On June 25th the Ministry of Health told 311 of the more than 2,000 counties in China to experiment with reforms aimed at weaning hospitals away from medicine sales. This month they were joined by a sprinkling of larger city hospitals, including Beijing’s Friendship Hospital (built by the Soviet Union as a comradely gift) and all the public hospitals in the southern city of Shenzhen. Xinhua, a state-run news agency, said these hospitals had embarked on “the boldest and hardest part” of China’s medical overhaul.
6月25日，卫生部在中国2000多个县中选择311个来进行改革试点，以期医院从药品销售上“断奶”。本月一些大城市医院也加入到试点行列之中，包括北京友谊医院（一座苏联援建的医院）和南方城市深圳的所有公立医院。国家通讯社新华社说，这些医院已经开始向中国医院改革深水区进军，这是需要极大的勇气的。

Banners and notices in the Friendship Hospital’s foyer proclaim the changes: no more mark-ups on medicine prices (hospitals are normally allowed to add up to 15%) or charges for diagnosis, and no more registration fees. Instead, a new fee has been introduced for “medical service”. This is a striking innovation. China’s doctors are usually paid just a few hundred dollars a month, a pittance in comparison with their Western counterparts and with private-sector professionals in China. In most Chinese hospitals, their share of profits from the sale of medicines is supposed to make up for this. At the Friendship Hospital, the new fee is meant to plug this gap. Patients can choose between different types of doctor, from a visit to an “ordinary” one at 42 yuan ($6.60) to a consultation with a “famous specialist”, costing 100 yuan.
友谊医院大厅里的横幅和标语向人们宣告了新变化：没有药品加价（医院通常要加价15%）和门诊费用，没有挂号费。实际上，医院引入了另一项名为“医疗服务”的费用。这是一次重大的创新。通常中国医生们月收入只能几百美元，这与西方国家的医生和中国私有企业专业技术人员的收入相比只是小巫见大巫。在绝大部分中国的医院里，药品销售的分成大大提高了医生们的收入。在友谊医院里，新的收费项目将试图填补这一空白。患者们可以选择不同水平的医生，其门诊花费普通医生为42元，专家则为100元。

The idea is that doctors will lose their incentive to over-prescribe medicines and tests, which has led to crippling costs for Chinese patients, whether or not they have insurance. (In 2010 those insured still had to bear 60-70% of their outpatient costs and more than half of their expenditure for inpatient treatment, according to another recent study in the Lancet.)
这样做是为了不再刺激医生开出大处方和进行昂贵的检查。无论患者是否有医疗保险，这种作法都导致医疗花费不断提高。（据最新一斯的《柳叶刀》研究显示，2010年时参保的民众仍然要承担60%至70%的门诊费用和超过一半的住院费用。）

The Friendship Hospital’s price list notes that insurance will cover up to 40 yuan of the new medical service fee, meaning an out-of-pocket payment of just 2 yuan for a consultation with an “ordinary” doctor. At the hospital pharmacy, a list of the old and new prices of medicines scrolls endlessly on a huge digital display, like a stockmarket update: ceftriaxone (an antibiotic) at 57.13 yuan, down from 65.69; Hirudoid cream (for bruising), down to 27.41 from 31.52.
友谊医院的价目表显示，医保将承担医疗服务费中的40元，即看普通门诊时患者只需支付2元。在医院的药房里，一个巨大的数字屏幕像股市一样不停地滚动提示新旧药品的价格对比：头孢曲松（一种抗生素） 57.13元，原价65.69；喜疗妥软膏（用于擦伤）31.52元，原价27.41元。

But some patients are sceptical. A 65-year-old woman says that last year she had to pay 10,000 yuan ($1,570) of her own money for treatment of her various ailments, even though she is insured. That amounted to five months’ pension payments. She worries that the new system will be no cheaper. Her complicated conditions will require more than just ordinary doctors and she will need to see several different specialists. She says the pharmacy does not always have the medicines she needs, forcing her to use others that are not on the list of drugs for which the government offers reimbursement.
但一些患者对此仍持怀疑态度。一位65岁的妇女说，尽管自己已经参保，但去年她为了治疗各种小病便自费花费为1万元（1570美元）。这相当于她5个月的退休金。她担心新的医疗体系并不比以前便宜多少。她的复杂病情可不是普通医生便能治的，另外她还要看不同的专科医生。她说医院的药房里并不是总有她要的药，这迫使她选择非医保用药（自费药品）。

Official media say the cut in the price of medicines will cost the hospital about 2m yuan in lost revenue this year. The government, they add, has promised to help cover this. But many experts believe that doctors and hospital administrators will have misgivings about the reforms. Doctors risk losing not only the direct benefits they receive from medicine sales, but also the kickbacks they receive from medicine companies when they stock their products and prescribe them.
官方媒体说，禁止药品加价使得医院今年将损失2百万元的收入。而政府承诺会承担这一部分费用。但是许多专家认为医生和医院管理层对改革充满了担忧。医生不仅担心自己会失去药品加价带来的直接利益，而且还会失去来自医药公司的回扣。

Mr Liu of Peking University reckons this “grey income” can amount to much more than doctors’ official salaries or what they receive from the mark-up on medicine sales. Because it is under the table, officials struggle to factor it into their reforms. Yet they are reluctant to boost doctors’ salaries, not least because they worry that many others on the government payroll would immediately demand pay rises too.
北京大学的刘先生认为医生们的“灰色收入”比他们的正式公交要高多了，甚至要高于来自药品加价的收入。政府官员一直想要将这种暗箱操作纳入改革。然而，他们又不愿意为医生涨工资，这尤其是因为他们担心其他政府人员会立即要求涨工资。

Crossing the river by feeling the stones
摸着石头过河

Various experiments with yiyao fenkai, or “hospital and medicine separation”, at lower-level hospitals have provided little encouragement. A study last year by government researchers in Hebei, the province surrounding Beijing, found that hospital managers were afraid that local governments would not make up for the loss of revenue from medicines and that hospitals would find it increasingly hard to cover their operating costs. “Expressions of support for reform in public hospitals are cold and cheerless,” the report said. Without clearer guarantees of financial support from the government, it said, doctors’ misgivings would harden into resistance and the reforms would struggle to succeed.
在基层医院进行的各种“医药分开”试验给中国带来了一些小小的鼓励。来自紧邻北京的河北省的调查报告显示，医院管理者担心地方政府不会负担医药分开带来的收入损失，最终导致医院经营困难。报告说：“对公立医院的改革竟然无从喝彩。”报告还说，没有明确的政府财政担保，医生的抵触会变强，改革也难以取得成功。

As Zhu Hengpeng of the Chinese Academy of Social Sciences points out, progress in the 311 counties chosen so far may not offer a clear guide as to how reform on a wider scale will work. Doctors will worry most in the poorest counties, where governments may well be unwilling to make up for their losses. But officials say they want to extend the reforms nationwide late next year at the county level. The plan is for all public hospitals to put them into practice by 2015. (Reformists are cheered by the thought that Li Keqiang, the man in charge of health reform, is almost certain to take over as prime minister next year.) “The deep pool is nothing to be afraid of,” wrote Mr Chen, the poet-minister. “Heroes dare to cross.”
正如中国社会科学院的朱恒鹏指出的，311个入选试点县取得的进步尚未给全国提供一个清晰的指导。医生们担心在中国那些最贫困的县里，政府会更加不愿意弥补他们的损失。但是官员们说，他们希望在县级水平上向全国推广改革经验。他们计划到2015年时所有公立医院都将推行改革。（改革者们受到了李克强的鼓舞，他负责中国的医疗改革，并且几乎肯定地会成为下一任政府总理。）诗人部长陈先生如是说：“深渊何所惧，英雄敢渡津。”