The price of nucleic acid testing is becoming more and more "close to the people", and medical staff have something to say

The domestic epidemic has not been calmed and has risen again. On weekdays, whether it is the nucleic acid testing of all employees after the epidemic, or the daily travel and travel needs, doing nucleic acid has become a part of people's lives. Large-scale and high-frequency nucleic acid testing is the key to the mainland's "external prevention of import and internal prevention of rebound".

In the more than two years of the new crown pandemic, with the continuous increase in demand, the price of nucleic acid testing has become more and more "close to the people", from the initial 260 yuan each time, it has dropped to less than 40 yuan per single and less than 10 yuan for mixed mining. There are more and more nucleic acid testing points, the time for issuing reports is constantly shortening, the service time is also constantly lengthening in response to the needs of the public, and some public hospitals have opened a 24-hour nucleic acid testing service model.

"The cost reduction is a good thing for the country and the people, and behind the 'people-friendly' price of nucleic acid testing, there is the party's 'people-centered' development concept, which shows the government's responsibility in epidemic prevention and control." A relevant person in charge of the National Medical Insurance Bureau said.

Behind this is the multi-party concession under the leadership of the government. In November 2021, the National Medical Insurance Bureau deployed the third round of national joint investigation, requiring provinces to reduce the price of testing in public hospitals, with a single test not exceeding 40 yuan per person, and a multi-person mixed examination not exceeding 10 yuan per person.

There is another side to the coin. A number of industry insiders told us that according to the current price of nucleic acid testing, this business is "at a loss" in hospitals. Front-line medical staff take a small number of subsidies and pay in a state of extraordinary work. Even so, misunderstandings occur from time to time. On the eve of the Spring Festival in 2022, a news story that "netizens reflected that medical staff have a commission on nucleic acid" triggered the indignation of many front-line medical personnel in nucleic acid testing.

The continuous reduction of the price of nucleic acid testing has greatly reduced the economic burden of the people. Behind this, however, there are still some issues that need urgent attention.

How did it become a "loss-making" business for hospitals?

Currently, all general hospitals above level II should have gene amplification (PCR) laboratories. This began on April 26, 2020, when the National Health Commission held a teleconference and proposed: "All disease control institutions at or above the county and district level and general hospitals above the second level have formed nucleic acid testing capabilities in a short period of time."

"To build a PCR laboratory, it takes about 1 million yuan to buy equipment, and 700,000 to 800,000 yuan to build and renovate, which is only a fixed investment." Zhang Mingze, director of the laboratory department of a prefecture-level and municipal third-class hospital in Henan, told us that in addition, every time medical staff enter the laboratory for nucleic acid testing, they need to wear protective equipment, as well as reagents and consumables.

Liu Hongwei, chief accountant of the People's Hospital of Inner Mongolia Autonomous Region, told us that there are three kinds of reagent consumables needed for nucleic acid testing: sampling tubes, extraction reagents, amplification reagents, and the price dropped to 25 yuan after the three reagent consumables were included in the national medical insurance belt procurement. In addition, nucleic acid testing also includes equipment purchase, manpower, and disposable protective equipment such as isolation gowns and protective clothing, as well as costs such as water, electricity, heating, and housing depreciation.

"If the government does not fund the purchase of equipment, medical institutions will definitely lose money on nucleic acid." Liu Hongwei said that as for the degree of loss, it cannot be generalized, but depends on the amount of nucleic acid testing in the hospital. He pointed out that for large tertiary hospitals with very large nucleic acid testing volumes, the cost of fixed assets will be diluted, and it may be covered; if the nucleic acid test volume of hospitals is small, it may lose money, and "the possibility of losses in grass-roots hospitals is greater."

Zhang Zeming confirmed this statement. He told us that in his hospital, during the normalization of the epidemic, the average amount of nucleic acid testing a day is hundreds of tubes, and it will increase to thousands of tubes during holidays, and 1 to 3 testers need to enter the laboratory every day.

"The daily profit can't cover the cost of protective equipment, and the hospital operates with a sticker." Zhang Zeming said.

"In Zhejiang, even if the government buys equipment for hospitals, according to the current price of nucleic acid testing, hospitals have almost no profit." Chen Tsunami, president of Taizhou Hospital in Zhejiang Province, told us. He said that if it were not for a sense of social responsibility and a "political task" that must be undertaken, the hospital itself would not have taken the initiative to expand the desire to carry out nucleic acid testing.

Chen Tsunami believes that for medical staff, whether it is outside the hospital or in the laboratory for nucleic acid testing, the working environment is relatively poor, and there is a risk of infection, and sometimes they need to work overnight. Therefore, it is only natural to give nucleic acid testing personnel a certain performance incentive.

"But performance and commission are two concepts that cannot be confused. Public hospitals do not have a commission, nor are they allowed to make direct commissions for any projects, and only through the workload of the most reflect the labor pay." He stressed.

Aggrieved medical staff

Once nucleic acid testing becomes a "loss-making" business for hospitals, it will have a direct impact on medical staff involved in nucleic acid testing.

Take performance bonuses, for example. When Zhang Zeming's hospital calculated the performance bonus of nucleic acid testing for medical staff, it was faced with two schemes, the first of which was revenue and expenditure, that is, income minus cost, and then multiplied by a coefficient. However, after actual measurement, most of the time the income of nucleic acid testing cannot cover the cost, which is obviously unreasonable.

The hospital adopts the second scheme, called "incoming processing", that is, the cost of consumable reagents is completely borne by the hospital, the laboratory department only undertakes the task of nucleic acid testing, and the hospital subsidizes it according to the amount of tasks, "each time you enter the laboratory, each person subsidies 50 to 100 yuan".

After undertaking nucleic acid testing work, daily business is naturally less done. Zhang Zeming said that in order to encourage everyone to be willing to enter the laboratory to do nucleic acid, the performance of the department was issued normally.

"Overall, however, the performance of section members is lower than before the pandemic. After the epidemic, the business volume and income of hospitals and departments have decreased, the big rivers are waterless and the small rivers are dry, and the hospital has given certain nucleic acid testing subsidies to the laboratory department, so it is naturally difficult to tilt more performance." Zhang Zeming said.

"The cost of the inspector's work and manpower are completely incompatible with the price of the fee." Wang Sheng, director of the laboratory department of a provincial-level third-class hospital in Hebei, introduced to us that in his hospital, there are not many laboratory personnel, ordinary testing work has not decreased at all, special qualifications and induction qualifications are required to carry out nucleic acid testing, and the emergency services of nucleic acid testing and emergency services of ordinary projects cannot be combined.

The workload of inspectors continues to increase, but subsidies and performance do not increase with it. "After two years of the epidemic, the physical and psychological tests of the inspectors are facing great tests." Wang Sheng said.

Zhang Zeming's hospital laboratory department has more than 20 staff, and can maintain normal operation on weekdays. However, during the epidemic period, in addition to the nucleic acid testing of medical institutions for staff and staff of hospital employees and accompanying patients admitted to the hospital, there are also a large number of people who are willing to check the due diligence.

After the amount of nucleic acid testing has been greatly increased, it not only affects the normal testing work, but also directly interferes with the medical order.

"When there is no epidemic, there is not enough to eat, and when there is an epidemic, it is directly messed up - it was originally a small trailer, and suddenly it was filled with a cart of stones." 」 Zhang Zeming said that when there is an epidemic, it has to bear double the workload, and the duty staff often has to answer the phone, "such as complaint calls that the nucleic acid test results are slow."

Zhang Zeming said that the duty telephone of the department is usually used to report the test results and communicate with the clinical department, but during the epidemic period, a large number of out-of-hospital calls come in every day, one by one to consult the report time, involving a lot of energy in the laboratory department to deal with.

The quality of work that is not understood

What makes the medical staff of the laboratory feel aggrieved is that in addition to the lack of recognition of the value of labor, there is also the lack of understanding of the professionalism of nucleic acid testing work, and they feel that their actions are "vulgarized".

"Nucleic acid testing involves multiple links, is a sensitive, precise and cumbersome procedure, but it is vulgarized." Wang Sheng introduced that ordinary people think that throat swab collection is nucleic acid testing, but they rarely understand the work process of the tester in the nucleic acid testing laboratory.

"A lot of people think that putting a nucleic acid test sample on an instrument will soon produce results." Zhang Zeming said that in fact, many links require inspectors to manually complete various delicate operations under the three-level protective equipment and in the negative pressure environment. A small mistake in any one step will cause the experiment to fail and affect the time to report the results.

After the front-line people have collected throat swabs and nasal swab samples, they are transported to the laboratory department in the middle. After that, they had to spray and disinfect the three layers of packaging in turn, then open the sealed bags one by one, take out the samples, then sort out and sort, and then enter the information.

Next up is the sample work. "Screw the caps one by one, suck the samples, add the samples, and then screw the covers, and the hand muscles of the testers will always remain tense." Zhang Zeming said that one can not be wrong, one can not be leaked, but also to avoid cross-contamination.

At the same time, in another clean area, isolated from sample contamination, the inspector needs to prepare the reagents used for subsequent amplification tests. The prepared reagents are also manually dispensed to a 96-well amplification plate, and finally the extracted nucleic acids of each sample are transferred to the amplification system.

"The whole process is fully manually packed, the pipetting volume is slightly upgraded, the operation process requires fast, accurate, stable, and to ensure zero pollution." Yang Yihui, Department of Clinical Laboratory, Zhongshan Hospital Affiliated to Fudan University, introduced in her article.

This is followed by the amplification process, which takes about 2 hours, and once the instrument starts the amplification process, no new samples can be added halfway through. "That's one of the reasons why nucleic acid testing can't be done on the go." If an instrument malfunction or some special circumstances arise, a batch of 91 tube samples should all be returned to the nucleic acid extraction step and start over." Yang Yihui said.

After that, the inspector needs to conduct professional analysis and interpretation of the reaction curve generated by the instrument: baseline setting, judgment of yin and yang property control, check the reaction curve of each sample one by one, raw data analysis, whether the interpretation results are true and reliable, and the inspector needs to confirm that it is correct. After this series of professional operations, the results can be published. At this point, a single batch of samples (91 samples + 5 negative/positive control products) samples, after several hours of testing, is initially completed.

"The preliminary preparation takes 0.5 hours, the nucleic acid extraction takes about 0.5 to 1 hour, the amplification is fixed for 2 hours, and then the results are analyzed." The whole process takes 3 to 4 hours. If a false positive is found to require a review, it will take longer." Zhang Zeming said.

"In this way, if we repeatedly ask for shortening the time for reporting and issuing reports and results, it will violate scientific principles, may lead to the abuse of certain testing methods in laboratories, and bring hidden dangers to epidemic prevention and control." Wang Sheng told us.

Repeated price cuts, who will bear the cost?

At the beginning of 2020, the supply of nucleic acid test kits for the new crown virus in various places was in short supply, and the price of nucleic acid testing once reached 260 yuan per person. The whole family does it, many times, and it is a big expense to accumulate.

In order to control the expenditure on testing and screening at an affordable level, the National Medical Insurance Bureau has launched three rounds of national joint investigation to guide all localities to reduce the price of nucleic acid testing. Up to now, the provinces across the country have successively reduced the price of single inspection per person to less than 40 yuan (including 40 yuan) per person, and the price of mixed inspection to less than 10 yuan per person (including 10 yuan).

It is undeniable that the price of nucleic acid testing has been continuously reduced, which has greatly reduced the economic burden of the people. However, in Zhang Zeming's view, the price reduction of nucleic acid testing is a double-edged sword, dampening the enthusiasm of medical staff. He analyzed that in the case of very low profit margins, the labor costs of medical personnel are easily compressed, and the work cannot be returned accordingly, if coupled with the increase in work intensity and long-term high load operation, it is easy to have burnout.

"We can't ignore the physical and mental wear and tear of medical staff, and we also need to give them reasonable compensation." He analyzed that if the epidemic continues in the future, nucleic acid testing in hospitals will become a common project like blood routine. In the long run, healthcare workers may be overwhelmed.

"Just like a balloon, if it is pressed to a certain extent, it will explode, and in the end it is the people who are damaged." Zhang Zeming said.

In addition, after the nucleic acid detection kit was included in the collection, several rounds of price negotiations were made, and the profit margin of the manufacturer became very small.

"If you deviate from the law of value and reduce prices indefinitely, it is difficult to ensure that there is no risk in quality, which will affect the accuracy of nucleic acid testing." Zhang Zeming gave an example - when the meat sandwich bun is 15 yuan a piece, it is real and solid meat. When the price is asked to drop to 5 yuan, 3 yuan, or even 1 yuan a piece, can you still guarantee good meat?

"In short, we must see the risk point after the repeated price reduction of nucleic acid testing, control the price in a reasonable range, and cannot drop again and again indefinitely." Zhang Zeming suggested that medical institutions should not be repeatedly asked to reduce prices, but should give more care to frontline anti-epidemic medical personnel.

How to make a business that does not make money performs?

For businesses such as nucleic acid testing, which has social benefits but lacks economic benefits, how should hospitals issue performance to medical staff?

"It can't be said that nucleic acid testing doesn't make money, so it doesn't give performance to the laboratory department, or the performance becomes less." Liu Hongwei told us that in the People's Hospital of the Inner Mongolia Autonomous Region, nucleic acid testing work is the same as other work, according to the difficulty of the project, the degree of risk, and the workload to calculate the work points, and according to the score value of the corresponding performance.

The pursuit of the overall performance of the hospital is the strategic goal of the hospital. Liu Hongwei said that when the hospital does operation management, it needs to balance the overall performance of the hospital and the performance of the department. In the pursuit of overall performance improvement, it is necessary to consider the special situation of some departments and artificially tilt these departments, "otherwise, the emergency department, ICU, pediatrics, infectious disease department, hematology department, etc. cannot retain people."

"Because the development of hospitals should also match the policy direction of the country, so as to assume the corresponding public utility functions." He said that therefore, the performance distribution of hospitals needs to be moderately inclined to departments and businesses with high social benefits but "not making money". He suggested that hospitals should follow the "constraint theory" to structure the overall performance plan to guide the hospital's development under the overall strategic objectives. However, when it comes to individual departments, it is necessary to artificially balance through secondary allocation.

*At the request of the interviewee, Zhang Mingze and Wang Sheng are pseudonyms

Source | The health community

Written by | Liu Wenyang

Edit | Swagpp