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【author: deng boyun】

recently, news that a private grade-a private hospital, wuxi hongqiao hospital, had defrauded medical insurance funds on a large scale has shocked people both inside and outside the medical industry. in fact, long before dr. zhu chenggang of the hospital's imaging department sought help from the media, his report had already spread widely in the local medical community.

medical personnel in public medical institutions, which account for the vast majority of medical services in my country, often experience or observe the contradiction of tight constraints on medical frontline medical care imposed by medical insurance cost control. ordinary people, as the recipients of medical services, have also heard of such phenomena.

however, the local medical insurance bureau's initial handling of the private hospital was surprisingly lax - it took four months to respond to the report, saying that "it went to wuxi hongqiao hospital twice for on-site verification, but because the clues provided involved many people and the problems reflected were a long time ago, it was impossible to confirm and verify the clues provided during the initial verification. it also specially coordinated and communicated with the wuxi public security department and submitted the relevant clues to the public security department for assistance in the investigation."

i believe that there is no systematic bias in the supervision of private hospitals by relevant management departments. so, how did the contrasting impressions of "loose" and "tight" supervision of medical insurance funds come about?

"management of hospitals" is "loose"

when dr. zhu first reported the case, the relevant departments had a relatively lax response, which was due to long-standing historical problems in my country's medical and health industry.

my country's medical and health industry management system was formed in the era of "one big and two public". under the system at that time, the management department was not only the enforcer of industry rules, but also the organizer of various medical and health institutions in the industry - the "big head", which led to a strong "house law" nature in the medical institution management system.

hospitals are state-owned assets, and their personnel, financial, and administrative powers are all controlled by health authorities. if a hospital deviates from the public interest during operation, superiors can easily replace its president and middle-level cadres, interfere with its financial and administrative powers, and keep the hospital operating within the "not out of line" range without having to impose severe penalties in accordance with the law.

just like in the 1980s, many social conflicts could be resolved without "going to court", "going to the police", "going to work units" or "going to the streets". similarly, the medical staff of the hospital are regular technical cadres. if the medical staff violates the regulations in their professional activities, the punishment from the superiors is also merciful, "it is not easy to train a cadre".

however, as medical services provided by multiple social entities become increasingly active and the number of private hospitals has exceeded that of public hospitals, the management system based on the old medical and health framework is increasingly unable to adapt to social development.

even the law enforcers themselves have discovered that, under existing regulations, if a hospital is determined to engage in various forms of fraud in the course of its practice, the law enforcers' handling of it is extremely awkward: it is difficult to revoke the licenses of the responsible health technicians and hospitals based on the fines formed based on the price levels of many years ago.

in a province on the southeast coast, where the "putian system" is rampant, there are only a handful of doctors whose medical licenses are revoked due to medical accidents every year. in a province with a population of nearly 100 million, the director of the medical administration department of the provincial health management department recalled that in his ten years in office, he only suspended the license of a psychiatric hospital where an inpatient committed suicide, and the punishment was not long. the competent authorities have no gradient in the intensity of punishment for illegal and irregular medical institutions and medical personnel, with only two levels of "three glasses of wine as a penalty" and "closing down the business".

this has led to a widespread "quick money" mentality in private hospitals, marked by the "putian system". the hospital's business strategy is to maintain high illegitimate profits and earn fines of "three glasses of wine", "three glasses of wine", and "three glasses of wine". when the relevant departments come to "close down" in accordance with the law, i rent a house, move the equipment and personnel, and continue in a new place and with a new sign.

the world is afraid of the word "seriousness". a private medical group that has a bad foundation from the beginning has a lot of experience in taking advantage of loopholes. we have all heard of the high professionalism of the legal departments of some large companies, which are like "pizza hut". some wealthy private medical groups also have such legal teams.

obviously, the current loose management of the medical and health industry has led to the industry's "bad money driving out good money". a large amount of resources in the medical market are occupied by "well-dressed quacks", and it is difficult for private medical companies with good intentions to grow. the "well-dressed quacks" trend has damaged the social image and credibility of the entire industry.

cctv news about the wuxi hongqiao hospital involved

the “tightness” and “looseness” of “managing medical insurance”

clinical frontline workers often complain about the "tight" management of medical insurance funds. in addition to the old sayings of "limited hospitalization days and fees", the author has collected many jokes:

the "high-flow oxygen inhalation" charge for inpatients is limited to 9 hours a day, and the excess will not be reimbursed by medical insurance. the reason is that patients who receive oxygen for longer periods of time should take more advanced life support measures.

outpatients undergo two abdominal ultrasound examinations at one time, one to check the appendix and one to check the gallbladder. the medical insurance bureau only pays the hospital for one examination item, and the other one is paid by the doctor who prescribes the order. the reason given by the medical insurance bureau is that according to common sense, how can a patient have two ultrasound examinations of the same part at the same time? (both are in the abdomen, but not the same organ.)

in order to avoid fraudulent use of medical insurance, staff from the medical insurance bureau came to hospital wards late at night to "check on the beds", asked patients who had suffered from cerebral thrombosis for many years to memorize their id numbers, and asked patients with advanced cancer "why doesn't the photo on your medical insurance card look like you?"

in order to prevent hospitals from "crossing accounts", the medical insurance department will also go to the hospital warehouse to check the accounts. ("crossing accounts" means that after a certain medical business occurs, the hospital, for various purposes, uses reimbursable items to record accounts, replacing non-reimbursable items to defraud medical insurance. for example, a patient with a background wants to prescribe aphrodisiac worth 1,000 yuan, and the hospital uses 100 boxes of cold granules as an equivalent when doing accounting. obviously, a patient cannot use 100 boxes of cold granules for a course of treatment.) as a result, it was found that the data of disposable syringes (a common "cross-account" prop) in some hospitals did not match the data of outbound and inbound storage, with a gap of six or seven digits.

……

once problems are discovered, no reconsideration will be accepted. hospitals are strictly prohibited from "uploading conflicts" of patients whose insurance claims cannot be reimbursed to the medical insurance bureau, otherwise they will "bear the consequences themselves."

however, when medical staff walked out of the hospital, they saw that pharmacies could use medical insurance cards to cash in and buy health products and rice cookers. the means of inter-accounting were extremely ridiculous: the cashier used common medicines with prices that were convenient for "equivalents" to offset the bills, such as a "foot foot ointment" that i witnessed for 10 yuan per dose. medical staff naturally had negative emotions: the money i used to treat patients and save lives was limited everywhere, and the money i saved was used by others to buy rice cookers at the pharmacy?

the root cause of "uneven tightness"

the reason for the contrast of "uneven tightness" in the supervision of the use of medical insurance funds is that the medical insurance fund supervision department does not have enough staff and technical means, and can only "grasp the big and let go of the small", strictly manage some "big targets" such as large hospitals, but is powerless over some private hospitals, clinics and pharmacies. medical insurance does not ignore the latter, but the means of management are often simpler and cruder "campaign-style law enforcement". "one size fits all", if you swipe your medical insurance card in a pharmacy and spend 100 yuan in your personal account, the medical insurance bureau will pay at a discount. this has led to some of the "small" ones who "grasp the big and let go of the small" either becoming more severe or simply withdrawing from the medical insurance designated points.

we cannot "presume guilt" of a certain industry or a certain practitioner, but we must improve the corresponding institutional constraints to avoid human nature from doing evil. as the administrator of medical insurance, an important task to ensure the healthy operation of medical insurance funds is to prevent and resolve moral risks. patients spend "everyone's money" to treat their own diseases. the desire to survive is instinctive, and they will inevitably want to receive better treatment and spend more money. doctors "spend other people's money to do other people's business", whether it is out of risk aversion or profit seeking, there is also a tendency to spend lavishly.

what is "over-medicalization"? the measure of whether it is "over-medicalization" lies in whether the patient benefits from it and whether the patient and the medical insurance can afford it.

in july 2024, a grade a medical accident occurred in a hospital in haidian district, beijing. the patient's lung nodules had shrunk after antibacterial treatment, indicating that they were caused by infection. the hospital still took advantage of the patient's anxiety, saying that this was a substantial nodule that could become malignant, and encouraged the patient to undergo a puncture biopsy. the risk of this operation itself far outweighs the benefits for the patient. during the puncture, the patient had an adverse reaction that led to his death, so this is a typical medical accident caused by excessive medical treatment.

the goal of medical insurance cost control is very clear: to live within one's means and ensure the healthy operation of the fund. however, the standards for measuring expenditure items are very vague. the uncertainty of medicine, the various situations at the medical site, the subjectivity of medical staff and patients... lead to the complexity and diversity of medical activities, and it is difficult for external observers to accurately observe whether these medical activities are reasonable. this requires regulators to adopt information technology to measure and regulate the rationality of medical payments.

in some large hospitals with a high level of informatization, the rationality of medical activities can be mutually confirmed in multiple procedures through the hospital information system. for example, if a doctor prescribes a specific drug to a patient after a blood transfusion, the information system will pop up a dialogue window to ask the doctor whether he has missed reporting adverse reactions to the blood transfusion; if the doctor prescribes antibiotics to a patient without relevant symptoms, the system will also prompt that the current patient's examination results do not support the use of antibiotics. however, this type of management method requires high investment and extremely high requirements for the connotation construction of medical institutions and the quality of medical personnel. it is only implemented in a few top medical institutions and is not even popular among the top 100 hospitals in the country.

at present, all parts of my country are steadily promoting the reform of medical insurance payment to "pay by disease group". it is mainly through grouping or converting the diagnosis and treatment of diseases, and making "package" payments. according to the patient's age, gender, main diagnosis, comorbidities and complications, surgery or not, etc., drg/dip provides thousands of permutations and combinations to standardize the range of medical expenses to guide diagnosis and treatment. for "patients who are not sick according to the textbook", such as long hospitalization, high medical expenses, use of new drugs and new technologies, complex critical illnesses or multidisciplinary joint diagnosis and treatment, which are not suitable for payment according to drg/dip standards, the medical structure can apply independently and propose special cases to the medical insurance department for funding.

in the children's icu ward of zaozhuang maternal and child health hospital in shandong province, medical staff prepare to inject the targeted treatment drug nusinersen sodium into a 4-year-old child with spinal muscular atrophy. xinhua news agency

conclusion

“payment by disease group” currently regulates the medical practices of compliant medical institutions more strictly. however, for illegal medical institutions such as wuxi hongqiao hospital that directly fabricate medical records, the system cannot currently identify the same ct scans for different patients. similarly, the medical insurance system cannot identify drugstores that oversell athlete’s foot ointment at a price of 10 yuan per dose.

at present, many readers have been affected by the delayed retirement. at present, the basis of my country's social insurance and medical insurance system is 270 million insured employees and 90 million insured retired employees. with the change of the ratio of insured persons "in service: retired" caused by the aging population, and certain public health problems leading to an increase in the rate of chronic diseases among residents and a younger age of chronic disease patients, the "tight balance" of social insurance fund operation will face complex challenges in the long term.

the long-term security of social security/medical insurance funds is closely related to each of us, but many insured persons will not realize this in the short term, and may even be willing to "take advantage of the situation". some medical institutions have long encouraged low-income people and chronic disease patients who participate in medical insurance to "stay in hospital" and assisted hospitals in defrauding medical insurance funds.

under current technical means, illegal acts of defrauding medical insurance funds require more external supervision measures in addition to relying on the courageous "internal explosion" of dr. zhu chenggang. medical insurance fund supervision needs to be "tight", and the management scale should be equal. the solution to the problem is to solve the "loose" supervision of the medical and health industry.