Surge! In 2023, the direct settlement of cross-provincial and non-local medical treatment across the country will hand over such an achievement.
In 2023, the number of inpatient inter-provincial direct settlements will exceed 10 million, doubling from 2022, and the number of outpatient inter-provincial direct settlements will exceed 100 million, an increase of 2.63 times compared with 2022.
When the movement of people is no longer restricted, it is more and more convenient to seek medical treatment in other places, and patients are more reluctant to stick to the place where they are insured. A number of county hospital directors told "Health News Consulting" that since 2023, the outflow of patients has been serious, and the county hospital is struggling, falling into a vicious circle, and it is difficult to escape.
The logic behind this is that patients are a resource to compete for, and local medical insurance funds should be used to support local hospitals, rather than expand hospitals in other places. The logic of direct settlement for medical treatment in other places is just the opposite, and many experts believe that the medical insurance fund should follow the patient.
At a time when medical resources are unbalanced and the overall level is difficult to improve rapidly in a short period of time, the implementation of hierarchical diagnosis and treatment has become the common voice of both parties.
However, patients generally have a high mentality, and it is necessary to implement hierarchical diagnosis and treatment, such as introducing policies to restrict the difficulty of patients seeking medical treatment in other places, which is contrary to the desire of direct settlement and convenience for patients.
How to make it convenient for patients who really need high-level medical services to seek medical treatment in other places, and to keep patients who are not seriously ill in the local area?
There is still huge room for policy optimization behind the seemingly small steps of evaluating, quantifying, formulating local policies and direct settlement.
There are more and more patients seeking medical treatment in other places, and the "opinions" of local hospitals are large
At the beginning of 2023, the medical and health system of a county in the eastern part of the mainland suddenly became tense.
The reason for the nervousness is that after years of running-in, patients who have been accustomed to seeking medical treatment in the county have begun to go to other places to see doctors again. Soon, the medical insurance fund expenditure data in the first quarter was released, with a year-on-year increase of about 8.4 million yuan, which was mainly medical expenditure outside the county. If this trend continues, the county's medical insurance fund in 2023 may be bottomed out again.
The county has a developed economy, is rich in the people, and is adjacent to the provincial capital, and it is even more convenient for individual towns to go to the provincial capital than to the county seat. As a result, most patients choose to seek medical treatment in other places, and the county's medical treatment rate has been less than 70% for three consecutive years, and it has been declining year by year.
The problem with this is that there is a serious outflow of medical insurance funds in the region. At its worst, more than half of the out-of-county hospitalizations, which accounted for one-third of the total hospitalizations under medical insurance, were spent on the medical insurance fund, and the local medical insurance fund was in deficit for three consecutive years.
In order to recover from the decline, the county carried out a medical community reform in 2019 to improve the competitiveness of the county's hospitals, and gradually explored the payment method of capitation package payment in the following years.
The results of the reform have been rapidly revealed, coupled with the impact of the epidemic, the county's medical treatment rate has gradually increased to more than 80%, and the tension of the medical insurance fund has also been greatly alleviated.
However, the performance in the first few months of 2023 has made them beat a drum in their hearts, whether the previous rebound in the county-level medical treatment rate is due to the good effect of the medical community reform, or is it simply because of the inconvenience of going out for medical treatment due to the backlog of the epidemic?
The county did not sit still, and in the second quarter of 2023, the county's medical community held meetings "desperately and repeatedly".
"Before, the lead hospital took most of the medical insurance balance, but now they realize the importance of grassroots brothers, and take measures to tilt towards the grassroots level, mobilize the enthusiasm of township health centers, and let the doctors of township health centers go deep into the community to keep patients."
An official of the county's health system said that under the packaged-payment model, the outflow of medical insurance funds is a concern for the medical community, "The medical community has many more methods than our administrative department, such as increasing the number of patrol vehicles, extending the clinic to the community, etc., and our methods are still a bit formalistic, everyone is working together to keep patients in the county." ”
The county's analysis found that the outflow was mainly cancer patients, "who were originally undergoing chemotherapy in the county, but this year it is convenient to go out, and many of them go out for re-examination." In the second quarter, especially in June, the growth of the fund has dropped significantly, and I judge that the fund will not bottom out this year. Said the director of a hospital in the county.
As expected, the county's medical insurance balance in 2023 is more than 2,000, which greatly exceeds the expectations of the local health system.
In areas where the overall level is not high, keeping medical insurance funds locally is one of the important tasks of the city and county medical and health systems, and it is also in line with their inherent cognition.
Medical treatment in other places is seen as the biggest obstacle to staying in the fund. It can even be said that they have a lot of "opinions" on the increasingly convenient direct settlement of medical treatment in other places.
"Patients keep going out, county-level hospitals can't grow, and they will enter a vicious circle." A county hospital director said, "County hospitals, which are an important part of the national healthcare system, have been allocated a lot of resources, and if there are no patients, the hospital will only cause waste." Provincial hospitals blindly seek to be bigger, but no matter how big they are, they can't meet the medical needs of the whole province, and they have also caused a deformed medical treatment structure."
Some county-level hospitals are not small in scale, and their ability to diagnose and treat common diseases is not bad, and it is often more cost-effective to stay in the local area for treatment, "for example, for gallbladder surgery, county-level hospitals may not need 9,000 yuan, but if patients go to the province, the cost may have to double."
The high-level development of county-level hospitals needs hierarchical diagnosis and treatment support, which can reduce the burden of social medical care and facilitate the people in the county to seek medical treatment.
The director recently went to Japan for an inspection, and he found that Japan has a strict hierarchical diagnosis and treatment system, and it is impossible to go to a tertiary hospital for treatment without referral. "Japan's population is only 30 million more than that of Henan Province, but the number of beds in Henan's largest hospital is 6~8 times that of the University of Tokyo Hospital."
The implication is that they hope that the health and medical insurance departments can come up with some strong measures to promote the real implementation of hierarchical diagnosis and treatment, and it is difficult to retain patients with only a 10% difference in reimbursement ratio.
The number of direct settlements for cross-provincial and non-local medical treatment has soared, do we need to be vigilant?
On April 11, 2024, the National Health Insurance Administration introduced the results of the direct settlement of cross-provincial and non-local medical treatment in 2023 at a press conference, and many of the data showed a "doubling" trend.
In 2023, the number of inpatient inter-provincial direct settlements will exceed 10 million, reaching 11.2548 million, an increase of 5.57 million over 2022, an increase of nearly 1 times, and the number of outpatient inter-provincial direct settlements will exceed 100 million, reaching 118 million, an increase of 85.42 million or 2.63 times over 2022.
In addition, during the Spring Festival in 2024, the direct settlement of cross-provincial and non-local medical treatment across the country will reach 3.385 million, an increase of 3 times compared with the Spring Festival in 2023, which was affected by the epidemic.
However, this is only the data of the number of people who directly settle for cross-provincial and remote medical treatment, considering that most provinces have not achieved provincial-level overall planning, the data of cross-city and remote direct settlement of medical treatment in various provinces may be even more alarming.
The rapid growth of data seems to have exacerbated some of the concerns that the overly convenient online direct settlement of medical insurance has led to an increase in the behavior of seeking medical treatment in other places, and the willingness of patients to flood high-level medical areas is like opening the floodgates.
However, can this set of data be interpreted in this way? In other words, should direct billing be responsible for the increase in the number of people seeking medical treatment in other places?
A number of social security scholars who are concerned about the direct settlement of medical treatment in other places pointed out that the pilot of direct settlement of cross-provincial and remote medical treatment began in 2021, and the data growth of the total number of people seeking medical treatment in different places in the country over the years is also in line with expectations, and there has been no growth beyond expectations.
As for the "doubling" of the data related to the direct settlement of cross-provincial and non-local medical treatment in 2023, it may be due to the impact of factors such as the effect of policy publicity and education, the release of the backlog of demand for remote medical treatment in 2022, and the full promotion of local medical insurance departments.
In addition, as a livelihood project, the direct settlement of cross-provincial and non-local medical treatment has set clear and quantitative development goals.
In July 2022, the Ministry of Finance and the National Health Insurance Administration jointly issued the "Notice on Further Improving the Direct Settlement of Cross-provincial and Non-local Medical Treatment for Basic Medical Insurance", which clearly requires that by the end of 2025, the cross-provincial direct settlement rate of hospitalization expenses will be increased to more than 70%; The number of designated medical institutions in the cross-provincial network of general outpatient clinics has doubled to about 500,000.
In order to achieve the assessment goal, local medical insurance departments will naturally spare no effort to publicize and promote the policy of direct settlement for medical treatment in other places.
According to the 2022 National Statistical Communiqué on the Development of Medical Security, in 2022, there were 110.5 million outpatient and emergency, outpatient chronic diseases and inpatient medical treatment in other places nationwide. 8,758,700 people were hospitalized for medical treatment across provinces and places.
However, since the "2023 National Statistical Communiqué on the Development of Medical Security" has not yet been released, there is currently no public data on the total number of people seeking medical treatment in different places in the country in 2023. Considering that from January 1, 2023, the direct settlement of cross-provincial and non-local medical treatment will be officially implemented. This could mean that 2023 could be an excellent window to gauge how much additional out-of-town billing will bring.
There seems to be a disagreement among academics as to possible answers.
As early as when the direct settlement of cross-provincial and remote medical treatment was about to be piloted, Wang Zhen, director of the Public Economics Research Office of the Institute of Economics of the Chinese Academy of Social Sciences, led a team to do a small-scale investigation, and the results showed that this policy will not bring about a surge in remote medical treatment, nor will it affect the safety of the medical insurance fund in the insured place.
However, there are also different opinions that due to its high degree of convenience, direct settlement of cross-provincial and non-local medical treatment will definitely bring about an increase in remote medical treatment, but the number of cross-provincial and non-local medical treatment itself is steadily increasing every year, and it seems that there is no good way to independently analyze and quantify it in terms of how much direct settlement plays in it.
Direct billing vs. remote medical treatment, who is the cause? Who is the fruit?
Many local hospitals and local health insurance bureaus believe in the magic of the word "convenience".
As a result, there has been great resistance to the implementation of direct billing, and many places will not even take the initiative to promote this policy, because they are worried that the "convenient" direct settlement will take away more local patients.
As a result, in the minds of these local hospitals and local health insurance bureaus, direct billing is a policy that runs counter to "hierarchical diagnosis and treatment".
However, in the eyes of central policy researchers and formulators, direct settlement of medical treatment in other places should not be responsible for the fragile status quo of hierarchical diagnosis and treatment, which seems to reflect a certain difference in the concept of the central government.
In the view of policy researchers, there are two main reasons for the growth of demand for remote medical treatment: one is that the population flow is accelerating, and the consequent demand for remote medical treatment is also increasing; The second is the imbalance in the allocation of medical resources in the mainland at this stage, which is not only unbalanced in the total allocation, but also in the structural allocation.
Wang Zhen bluntly said that even if there is no direct settlement, there will be more and more demand for medical treatment in other places.
"Health News Consulting" has reported that the introduction of the direct settlement policy for remote medical treatment is because in the context of the low overall level of the medical insurance fund, it is too troublesome for a large number of remote medical personnel to reimburse manually, so they want to provide a more convenient way of reimbursement.
To a certain extent, direct settlement for medical treatment in other places is a temporary method that comes up when the overall planning stage of medical insurance funds is not high enough. If the national overall planning of the medical insurance fund is realized in the future, the concept of "remote medical treatment" may no longer exist, and there is no longer a need for direct settlement of medical treatment in other places.
Wang Zhen believes that many people have a misunderstanding of hierarchical diagnosis and treatment, and the so-called hierarchical diagnosis and treatment cannot be understood as allowing all diseases of patients to be solved in local or primary medical institutions. "Hierarchical diagnosis and treatment is the linkage between the upper and lower, the acute and slow treatment, and the ability to turn up and down. Beijing, Shanghai and other cities have set up so many tertiary hospitals, which are responsible for the mission of treating patients across the country with incurable diseases, not for colds. ”
Li Li, a full-time researcher at the Yangtze River Delta Institute of Health at Shanghai Jiao Tong University, also agrees that the medical resources of large cities should have a radiation effect, which is also complementary to each other.
Taking Shanghai as an example, as a medical highland in the country, Shanghai has always been an inflow place for remote medical treatment in the Yangtze River Delta region. In the first half of 2022, due to the impact of the epidemic, almost all public hospitals in Shanghai were in a loss-making state, and one of the reasons is that the epidemic has greatly affected the number of patients accepted by Shanghai hospitals.
"The demand for medical treatment from out-of-town patients is the only way to support the continuous expansion of hospitals in Shanghai. If it only covers local medical needs, Shanghai's medical resources can be said to be too rich. Considering that the country has a regional medical center, Shanghai will inevitably take on a more important mission to attract incurable diseases from all over the country, which is also a goal of Shanghai's medical development. ”
Wang Zhen emphasized, "hierarchical diagnosis and treatment is to establish a smooth relationship between different types of medical services, and the premise of the so-called 'serious illness does not leave the province' is that some diseases can be cured in the province." It cannot be understood that people in province A must see a doctor in province A and cannot go to province B. This is not called hierarchical diagnosis and treatment, this is called drawing the ground as a prison. ”
However, in reality, due to the perception of local block management, local medical insurance bureaus and local hospitals often complain, believing that they have "raised" hospitals in big cities with their own money.
Wang Zhen believes that this statement does not recognize the essence of medical insurance funds. "The positioning of medical insurance in various places should be to provide high-quality and low-cost services for the insured. Money is for patients, not hospitals. Whoever provides a better service will be allocated the funds. ”
To put it more bluntly, local hospitals do not naturally have local medical insurance funds, and medical insurance funds are not set up to support medical staff and medical institutions.
Having said that, adequate funding and quality service can be a chicken-and-egg problem.
Li Li expressed his understanding of the plight of local hospitals, "You may think that residents pay for medical insurance, and medical insurance gives the money to hospitals, and hospitals use the money to build hospitals to make hospitals higher, and then in a virtuous circle, people are more willing to see doctors in local hospitals." However, now that a considerable part of the funds are used to build hospitals in other places, their own doctors cannot be retained, the hospitals cannot be expanded, and the equipment cannot be updated, entering a vicious circle, and local patients are even more reluctant to see doctors locally. ”
The dilemma of "hierarchical care" lies elsewhere
In order to prevent patients from "carrying" medical insurance funds from outflowing, some local policies will set some inconspicuous thresholds in an attempt to make it more difficult for patients to seek medical treatment in other places.
Liu Xiaojing (pseudonym) was diagnosed with a pituitary tumor in 2012, and when she sought medical treatment at a local tertiary hospital in Taizhou, where she was insured, the doctor clearly informed her that the hospital did not have the equipment to complete the operation, and took the initiative to prescribe a "referral certificate" for Zou Min to go to Huashan Hospital affiliated to Fudan University in Shanghai for treatment.
Due to the particularity of the condition of pituitary tumors, patients often need lifelong follow-up, and they have to go to the hospital for examination every 6-12 months.
In 2012, Liu Xiaojing needed to go to the Labor Bureau with the referral instructions issued by Taizhou medical institutions for filing and manual settlement; Since 2015, doctors have written a referral, which is valid for a whole year, and they have to go through the process again every time they go to the doctor. In 2017, direct settlement was gradually promoted, and Liu Xiaojing's reimbursement process was simplified a lot.
Such convenience did not sing all the way. Around 2020, Liu Xiaojing discovered that doctors in Taizhou were no longer willing to issue her referral certificates. She tried to find a way to support the relationship, and finally got the proof. However, since last year, no matter how much you talk to the doctor, the certificate can no longer be prescribed.
"The doctor wrote me a certificate (referral) and transferred it directly to me on the mini program, although I can be referraled for reimbursement, but the reimbursement amount will be reduced by 10%."
The change in doctors' attitudes comes from the pressure of hospital performance appraisal. Liu Xiaojing recalled, "The explanation given by the hospital at that time was that the director had a rule that did not allow casual transfers. The hospital has clear regulations to limit the number of patients who are transferred out of other places, and it is linked to the year-end assessment. ”
Liu Xiaojing also tried to communicate with the doctor, but with little success, "You go and tell others, and the doctors can't help it, so they say that they don't reimburse you, but the reimbursement ratio is 10% less." ”
Liu Xiaojing felt very helpless, and was no longer willing to find trouble, so she tried her best to apply for reimbursement in the past two years. Although the annual cost may only be more than 1,000 yuan, it is still a concern to accumulate year after year.
She was puzzled: "If the local hospital can treat it, forget it, the local hospital can't treat it, why don't you give me a certificate?" ”
There are many similar situations, and the "shunts" and "filters" involved in preventing excessive medical treatment in other places have indeed caused some trouble for patients. Small thresholds are constantly being designed, but it is still unclear how to set them, to what extent, and which diseases they are targeted.
Li Li believes that in fact, the vast majority of people consider the cost of transportation and time, and ordinary minor illnesses and disasters will still choose local hospitals for treatment. However, how to limit the possible excessive demand for medical treatment in other places still requires more sophisticated policy design.
Medical reform is overall, while the dilemma of "hierarchical diagnosis and treatment" lies elsewhere.
The weakness of primary medical institutions has accelerated the spillover of patients, and strengthening the grassroots is the root cause. However, the current health system is grossly inadequate in support for primary and general practice. This deficiency is not only reflected in the economic level, but also in the administrative resources and policy resources are not inclined to the grassroots, and the treatment of medical staff at the grassroots level is not attractive.
On the other hand, large hospitals seem to be a little "greedy" and do not do a good job in line with their own positioning - not only to treat incurable diseases, but also to see minor illnesses and disasters.
Wang Zhen believes that in order to solve the problems including the dilemma of hierarchical diagnosis and treatment, what needs to be done now is to carry out overall reform, not just focus on remote medical treatment and direct settlement. For example, various reforms, including the reform of DRG/DIP payment methods, are to control the behavior of large hospitals.
When the topic comes here, it seems to be back to those cliché questions, and direct settlement seems to be less important.
With the "conflict" between direct settlement and hierarchical diagnosis and treatment as the window, we can more intuitively feel the difficulty of medical reform, and the reform itself is also being promoted in a multi-pronged manner. The medical field is interlocking, and it is far from an overnight task to break the stable state and benefit distribution pattern that has been formed over the years.
Source: Yicai