Since the beginning of this year, some patients have reported that some hospitals require "a single hospitalization of no more than 15 days". In this regard, the national medical insurance department made a special response, saying that no such restrictive provisions have ever been issued. Banyuetan reporters visited a number of hospitals and learned that although the hospital did not clearly stipulate the limit on the number of days of hospitalization, it was generally said that "the longer the patient stays, the more the hospital loses". What is the crux behind this phenomenon?
Each time I was admitted to the hospital for more than 10 days, I had to find another hospital
The reporter visited a number of secondary and tertiary hospitals and learned that some hospital departments are indeed mobilizing patients who need to be "hospitalized for a long time" and transfer them to hospitals when their conditions are relatively stable. Most of these patients are elderly, usually chronically ill or convalescent patients with a longer hospital stay.
It is understood that the long-term inpatients faced by the hospital are mainly divided into two categories, one is the elderly patients who suffer from a variety of underlying diseases at the same time, and the other is the terminal cancer patients in hospice care, which are difficult to completely cure and require continuous medical treatment.
The person in charge of a public second-class hospital in Dongguan, Guangdong Province, said that under the relatively preferential medical insurance benefits, "after some elderly patients are admitted to the hospital by their families, the family members think that the hospital bears full responsibility and even saves money for someone to take care of them." The director of a district-level traditional Chinese medicine hospital in Guangzhou said that more than 80 percent of the hospital's inpatients were over 80 years old, and more than 60 percent were over 85 years old.
The interviewed medical workers said that for patients in the acute stage, no matter how long they stay in the hospital, the hospital will do their best to treat them; However, for patients who are in chronic recovery and are relatively stable, they may be mobilized to transfer to a hospital. "Under the current Value-Based (DIP) medical insurance policy, hospitals have tightened their maintenance costs and have to tighten their pockets."
The vice president of a large tertiary hospital in Guangzhou said that the beds in the tertiary hospitals need to ensure the treatment of critically ill patients, and when patients have passed the dangerous or acute stage, they should be transferred to lower hospitals for further rehabilitation treatment, so as to reserve the shortage of beds in large hospitals for patients who need more urgent needs. Banyuetan reporter's investigation found that the current proportion of inpatients in the chronic rehabilitation period in secondary hospitals is relatively high, and the situation of "bed pressing" is serious, and patients are often required to be discharged before they can fully recover.
Due to the hospital's control over the length of hospital stay, some patients who need to stay in the hospital for a long time have to transfer from hospital to hospital multiple times. Ms. Feng, a resident of Guangzhou, said that her mother, who is in her 80s, had suffered from heart disease, stroke and other diseases, and was in a semi-disabled state of bed rest. Due to the long treatment cycle, "the elderly had to find another hospital for more than 10 days each time, and they were admitted to four hospitals within two months of the same disease."
Assessment-oriented puts pressure on grassroots hospitals
In the past, the medical insurance fund paid for each item consumed in the treatment process, and paid the reimbursement expenses directly to the medical institution after determining the scope and reimbursement ratio of drugs, consumables, and medical services. This approach is relatively simple, but it is easy to induce problems such as excessive growth of medical expenses and excessive medical treatment.
In recent years, the state has promoted the DRG/DIP reform, focusing on changing the past medical insurance fund to medical institutions mainly "payment by project" to "payment by disease", that is, "payment for the treatment process" to "payment for the treatment result", so as to achieve standardized payment for each case, so that medical institutions can control costs and obtain income. Primary medical workers said that this effectively promoted the "squeezing of water" of medical cost control and improved the medical level of primary hospitals, but there is also the problem that the applicability of the current policy is not flexible enough, which has led to pressure on some primary hospitals under the assessment mechanism that emphasizes operating income.
It is understood that after the reform is promoted, medical institutions will settle with the medical insurance fund according to the score of the main disease group, and when the actual cost of the patient exceeds the total amount of the medical insurance score payment, the difference will be basically borne by the hospital. If this difference is large, it will be difficult to cover the cost of manpower and equipment in the hospital, and may not even be able to cover the basic drug and consumables expenses of the hospital. When a patient is hospitalized for more than a certain number of days, the amount of medical insurance points will be used up, and hospitals around the country will have "hospitalization restrictions" in disguise in order to control costs and ensure operations.
From the perspective of hospital management and operation, patients who are hospitalized for more than 3 days are less effective or even lose money for the hospital. ”
A number of respondents said that the average length of stay in public hospitals has been gradually reduced by higher management departments in order to improve the utilization rate of hospital beds. It is understood that there are many types of patients in tertiary hospitals, and many of them only need to be hospitalized for two or three days, which can generally meet the assessment requirements of superiors. However, there are many long-term inpatients in secondary hospitals, and the average length of stay in the above-mentioned district-level TCM hospitals is 11 days, which exceeds the average length of stay target required by the higher-level assessment.
"The second-level hospital is small in size, the balance of medical insurance is small, and there is a lack of space for many departments in tertiary hospitals to 'make up for losses with profits'." The person in charge of a second-level hospital said that in order for the hospital to control losses and meet the assessment requirements of higher departments, it is necessary to speed up the circulation of beds.
Promote the deepening of reform and ensure reasonable demand
Some hospitals require "long-term hospitalization" patients to be transferred for reasons of loss control, which on the one hand causes distress to patients, and on the other hand, it will also increase the overall medical and social costs if patients are repeatedly transferred. To solve this problem, it is urgent for the medical insurance and medical systems to work together to ensure the reasonable medical needs of recovered patients.
The vice president of the above-mentioned Guangzhou tertiary hospital said that the tertiary hospital is facing "referral difficulties", and patients with chronic diseases, rehabilitation departments, neurosurgery and other postoperative patients who need to be hospitalized for a long time can be transferred to the next level hospital for follow-up rehabilitation treatment according to the norms of tertiary diagnosis and treatment, so as to release more high-quality resources for patients with critical illnesses. The interviewees suggested that the construction and expansion of geriatric wards and palliative care wards in secondary hospitals for "long-term hospitalization" patients should be established, and special medical insurance payment policies should be formulated for "long-term hospitalization" diseases.
On July 23, the National Health Insurance Administration held a press conference on the DRG/DIP2.0 version of the grouping plan, proposing to make good use of the special case single discussion mechanism to cover complex and critically ill patients. Recently, some regions have proposed to carry out daily payment for cerebral infarction, cerebral hemorrhage and other related rehabilitation diseases, and the medical insurance departments in Guangdong and other places have issued new policies, requiring that the total budget control indicators for a single medical institution no longer be issued, and proposing to improve the mechanism for special cases such as long-term hospitalization.
The interviewed primary medical workers believe that the relevant measures are expected to alleviate the problem of hospitalization to a certain extent, and expect the specific measures and standards to be continuously refined and improved, consistent with the actual operating costs of medical services, and fully consider the situation of patients exceeding the standard medical expenses due to comorbidities, complications, special constitution and other reasons, so as to better adapt to the actual needs of medical institutions and the public.