Behind aifen's explosive Aier ophthalmic kickback list hides a stubborn disease in China's medical system

In early January, Ai Fen, a well-known anti-epidemic doctor in Wuhan and director of the emergency department of Wuhan Central Hospital, posted four weibo posts in a row under the label of "Aier Ophthalmology, Bribery china", accusing Jiangsu Suqian Aier Eye Hospital (hereinafter referred to as "Suqian Aier") with a total surgical kickback details of more than 780,000 yuan.

The year-long dispute between Effin and Aier Ophthalmology was once again brought back into the public eye.

According to the four lists disclosed, Suqian Aier has issued "referral fees" to doctors and public officials in many local county and city hospitals and clinics in the past three years to divert more than 500 patients to the hospital for eye-related surgery. Among them, the cost of surgery ranges from 1,000 yuan to 13,000 yuan, and the referral can commission 6%-15% from each operation fee.

Since Aifen's rights protection, Aier Ophthalmology's stock price has almost cut to the waist, and the market value has evaporated by nearly 190 billion yuan. This kickback storm once again pushed Aier Ophthalmology to the focus of public opinion.

On the evening of January 9, Suqian Aier issued a statement on its public account saying that in response to the information transmitted online, the hospital has carried out rectification in 2019 in accordance with the relevant requirements of the board of directors, seriously dealt with the illegal employees, and replaced the management team.

At the heart of the incident, namely whether the referral fee was reasonable, was also controversial.

Multiple respondents said referrals are common in the industry, and the key is whether there are interest issues involved.

A director who has worked in a private hospital for many years told Eight Points Jianwen, "Without these means, many small and medium-sized private institutions simply cannot survive." ”

Some insiders also said that the means of private hospitals relying on paying referral fees to obtain customers are very inappropriate, and they are "sucking the blood of public hospitals".

Whether it is tumors, rehabilitation and other diseases that require a long recovery cycle, or ophthalmology, stomatology, women and children and other consumer medical treatment, public hospitals can only solve the needs of some patients and a certain stage of diagnosis and treatment, a large number of spillover patients and follow-up diagnosis and treatment services need to be undertaken and supplemented by private institutions, and both sides have matched needs.

In this sense, inter-hospital referral is an important means of effective allocation of medical resources, but the referral fee derived from the "marketing dilemma" has become a "parasitic means" for many private hospitals. Is this a reasonable move? What should a healthy referral system be like between public and private hospitals?

The sunshine referral road from the hospital to the courtyard was blocked

In fact, patient referrals between private and public governments have gone through a period of reasonable compliance and government support.

After the launch of the new medical reform in 2009, the government encouraged public hospitals and private hospitals to explore the PPP model together, that is, the "public-private partnership model". This direction and voice of the wind, even after 2014, became more and more clear. At that time, it was widely believed that the cooperation between the public and private sides to provide services would not only alleviate the shortage of medical resources, but also better meet the needs of patients.

During that time, patient referrals from public hospitals and private hospitals were not only open and transparent, but also the acceptance and trust of patients.

For a time, many public hospitals and private hospitals signed PPP cooperation agreements.

One sample that is regarded as a compliant diversion and referral sample between public hospitals and private hospitals is the PPP cooperation between the Cancer Hospital of the Chinese Academy of Medical Sciences and the Beijing Sanhuan Cancer Hospital.

At that time, as the first cancer hospital in the country, the Cancer Hospital of the Chinese Academy of Medical Sciences was difficult to find and a bed was difficult to find, and many tumor patients from all over the country were suffering from cancer, but they often had to wait for several months or even half a year later if they wanted surgery and hospitalization.

In order to alleviate the pressure on bed turnover, the Cancer Hospital of the Chinese Academy of Medical Sciences (hereinafter referred to as "Dong Tuo") purchased services from Beijing Sanhuan Cancer Hospital (hereinafter referred to as "Sanhuan Tumor"), which is 2 kilometers away, rented beds, sent doctors to visit, perform surgery, provide technical support and teach.

"Some patients who have completed surgery in Dongtuo will be transferred to the tricyclic tumor to be hospitalized for rehabilitation, and the doctor of Dongtu will remotely guide the medication." In this way, the bed of Dong Swollen can also be given to patients who need surgery as soon as possible. A private hospital industry researcher told Eight Point Health News that the two sides have clarified the details in the agreement on renting beds and providing technical training.

Similar PPP cooperation methods have been successfully implemented between public hospitals and private hospitals.

However, the PPP model, which has been maturely applied in hospitals in many countries, has not been implemented in China for a long time, and it has encountered Chinese-style problems.

Wu Qi (pseudonym), a former employee of a top three hospital in Zhejiang, once experienced the failure of a PPP cooperation model.

About 4 years ago, a private hospital was listed as the international campus of Wu Qi's hospital, and the two sides fought fiercely. Public hospitals support famous doctors and open outpatient clinics. Wu Qi and his colleagues were also assigned to work in the International Institute, rotating every 2 to 3 months.

At the beginning, the doctors of our hospital were very energetic and liked to run to the International Campus. Although the workload is large, the income has increased significantly, and doctors have received cash.

The honeymoon period is fleeting, and the contradictions are gradually revealed. At first, it was justified as the diversion of patients in the international hospital, but the source of diseases in the hospital was reduced, and the relationship between the two sides gradually became rigid. In addition, the international hospital paid the doctors in the form of "transfer plus tax returns", and the doctors who ran the branch became less interested.

A year later, in this delicate relationship, as public hospitals began to withdraw, the International Campus declined. Wu Qi remembered that after the department was withdrawn one after another, the number of patients in the International Campus was significantly reduced, and the disease became ordinary and single. Some of the complex diagnostic and treatment techniques previously introduced from our hospital have not only lost the guidance of skilled doctors, but also no longer have suitable patients to use.

The source of the disease is gone, and private hospitals have tried to help themselves, carry out simple diagnosis and treatment, and expand physical examination projects, but it is still to no avail. By the end of 2020, the two hospitals were completely decoupled, and the international park was gradually declining.

The above researchers said that there are also some private hospitals, after the diversion of patients, do not provide good services and receive patient complaints; and because of irregular management, doctors in some private hospitals for personal interests indiscriminately prescribe drugs and indiscriminate diagnosis and treatment incidents occur frequently, and patients will also be angry with cooperative public hospitals.

In the medical field with strong regionality, Chinese patients recognize hospital signboards and doctors. Doctor-patient disputes that occur in private enterprises that actually undertake diagnosis and treatment smash the signs of public hospitals.

After the chaos, there are more and more doubts about the medical PPP cooperation model. Profit transmission, loss of resources, disruption of the medical market – criticism of all kinds. Since then, although the national level has not been stopped, many provinces have suspended the public-private cooperation medical PPP cooperation model in their jurisdictions.

Even in the provinces that have not been stopped, at present, the PPP model is "not popular".

"The mixed private hospital has broken everyone's heart." A private hospital president told Eight Point Jianwen that he had been rejected by public hospitals this year, and the other party thought that this model was not feasible, did not dare to do it, and was worried about being blamed.

In this way, it seems that the reform exploration that was once regarded as a joint effort between the public and private sectors, after some failed "social experiments", this "sunshine referral road" that was originally compliant and reasonable has been blocked.

Hidden grey referral route

After the reasonable "sunshine referral road" of "public-to-public" was blocked, the private-to-public referral road began to flourish.

But it is worth tasting that Zhao Chun, executive vice president of the Private Hospital Branch of the China Hospital Association, told Eight Point Health News that there are 24,000 private hospitals in the country, and only a few private hospitals with good management and large volume are accounted for, and 70% to 80% of small and medium-sized private hospitals are more urgently facing survival pressure and customer acquisition needs. Under the pressure of reality, after the sunshine customer acquisition channel cooperating with public hospitals disappeared, the "gray" customer acquisition channel grew behind the sun.

One of the fastest of the "gray" customer acquisition channels is to recruit a well-known expert in a public hospital or "bribe" a doctor in a public hospital. "Get a doctor and bring a group of patients" has become the easiest and fastest way for private hospitals to make quick gains.

At present, doctors are allowed to practice in multiple hospitals, which means that the cooperation between doctors and private hospitals is more flexible, and this peer-to-peer "cooperation" is more private and secretive.

In front of the patient, the doctor has the absolute right to speak. Especially the first doctor in public hospitals, surgical doctors, many times, as long as the doctors in public hospitals mention a mouthful, there will be patients asking around, willing to pay for the bill, which will inevitably have benefits.

Wu Qi told Eight Point Jianwen that the situation of referring patients to private hospitals often occurs in the operating department:

"The main means of income for famous surgeons is the traditional 'flying knife'. The patient from the first diagnosis to the operation process is long, after confirming the treatment plan, the hospital may not have a bed, the chief surgeon will tell the patient that he is operating in a hospital on the weekend, there is no need to queue, that is, the price is more expensive. ”

Many patients will follow the doctor's advice and refer them to private hospitals. Doctors involved in the flying knife can get higher surgical fees, and Wu Qi learned that the "market price" of some surgeries can be as high as 15,000 yuan or cash for one case.

Among them, even if the cooperation is not compliant, it will be difficult to be known and even more impossible to supervise.

In the "Aier Ophthalmology Bribery" incident that Aifen broke the news, Suqian Aier Eye Hospital will give a "referral", and 6%-15% of the transfer surgery fee will be used as a "referral fee". Most of these referrals are doctors and employees of public hospitals.

In the past two years, the impact of the epidemic on the operation of public hospitals, coupled with the impact of policies such as medical insurance price limits and quantity procurement, has squeezed out the moisture of drugs and consumables, and the income of doctors in public hospitals has dropped sharply. Driven by profits, the phenomenon of doctors "making up for losses" by referring patients and practicing multiple points may become more common.

A senior manager in the industry told Eight Point Jianwen that the departments with considerable incomes in Shanghai and the middle and high-level senior doctors have been greatly affected in recent years. For example, suppose that the surgeons of Shanghai Top 3 Hospital have an annual income of 1 million yuan, of which only 1/3 to 1/2 of the income comes from the complete salary and performance of public hospitals, and the remaining part comes from pharmaceutical equipment companies, scientific research fees, lecture fees, etc.

"After the purchase of quantity, the decline in the price of pharmaceutical equipment has not only reduced the performance of the department that can be allocated due to the reduction of hospital treatment income, but also the part paid by the previous enterprise has also been greatly reduced." Although the state has made several rounds of adjustments to the prices of medical services, the adjustment of surgical fees and treatment fees is far from making up for the impact of the price reduction of medicine and equipment on the reduction of hospitals and doctors' income. The above-mentioned senior managers in the industry said.

What is a healthy referral system?

Aifen reported the incident of Aier Ophthalmology's bribery of doctors, and the industry continued to discuss:

Some people believe that this is an inevitable stage of private development, and even "most private hospitals will not survive without this means" Some people also said that foreign general practitioners referring patients to specialized hospitals are not allowed to have rebates, and only by following the law can they form healthy competition.

Whether it is industry discussions or observations from respondents, the "referral" itself can be accepted, but what is unacceptable is that doctors refer patients to private hospitals as if they were commodities in return.

And behind this matter, stripping away the cocoon, we want to clarify the cause.

For example, if a doctor in a public hospital refers a patient from a public hospital to a private hospital, is this behavior wrong and allowed?

In fact, it is not uncommon for doctors in tertiary hospitals to practice in private hospitals. An expert who studies private hospitals told Eight Points That in the process of seeking medical treatment, she had met doctors from public hospitals and recommended that she go to private hospitals for treatment.

Because it takes a long time for a top three hospital in a big city to queue for an operation, the doctor will tell the patient after the consultation, at the patient's request or emergency, if the doctor has more personal practice, he will tell the patient: "If you want to operate as soon as possible, you can go to another private hospital where I am sitting to find me." ”

"Even the doctor detailed that the private hospital has medical insurance, or there is no medical insurance, and it is not going to choose for itself." The above expert said that doctors in private hospitals charge according to the standard of that hospital, get the corresponding commission, and there is no gray rebate. The doctor's purpose is to give the patient another option for the convenience of the patient. "It's acceptable."

In the view of Zhao Chun, executive vice president of the Private Hospital Branch of the China Hospital Association, under the medical system of "public medical treatment is the mainstay and private medical treatment is supplemented" in the mainland, public hospitals have absolute discretion and discourse power.

If referral is essential, who should the hospital and its doctor choose when choosing the hospital to refer to? What standards are adhered to? There are no rules to follow.

For private hospitals that rely heavily on referrals from public hospitals, obtaining customer resources is only the first step. In the view of Guan Weili, chairman of Wenzhou Corning Hospital Group, operating a private hospital, short-sighted means of customer acquisition, whether advertising or marketing, improving popularity does not mean improving the brand, brand and reputation in order to truly attract customers.

Guan Weili has operated a hospital brand based on psychiatry for 26 years and developed it into a national clinical key specialty (psychiatric) unit. The method is also very "stupid": endure loneliness, cultivate talents by yourself, through time deduction, improve technology and services, and let society accept the brand.

Liao Zhiren, chairman of Shenzhen Huaqiao Hospital, is now often deeply pondering, "Which link is the problem with the referral between public hospitals and private hospitals?" ”

The private president's question has aroused deeper questioning: Since when has the trust between the public and private sectors been almost reduced to the minimum, and the private hospital has become the dark thunder of the public hospital president's "more is better than less"? If referral is an important means of rational allocation of medical resources, what should a healthy referral system look like?

Written by Li Lin and Shi Chenjin

Chen Xin 丨 is responsible for editing

This article was first published on the WeChat public account "Eight Points Health" (ID: HealthInsight)

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