The National Health Insurance Administration has made a high-profile denial, but who exactly stipulated that "only 15 days of hospitalization" was stipulated?

"The fifteen-day mandatory discharge rule is very bad. ”

On social media, a netizen shared an experience around him. My friend's father was sent to a tertiary hospital in a southern city for treatment due to cerebral hemorrhage, and after 15 days of hospitalization, the old man's condition did not recover, but he was required by the hospital to be "forced to discharge", and even fell into a semi-coma after returning home.

Then, the hospital requires the elderly to stay at home for 15 days before they can be hospitalized again. This was repeated 8 times in and out of the hospital, and the old man finally passed away.

In the past year, there has been a lot of discussion on social media about the "15-day forced discharge". If you search for keywords such as "15-day forced discharge" or "only 15-day hospitalization", you can see similar experiences from many patient netizens. When most patient netizens ask the reason for the hospital, the reply they get is often "medical insurance does not allow it", but if they need to continue to be hospitalized, they can't, "you can be discharged first and then hospitalized".

Recently, the National Health Insurance Administration has held a regular press conference to respond positively to public opinion. The relevant person in charge said that the national medical insurance department has never issued restrictive regulations such as "a single hospitalization does not exceed 15 days" and "must be transferred to a hospital when it reaches a certain standard", and the public is welcome to report to the local medical insurance department.

But in the past two weeks, in the face of the statement of the National Health Insurance Administration, the medical community has launched a debate.

The relevant person in charge of a county-level hospital said the mystery, "The medical insurance department does not explicitly stipulate that 15 days must be discharged, but the medical insurance stipulates the total reimbursement for a single patient." ”

"Behind the phenomenon of 'forced discharge after 15 days of hospitalization', who is the responsibility of the medical insurance department, the health department, and the hospital?"

Tightened "length of hospital stay"

"I think it's an isolated phenomenon. Wang Shuai said that most hospitals will not have a strong requirement of "15 days in the hospital to be discharged". But he went on to say bluntly, "But from a management point of view, most hospitals really don't want patients to stay more, that's for sure." ”

Wang Shuai used to be the vice president of a tertiary hospital in a municipality directly under the central government, and in Wang Shuai's view, there is an unsolvable problem between the hospital and the patient on the matter of "how many days the patient will be hospitalized".

From Wang Shuai's point of view, many patients encountered in clinical practice often "want to be hospitalized too much".

Although some patients are not at ease, they still want to stay in the hospital for a few more days to "recuperate"; there are also patients who seek acquaintances to postpone their discharge for a few days; and the elderly with chronic diseases are also reluctant to be discharged because they want to receive more thorough care. Different departments are often troubled by patients who are "pressed on the bed".

But in the ward, time is the cost.

Wang Shuai said that in the assessment project of the higher department, the hospital has to face the challenge of the assessment of bed turnover rate and DRG cost. The "bedridden" patients will have a real impact on the operation of the department. For example, in the face of DRG's assessment, the shorter the hospitalization time, the more beneficial it is to the hospital, "no matter how many days of hospitalization, the payment under DRG/DIP, the medical insurance settlement amount is exactly the same." ”

Regardless of whether DRG/DIP is the main reason, medical insurance policies are complicated and difficult to understand for the majority of ordinary patients. I can't figure out the problem, and I can only guess the behavior of medical institutions and doctors in online communication, trying to find clues.

"15 days in the hospital" is not a new topic, and it is not the first time that the health care system has denied it.

In the past few years, when replying to the messages of the masses, the medical insurance departments in many places have made it clear that they have not issued any medical insurance policies to limit the length of hospitalization of insured patients and the amount of single medical insurance settlement.

In 2016, the Nanjing Social Security Center sent a special letter to reply that Nanjing's basic medical insurance has never limited the number of hospitalizations and hospitalization time of insured persons per year. "Medical insurance designated medical institutions shall not shirk and refuse to meet the hospitalization standards of insured persons for hospitalization, early discharge without meeting the discharge standards, or self-paid hospitalization. At that time, the relevant personnel of the Nanjing Social Security Center said that whether to be discharged from the hospital should be decided according to whether the patient's specific condition meets the discharge criteria and whether the hospital can provide corresponding medical services.

On September 29, 2021, the Sichuan Provincial Medical Insurance Bureau also stated that the medical insurance department has never stipulated the number of days a patient stays, and the reimbursement of medical insurance benefits has nothing to do with the number of days a patient stays. In October 2021, some netizens reflected on the "leadership message board" of People's Daily Online that medical insurance hospitalization should be discharged and readmitted every half month. The Yichang Municipal Health Commission and the Yichang Municipal Medical Security Bureau replied: The medical insurance agency has made it clear in the service agreement of the medical institution that the medical institution shall not require the insured person who does not meet the discharge standard to be discharged from the hospital in advance or hospitalized at his own expense.

However, nationwide, this phenomenon is still common in many medical institutions, and "no hospitalization for more than 15 days" has become an open "unspoken rule". Although these unspoken rules are not written in black and white, the requirements for how hospitals use medical insurance funds are changing the behavior of hospitals.

Liu Man, an industry analyst, said that although the medical insurance department does not explicitly stipulate that "hospitalization cannot exceed 15 days", various system indicators and behavior management will drive hospitals to do so. "Because there are policies and countermeasures, if you evaluate me like this, it is clear that you want me to do this. ”

Hospitals are anxious, and so are patients.

"By the fifth or sixth day, many patients wonder if it's time to be discharged. "There is a subtle rift in the doctor-patient relationship.

The original intention of the DRG/DIP reform was to use the limited health insurance funds more efficiently. However, it is very difficult to correct the medical behavior of the hospital, as a highly professional field, the hospital used to be an independent world with doctors as the absolute authority, and it is very difficult for "outsiders" to put their beaks in clinical behavior. In the past, the medical insurance department once suffered from unreasonable waste of medical resources.

But as David Rothman explains in The Stranger at the Bedside, as the modern healthcare system has evolved, various forces, including the health care sector, have become increasingly important in medical decision-making.

In hospitals, the status of the medical insurance office has risen, and it has become independent from the medical department, and later the price department has been merged, and its functions have been further extended to many departments such as finance, medical records, and information, and have become the only first-level department in the administrative department of the hospital.

The once "unrestrained" clinical departments have been tightened by the medical insurance policy, and the "length of hospital stay" is the object of tightening.

Intensified contradictions

The overly simplistic and crude implementation of some local medical insurance departments has also intensified the contradictions.

In fact, the general direction of the medical insurance policy is that, according to big data calculation, the average cost of a single disease group is 6,000 yuan, but it is allowed to fluctuate within a reasonable range. However, Zhong Chonghai, a medical management expert, said that the original intention of the medical insurance policy is this, but there may be problems in the implementation of it in various places.

"Some county-level or prefecture-level city medical insurance bureaus will be one-size-fits-all if they are troublesome in implementation. "For example, if the average line exceeds 6,000 yuan, the hospital will have to bear it.

In the end, the policy was transmitted to the hospital, the patient's medical experience declined, and the pot was thrown back to the medical insurance by the hospital.

Xu Yucai, a member of the Hospital Management Branch of the Chinese Medical Association, said frankly that although there are no relevant regulations on medical insurance, it is sometimes difficult for doctors to mobilize patients if they do not do so when communicating with patients. "If the limit is exceeded, the salary will be deducted, and the medical staff will definitely do the patient's job as best as they can. ”

Another industry analyst, Zhou Maohui, also found another hidden detail of regional differences when observing local policies: the standards vary from region to region, and although some places do not use "15 days" as a threshold, the payment standard is halved when readmitted to the hospital after 15 days. The health insurance department uses the 15-day readmission rate as an indicator to prevent hospitals from breaking down hospitalizations and breaking down what should have been a good treat into two cases.

Although it is not a "15-day mandatory discharge", the indicator of "15 days" appears in another form.

"When the medical insurance and the hospital settle every month, sometimes only 90%~95% of the total amount is settled, and the remaining 5%~10% of the amount is assessed and settled at the end of the year. Liu Man said that the "15-day readmission rate" will become one of the year-end assessment indicators in some areas, affecting how much medical insurance funds hospitals can get at the end of the year. If the "15-day readmission rate" exceeds the standard seriously, such as 10% or 20% beyond the regional average standard, the hospital will be deducted points proportionally, and finally the remaining 5%~10% of the medical insurance funds will only be discounted by the hospital.

Zhong Chonghai found that the influence of medical insurance in hospitals also comes from refined management. "The data from the health insurance department is very clear, and it is clear which cases have exceeded the limit. The medical record is clear, the medical record corresponds to the specific department and the doctor is clear, and it is easy to impose a fine according to the medical record. "When the pressure is transmitted to every doctor, the doctor's behavior changes as a result.

Whether it is "15 days of readmission" or "15 days of discharge", the presentation is different in different regions, but the result is the same - inevitably closely tied to the "money" of the hospital.

Who's pushing for a lower "average length of stay"?

The National Health Insurance Administration used the press conference to call out the hospital in a high-profile manner, saying that there is no such thing as "hospitalization cannot exceed 15 days", which rushed to the hot search in one fell swoop and attracted discussion on the whole network.

In front of the stage, there is a debate between medical insurance and hospitals, and behind the stage, the health department is also affecting the hospital to control the average length of stay.

"Average length of stay" is a hospital management indicator that can be traced back to 1955 to evaluate the effectiveness and efficiency of a hospital's medical care, and its length is related to factors such as medical standards, and will significantly affect the hospital's revenue. As an important indicator to evaluate the development of hospitals and even the development of health care, the average length of stay in public hospitals in mainland China has shown a continuous downward trend.

In 2017, the average length of stay for those discharged from public hospitals in mainland China was 9.4 days, but in 2022, this number has dropped to 8.7 days.

However, when comparing the international community horizontally, it is found that there is still a large room for the average length of stay in Chinese hospitals.

In 2016, Wang Yaogang et al. from the School of Public Health of Tianjin Medical University published a study comparing the allocation of bed resources and the average length of stay in five countries: China, the United States, Australia, the United Kingdom, and Chile from 2003~2012. The results showed that the average daily stay in hospitals in various countries decreased from 2003~2012. The average length of hospital stay in mainland China has decreased from 11.0 days to 10.0 days, which is still much higher than in the other four countries.

The flip side of the decline is the increasing policy requirements year by year. "Average length of stay" has appeared in a number of important national health policy documents, including the Evaluation Indicators for High-Quality Development of Public Hospitals (Trial), and is also included in the performance evaluation of public hospitals ("national examination").

This means that local public hospitals, local health commissions and even local governments will require "average length of stay" as an important hospital management indicator.

For example, on November 7, 2023, the "Implementation Opinions of the General Office of the Jiangxi Provincial People's Government on Further Improving the Medical and Health Service System" issued by Jiangxi Province clearly mentioned that by 2025, the bed utilization rate of public hospitals in the province will remain above 90%, and the average length of stay will be controlled within 8 days.

The consensus of the academic community and the industry is that the "average length of stay" is only a modest indicator, and not the lower the better, nor the shortest or the best. However, in some hospitals, the action is easy to deform when it is executed. For example, prevarication or even refusal to admit patients with complex conditions, or requiring patients to be discharged as soon as possible on the grounds stipulated by the competent authorities at a higher level......

And the higher-level authority that is used as a reason is often the medical insurance department.

This means that while the health and health departments may have slightly different starting points when it comes to controlling the average length of stay, they share almost the same goals.

Many medical staff believe that there is a tendency to over-pursue the "average length of stay", which may be the result of the combined efforts of the health department, the medical insurance department and the hospital management demand.

The medical staff of a tertiary hospital in southwest China bluntly said that for his hospital, the "average length of stay" assessment has little influence, and the medical insurance assessment has taken absolute control.

Can the length of hospital stay be reduced indefinitely?

Wang Meng, who works in the orthopedic department of a well-known tertiary hospital, has witnessed the gradual reduction of the average length of stay. After the efforts of the past few years, the average length of stay of patients in its department has been compressed to about 7 days, which is lower than the national average of 8.2 days in tertiary hospitals.

But this year, Wang Meng felt that the average length of stay set by the hospital "will never be completed".

Metrics are distributed to everyone in the hospital. At the hospital's weekly business meeting, the length of stay in each department will be announced one by one and made into a list. "There shouldn't be any money deducted because of this, but the section director will feel faceless. ”

Wang Meng knows very well that what the hospital hopes is that the number of patients will increase year by year, the number of surgeries will increase year by year, the average hospitalization rate will be shortened year by year, and the bed turnover rate will increase, which is the most ideal situation. Therefore, shortening the average length of hospital stay is a natural step in the process.

Today's public hospitals are already high-speed medical machines. Not only that, whether it is the medical insurance department or the health commission, in order to pursue the ultimate medical efficiency, the average length of stay is required to drop again and again.

But the objectively existing "limit" cannot be changed. "The human metabolism is so fast, it may take 14 days for the wound to heal. Wang Meng said helplessly, "Unless the patient evolves to the wound in three days, the average length of hospital stay can be further reduced."

When this kind of absolutely uncomplete situation occurs, and when facing the pressure of assessment, action deformation is very easy to occur. At the extreme, as we are experiencing today, instead of reducing the average length of stay in order to improve the quality and efficiency of medical services, patients are required to be discharged from the hospital in 15 days.

In terms of compressing the average length of stay, the pressure on clinicians from medical insurance is more reflected in the payment standards.

Yang Ruichun, a surgeon at a tertiary hospital in a fourth-tier city, adopted a new countermeasure after the hospital implemented DRG. He heard that some hospitals and departments will bring the preoperative examination that patients would have done after hospitalization to the outpatient clinic earlier, so as to shorten the number of days in the hospital. Yang Ruichun's department has adopted a different approach, allowing "patients who are about to overrun DRG costs to be discharged a little earlier."

The medical insurance department has brought the pressure of "money", the health commission has brought the pressure of "government", and the hospital itself has the pressure of "operation".

For restaurants, the higher the turnover rate, the more money they make. The same is true for hospital beds. Compressing the average length of stay and increasing the bed turnover rate will naturally increase the output value of each bed.

Wang Shuai said bluntly, "In the past, the average length of stay stipulated by the state was passive, but now under the pressure of medical insurance, hospitals and doctors take the initiative to shorten the length of stay." If the average length of stay per medical group is too long, the hospital itself will not be effective. ”

Wang Meng's hospital implements the attending physician responsibility system, and the profit and loss of medical insurance will also be linked to the income of the treatment group. In general, the orthopedic group has a higher standard of payment and is usually less likely to involve critical illness, and overspending is rare. Of course, there are also high-cost patients with many complications, but in general, there are more surplus months.

"For example, if a patient has a new cerebral infarction during our treatment, he may need rehabilitation, and he needs to be admitted to the ICU and come back, and this kind of cost has exceeded the payment standard, so we try to call on the patient to go to rehabilitation and go to a secondary hospital, and he will not go to DRG in this process, while some other patients who are really seriously ill and cannot be discharged from the hospital will not go to DRG if they are hospitalized for more than two months. ”

In reality, every hospital must have patients who need to be hospitalized for a long time, and the disease will not occur completely according to the disease group, and there will always be some special circumstances.

Although DRG/DIP payment has a relatively complete "high-rate" case appeal channel, it can allow some complex and severe patients with obvious cost overruns to settle their costs by "paying according to the project". But in practice, "it is impossible to appeal all of them". As long as a certain proportion of seriously ill patients are admitted, "it will still bring a relatively large loss".

The DRG/DIP reform is in full swing, and while maintaining policy rigidity, it may also be necessary to consider the flexible side.

Industry analyst Zhou Maohui lamented that personalized policies are to leave room for them. Once there is no exit, the hospital will not have a good result, and it will definitely want to deal with more crooked ways. "More consideration of special diseases may gradually repair the rift between policy and reality.

For patients who are commonly required to be admitted to the hospital frequently due to radiotherapy and chemotherapy, Zhejiang Province has excluded them from the assessment scope of "15-day hospitalization", and fetal preservation patients who need to be admitted repeatedly due to unstable fetal position are also isolated.

Zhong Chongming, a researcher at the Medical Insurance Payment Research Center of the Medical Consortium of the China Medical and Health Culture Association, paid attention to Xuzhou, Jiangsu Province, where he explored the payment method of rehabilitation treatment and has formed a set of experience. The implementation of a hybrid of multiple payment methods on the basis of the total budget can avoid many clinical pain points.

"If 80% of patients who need to stay in the hospital for more than 15 days can be extracted and connected to the payment method unique to rehabilitation, then the complaints of discharge after 15 days may be much smaller. “

(Source: Health News Consulting)