Outstanding county ** encountered talent "countercurrent"

As one of the first batch of county-level public hospital reform pilot units in the country, what problems have arisen during the reform process and what experiences have been summarized? Recently, on-site observation was conducted at the county-level public hospital reform pilot unit, Lufeng County People's Hospital of Yunnan Province, which was once famous for the "Lufeng Model."

Lufeng model encounters new difficulties

The “Lufeng Model”, which is second to none in the reform of payment methods at county-level hospitals across the country, has encountered difficulties.

In the January-February this year, the balance ratio of the People's Hospital of Lufeng County was significantly reduced, and the number of discharged people, the average number of days of hospitalization, and the referral rate for referral were abnormal. This is the biggest dilemma since the hospital initiated the reform of the payment method of the Diagnostic Group in October 2012.

“All the data in the group was excellent in 2013, and all the data in this year's group was abnormal. I feel very bad and very annoyed.” Dean Xiong Wenyun recalled that time.

After two months of trial operation, from January 2013, Lufeng County People's Hospital began to formally implement the reform of payment methods according to the disease diagnosis team and control medical expenses from the source. The so-called payment according to the Diagnostic Group, or DRGs, is one of the more advanced payment methods recognized in the world today. It is to classify several diseases with similar clinical characteristics and consumption of similar medical resources into one category. According to the medical treatment items that are usually required for the treatment of such diseases, scientifically calculate a price and pay the price uniformly. While encouraging the hospital to strengthen the management of medical quality, it is forcing hospitals to actively reduce costs, shorten the number of hospital stays, and reduce the cost of induced medical expenses in order to obtain profits, which is beneficial to cost control.

In the Lufeng County People's Hospital, the reform of the payment method was only for the patients of the new rural cooperative medical system, and 70% of the patients in this hospital were new rural cooperative medical patients. Therefore, the effect was obvious.

In 2013, Lufeng County People's Hospital discharged 18,000 patients from the New Rural Cooperatives, saving 4.6 million yuan in funds, an average hospital stay of 5.99 days, an average cost of 2,600 yuan, a drug ratio of 23%, a saving rate of 13%, and a transfer rate of 8.29%.

Last year, Du Kelin, deputy director of the Yunnan Provincial Department of Health, observed that the DRGs of the Lufeng County People's Hospital had run for half a year. He pointed out: “The pilot reform of the payment system has created the Lufeng model. Using the payment reform as a breakthrough, it has shaken Through the overall reform of the county-level public hospitals, we have also seen that Lufeng County Hospital has now received a full-fledged data display, which is simply not expected.”

The former glory has changed dramatically due to the adjustment of the payment limit by the social security department. Currently, the hospital's DRGs contain 436 disease groups. Their "difficulties" stem from the fact that the social security department has lowered the prices of individual disease groups.

“For example, cataract surgery was priced at 2,830 yuan in 2013, and this year it was adjusted to 2,130 yuan, a decrease of 700 yuan. With reference to 394 cases of last year's surgeries, we will spend 275,000 less this year.” Xiong Wenyun said, also because of this, In the 1-2 months when the hospital did not find a countermeasure, the "data of abnormal group data" will appear.

"We have taken many measures and held emergency meetings several times. After many efforts, we finally got out of trouble." Xiong Wenyun said.

So how did they get out of the predicament?

"For example, in the cataract surgery, consumables are used, and the quality of consumables is different. Now, in order to save money, it is not advisable to use high-end products. For example, viscoelastics, previously used 300 yuan, and now use 90 yuan. There are surgical types, same Cataract treatment, if it is phacoemulsification cataract need 3000-4000 yuan, and now use a small incision cataract, although the recovery time is slightly longer, but the same effect can be achieved, at least can save 1,000 yuan." Xiong Wenyun stressed that "despite some treatment The method has changed, but we have strict quality control. The new rural cooperative medical system has always been basic medical care and does not advocate high-grade."

Why did the social security department adjust the disease group pricing? Afterwards, will hospitals continue to reduce consumption and surgical techniques?

In response, Xiong Wenyun said that the purpose of social security department adjustment is to promote the classification of treatment. County-level hospitals need to treat serious illnesses and serious diseases, reduce the prices of common and frequently-occurring diseases, and curb the incentives for hospitals to treat such patients, so that patients with these diseases can return to townships for medical treatment. “But we have analyzed it carefully. This needs a stage. Township hospitals can't reach this level at all. Just like eye surgery, township hospitals can't do it, and we can't refuse patients.” He believes that current policies and levels are not matched. Under the circumstances, the price of the disease group should be adjusted downwards, and the hospital's solution is also limited.

DRGs are not the first bottleneck

Despite being considered as one of the most advanced payment methods in the world, the implementation of DRGs in the People's Hospital of Lufeng County is still difficult.

In October-December 2012, the hospital began trial operation of DRGs and became the first person to eat crabs in China's county-level hospitals. In order to test the effectiveness of this approach, Xiong Wenyun adopted a traditional management approach: “Not to say that you are the most advanced in the world, and where is the advanced? Look to suit our traditional management methods.”

Thus, under the approval of superior health authorities, Lufeng County People’s Hospital implemented “five changes” to test DRGs. The five changes are: the quality management requirements are unchanged, the cost control is not changed, the standard of hospital admission and withdrawal is unchanged, the inspection medication management is unchanged, and the performance allocation plan is not changed.

The results of the three-month trial run found that if the old methods and traditional methods were used to manage DRGs, the results were very poor. In the words of Xiong Wenyun, the results of the inspection are: the results of the implementation of monthly and monthly losses, uneasy working conditions, and the urgent need to resolve them as soon as possible. The reason for this is Xiong Wenyun’s point of view: “Why is this happening? We use the concept of no change, and the old traditional method of management.”

"The results of the trial run tell us that the traditional hospital management model cannot adapt to advanced payment method reforms. In other words, if our management ideas and management thinking do not change, then the medical reform will have to succeed." Xiong Wenyun said, "So we reshuffled the rules and regulations and brainwashed them, especially incentives. In the past, it was more to earn more and earn more prizes, and now it is more reasonable to save more. The reform of payment methods has stimulated a number of management reforms. ”

In order to advance the management of modern hospitals, the Yunnan Provincial Department of Health organized the "Walk into the West - Training of Health Talents" project, training 370 county-level key physicians and 500 management personnel each year. Held a training class for the dean of county hospitals, and provided training for the president of the hospital from the aspects of medical reform policy guidance, hospital grade assessment, hospital strategic management, human resources and performance, and informationization. As an old dean, Xiong Wenyun also moved the idea of ​​comprehensively reforming hospital management.

Since January 2013, the institute has officially launched DRGs. Together with the launch of DRGs, there have been comprehensive reforms in hospital management. Including personnel system, distribution system, talent introduction and training, logistics and socialization and a series of measures. To cope with the DRGs' payment according to the disease group, 260 disease groups were created. In 2014, the number of disease groups was subdivided to 436. At the same time, Lufeng County People’s Hospital has also done a “Localized Clinical Pathway.”

Xiong Wenyun recalled: “Because of the change in management methods, the new payment method was officially run for one month, and most disease types have surpluses, and the balance between profit and loss is still positive. This mixed result has made us more concerned about quality and safety. As a result, the company made a decision to “complicate the hospital's actual preparation of a local clinical pathway, with a total of 100 disease types to standardize the medical staff’s diagnosis and treatment behaviors” in addition to strengthening the medical quality inspection, and clearly stated that: The cost must be based on the protection of medical quality and medical safety."

The reform of "advanced hospital" is hidden

“The reform of the payment method has incited the comprehensive reform of the hospital.” This is what Xiong Wenyun said most in an interview. As the pilot unit for the reform of the first batch of public hospitals, Lufeng County People's Hospital has a major reform initiative - pharmacy trusteeship.

Since February 2013, all medicines (except Chinese Herbal Pieces) of the Lufeng County People's Hospital have all been sold at zero margin. After canceling the “medication with drugs”, Xiong Wenyun proposed that “we must make a profit on a zero-plus basis”. In 2013, the hospital began to implement reform of drug trusteeship under the premise of “zero markup”. In October of the same year, after negotiations, the People's Hospital of Lufeng County determined a drug distribution company as a hospital drug provider.

Xiong Wenyun said that after the custody, the pharmaceutical distribution company has become one from a number, and the management and wages of the pharmacy staff are borne by the drug distribution company. The renewal and maintenance of large pharmacy equipment is also undertaken by the custodian, which speeds up the modernization of drug management. The service level of the hospital has been improved, the hospital has reduced the burden, the doctor has been calm, and the patient has benefited.

However, pharmacy hosting is still a controversial topic in the industry. Under the background that the country has not yet introduced supporting policies, the future of pharmacy trusteeship is not clear, and even faces the risk of being called to stop.

In addition, Lufeng County People’s Hospital still has the same problem as other county-level hospitals—talents.

"Tired." Said Hu Congheng, director of the Department of Endocrinology. Compared with pre-DRG reforms, the current pace of work is getting faster and faster. Doctors need to save money, prevent treatment fees from exceeding the limit of the disease group, and ensure the quality of medical care. They must follow the localized clinical approach and strictly enforce the speed. Otherwise, performance evaluation will cause problems. "The income is high, but it is too busy and too tired, and the increase is not proportional. We have many nurses in the hospital."

Xiong Wenyun also said in an interview: “There are relatively few professional and technical personnel in various disciplines, and it is difficult to introduce them. Our medical personnel are overloaded, and their efforts and returns have not been fully reflected. We hope to have relevant policy protection.”

Director of the Medical Management Department of the Yunnan Provincial Department of Health, Jiang Xu, said that due to the economic and social development and the personal professional development environment of medical personnel, the phenomenon of “talent counter-current” in county-level public hospitals is prominent, and a large number of skilled backbone doctors are transferred to higher-level hospitals. The county hospitals, which originally lacked highly qualified professionals, brought even greater shortages of talent. “There are also problems with treatment. Many people who have been in the hospital for several years have been dug away by private hospitals. The wages they open are high, and public hospitals have become their training base.”

The lack of medical personnel corresponds to the full load of patients. According to Xiong Wenyun, at present, the hospital has achieved the goal of “90% of patients do not leave the county”, but the problem of hospitalization is also very prominent. Therefore, it is hoped that “all levels of government will boost our hospital”, first of all “covering the comprehensive building”.

On April 8, the “Opinions on Promoting the Comprehensive Reform of County-level Public Hospitals” issued jointly by the Health and Family Planning Commission, the Ministry of Finance, the Central Office, the Development and Reform Commission, and the Ministry of Human Resources and Social Security, strictly control the size of hospital beds at county-level public hospitals. And construction standards, prohibit the construction of debt. Faced with this situation, how county-level hospitals should be broken has yet to be further observed.