Written by Xin Ying, Cao Yujie
Editor/Wang Xiao
Picture/Pixabay
Would patients be happy if there were no general outpatient clinics in tertiary hospitals?
On August 30, 2022, Hainan Province issued the “Implementation Plan for Promoting the High-Quality Development of Public Hospitals”, which clearly stated that general outpatient clinics in tertiary public hospitals will be gradually cancelled.
Domestic hospitals are divided into “three grades and six grades”. According to the positioning, the tertiary hospital is the highest level, mainly providing diagnosis and treatment services for acute and critical diseases and difficult and complex diseases. If the action of canceling outpatient clinics in tertiary hospitals is promoted, as the health authorities wish, it will affect a quarter of the country’s patients.
Going to a tertiary hospital to see a doctor when feeling unwell is still the first choice for most patients, especially trusting a tertiary (tertiary grade A) hospital. According to the 2021 Statistical Bulletin on the Development of China’s Health and Wellness Development, the number of diagnosis and treatment in tertiary hospitals is 2.23 billion, accounting for more than a quarter of all diagnosis and treatment.
The cancellation of outpatient clinics in tertiary public hospitals in Hainan Province will allow patients to choose hospitals according to the designer’s thoughts and diseases?
“From the previous reform experience in various places, it is the core problem that patients are unwilling to go to the grassroots for the first consultation.” Cao Jian, a researcher at the Hospital Management Research Center of Renmin University of China, analyzed the reporter of Caijing. It will take quite a long time for Hainan to cancel general outpatient clinics in tertiary hospitals.
Is the lower level hospital ready?
A cardiologist at a Beijing tertiary hospital feels that a lower-level hospital is not good enough. “For example, acute coronary syndrome requires urgent treatment after diagnosis, and it is easy to be misdiagnosed. Once it is not recognized, the consequences are very serious.”
Under the tertiary hospital, there are secondary hospitals and primary hospitals. They transfer difficult and miscellaneous diseases to higher-level hospitals, and receive patients in the convalescent stage of acute illness, patients in the post-operative recovery stage, and patients in the stable stage of critical illness who are referred by tertiary hospitals.
Patients prefer to stare at a good doctor if given the choice. Choose a hospital, and play a card with a high probability that the third-class hospital has better technology.
In the opinion of a neurosurgeon in a tertiary hospital in a capital city in Northeast China, it is technically feasible for the tertiary hospital to cancel the general outpatient clinic, but the patients are not willing. Among the patients he sees on a daily basis, there are some common head injuries and hemorrhages. “These community hospitals can completely accept and treat patients, and if they can’t be dealt with, it is very convenient to transfer them to higher-level hospitals.”
This is the idea of GPs in Europe. Independent GP clinics take care of each other. Those who can diagnose and treat, and those that cannot be treated, he will help patients to be referred.
China’s health and health authorities promote hierarchical diagnosis and treatment, and expect community health service centers and township health centers to become the main choice for patients’ first diagnosis. Many places have made efforts to adjust this. Before Hainan, Shanghai, Guangdong, Qinghai, etc. have all issued notices for large tertiary hospitals to gradually cancel general outpatient clinics.
But overall, more and more patients choose to go to tertiary hospitals for registration.
Data from the National Health and Medical Commission shows that From 2014 to 2021, the number of patients in tertiary hospitals will increase from 1.4 billion to 2.23 billion, accounting for 18.4% of the total number of patients in the country. % rose to 26.3%.
In the view of Liang Wannian, executive vice president of the Vanke School of Public Health and Health at Tsinghua University, the root cause is the inhomogeneity of doctors.
China’s doctor training model, which used to be the former Soviet model, quickly solved the shortage of doctors in China at that time. However, the doctor training system varies greatly. There are one-year, three-year, four-year, five-year, and eight-year systems. In particular, there are more than 1 million rural doctors, most of whom have not received professional doctor training.
Liang Wannian once analyzed the Caijing reporter, To achieve hierarchical diagnosis and treatment, from a global perspective, the basic practice of most countries is to enforce it. For example, in some countries, if there is no grassroots hospital or Referrals from general practitioners, large hospitals will not accept patients directly. However, the real difficulty in China is that the training of talents is not homogeneous, and it is difficult to force it.
In May 2022, the First Affiliated Hospital of Zhengzhou University, dubbed “the largest hospital in the universe”, caused dissatisfaction among its peers by poaching people from the “Brother Hospital”, and was eventually approved by Henan Province. The Health and Health Commission sent a letter to stop it.
According to the “Health Times” report, a vice president of the Seventh People’s Hospital of Zhengzhou City complained that more than 10 medical staff in the cardiac surgery department left without saying goodbye, and they did not even change their practice location. Go directly to the First Affiliated Hospital of Zheng University to work.
This is a microcosm of a doctor’s level-by-level gathering to the head hospital.
Big cities siphon high-quality talent, as do big hospitals. How to solve it, Wang Quan, a professor at the School of Public Health of Wuhan University, believes that the core is to improve the treatment of personnel in primary medical services, appropriately introduce the power of the market economy, retain doctors through an incentive mechanism, and provide medical services that meet the needs of the grassroots.
The tertiary hospital does not want to let go
The volume of outpatient visits is directly related to hospital revenue. Under the new crown epidemic, now does not seem to be a good time for tertiary hospitals to cancel outpatient visits.
“The COVID-19 outbreak has led to a general decline in the medical income of public hospitals, and outpatient clinics are an important source of income for public hospitals.This time the push resistance is greater than ever. “ According to Cao Jian, 30%-40% of the income of tertiary hospitals generally comes from outpatient clinics.
Usually inpatients come from outpatient clinics. Even if the patient has a small problem, the neurosurgeons of the above-mentioned tertiary hospitals will not refuse to see the doctor. “Now all the people who come to see the doctor will be seen. If there is an indication for surgery, the patient will be accepted, and if not, they will be transferred to the internal medicine department or go home for observation. , if there are people from other places, it is recommended to go back to the local hospital.”
A tertiary hospital in a central province has seen fewer patients from other places affected by the epidemic. “The director has begun to pay attention to attracting local patients,” an industry insider said.
Clearly, it is difficult for tertiary hospitals to give up outpatient revenue. A batch of tertiary hospitals’ previous plan of endowment was to open “general outpatient clinics” to play the role of foreign general practice clinics.
Beijing Anzhen Hospital, Zhongshan Hospital Affiliated to Fudan University, Yangpu Hospital Affiliated to Tongji University, Shenzhen Hospital of the University of Hong Kong, Henan Provincial People’s Hospital, etc., have established general medicine departments.
“The purpose of opening (general practice) outpatient clinics in tertiary hospitals is very simple, and everyone knows that it is inconsistent with the direction of reform.” Outspoken on institutional reform forums.
A patient, to the hospital, represents an income. In the referral system, more patients are referred to higher-level hospitals from grass-roots hospitals such as township health centers and community health service centers, but relatively few patients are referred downwards from higher-level hospitals.
A person in charge of a township health center said, “The increase of patients in the health center mainly depends on strengthening the connection with the village clinic. The village doctor directly introduces the patient to the health center for treatment, without going to the city. There are very few patients transferred from higher-level hospitals in the city.”
Involving the division of core interests, it is difficult to abolish outpatient clinics in tertiary hospitals in one step, but gradually reducing the scale and number of general outpatient clinics in tertiary hospitals has been the trend of public hospital reform in recent years.
On February 9, 2022, the State Council issued the “Notice on Promoting the Implementation of the Opinions on Promoting the High-Quality Development of Public Hospitals”. There are two assessments. The scale of outpatient clinics, and secondly, the proportion of the total number of clinics and treatments in primary medical and health institutions should reach a reasonable level.
Policies in some regions are beginning to pay off. According to data released by the Xining Health and Health Commission in 2022, compared with 2016, the transfer rates of secondary and tertiary hospitals dropped from 10.4% and 0.9% to 4.5% and 0.3%, respectively, and the transfer rates from 15.4% to 22.6%. % rose to 39.0% and 24.0%, and the proportion of primary care visits rose from 55.3% to 64.4%.
This time, Hainan Province’s plan also proposes to strictly control the number and scale of tertiary public hospitals, strictly carry out hospital grade assessment, and gradually carry out tertiary public hospitals that exceed scale standards and actual needs. Compress the bed. A reporter from Caijing interviewed the Hainan Provincial Health Commission on the implementation of the solution for tertiary hospitals to cancel outpatient clinics. As of press time, there has been no reply.
Can chronic disease be a breakthrough?
Hainan’s medical resources are not abundant, with 6.02 beds per 1,000 population and 2.91 licensed doctors per 1,000 population, all lower than the national average.
When the overall medical level is relatively weak, patients tend to choose to go to a tertiary hospital for registration.
In recent years, Hainan has introduced tertiary hospitals from other places to build branches in Hainan, which also helps to build a network of secondary hospitals. In 2021, the Affiliated Hospital of Qingdao University will officially entrust Lingshui County People’s Hospital to carry out assistance work, and the Hainan Branch of the Affiliated Hospital of Qingdao University will be established as a secondary hospital, which will be put into use in April 2022.
Hainan Province also provides various benefits for the introduction of senior medical personnel. Cao Jian analyzed that the introduction of good hospitals and good doctors is a way to actively improve the medical level.
Hainan introduced “good deans” for tertiary hospitals, subsidizing a one-time settlement fee of 600,000 yuan, and second-level hospitals “good deans” 500,000 yuan. Also, priority should be given to benefits such as establishment, employment placement for spouses, and schooling for children.
One of the breakthroughs in Hainan’s development of hierarchical diagnosis and treatment is to let patients with chronic diseases sink first. sink to a lower-level hospital.
Hainan is a gathering place for people from Northeast China. The Second Hospital of Harbin City has built a branch in Hainan, which is a secondary hospital and focuses on the characteristics of the rehabilitation department. The hospital has opened 500 beds, attracting more than 30 experts, professors and academic leaders.
At the same time, Hainan Province continues to expand the list of chronic special diseases in outpatient clinics, expand the scope of reimbursement of diseases, and authorize the identification of outpatient chronic special diseases treatment to 53 second-level hospitals in the province in 2021. The above designated medical institutions handle. Insured persons can “diagnose and apply nearby”, and after approval, they can choose two hospitals for chronic disease treatment, which is also creating opportunities for secondary hospitals.
However, Cao Jian does not believe that guidance on chronic diseases alone can change patients’ medical habits, “Forcibly canceling outpatient clinics in tertiary hospitals may lead to hospitalization for minor illnesses If a pilot area cancels outpatient clinics in tertiary hospitals first, it may also lead to the outflow of patients to other areas, which is still difficult to achieve in the end. To promote hierarchical diagnosis and treatment, it is necessary to reform medical service prices, salary reforms, public Comprehensive promotion of hospital system reform and medical insurance system reform.”