 
The latest data from the Ministry of Civil Affairs (MCA) and the National Health and Family Planning Commission (NHFPC) shows that China is now home to over 5,500 elder care homes that provide both medical and nursing services, 2,100 of which have been included in the social medical insurance system. Besides, nationwide, 3,100 second-tier or above hospitals have set up a gerontology department and over 73,000 hospitals have opened “green passages” (a fast pass that enjoys quick access and simplified formalities) for seniors.  

Hard to Profit 

The figures, however, are not yet sufficient to prove the new policy is a success. Zhu Ping, who works in the elder care industry, told NewsChina that disputes are frequent in the implementation of the incorporation policy – some nursing homes feel reluctant to set foot in the medical care system, a field which they believe is a world away from elder care. Others seem very eager to make money from the new field. 
Zheng Zhigang, a post-doctorate in the elder care industry from Peking University, agreed. He told our reporter that hospitals and nursing homes are on opposing sides of the policy – overloaded hospitals have neither the time nor the desire to get engaged in elder care, but in contrast, many nursing homes welcome it. 
Due to reluctance from hospitals toward cooperation, many nursing homes set up their own hospitals or clinics, only to find it hard to make ends meet. Many nursing homes did not realize there wasn’t sufficient demand for their hospitals until after they had put too much into their medical services.
Taiyangcheng, in the outer Beijing district of Changping, is a good example. As one of Beijing’s oldest nursing homes, Taiyangcheng invested a huge amount of money into setting up its own hospital, but it led to them filing for bankruptcy in 2016. Media reported that the number of seniors in nearby communities was not high enough to sustain the hospital, and even before it went bankrupt, many doctors and nurses quit.
It had already stopped replenishing its stocks of drugs due to a lack of money. 
“In the first few years after the government promoted the incorporation system, nursing homes preferred to set up hospitals of their own. But now, they’ve realized that few can afford a nursing home and a hospital, since medical equipment and personnel are expensive, but the actual demand from local seniors is not that high,” 

Wu Danxing, a member of the expert committee for the elder care industry under the MCA and also director of the Society for Health Care for the Elderly under the China Science and Technology Industry Association, told NewsChina. 
Even setting up an internal clinic is not easy. In a bid to raise funds, Yan Shuai, president of the Puleyuan Home for the Elderly in Beijing’s Fangshan District, appeared on a reality show called Dream of China, produced by Zhejiang Television Station where participants can appeal or perform to raise money for a cause. Thanks to his outstanding performance, he received 600,000 yuan (US$92,300) in “dream money” from the show, and a foundation affiliated to the program promised to donate funds for medical equipment and staff to Yan’s home. But, four years have passed and Yan’s dream remains on paper, as there still isn’t enough money. Since most of the home’s residents cannot care for themselves or have dementia, the nursing home had to buy a car to drive doctors and nurses from the nearby community hospital to treat the home’s residents. 
Puleyuan is not alone. According to NHFPC regulations issued in 2014, a nursing home clinic must have at least one waiting room, one treatment room and one processing room, plus at least one qualified doctor and one qualified nurse, or it will not be allowed to operate. Few medium or small-sized nursing homes have enough money to meet such requirements.  

Other Barriers 

Yan finally took over a nursing home in Fengtai District, another area of Beijing, to try to develop the clinic. But even though he tried his utmost to raise the funds, he was obstructed by red tape – the MCA refused to grant the clinic an operating license, since it was registered as “internal” with the NHFPC. 
Overlapping functions of government departments are common – nursing homes are approved and managed by the MCA, while clinics are under the jurisdiction of the NHFPC. And the social insurance department reimburses medical fees. Given that no document has clearly defined the responsibilities of each department, many elder care facilities are kicked between different departments. This has become one of the biggest obstacles to the incorporation policy. 
To ease the difficulties, the government issued a document on the need to stimulate investment in medical care for seniors in August 2017, claiming that any internal clinic in a nursing home only needs to register with the relevant departments rather than apply for a permit. Experts praised the document for paving the way for the incorporation policy, but they pointed out that government requirements for internal clinics are still too high for a nursing home. 
Shortages of professional staff, for example, are a big problem. Yan told NewsChina that he once employed a professional nurse for his to-be-built clinic, but she was soon poached by a bigger nursing home. 
Yet even big, successful homes find it hard to attract qualified staff. Lian Jie, deputy president of Cuncaochunhui Home for the Aged in Beijing’s Chaoyang District told NewsChina they had received only seven or eight resumes after they posted a recruitment notice for doctors, and when some young applicants learned they would be treating seniors with physical or mental disabilities, they quit the process. Nursing homes cannot offer senior clinicians as high a salary as other private clinics. 
Golden Heights shares the same problems. Its president, Zhao Ting, told our reporter that they have to offer a salary 20-30 percent higher than the market average to attract professional doctors and nurses, which makes the price of treatment beyond what many can pay. 
Worse still, Zhao believes that the ideal staff for a nursing home with medical services should possess professional knowledge in both medical care and nursing care to minimize potential risks. However, in practice, they found that medical personnel often lack knowledge in elder care, while carers lack knowledge of medical care.
As the government has not yet issued any guidelines on managing the medical risks arising from medical services provided by elder care homes, the sector has become very cautious in deciding what medical services to offer, and generally limits the services provided to the basics, such as physical examinations, changing dressings and blood tests. Cuncaochunhui even refuses to give injections – they would rather ask doctors and nurses from neighboring hospitals to do that.  

Making Homes Affordable 

Such an embarrassing situation has led some experts to have different opinions on how to incorporate medical services into elder care. Zhu Hengpeng, deputy director of the Institute of Economics, Chinese Academy of Social Sciences, for example, suggested promoting private community-level clinics rather than encouraging nursing homes to set up their own clinics. 
“Medical care is the crux of elder care, which should be attributed to our lack of community-level outpatient services – it is unreasonable that in Chinese cities, over 60 percent of outpatient services are in big hospitals,” he said. “When the government loosens control on the founding of small- and medium-sized private clinics, and when such clinics are rolled out in residential communities to provide door-to-door medical services, it won’t be an issue whether seniors are taken care of by families, communities or nursing homes,” he added. 
However, supervision and expense are two big concerns of those against the idea – complaints have already arisen among the public that most nursing homes are unaffordable for ordinary families, and the few that target ordinary families always run out of beds.
Moreover, to lighten the economic burden of medical care for seniors, the government included nursing homes in the medical insurance system, only to find that many nursing homes have allegedly been involved in insurance fraud. An anonymous operator of an elder care home told NewsChina that many nursing homes are involved in coaxing the residents to undergo unnecessary treatment and even to buy non-medical services, like foot baths with traditional Chinese medicine. This is all charged to their medical insurance. 
Wu Danxing attributed the alleged fraud to misunderstanding of the incorporation concept. “Regular hospitals aim to cure disease and discharge patients, but medical care in nursing homes targets seniors who have lost some abilities due to chronic disease… The incorporation idea was initiated in China, which the international community interprets as nursing and caring for seniors by both non-professionals and professionals to ensure they have the best quality of life with maximum independence and self-esteem,” she said.
“The misunderstandings about medical care in the elder care system means too many clinics will be built, and the insurance system will be overburdened with treatments that should not be included,” she added.
The government is aware of the situation, and has adopted some expert suggestions to try out a system of “long-term nursing social insurance.” Mi Hong, a public management professor from Zhejiang University who has tracked the implementation of this long-term insurance in Qingdao, Shandong Province, told NewsChina that Qingdao started offering the insurance in 2012, and it has been very successful in relieving families of the burden of caring for physically or mentally disabled people and optimizing medical resources. 
In July 2016, the NHFPC issued a guidance document on launching a pilot long-term nursing insurance program, announcing it would test it in 15 cities in the following two years, and then roll it out nationwide by 2020. 
Wu Danxing, however, expressed caution, and has repeatedly appealed for the government to undertake a deeper study of the payment and assessment systems of the insurance before officially launching it.
“The incorporation policy is the right direction for our elder care system, and it well meets seniors’ demands and expectations, but the support measures and detailed implementation rules lag far behind the general policy. We need to issue clear and unified criteria, assessment and supervision systems for the new policy,” she said. “The market would not have been chaotic if we had the [said] regulations.”