[Depth] The root cause of the failure of China's grading diagnosis and treatment system construction

2009--2014 National Health Expenditures in Fiscal accumulated over four trillion yuan, of which a portion of the investment in grassroots medical institutions, is intended to establish a strong grassroots grading diagnosis and treatment system, part of urban and rural residents into health insurance at their own expense in order to reduce the burden on residents. The fundamental goal of increasing financial investment on a large scale is to solve the problem of “difficult medical treatment and expensive medical treatment” for urban and rural residents. Regrettably, this goal has not been achieved. One direct reason is that in the past five years or so, the three-level hospitals have expanded at a high speed, forming three siphon effects on doctors, patients and medical expenses, which has aggravated the dilemma of “difficult to see a doctor and expensive to see a doctor”.

When General Secretary Xi inspected the Zhenjiang Shiye Town Health Center in December 2014, he pointed out that some large hospitals in big cities have always been in a “wartime state” and need to be improved.

Taking Beijing as an example, the proportion of hospitals in 2006 was 67%, of which tertiary hospitals accounted for 45%, and community health service centers accounted for less than 22%. In 2013, 65% of Beijing Medical Insurance Co-ordination Fund expenditures were spent on outpatient compensation, of which only 12% went to community medical institutions and 88% to hospitals. Up to 58% of medical insurance funds flowing to tertiary hospitals are used in outpatient clinics.

Similar to Shanghai. In 2013, the proportion of hospitals in Shanghai was 56.8%, and that in community health service centers was 33.6%. The proportion of services in primary health care institutions also performed poorly. It is worth pointing out that the community health service center in Shanghai is huge, and its doctors and beds are basically equivalent to county-level hospitals in the central and western regions. In fact, it is not a primary medical institution.

Let us look at the data of several major countries and regions in the world. In the UK, 90% of emergency cases are first diagnosed by family doctors, more than 90% of which are not referred to, completed by general practitioners, and 98% of outpatient prescription drugs are prescribed by general practitioners. In the United States, 1.2 billion visits per year, 81% of which occur outside the hospital's Physician offices in Australia, Canada/Japan, our Hong Kong and Taiwan, and this proportion also exceeds 80%.

Needless to say, our graded diagnosis has failed very much.

Existing policies are not helpful for graded diagnosis and treatment.

At present, the measures to control the scale of the tertiary hospitals and to try to establish a graded diagnosis and treatment system are unsuccessful, and a lot of administrative resources are wasted. Let us analyze the following:

Medicare cannot effectively control tertiary hospitals

Medical insurance is an important part of guiding the formation of a graded diagnosis and treatment system, and plays a key role in guiding the allocation of medical resources and the behavior of doctors and patients. However, in the face of such a strong tertiary hospital, the role that medical insurance can play is greatly reduced.

The scale of China's tertiary hospitals is rare in the world. There are less than 1,000 large hospitals in the United States, such as the Massachusetts General Hospital, and less than 1,500 Mayo Clinics. The average number of hospital beds in China’s tertiary hospitals is 905, of which the number of hospital beds in the top three hospitals is higher. Many second-tier cities have more than 3,000 beds in the top three hospitals. At present, the number of beds in the Zhengda First Affiliated Hospital, the largest public hospital in the country, is expected to reach an astonishing 10,000.

These large hospitals occupy a monopoly position in the region. There is almost no choice for ordinary people to seek medical treatment. The medical insurance department can neither require the abolition of medical insurance as a deterrent to require its standard medical treatment and charging behavior, and it is difficult to find a suitable reference sample to supervise and evaluate it. Moreover, the internal operation of these large hospitals is complicated, and different medical services are suitable for different payment methods. The hospital can respond to the medical insurance department through cross-subsidization and transfer costs, so complex medical insurance payment methods are also difficult to play a role. Therefore, in the face of the Big Three-level hospitals, medical insurance is seriously lacking in management and control, and from the perspective of the local market position and political status of these tertiary hospitals, medical insurance is lack of effective negotiation. The ability, so medical insurance does not have the ability to control the tertiary hospital, to be honest, the current top three hospitals have developed a paralyzed patient to make medical insurance and the government situation.

That is to say, for these tertiary hospitals that consume most of the medical insurance funds, medical insurance has no control ability. In our research and research, we found out which new payment methods are available for public hospitals, especially tertiary hospitals. The effect of the plan is not achieved. In the case that the existing supplier structure does not change, only the total amount control method is effective, and because the medical insurance lacks a reasonable reference frame in the region, the hospital performance is controlled and controlled, so-called refinement. Management is basically impossible.

In other words, the only hard constraint that can now restrict a tertiary hospital is the total amount of medical insurance funds and the ability of patients to pay at their own expense. Generally speaking, the fundraising level of the local medical insurance fund and the patient's self-paying ability determine the upper limit of the local tertiary hospital. At present, the general practice of the tertiary hospital is to use the medical insurance to distribute the total plate of the fund and over-spend every year. It may increase the patient's own expenses. Therefore, a seemingly abnormal phenomenon is normal. The more economically developed areas, the lower the actual compensation rate for hospitalization expenses for medical insurance patients. For example, the actual compensation rate for hospitalization of Shanghai urban workers in the top three hospitals is only about 60%, while the poverty-stricken areas This data of Bijie City participating farmers can exceed 75%. It seems that the abnormality is because the level of medical insurance financing in developed areas is high, so the actual compensation rate for hospitalization should be higher. In fact, it is normal because patients in developed areas have high self-paying ability, so hospitals can induce more use of self-funded projects, and ultimately As a result, its actual compensation rate is lower than that of underdeveloped regions.

The resulting knock-on effect is that patients are strongly dissatisfied with the low rate of medical insurance compensation for tertiary hospitals, and the explanation given to patients by the top three hospitals is that the amount of medical insurance given to them is too low, thus forming a situation in which patients are paralyzed to increase the amount of medical insurance. .

In fact, medical insurance can not only punish the violations of tertiary hospitals by stopping the medical insurance qualifications, even if the fines are limited, it is difficult to use, because once the fines are large, these three-level hospitals with monopoly status in the region It is often necessary to force the government and medical insurance to waive punishment by withdrawing from medical insurance and not accepting medical insurance. This is the typical phenomenon of using monopoly status to slap patients to make the government (medical insurance). For example, in 2014, Zhejiang Medical Insurance launched anti-fraud operations, and investigated and handled a number of designated hospitals and designated pharmacies that took medical insurance funds. However, from the list of investigations and investigations, most of the fixed-point institutions were only ordered to rectify, only a few pharmacies and very few The medical institutions were deprived of the designated qualifications, and most of them were unknown small pharmacies and clinics. At present, the average domestic hospitalization rate is more than 14%, and there is obvious over-hospitalization. The industry knows that this is the hospital's method of taking medical insurance funds by hanging the bed or falsely reporting the number of hospitalizations. The medical insurance party also knows the truth, but can't do anything about the hospital.

In addition, the medical insurance itself has poor management ability, and the payment method is also a fact, which also restricts its ability to control the hospital.

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