On the occasion of the three-month anniversary of the release of the Draft for Comments, the "national version" of the policy on mutual recognition of medical institutions' examination results was introduced. A few days ago, the National Health Commission, the National Medical Insurance Bureau and other four departments issued a notice on printing and distributing the administrative measures for mutual recognition of inspection and inspection results of medical institutions (hereinafter referred to as the management measures). This marks that the mutual recognition of the results of the inspection and inspection that has been difficult to promote for many years is finally about to "land".
The Administrative Measures clearly emphasize that for inspection and inspection projects that meet the conditions for mutual recognition, the relevant fees shall not be re-charged in the form of packaging with other projects.
It is worth mentioning that the newly released "Administrative Measures" deletes the expression "mutual recognition of inspection and inspection results into the performance appraisal requirements of public medical institutions" in the previous version of the "Draft for Comments" and replaces it with "local health administrative departments should regularly carry out work assessments, and pursue relevant responsibilities for medical institutions and their medical personnel who violate relevant regulations in accordance with laws and regulations".
What results can be mutually recognized?
There is no doubt that the mutual recognition of examination results is formulated from the perspective of reducing patients' diagnosis and treatment expenditure and controlling medical insurance costs.
So, which inspections support mutual recognition? The examination results mentioned in the "Management Measures" refer to the images or data information obtained by examining the human body by means of ultrasound, X-ray, nuclear magnetic resonance imaging, electrophysiology, nuclear medicine and other means; the so-called test results refer to the data and information obtained by the biological, microbiological, immunological, chemical, blood immunology, hematology, biophysics, cytology and other tests of materials from the human body. In particular, it is emphasized that the results of the examination do not include the diagnosis conclusion issued by the doctor.
In the future, HR will not only be synonymous with "human resources", but also "a unified identification for mutual recognition of inspection results in medical institutions." The "Administrative Measures" pointed out that the mutual recognition mark of the inspection and inspection results of medical institutions is unified as HR. Where inspection and inspection items participate in the quality assessment carried out by quality control organizations at all levels and are qualified, medical institutions shall mark their corresponding mutual recognition scope + mutual recognition logo. Such as: "National HR", "Beijing-Tianjin-Hebei HR", "Beijing Xicheng District HR", etc. Inspection and inspection items that do not participate in the quality evaluation as required or fail the quality evaluation shall not be marked.
In the interpretation of the "Management Measures", the National Health Commission requires that medical personnel should strengthen doctor-patient communication, and if the inspection and inspection items are not mutually recognized, they should do a good job of explanation, and fully inform the purpose and necessity of the re-examination.
What conditions allow for repeated checks?
As with the previous draft for comments, in the Administrative Measures, medical institutions and their medical staff can conduct repeated examinations in six cases.
Check the mutual recognition of test results
You need to pass the hospital "income" pass first
In fact, in the past few years, the results of inspections and tests in pilot medical institutions have been mutually recognized. For example, some medical communities or medical federations have long realized mutual recognition, but the mutual recognition model has not yet been "landed" in the country. "It's actually very difficult to implement it nationwide." Liu Yuan, director of the clinical department of a third-class hospital in Guangdong, said.
After the elimination of the drug markup, the examination became a hospital revenue rather than a cost, and the hospital needed this part of the revenue to support normal operation. Over the years, there have been three main sources of income for medical institutions: medical service fees, drug revenue, and inspection income. With limited room for price increases in medical services in public hospitals and the elimination of drug markups, hospitals are clearly unwilling to give up the revenue generated by examinations.
According to the 2018 Statistical Communiqué on the Development of The National Basic Medical Security Undertaking released by the National Medical Security Bureau, the proportion of drug expenses to hospitalization expenses decreased by 3.1 percentage points compared with the previous year, and the proportion of examination and treatment expenses increased by 3.0 percentage points compared with the previous year. This indicates that some medical institutions have passed on the loss of drug costs to the cost of examinations, and the reform expectation of "using medical services to make up for it" has not been met. If the hospital does not have other sources of income to compensate accordingly, it is inevitable that there will be a "soft resistance" to the mutual recognition of the test results.
How to ensure the timeliness and credibility of the test results?
Some clinicians believe that mutual recognition of examination and test results is not feasible in the actual operation process. This stems from the fact that people are dynamically changing individuals, and some of people's biochemical indicators fluctuate over a certain period of time, such as blood glucose, and the value will vary within a few days.
"The size of the tumor will change, assuming that it is a tumor patient's CT test results, if the patient is a report from 1 month ago, I hope that the patient will re-examine, especially breast cancer, lung cancer, liver cancer and other tumors that are advancing rapidly, and the report over a long period of time will have a great impact on the doctor's judgment." 」 Liu Yuan said.
Different levels of medical institutions have different testing capabilities, different quality control standards, and different methods of examination and inspection, which also directly affects the credibility of clinicians in patients' previous examinations. Some clinicians say that sometimes the same test, the test reagents and instruments at all levels of hospitals are not the same, and there is a risk in mutual recognition of such tests.
In this regard, the "Management Measures" require that local health administrative departments should formulate and improve the quality evaluation indicators and quality management requirements of inspection and inspection projects at the same level. Quality control organizations at all levels shall strengthen the quality management of inspection and inspection projects in their respective regions, regularly standardize the quality evaluation work, and promote medical institutions in their respective regions to improve the quality of inspection and inspection.
Obviously, the homogenization of laboratories and imaging departments is the basis for promoting mutual recognition of inspection and testing. After the implementation of the "Management Measures", the quality inspection of imaging departments and laboratories in various places will be more normalized, and how to ensure the implementation of inspections will become a challenge for various geological control agencies.
Qian Yun, director of the Reproductive Center of the Second Affiliated Hospital of Nanjing Medical University, told the health community that Jiangsu Province once stipulated that the examination results of the tertiary first-class hospitals were allowed to be mutually recognized, but in order to avoid corresponding medical disputes, the first eight blood transfusions, including AIDS, hepatitis B, syphilis, etc., never recognized each other, which stemmed from the fact that once the test results of the previous medical institution were inaccurate and there was a dispute in the treatment of this hospital, the hospital would be placed in a very passive situation. Qian Yun said that in the department he works in, a large part of the patients will have the experience of treating and examining in private hospitals before, and they will be more cautious about the relevant examination reports.
It can be seen that the "consistency and comparability" of the examination results should not be the only condition for "mutual recognition", and whether there is "mutual recognition" lies in the clinical adaptability of the test report and whether the clinician's ability to diagnose and treat diseases truly meets the clinical needs.
After mutual recognition, how to determine the liability for disputes?
After the mutual recognition of the inspection results, once there is a medical dispute arising therefrom, how should the two parties bear responsibility? The "Administrative Measures" show that for disputes arising from mutual recognition of inspection and inspection results, each responsible entity shall bear corresponding responsibilities in accordance with laws and regulations. Where the results of forgery, alteration, concealment, or alteration of inspection and inspection results cause negative consequences, the violating entity shall bear corresponding responsibility in accordance with laws and regulations.
Daniel Zhang, founder of the medical legal team of "Medical Law Hui", mentioned in an interview with the health community that auxiliary examinations such as ultrasound and X-ray are not only the basis for diagnosing diseases, but also one of the important evidences in medical dispute cases, and if there is a medical dispute due to the use of other hospitals' examination results, both hospitals will inevitably be involved in medical disputes.
"The doctor's diagnosis of the patient's disease is a comprehensive and systematic process, generally speaking, including the doctor's consultation, physical examination, laboratory examination and auxiliary examination, ultrasound, X-ray and other auxiliary examinations are only one of the diagnostic links, and doctors cannot rely only on mutual recognition of auxiliary examination results to diagnose patients." Therefore, the fact that the first medical institution misdiagnosed and the result of mutual recognition does not mean that the second hospital will also misdiagnose."
Daniel Zhang lawyer also mentioned that if the second hospital fails to fulfill its duty of medical care and relies too much on the results of auxiliary examinations to cause misdiagnosis, resulting in damage to patients, it needs to be held responsible. In practice, it is necessary to determine the effect of specific medical fault on the patient's damage result through medical damage appraisal. Medical institutions shall bear the corresponding medical damage liability according to the role of their medical fault acts in the consequences of patient damage.
"Doctors need to strictly implement the diagnosis and treatment norms, do not rely too much on the examination results, and also pay attention to the standardization of medical records, so as to prevent the patients from complaining about repeated examinations, due to the irregular writing of medical records, resulting in difficulty in arguing, and bear unnecessary legal consequences." Daniel Zhang lawyer said.
Liu Yuan, who has worked in the laboratory department for more than ten years, frankly said that after the issuance of the "Management Measures", corresponding supporting measures need to be introduced if she wants to truly "land". First of all, refine the diseases that can be repeatedly examined or even examined multiple times, such as some tumors with high complexity and rapid disease progression. In addition, local or hospitals should establish a complaint system, such as the development of small programs, when patients put forward mutual recognition of test results, doctors can write their own reasons on it to refute. An important point is that doctors should have a normal complaint mechanism, and Liu Yuan suggested setting up a grievance committee in the region to avoid the punishment of doctors and hospitals without asking questions when patients raise objections to repeated examinations.
(Liu Yuan is a pseudonym in the text)
Sources | the health community
Written by | Li Zijun