Hospitals should be refined and scientific in the assessment of hospitals, giving doctors a healthier practice environment, and the ultimate goal is to weaken the "accountant" attribute of doctors and return to the medical standard.
Written by | Wang Hang
In the past few days, as the topic of "hospitalization for 15 days must be discharged" continues to ferment, more and more netizens have told similar experiences of being asked to be discharged and transferred within a time limit. A family member of the patient said that his mother has been hospitalized for more than a year and is still transferred every half month. There are also doctors who confirm that in some departments, patients who are bedridden for a long time need to be admitted and discharged regularly, otherwise it is considered a violation.
By questioning multiple patients and doctors, the "medical community" found that this practice not only occurs frequently in hospitals in many places, but also gives rise to problems such as forced discharge, decomposition of hospitalization, rejection and prevarication of patients, and also has a negative impact on the doctor-patient relationship.
On March 4, the National Health Insurance Administration replied to the proposal of the representatives of the two sessions that medical insurance departments at all levels have unlimited policies on the number of days of hospitalization of insured patients, and the enjoyment of medical insurance treatment has nothing to do with the number of days patients stay in the hospital. The National Health Insurance Administration said that it will cooperate with relevant departments to strengthen supervision and assessment and continue to enhance the sense of gain and happiness of insured patients.
"Disaggregation hospitalization" is not uncommon
In 5 years last year, Li Huiqin's grandmother suffered a sudden cerebral infarction and stayed in the Department of Neurology of a hospital in Huai'an, Jiangsu Province for 8 days, and then transferred to the rehabilitation ward of the hospital for continued hospitalization. After being transferred to the rehabilitation department, Li Huiqin learned that a patient can only be hospitalized for a maximum of 20 days, after which he needs to be transferred.
"I didn't ask the doctor in advance how many days he could stay, because I had no idea about this, and I only found out after the aunt in the same ward told me." At first, Li Huiqin was a little hesitant, because the level of local rehabilitation hospitals was uneven, and she was worried that she would need to do various examinations again after transfer, and the run-in between doctors and patients would also take time.
In order to spend more time in the rehabilitation department, the doctor asked the family to be discharged first and then admitted. Li Huiqin understands that "if you go through the transfer procedures directly in the same hospital, then the days spent in the neurology department will also be counted as the 20 days in the rehabilitation department, so that the time spent in the rehabilitation department will be less." Only when the neurology department is discharged and the rehabilitation department is admitted can the complete recovery be completed for 20 days. ”
If you are readmitted after discharge from the rehabilitation department of the same hospital, you need to wait half a month. Li Huiqin recalled that regarding the 20-day discharge rule, the doctor only said that it was a medical insurance restriction, but did not explain it in more detail, and the family did not ask again.
After 15 days in the rehabilitation department of the first hospital, Li Huiqin's grandmother transferred to the Chinese medicine department of another hospital to continue her rehabilitation. As she had expected, all the test results were repeated before hospitalization, and the 20-day discharge rule also existed at this hospital.
"The second hospital can only be hospitalized for 20 days, after which we will be discharged, we mentioned to the doctor that we will be hospitalized at our own expense, but the other party said that the medical insurance staff in the hospital will check it, and if the patient meets the medical insurance requirements but does not report it, it will violate the regulations." As a family member, Li Huiqin wants her grandmother to seize the short golden recovery period, "If you can live all the time, it doesn't matter if you pay for it." What puzzled her was, "Rehabilitation is a long-term process, why hospitalization also has a time limit, and you can't pay for it yourself." ”
Finally, under the condition of respecting the rules of the hospital and not affecting her grandmother's recovery, Li Huiqin had to hang the rehabilitation in the outpatient clinic, rented a hotel next to the hospital for a month, and pushed her grandmother to the outpatient clinic every day for rehabilitation.
The phenomenon described by Li Huiqin is common in many hospitals. A family member of a patient from Shenzhen, Guangdong Province, summed up her experience with the "medical community", saying that for hospitals in different places and levels, the regulations for time-limited transfer are different, "You can stay in Shenzhen Grade 2A and 2B hospitals for one month, and you have to transfer to a tertiary hospital after 15 days. ”
People's Daily reported in December 2021 that some netizens reported that their father was hospitalized in a hospital in Yichang City due to a variety of underlying diseases such as uremia, heart, brain, lung, gastrointestinal and gastrointestinal bleeding, and the hospital informed that medical insurance stipulated that he must be discharged or transferred after half a month of hospitalization. Because the elderly have been managed as critically ill patients, patients can only be hospitalized for half a month, and then hospitalized for half a month at their own expense after discharge.
The final result of this incident was that the Yichang Municipal Health Commission and the Municipal Medical Security Bureau interviewed the hospital and asked it to rectify problems such as failure to properly publicize medical insurance policies and failure to fulfill the agreement, and must not require insured persons who did not meet the discharge criteria to be discharged early or hospitalized at their own expense.
"Collect one and lose one",
Hospitals should improve bed turnover
In response to frequent hospital transfers, Lin Yong, a deputy to the National People's Congress, submitted the "Suggestions on Controlling the Chaos of "15 Days of Being Discharged" to Protect the Medical Rights and Interests of Medical Insurance Participants in accordance with the Law during the Two Sessions in 2021, hoping to strengthen supervision and governance of this violation.
Lin Yong has done a special survey in Guangzhou and found that there are no similar regulations in the country, provinces and cities, but this phenomenon has become the "unspoken rule" of many hospitals. He also found that "reaching the medical insurance limit" and "the need for bed turnover assessment" are the two main reasons for "medical insurance patients to be discharged".
At the 2022 National People's Congress, Zhang Xiao, a deputy to the National People's Congress, submitted the "Proposal on Standardizing the Policy on Bed Turnover for Seriously Ill Patients", which also mentioned that some hospitals require patients to be discharged within 15 days in order to improve the bed turnover rate. In this regard, some insiders pointed out to the "medical community" that this frequent medical phenomenon may point to the reform of medical insurance payment methods being implemented in China - disease diagnosis related group (DRG) payment and big data based on disease score (DIP) payment.
Taking DRG payment as an example, it divides related diseases into a group, sets a fixed price, and then pays the hospital in a package by medical insurance, in order to promote hospitals to effectively control the unreasonable growth of medical expenses under the premise of ensuring the quality of medical services, and reduce the economic burden of patients. A more popular understanding is that medical insurance sets prices for relevant patient groups, and the excess part is discounted by the hospital, and the savings are retained.
A doctor who did not want to be named calculated that if the medical insurance amount for a certain disease this year is 10,000 yuan per person, if the actual cost is 11,000 yuan, then the excess 1,000 yuan will be borne by the hospital. But if it only costs 9,000 yuan, the amount of disease given next year may become 9,000 yuan, and in the case of individual differences, the hospital may have to pay money according to this standard.
Taking radiotherapy for nasopharyngeal carcinoma as an example, a staff member in charge of DRG management in a tertiary hospital introduced to the "medical community" that no matter what kind of tumor radiotherapy is in the radiotherapy group, the payment standard is only about 70,000 yuan, but the radiotherapy for nasopharyngeal cancer basically reaches 90,000. ”
In this context, in order to ensure that there is no loss, some hospitals decompose the pressure to each department, set specific indicators such as average length of stay, bed turnover, average cost and other specific indicators to evaluate the performance of doctors, and doctors in order to meet the assessment standards, shortening the length of stay and transferring expenses to outpatient is the primary way to respond.
An ICU doctor in a third-class hospital in Nanjing told the "medical community" that due to frequent transfers, there are often family members making noise in the hospital, but he said that the time-limited discharge is also a helpless move, related to the low payment price set by medical insurance, "Severe illness to lose one by one, if you want not to lose money, 96 hours on the ventilator, no medicine, no treatment, once more than 96 hours, the department will lose." ”
Taking severe pneumonia and respiratory failure as an example, he said that the medical insurance line is only more than 10,000, which can only cover some routine examinations and treatments, "We had a chronic heart failure patient in his 80s before, and surgery was not allowed to have a cardiac ultrasound." Multiple injuries come in, after shock can not play cardiac ultrasound, a dozen will be punished, sepsis more is also punished, the reason is not conducive to DRG payment, but we have to monitor heart function ah, the result is that this examination can not be done that treatment can not be done. ”
According to the ICU doctor, the hospital assigned the DRG assessment to specific departments. This means that department heads and doctors at all levels need to tighten the price red line at all times, and how long a patient stays, what drugs to use, and how much money to spend. To this end, his department had specially calculated how to treat in order to spend less money, and came to the conclusion that "it is impossible not to lose money", "The performance of doctors is much less, and now I like the patients sent by the orthopedic department, lying down for a day and returning to the ward, which not only lowers the cost, but also earns, win-win." ”
The above-mentioned industry insiders said that under the dual pressure of assessment and survival, doctors have to retreat to the second place and continuously shorten the length of hospital stay, which has also become one of the important reasons for the continuous improvement of hospital bed turnover. According to the 2021 Statistical Communiqué on the Development of Mainland Health Services, in 2021, the average length of stay of patients discharged from mainland hospitals was 9.2 days, compared with 10.5 days in 2010, the average length of stay of patients discharged from hospitals decreased by 1.3 days.
How to get doctors back to their medical position?
In a reply to Zhang Xiao, a deputy to the National People's Congress, the National Health Insurance Administration said that medical insurance departments at all levels in the mainland do not have an unlimited policy on the number of days of hospitalization of insured patients, and the enjoyment of medical insurance treatment has nothing to do with the number of days patients stay in the hospital.
The National Health Insurance Administration said that it will continue to further promote the reform of multiple composite payment methods under the total budget, promote DRG payment and DIP payment, continuously improve payment policies, adjust the structure of medical expenses, and refine performance evaluation indicators, focusing on preventing violations such as prevarication of patients, breaking down costs, and reducing service quality.
According to the Three-Year Action Plan for DRG/DIP Payment Method Reform issued in 2021, by the end of 2024, all coordinated areas across the country will carry out DRG/DIP payment method reform, and by the end of 2025, DRG/DIP payment methods will cover all eligible medical institutions that provide inpatient services.
While this payment method is being covered by more hospitals, practical problems are also coming to the fore. In addition to the decomposition and cost transfer in some hospitals, the chief physician of a tertiary hospital in Zhejiang expressed to the "medical community" the actual confusion encountered by front-line doctors in the process of daily work.
"For example, if medical insurance sets the same price for cerebral infarction, then the higher level hospital will be more 'loss' for patients admitted to the same disease, because the general condition of the higher level hospital is complicated, or the patients with more serious and more complications, these patients will need more complicated diagnosis and treatment process than the lower level hospital, so there will be more links in examination and treatment, longer hospital stay, and more medical resources consumed."
According to him, the cost of manpower and equipment in higher-level hospitals is high, such as medical staff with higher education, better equipment and more advanced technology. Under the DRG model, the difficulty of having doctors meet the standards will increase significantly, so the diagnosis and treatment of patients with acute and critical diseases, chronic severe diseases, and elderly underlying diseases will be more stressful.
In his view, technological progress and innovation is an important driving force for medical development, and the core of DRG is to guide reasonable medical costs, "cost control" is crucial, may be contrary to the application of new technologies in the short term, "for the same group of diseases, the use of new technologies will cause an increase in overall costs, which is likely to lead to clinical circumvention of some necessary but expensive technological innovations." It is reflected in the difficulty of doctors to improve medical technology, and it is difficult for patients to obtain better treatment, which ultimately affects the layout and development of medical technology. ”
Taking the treatment of refractory epilepsy as an example, he told the "medical community" that drug control and radical surgery are the two main ways available, but the cost of treatment between the two is dozens of times different, and it is difficult to judge how much a refractory epilepsy patient should spend with a specific figure, but it is certain that "the burden of the department brought by an epilepsy operation will be very large, and the effect of conservative treatment of patients with drugs is not good." ”
Many doctors who spoke with the "medical community" mentioned that reasonable pricing and payment are their biggest demands, and hope that the policy can be optimized and adjusted. A person close to policy-making told the "medical community" that the starting point of the DRG reform is to ensure that the public has access to high-quality medical services and improve the efficiency of the use of medical insurance funds. Through the reform of payment methods, the behavior of hospitals and doctors has changed, and then the operation mechanism of public hospitals has been transformed.
From the perspective of DRG design principle, after the implementation of DRG, there may be coding upgrades, prevarication, reduction of services, early discharge and other phenomena. In order to put an end to this phenomenon, experts believe that the first thing is to strengthen the understanding of hospitals, "the reform of payment methods should still be patient-centered, adhere to the public welfare of public hospitals, and not save medical costs as the main consideration." ”
The expert said that reducing costs is not only illegal methods such as forced discharge, but also can be achieved by optimizing the diagnosis and treatment path, improving coding quality, strengthening cost control, and giving full play to the advantages of hospital diagnosis and treatment, "The clinical pathway has a significant effect in shortening the average length of stay of inpatients and reducing hospitalization costs, which helps improve hospital operational efficiency and promotes doctors to choose the best and most cost-effective treatment plan to benefit patients." ”
According to this expert, relevant departments in various places continue to pay attention to the difficulties and problems that arise in the implementation of DRG reform, and strengthen the orientation of policies from multiple perspectives such as supervision and consultation. At the same time, he called for hospitals to be refined and scientific in the in-hospital assessment to give doctors a healthier practice environment, "The ultimate goal is to weaken the 'accountant' attribute of doctors and return to the medical standard." ”
(In order to protect the privacy of the parties, Li Huiqin is a pseudonym)
Source: Medical community
Responsible editor: Zhang Haoyu
Editor: Zhao Jing
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