Development slowed, incomes decreased, and expenditures increased
Written by | Tian Wei
Source | "Medical think tank" public number
More than two years have passed since December 2019, when the coronavirus first appeared. Over the past two years, non-public medical care has suffered heavy blows, and public hospitals, which are the main body of the mainland medical system, are also struggling to survive.
Continued anti-epidemic expenditure, rising labor costs, high-load operation of medical care, coupled with the occasional outbreak of the epidemic caused by the sharp decline in business volume from time to time... Since the second half of the epidemic, public hospitals have been exhausted, tense and passive.
"The most critical thing is that, like the farmers in the past who 'watched the sky to eat', now (public hospitals) are 'watching the epidemic to eat', and usually can improve efficiency through cost control, performance adjustment, opening weekend clinics, etc., but once the epidemic comes, epidemic prevention and control is the most important thing, quite passive." Dr. Zhuang Yiqiang, director of GAHA of Guangzhou Elippi Hospital Management Center, said.
Leading hospitals in areas with high outflow rates of original patients,
Or become the biggest beneficiary of the epidemic
There is no doubt that the winter in public hospitals began in early 2020.
The results of a questionnaire involving 316 hospitals in 26 provinces and cities (204 of which are public hospitals) showed that in February 2020, almost all of the hospitals surveyed had a year-on-year decline in business volume and operating income. Among them, 78.48% of the hospital outpatient volume fell by more than 40% year-on-year, and 58.86% of the hospital inpatient volume fell by more than 50% year-on-year.
From the second half of 2020 to the first half of 2021, the domestic epidemic tends to ease, the situation of public hospitals begins to improve, and people gradually begin to return to normal life except wearing masks. Then, delta and the Omicron mutant strains appeared one after the other.
"Especially in Omi kerong, the transmission is strong, most of them are asymptomatic infected people, people are invincible, the epidemic situation frequently flashes everywhere, and the prevention and control of hospitals has become very difficult." Zhuang Yiqiang said.
Li Wei (pseudonym), secretary of the party committee of a top three maternal and child health hospital in the Yangtze River Delta region, agrees that compared with 2020, the hospital's epidemic prevention and control management is now more stringent, "such as obstetrics, because both mothers and babies need the care of family members, considering the needs of patients, so the hospital will relax in management in the past, allowing 2 family members to enter the ward to accompany."
However, recently, the hospital has begun a strict "1 bed, 1 escort" policy, and requires that the accompanying staff must not leave the ward during the patient's hospitalization. To this end, the administrative and logistics staff of the hospital formed a volunteer, and if the escort staff has needs such as express delivery and takeaway, the volunteers will send them to the door of the ward.
The reason for this is that the city where the hospital is located has launched a major public health emergency Level II emergency response and public transportation has been suspended. This has also led to the hospital's recent outpatient volume almost waist-cutting, from an average of about 4,000 per day to an average of about 2,000 per day.
But for hospitals where there is currently no outbreak in their area, it has not been easy. Wang Ling (pseudonym), director of the operation management department of a comprehensive tertiary hospital in the central region, told the "medical think tank" that in the context of normalized prevention and control, the overall business volume of the hospital has declined to a certain extent, and the differences between different departments are obvious.
"General pediatrics, stomatology, dermatology and other departments with relatively mild diseases have declined significantly, and the business volume has dropped significantly, which is about 40% lower than before the epidemic. Departments with intractable diseases, such as oncology and pediatric intensive care units, have little change in business volume. However, the hospital as a whole has basically returned to its pre-epidemic state. ”
She said, "But once there is an epidemic, many patients from other places will not be able to come over, or they will have to be isolated before they can be treated, and the impact will be greater for departments such as oncology, which account for about 40%-50% of foreign patients." ”
This is very much in line with Elips's recent observations. After the epidemic entered the second half, it showed the characteristics of many points, wide coverage and frequent occurrence, "I don't know which of the epidemic and accidents will come first"; and once the epidemic occurs, some areas will begin to "layer by layer" prevention and control. This has led to the general development of "can not seek medical treatment without medical treatment, can see the disease can not see first" mentality.
Secondly, the necessary living habits such as wearing masks, washing hands frequently, and gathering less during the epidemic have also reduced the incidence of infectious diseases such as hand, foot and mouth disease, and seasonal epidemics such as influenza to a certain extent. According to Li Wei, this is also one of the reasons for the significant decline in the volume of pediatric business.
"As a result, the total number of patients seeking medical attention has decreased. The people of our country are accustomed to going to big hospitals to see patients, for these patients who have more serious diseases and must go to the hospital, because of the epidemic, the unknown risk of going to large hospitals in other places has become greater, so they will be more inclined to go to the local leading hospitals for treatment. Zhuang Yiqiang analyzed.
According to his observation, after the second half of 2020, in those places where the outflow rate of patients was originally high, the business volume of local leading hospitals mostly recovered rapidly, or even rose slightly. In those hospitals with weaker local strength, the business volume can only recover to 80% or even 50% before the epidemic, "accelerating the reshuffle".
"On the other hand, for hospitals in Beijing and Shanghai that have abundant medical resources and a large proportion of patients from other places, the business volume will also be affected to a certain extent." "But overall, the overall benefits of all hospitals will decline," he said. ”
In order to fight the epidemic, some hospitals have nearly doubled the number of nursing staff
There is no doubt that the epidemic has slowed the development of public hospitals.
According to Li Wei, compared with 2019, the number of outpatient visits in the hospital in 2020 fell by 18%, and the number of discharges fell by 21%. In 2021, the number of discharges was basically restored to the pre-epidemic period, and the number of discharges was only 2.13% lower than in 2019. But without the epidemic, the hospital's annual business growth rate is about 7%.
The same is true of the Ninth People's Hospital of Zhengzhou City, palliative (palliative) treatment and palliative care center. Li Ling, head of the center, told the "medical think tank" that before the epidemic, the average increase in the number of hospitalizations in the center each year was about 25%-27%, with a slight increase in 2020, and a slight decline in 21 years compared with 20 years, basically flat, "the growth of hospitalization volume has slowed down significantly."
The center's fully open featured services, such as outpatient drug titration treatment for cancer patients, bereavement counseling, malnutrition risk assessment, etc., have been open to inpatients only since the epidemic. "Mainly for risk considerations, because the patients in the center are terminally ill and terminally ill, and their immunity is extremely low. General clinics such as palliative care clinics, cancer pain clinics, and multidisciplinary collaboration (MDT) clinics are open as usual. She said.
Slowing development or reducing incomes has been accompanied by increased spending, especially for the fight against the pandemic. For many hospitals in China, fever clinics, negative pressure wards, and "three districts and two channels" are all emerging products that began to be equipped after the emergence of the epidemic. If the original construction area of the hospital is sufficient, it will spend money to renovate on the spot; if the construction area is insufficient, it will be built in a new place.
According to Li Wei, because other general hospitals in the city do not have obstetrics departments, in order to ensure the normal production of local mothers, the hospital began to transform some administrative offices into fever clinics in 2020, and "the decoration cost about 1.6 million yuan."
Wang Ling also said that when the epidemic was most serious in 2020, as a designated hospital for the treatment of new crown, in order to treat the largest number of new crown patients, the hospital vacated a whole floor of the old hospital area for hardware transformation. About 1.5 million was then invested to add negative pressure wards to the respiratory medicine department.
After the fever clinic and negative pressure ward are built, they should also be equipped with corresponding equipment such as CT. There are also protective clothing, masks and other materials that need to be equipped daily. "The expenditure on epidemic prevention and control can account for 2.14% of the total expenditure of hospitals." Li Wei said, "Although the state has subsidies in this regard, the proportion is relatively small. ”
The increase in labor costs is probably the biggest dilemma facing public hospitals right now. Due to the needs of epidemic prevention and control, hospitals should frequently send medical nurses out to "do tasks" according to the arrangements of their superiors, or support nucleic acid testing and vaccination, or send them to support the new crown designated hospitals and square cabin hospitals.
"The salary bonus for expatriate support for this part of the population is borne by the hospital, and it is necessary to ensure that its treatment is not lower than that of employees in the same position who stay in the hospital." Li Ling, who is also the vice president of the Ninth People's Hospital of Zhengzhou, told the "medical think tank" that "those who stay in the hospital to work must not only complete their established workload, but also 'take over' the established workload of expatriates, and the labor intensity has increased compared with before." ”
Even if the matter of expatriate is not considered, in order to strengthen the prevention and control of hospital infection, the hospital must also draw personnel from various departments to be responsible for fever diagnosis and buffer wards, as well as send people to "guard" the door of the clinic to screen the flow of information for patients.
"The pressure on the deployment of personnel is indeed relatively large, considering that because of the recent epidemic, the business volume of some departments has declined more, and we have compressed and integrated the wards of some departments." After the number of beds is reduced, the medical care in the ward can be enriched in the hospital or dispatched to the anti-epidemic team to alleviate the tension of personnel. Li Wei said.
The Ninth People's Hospital of Zhengzhou City has recruited medical and nursing staff. It is reported that the hospital is a tertiary hospital characterized by the treatment of geriatric diseases, and there are about 600 beds in the ward of the elderly unaccompanied center and the ward of Zhengzhou Psychological Hospital (hospital middle hospital) in the hospital. A considerable number of patients have the characteristics of long hospitalization period, little mobility, and difficulty in returning to family or society during the epidemic.
"Therefore, in the Zhengzhou health system, the business volume of our hospital is almost minimally affected by the epidemic, especially the number of inpatients, which does not seem to have changed much." Li Ling said, "But after entering the normalization of epidemic prevention and control, medical and nursing human resources are more tight, because it is necessary to ensure that the daily work of the hospital and the epidemic prevention and control work can operate normally." Therefore, we will recruit dozens of new doctors and more than 100 nursing staff in 2021, especially nursing staff, nearly half of which will be expanded to cope with the normalization of the epidemic prevention and control needs. ”
In addition, li Wei judged from his own experience in the management of grass-roots hospitals that grass-roots hospitals such as community health service centers and township health centers will face greater manpower pressure, because "they can allocate fewer medical care and may have to undertake more epidemic prevention tasks."
According to the president of a general hospital of a medical community in South China, "Due to the regional medical insurance deficit caused by the epidemic, the medical insurance and the hospital in the past two years have been discounted." The decline in overall medical income, coupled with the hospital's own anti-epidemic expenditure, the per capita treatment of grass-roots hospitals in 2020 is reduced. In 2021, we strive to achieve a basic balance of payments, and we expect per capita annual income to increase by 70-10,000 yuan in 2022."
No bonuses have been issued for more than half a year, and many discipline leaders have left
In any case, for public hospitals where the proportion of financial subsidies is only single digits and they are basically self-financing, the epidemic situation over the past two years has brought severe operational management tests.
Hospitals that previously had surpluses and "capital" to use, and those that had previously operated poorly had to maintain cash flow through bank loans and credit to suppliers. Public hospitals as public institutions will not go bankrupt, but once their cash flow is insufficient to support the normal operation of the hospital, the first to bear the brunt is the overload of medical staff.
An industry insider who did not want to be named revealed to the "medical think tank" that from the second half of 2020 to 2021, due to the epidemic, some public hospitals in the northeast region have long-term deficits, and some public hospitals have not paid bonuses to medical care for more than half a year.
"The income of medical staff is composed of two parts: basic salary and performance bonus, the latter accounting for at least 50%. So without a bonus, it means that the income has shrunk by at least half, and the mortgage may not be repaid. It is also for this reason that these public hospitals have left a number of discipline leaders at the deputy director level, which is already an open secret in the industry. The above-mentioned person said.
In the face of the operational and management pressure brought about by the epidemic, public hospitals are also "making moves", or setting up weekend outpatient clinics and evening outpatient clinics to try to take the amount of secondary; or through cost control and performance adjustment, etc., to improve quality and efficiency, and develop in the direction of refined management.
Wang Ling felt this very deeply. Her hospital has been a performance reform since 2015. The hospital sets up a specialist assistant position in the operation management department, and the specialist assistant sinks down to each department to help the section director carry out operational affairs such as cost control, equipment project approval, and budget management.
"When the hospital was first reformed, there were still voices of doubt. But after the epidemic, everyone was very thankful that the hospital was 'planning ahead', because it was obvious that the 'tight days' of public hospitals had come. She said. On the other hand, after the epidemic, how can hospitals attract patients and 'restore livelihoods'? This makes the hospital realize the importance of building a core clinical core competitiveness. In the future, whether it is performance or investment, we will tilt towards the key development direction of cardiovascular disease and tumor. ”
In fact, this is also the direction of high-quality development of public hospitals advocated by the state in recent years: the development mode of public hospitals has shifted from scale expansion to improving quality and efficiency, the operation mode has shifted from extensive management to refined management, and resource allocation has shifted from focusing on material elements to paying more attention to talent and technical elements.
Some insiders believe that the operational pressure brought about by the epidemic has forced public hospitals to reform and transform, which has boosted the operation of medical reform to some extent.
The impact of the pandemic on public hospitals is many more. One of the highlights is the shift in service models – public hospitals that used to rely almost entirely on offline in-person diagnosis and treatment began to explore and embrace online services. According to the "2021 China Internet Hospital Development Report" released in May 2021, public hospitals have become the main force in the construction of Internet hospitals, accounting for nearly 70%.
Li Wei's Maternal and Child Health Hospital also incorporated information construction into the "number one" strategy of hospital development. According to him, relying on the balance of the hospital in previous years, the hospital plans to achieve the construction goals of electronic medical record level 6, interconnection level 5 and smart hospital level 4 by 2023.
He explained the reason for the hospital's decision: although the information construction cannot produce direct economic benefits in the short term, it can liberate the labor force of medical staff, allow them to have more time to communicate with patients, and improve the service quality of the hospital;
Second, online guidance and consultation interaction can increase the stickiness between the hospital and patients, establish trust, and patients (especially pregnant women) will be more willing to come to the hospital to seek health services throughout the life cycle; third, the digital management model established by information means can break through the bottlenecks and constraints of traditional management and promote more refined management.
However, for the current public hospital managers, there may be another "task" that cannot be ignored, that is, to face up to the impact of the normalization of the epidemic and lead medical staff to better adapt to the new normal of the epidemic through the timely adjustment and improvement of management measures.
"I think managers can relieve the physical and mental stress of employees and make everyone happier by carrying out team-building activities within limited conditions." Li Ling gave an example, "For example, on Women's Day this year, the epidemic prevention and control situation in Zhengzhou was stable, and our hospital organized a spring walking activity to call on all hospital staff, both men and women, to participate." The union also prepared daily necessities as prizes, which everyone had a share of. ”
"Even though I was wearing a mask that day, I could feel the happiness of the big guys."
Source: Medical Community Think Tank
Editor-in-charge: Zheng Huaju
Proofreader: Zang Hengjia
Plate making: Xue Jiao
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