in today's hospitals, the requirement for efficient medical care is dominating the operation of hospitals to a certain extent.

whether it is the health and medical care department or the medical insurance department, the assessment of efficiency medical representative indicators (average length of stay, payment by drg/dip, etc.) is gradually highlighting its impact on hospital development. in the assessment standards, efficiency is usually an important indicator. not only speed is required, but drg also clearly constrains the medical insurance funds consumed by a single patient. once the patient's hospitalization time is prolonged, the cost of a single patient is very likely to exceed the budget.

under the theme of efficient medical care, psychiatry and rehabilitation departments have become "slow departments" in hospitals. the root cause is that patients stay in hospital for a long time, ranging from 20 days to one month, and as long as half a year. the departments often have problems of overspending and losses.

a director of the rehabilitation department talked about the painful experience of the rehabilitation department. he said: "from the top performance of the entire hospital to the bottom, in the two years after the implementation of drg, we have witnessed the decline of the rehabilitation department." the department, which used to make money, has become a negative example in the hospital's internal meetings. it has suffered losses from drg settlements and the average length of stay has been extended, which has hindered the national examination indicators.

rehabilitation doctors are in a state of anxiety and confusion. “now we are mainly evaluated based on efficiency indicators. even if our leaders don’t deduct our performance, we still can’t hold our heads up in front of our colleagues.”

according to the data from the medical insurance bureau, the rehabilitation department lost millions of yuan a year. after the director of the rehabilitation department reported the situation to the local medical insurance bureau, he learned a more cruel reality from the reply of the director of the local medical insurance bureau: none of the rehabilitation departments of the city's tertiary hospitals are not losing money. in order to eliminate the negative impact of indicators, some tertiary hospitals have even separated their rehabilitation departments from their own hospitals and moved them to health centers or community health service centers under the medical community.

the psychiatric department is also feeling anxious as most of the patients in the department are long-term inpatients. the more patients are admitted and the longer they stay, the greater the losses.

in fact, the consensus on "slow departments" has long been reached: long-term hospitalization cases are not suitable for drg/dip payment, and payment by bed day is the optimal solution at present.

however, it is not easy to implement the policy in various places. due to the lack of specific guidance, local medical insurance bureaus are worried about over-implementation, and there are many cases of one-size-fits-all payment according to drg/dip. moreover, how to set the standard for bed-day fees has also become another focus of subsequent disputes.

caught in this dilemma, doctors in the "slow department" are eager to know: under the premise of efficient medical care, is there still room for our department and our patients to take things slow?

is the rehabilitation department at risk of being “marginalized”?

chen hong (pseudonym), director of the rehabilitation department, experienced a terrifying conversation with the hospital leaders.

after the drg settlement, the department lost millions of yuan for two consecutive years. recently, the hospital leader suddenly asked her: "do you want to move the rehabilitation department out?" a tertiary hospital in the same city did just that. it separated the rehabilitation department from the hospital and moved the entire department to the community health service center of the medical community. the tertiary hospitals not only reduced medical insurance costs and losses, but also avoided affecting national examination indicators such as the average length of stay.

chen hong then realized that the status of the rehabilitation department in the hospital was in jeopardy. as the earliest founding director of the department, she witnessed the rehabilitation department's "deterioration from a leading role".

the decline in performance is most obvious. in the two or three years after the implementation of drg, the remuneration of medical staff in the rehabilitation department has dropped significantly. chen hong said frankly: "the rehabilitation department mainly relies on medical service income. our department used to have very good performance, but now it ranks last in the hospital."

from a policy perspective, medical insurance policy clearly stipulates that drg/dip payment cannot be linked to the performance of medical staff, but when it comes to the details, each hospital often finds the opposite of what they want.

chen hong complained to the local medical insurance bureau, but the reply she received was: drg payment applies to the entire hospital, not the department, and it's ok as long as there is no overall loss.

she felt helpless, and her leader also knew that losing money was not the department's problem. however, when it came to distributing performance, it was impossible to give very high performance since the department was losing money after all.

drg losses and lower national examination indicators are like mountains weighing on the back of the rehabilitation department. the rehabilitation department has one of the few advantages, which is the high proportion of medical service income. however, this is also a "double-edged sword". at a time when medical insurance inspections are becoming stricter, the rehabilitation department, which mainly relies on medical service income, faces huge pressure from random inspections.

for example, to provide exercise therapy for a hemiplegic patient, the rehabilitation department used to combine comprehensive hemiplegic training, exercise therapy, joint mobilization (large joints), joint mobilization (small joints), etc., with a total medical fee of about 200 yuan per time. however, in the medical insurance examination, if comprehensive hemiplegic training is done, the exercise therapy fee cannot be charged, and if exercise therapy is done, the joint mobilization training fee cannot be charged.

after the medical insurance inspection becomes normalized, the medical cost of a set of exercise therapy is about 100 yuan according to the current policy. chen hong believes that "the current pricing of rehabilitation projects is too low. only one exercise therapy for 45 minutes can only be charged more than 50 yuan, which is actually not commensurate with the efforts of medical staff."

in any case, the rehabilitation department, which suffers from huge losses and many problems during unplanned inspections, has become a "troublesome" department. in addition to internal considerations within the hospital, external changes have also made the future of the rehabilitation department foggy.

a non-urgent but critical question is, in the context of tiered diagnosis and treatment, in the future, between tertiary hospitals, secondary hospitals and grassroots hospitals, will the development of rehabilitation departments present an inverted pyramid structure, a spindle structure, or a positive pyramid structure?

in early august this year, huang xinyu, director of the medical services management department of the national health insurance administration, said at a live broadcast meeting of the national health insurance administration that "after some acute treatments are completed, some subsequent rehabilitation treatments may need to be transferred to more suitable secondary hospitals or grassroots hospitals."

in this case, won't the status of the rehabilitation department of tertiary hospitals be even more marginal? in this regard, zhang xiao, a professor of public health at southeast university, believes that the rehabilitation department of tertiary hospitals is indispensable. acute patients have a process of in-hospital rehabilitation. only after they have passed the so-called dangerous period or the best recovery period can they be placed in professional rehabilitation institutions. it is an important task to explore the medical insurance payment settlement methods for long-term hospitalization cases in different medical institutions.

acclimatization

the "slow disease department" is walking on thin ice.

the most basic logic is that after drg package payment, departments with faster turnover will be more adaptable to assessments. however, for departments such as rehabilitation and psychiatric departments, where long-term hospitalization cases account for the vast majority, once the number of "safe days" covered by the medical insurance payment standards exceeds the number of days covered by the medical insurance payment standards, they will become a "bottomless pit" where they will lose money every day they stay.

a mental health center in northeast china is a typical example. after the dip was implemented, the local people were trembling on a tightrope and could barely survive. zhang wei (pseudonym), a medical insurance officer at the hospital, said, "many patients can 'cooperate with the hospital' and be discharged when the medical expenses reach the dip medical insurance standard. they can wait for a while before being hospitalized, or they don't need to come."

patients are "voluntarily discharged" before medical insurance costs are about to exceed the budget. even if it is not stated explicitly, industry insiders are well aware of the subtleties involved.

recently, zhang wei is also worried about another thing. as the only tertiary institution in the area, the average calculation of the local medical insurance dip payment is based on the base of this hospital, so it can basically cover the actual treatment costs of this hospital. however, as the dip policy continues to change, and some private mental illness hospitals join the competition, they adopt a lower level of treatment and a lower average cost per visit, which will soon lower the average cost standard per visit.

zhang wei is worried about the possibility of a decline in dip medical insurance payment standards. "if the loss is within 5% to 10%, we can bear it normally, but if it continues like this, we may not be able to make ends meet."

for the rehabilitation department, maintaining balance is a great luxury, and losses have become "normalized."

chen hong truly realized the advent of the "dark period" of the rehabilitation department after hearing two sentences from the local medical insurance bureau: the first sentence was that no rehabilitation department in a tertiary hospital was not losing money. the second sentence was that if the rehabilitation department of a hospital made little loss or profit, it would also be questioned whether it "did not provide adequate medical services to patients."

in her understanding, the implication was that the rehabilitation department's losses were "natural" and there was no possibility of recovery.

the more serious the patient's condition, the greater the loss. neurological rehabilitation and critical care rehabilitation cases suffer the most severe losses, while orthopedic rehabilitation has a relatively short cycle and is less affected by drg. "a neurological rehabilitation or critical care rehabilitation case basically costs about 20,000 yuan. our hospital used to spend 40,000 to 50,000 yuan a month to treat a critical care rehabilitation patient," chen hong waved her hands and said, "now sometimes we are afraid to admit a critical care rehabilitation patient."

not only are the payment standards difficult to match the provision of medical services, but the difficulty in drg enrollment is also one of the reasons why the rehabilitation department suffers losses.

theoretically, if patients in the acute phase have early demands for functional impairment, rehabilitation therapists should intervene at the bedside for rehabilitation treatment. however, under the drg rules, if a neurology patient needs rehabilitation treatment, the case can only be included once and cannot be counted twice.

chen hong explained that if the drg payment standard is 10,000 yuan, the neurology department spent 8,000 yuan, and we did 4,000 yuan of rehabilitation, the medical insurance would still only pay 10,000 yuan, and early rehabilitation intervention would be embarrassing. she sighed and said, "do you think we therapists dare to do it in other people's wards? if we overspend, they will blame us for increasing the patient's expenses."

another situation is that a rehabilitation patient undergoes surgery midway, and the drg inclusion rule that gives priority to the surgical group is not beneficial to the rehabilitation department.

chen hong gave an example. for example, a patient with hemiplegia was hospitalized in the rehabilitation department and had deep vein thrombosis in the lower limbs. the clinical department went to the rehabilitation department to perform deep vein thrombosis removal on the patient and placed a filter. there was no need to transfer the patient to another hospital or department. in the end, the patient would be included in the surgery group, not the rehabilitation department-related group.

she was puzzled because: "there are clearly two diseases coexisting, and two completely different treatments coexisting, but they will only be included in one group and only incur the drg costs of one group."

zheng jing (pseudonym), the medical insurance director of a tertiary hospital in sichuan, also said frankly, "in fact, the most important thing is whether the medical insurance department considers separating the two types of patients in the acute stage and the recovery stage, and allowing patients to apply for different hospitalizations."

finding a quick fix

since the patient's hospitalization time is long, if we can pay by bed day instead of by drg disease group, wouldn't that be a perfect solution to the problem?

let's look at a set of data. the 2020 medical insurance simulation data of quzhou city, zhejiang province showed that after the implementation of payment on a bed-day basis for recovery cases, the losses of medical institutions dropped from 4.465 million yuan under drg payment to 2.884 million yuan.

the loss has been reduced, but not much. this also reveals two pieces of information: first, the accuracy of payment for long-term hospitalization cases by bed-day payment is higher than that of drg/dip payment; second, under the current bed-day payment standard, even if the payment is made by bed-day, it is impossible to save the chronic department from the loss dilemma.

the key here is whether the payment standard based on bed days can cover the average daily cost of actual treatment?

at the beginning of the design of the drg/dip payment policy, the top-level design document only proposed "payment for long-term hospitalization based on bed days" without any specific guidance. in the words of the doctors, "the national health insurance administration hopes that local governments will formulate policies according to their own needs, but local governments are afraid of exceeding the scope when implementing them, or they don't know how to do it."

therefore, the progress varies from place to place, and in areas where payment is made on a bed-day basis, the actual implementation intensity and effectiveness also vary greatly.

for example, in jiangsu, a psychiatry department of a secondary hospital has successfully implemented payment by bed day. a doctor from the psychiatry department of this hospital said that after implementing drg for a period of time, the psychiatry department changed to payment by bed day, with the bed day standard being 300 yuan per person per day. she said frankly: "this change has little impact on us, because our medical expenses are about this level, and we don't even spend that much."

turning our attention to the northeast, there is constant controversy over whether the psychiatric department of heilongjiang provincial hospital pays according to the bed-day standard.

a staff member of a mental health center in a city in heilongjiang revealed that the hospital had communicated with the medical insurance bureau many times on whether to pay by bed day. "the city medical insurance bureau had once determined that the minimum bed day for long-term inpatients in the psychiatric department under the resident and employee medical insurance was 162 yuan per day and 270 yuan per day, respectively. however, due to the large disparity in the fee standards across the province, our city medical insurance bureau finally decided to delay implementation."

how big is the difference in standards between different cities? the lowest bed-day payment standard for psychiatric departments in the province is only 65 yuan per day in a city; in cities with slightly better conditions in the province, the bed-day payment standard for employee medical insurance can reach more than 4 times that.

what the above-mentioned person is most worried about is that as the medical insurance policy is gradually implemented at the provincial level, his hospital is admitting more and more patients from other places, and currently accounts for more than 20%. there may be conflicts between the local medical insurance bureau and the medical insurance bureaus of other cities on payment standards. perhaps in the near future, the standards will be lowered and the cost of treatment will also be reduced.

the rehabilitation department is more cautious about paying by bed day.

chen hong believes that the current bed-day standard cannot compensate for the medical expenses of patients in the recovery period. "the standard we give here is very low. for example, the rehabilitation of hemiplegic patients after stroke is 400 yuan per day, including all expenses such as examination, medication, and treatment, which is only 12,000 yuan a month."

in comparison, the standard of bed-day payment for rehabilitation departments in first-tier cities can reach 900 to 1,200 yuan per day. in quzhou, zhejiang, the medical insurance standard for rehabilitation patients with central nervous system damage from the first to 40 days of hospitalization is 450 yuan per day; in lishui, zhejiang, the average bed-day payment for rehabilitation patients in tertiary hospitals is 680.73 yuan.

"thirty-level hospitals are generally unwilling to pay on a bed-day basis unless the bed-day payment standard is set high enough," chen hong pointed out that if the patient's condition has stabilized and he can be transferred to a specialized rehabilitation institution or a lower-level secondary hospital for rehabilitation, it is more reasonable to pay on a bed-day basis.

due to different policy standards, chronic disease departments in various places present a variety of situations, some are still doing well, while others are losing money day by day. in theory, frg (function-related groups) is most in line with the reality of rehabilitation and psychiatry departments, that is, medical insurance pays according to the functional recovery of patients after treatment. however, how to objectively evaluate the effect of treatment is another new framework system, which is extremely difficult to design, and it is not realistic to expect it to solve the current problems.

in zheng jing's view, "for rehabilitation and psychiatric departments, payment by bed day is not the ultimate solution, it is just a transition."

text/ he jingwei

editor/ li lin