In any system reform with the right general direction, some related parties will inevitably become the losers of interests. In the wave of DRG/DIP medical insurance payment system reform, internal medicine seems to be becoming this "loser".
A medical insider said that under DRG/DIP, internal medicine is "shrinking" in losses.
An internist said that at present, the hospital implements two years of DRG, and internal medicine continues to "shrink", and stagnation will be an inevitable result.
Whether it is the DRG payment model by disease diagnosis-related group or the DIP payment model by disease score, to a large extent, it tends to be the simpler the disease, the better, and the more complex the disease, the more difficult it is. Under the new payment method, internal medicine naturally has a disadvantage.
Over the years, when it comes to DRG/DIP, surgery and internal medicine have become synonymous with "making money" and "losing money" respectively.
After talking with a number of physicians, we found that some internal medicine departments with chronic diseases have shrunk their income and reduced their beds. But under the wave of change, the struggles of these internal medicine seem silent.
What is more worrying is that in the shadow of "fear of loss", in order to achieve higher scores, between accurate diagnosis and overtreatment, some physicians inevitably appear "action deformation" of diagnosis. This deformation is difficult to regulate and tugs on the conscience of physicians.
There was even a doctor in the respiratory medicine department who said, "It's like watching a movie in a movie theater, everyone in front stands up, and if you don't stand up, you can't see the movie." ”
If viewed with a more optimistic vision, the development of internal medicine itself has come to the crossroads of change. DRG/DIP is just a pressure to reverse, whether it is the "large outpatient and small ward" model, or the "internal medicine surgery", the various departments of internal medicine have to go a new way.
Losing money, shrinking, being cut beds
Compared with surgery, under DRG/DIP, internal medicine is the "main force" that loses money.
In this case, with some hospitals linking department losses and personal salaries, the loss of internal medicine departments will be directly transmitted to "damage to the personal interests of internal medicine doctors".
At the beginning of last year, the cardiology department of a third-class hospital in Zhejiang Province suffered losses after the implementation of DRG, and part of the loss had to be shared by the doctors in the department, which finally led to a sharp salary reduction for doctors and a strike at one point.
Under DRG/DIP enforcement, it is an open secret that some hospitals link performance to physician compensation. Even though the Health Insurance Bureau has issued a civilized order strictly prohibiting the issuance of income-generating targets, and medical remuneration and department income cannot be directly linked, many hospitals still act in a negative way, and clinical departments sometimes have to be as meticulous as accounting studios under the baton of reform.
Relevant personnel from a local medical insurance bureau in Guangxi told Eight Points that medical institutions directly link the surplus reward of DRG/DIP with the performance of doctors, which is tantamount to killing chickens to obtain eggs and exhausting the water and fishing, but it is true in many hospitals.
Fortunately, not all hospitals link losses to physician performance. Yu Yan, director of the rehabilitation department at a tertiary hospital in the north, said that the rehabilitation department after DRG loses money, which is a common situation faced by rehabilitation departments across the country, but in her hospital, personal income will not be affected, "otherwise doctors will not be able to do it."
Not linking to performance alleviates some of the anxiety caused by reforms. However, when the general loss of money in internal medicine cannot be reversed, doctors in internal medicine still frequently feel exhausted.
In a third-class hospital, neurologist Zhang Min found that since the hospital implemented DRG in 2022, the more patients in the neurology department received, the more the department lost. Zhang Min's dilemma is that "most neurology patients are difficult to meet the payment standards of the high-scoring group, but the low-scoring payment standards cannot cover the various expenses of hospitalization."
In the neurology department where Zhang Min works, most of the top ten diseases are related to ischemic cerebrovascular disease, and most of the patients cannot meet the criteria for high score payment when enrolled.
Taking acute cerebral infarction as an example, those who meet the conditions for thrombolysis or thrombectomy can be treated with thrombolysis and thrombectomy, "The DRG point value of thrombolytic therapy is relatively high and reasonable, but the proportion of patients who can reach the hospital for treatment within the thrombolysis time window is very low." As a result, the vast majority of patients with 'overtime' can only be treated with conventional medications, and the point value of DRG is much lower than that of thrombolytic therapy. ”
What further disturbs physicians is that if the department continues to lose money, it will be the result of the department's "shrinkage" not far away.
The most direct manifestation of "shrinkage" is that the beds in the department are "taken away".
Wang Shu, an endocrinologist, told Eight Points that in his hospital, the internal medicine department that cannot carry out operations is reducing the number of ward beds, "The endocrinology department is reducing the number of beds, and the future direction is to increase outpatient clinics and allocate beds to surgical departments that are often full." ”
Another respiratory physician at a university hospital encountered a similar situation. The hospital where respiratory physician Shi Yong works is also reducing the number of beds in endocrinology, rheumatology and immunology departments.
Not only in the endocrinology department, rheumatology and immunology department, but also the rehabilitation department that relies on beds the most, is also facing the dilemma of possible "shrinkage".
Yu Yan, director of the rehabilitation department, said, "The department has changed from a positive benefit department before DRG to a department that loses money and has negative benefits. "In the two years since DRG was implemented, the changes have changed dramatically. As a third-class hospital, the rehabilitation department often accepts patients with complex neurorehabilitation, intensive care and internal medicine rehabilitation, which requires a long rehabilitation period. However, under DRG's charging standards, the past two years have often "not recovered well, and the money has been spent".
Yu Yan often faces the situation of transferring patients to other secondary hospitals; To not accept the occurrence of losses, the department or hospital will subsidize the money.
In the long run, sooner or later, the hospital will reposition the rehabilitation department for the consideration of global operation. "The department may not be allocated resources for development, not only to stop and develop, but even maybe not to develop." According to Yu Yan, most of the rehabilitation departments of the third-class hospitals in the country are almost in a loss-making state, and the "shrinkage" and "stagnation" of their own departments may also be inevitable results.
Some people say that to a certain extent, the bed is a symbol of the power of a clinical department, and is the department head willing to cede "power"?
"This adjustment is not for the department director to say, the hospital has a special operation department to analyze and measure, an inefficient, low-quality inferior department is bound to reallocate resources." Wang Shu said.
But thinking about it, reducing the number of beds and increasing outpatient clinics may not necessarily be a bad thing for some internal medicines.
Does the department lose money, or persuade the patient to leave the hospital? The dilemma of internal medicine
"Most internal medicine patients suffer from systemic diseases, and it is common sense that complex diseases cost a lot."
However, in the context of DRG/DIP, this feature of internal medicine has become the reason why most internal medicine is doomed to lose.
In internal medicine, especially elderly patients, there may be problems with the respiratory, circulatory, and digestive systems. Zhou Yiping, a consultant at Firetree Technology, told Eight Points Jianwen, "Doctors cannot only treat digestive problems for patients because they are doctors in gastroenterology, out of responsibility for the patient's life and health, other treatments should still be treated." However, in this case, the consumption of resources of the internal medicine department will be increased to a certain extent. ”
Whether it is the DRG payment model by disease diagnosis related groups or the DIP payment model by disease value, to a large extent, it tends to be the simpler the disease, the better, and the more complex the disease, the more difficult it is. According to Xu Yucai, former deputy director of the Shanyang County Health Bureau in Shaanxi Province, from this point of view, internal medicine naturally has disadvantages under the DRG/DIP payment method.
The difficulty of grouping diseases further aggravates the burden on the shoulders of internal medicine.
Shi Yong, a respiratory physician, said, "There are indeed many complications in internal medicine, and they are not as simple as surgical diseases. For example, the tumor can be removed directly after surgical examination, but there are many internal medicine complications so that the diagnosis of discharge can often be prescribed to a dozen. Zhang Min, a doctor in the Department of Neurology, also mentioned that imagination is beautiful, but in reality, there are few "simple" diseases, and many complications make the grouping of diseases difficult.
The difficulty of grouping makes doctors pay extra attention when filling out the first page of the case, which disease is placed in front and which disease is put behind.
"The first 5 reimbursements of medical record diagnosis, hypertension, diabetes must not be omitted, but also rely on the front, the more you rely on the reimbursement, the more money you will reimburse." A psychiatric doctor told Eight Points that if the arrangement was wrong, the cost would have to be borne by the department.
In addition to the difficulty of grouping, the unscientific grouping of diseases is the root cause of the often stretched throat of some internal medicine departments.
In the hematology department, the same chemotherapy, leukemia, lymphoma and other blood diseases often require higher medical costs than other cancers such as lung cancer and stomach cancer. If the former's chemotherapy is not listed separately, but is generally classified as a unified payment for one patient group, the objective cost of chemotherapy for blood diseases is destined to lose money.
Physicians complain that the current DRG grouping is not scientific enough and is not unique.
Zhang Min, a neurologist in the department of neurology, said she and her colleagues found that patients undergoing endotracheal intubation were not paid according to the high magnification rate, but only according to the main diagnosis, which puzzled them. A careful study of the payment criteria found that only those who were intubated for more than 96 hours could be assigned to group A and received an 11-fold payment ratio. Zhang Min said bluntly, "I don't know how the 96-hour division standard was formulated. ”
One-size-fits-all groupings and huge cost differences between groups often confused Zhang.
Even if you meet the criteria for paying for high scores, the fees can sometimes be stretched. Most of the internal medicine is in a state of losing money, and the payment of an acute cerebral infarction patient in the neurology department is about 5000~7000 yuan, "after using thrombolytic drugs, the cost is excessive, and 5000 yuan is not enough." "Some doctors said.
For patients with complex conditions, the cost is stretched, and doctors can only choose between persuading patients to leave the hospital and losing money in the department.
The cost paid by DRG has bottomed out, and if the patient continues to be hospitalized, the department needs to reverse the money to make up for the shortfall; If the patient is not hospitalized, where should the patient go? Yu Yan of the rehabilitation department said that the cost is not enough, so it can only shorten the hospitalization of patients, or let patients who have passed the emergency period be transferred to the rehabilitation department. The rehabilitation department became the last "takeover man".
However, the rehabilitation department also faces the problem of insufficient DRG costs. Yu Yan told Eight Points that there are two groups in the rehabilitation department, and for patients with serious comorbidities, the DRG group will reimburse 12,000 yuan; Patients without comorbidities are reimbursed about 5,000 yuan. However, the hospitalization period of the rehabilitation department is longer than that of other departments, and it is normal for three months to half a year.
"Patients have nowhere to go, continue to stay in the hospital, spend tens of thousands of yuan a month or more, the more departments and hospitals will lose, and doctors have no choice but to transfer to other hospitals." Yu Yan said.
Yu Yan sometimes envies some developed cities, because in some developed cities, the rehabilitation department does not pay according to DRG, but more scientifically according to the bed day. As far as she or he knows, for example, DRG in developed coastal areas pays by bed day, and the standard is about 900-1200/day.
"The rehabilitation department is not suitable for entry into DRG fees." Yu Yan said helplessly, "But many places are one-size-fits-all, whether it is suitable or not, just follow DRG." ”
Internal medicine survival: either surgery or "big clinic"
Internal medicine, which lost money, had to start looking for a way out. Although most of the way out, it is the hospital that is "helping" internal medicine planning.
Many doctors mentioned that hospitals attach great importance to CMI values.
Respiratory physician Shen Ming said bluntly, "The purpose of DRG is to reflect the value of departments and doctors, and this value is mainly reflected in intervention, surgery and other operations." ”
"Even if it is all internal medicine, the point value of the disease with operation is high, and the point value of the disease in pure internal medicine is low. For example, if you need hemodialysis for kidney failure, the point value is high; It's just simple diabetes, no additional operations are required, and the point value is low. Wang Shu, a doctor in the endocrinology department, said.
Under such a set of logic, some internal medicine departments that basically have no operation, low CMI values and overspending have become so-called "inferior departments".
The new way out began to focus on finding "operation" - "internal medicine surgery" and "internal medicine minimally invasive", and some internal medicine departments began to introduce interventional therapy.
Zhang Min said that if internal medicine does not have special treatment methods, it will face an embarrassing situation.
For example, neurology patients can get a higher payment percentage if they undergo interventional examinations, which prompts more neurologists to study techniques such as cerebral angiography and stent therapy. Previously, Zhang Min's neurology department had doctors studying the technology, and now the hospital is preparing to introduce interventional treatment equipment.
Some people have also raised concerns about the "surgical transformation of internal medicine", but in the actual operation of the hospital, it seems that the pace has not stopped.
Respiratory physician Shen Ming's hospital has been practicing DRG for four or five years, and he told Eight Points that DRG will induce medical staff to overtreat from another angle. If a patient has a lung nodule, observation can be used in the past, but now for a high score, doctors are very likely to recommend surgery for the sake of high scores.
What's more, it can distort the diagnosis. If a patient has a history of COPD and actually has pneumonia at the time of presentation, the doctor is also very likely to write the diagnosis as an exacerbation of COPD disease. Because in DRG, the subgroup score for pneumonia is low, and the subgroup score for COPD exacerbations is high.
Zhou Yiping, a consultant at Firetree Technology, said that such "high-leaning" behavior is very hidden and not easy to be supervised. "Like a patient who has some problems, the attending doctor chooses to open the surgery, but maybe other doctors feel that they can not do the operation. This is a medical judgment, and it is difficult to directly conclude whether the doctor has acted at fault. ”
Not all internal medicine can be linked to intervention, surgery, and some can only rely on pure drug treatment, where do they go?
Some hospitals are cutting medical beds that are not profitable and have little demand. "The original department has 100 beds, but in fact, it is often dissatisfied, or the efficiency is relatively low, the hospital will reduce the number of beds in this department to 50 through resource allocation, and the eliminated beds are allocated to departments with relatively large demand. Although the number of beds in this department has been reduced, the number of outpatient clinics in this department will be increased. Respiratory physician Shi Yong said.
"Large outpatient clinic, small ward" has become a pure drug treatment internal medicine, another way to explore.
The hospital where endocrinologist Wang Shu works has begun to adjust the proportion of wards in different departments, and departments with chronic diseases will focus on outpatient clinics, control the scale of wards, and create characteristic outpatient clinics. Respiratory physician Shi Yong's hospital has also implemented the "large outpatient and small ward" program for pure internal medicine departments, such as rheumatology and immunology, endocrinology and other departments.
For some internal medicine departments, before the implementation of DRG, beds were often dissatisfied, but in order to use the bed, it was necessary to catch some mild patients who did not need to be hospitalized to be hospitalized, but after the implementation of DRG, this was equivalent to entering a dead end. DRG payments are adjusted based on the previous year's health insurance settlement, and if the previous year's health insurance settlement value is low, the next year will suffer.
If the bed is vacant, and the bed utilization rate cannot be satisfied, it is somewhat cumbersome. It just so happens that the hospital is often full of department beds, and "patients can't get in line if they want to be hospitalized."
Fewer wards, more outpatient clinics, and the development of medical and surgical misalignment look like a win-win for all parties. Moreover, outpatient payments are not made according to DRG, and the increase in outpatient volume and income can also improve the situation of insufficient medical insurance payment in these internal medicine departments. Wang Shu imagined, "In the future, the status of outpatient clinics may be improved. ”
Now, internal medicine has reached a crossroads.
Although the bed represents the power of a department, the empty hospital bed is also becoming a survival pressure for internal medicine. In the face of DRG/DIP reform, for internal medicine, it seems to be a new way to re-balance inpatient and outpatient clinics, find a way out, and retreat into progress.
(Zhang Min, Shen Ming, Yu Yan, Wang Shu, Shi Yong are pseudonyms)
Written by Tang Zhuoya and Li Lin
Li Lin丨Responsible editor
This article was first published on the WeChat public account "Eight Points Jianwen" and may not be reproduced without authorization
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