December 17, 2017, a public hospital in Shandong Province, bone joint bone tumor surgery ward. Nurses say the ward doesn't admit many patients after December.
High-value consumables limit some hospitals to stop part of the surgery doctor:can not do it on December 16, 2017, a public hospital in Shandong Province, joints inpatient department corridor, beds are still more than half empty.
High-value consumables limit the use of some hospitals to stop part of the operation doctor: can not do not do December 21, 2017, a public hospital personnel are unpacking boxes of disposable medical consumables.A12-A13 Edition
By the end of 2017, the first four batches of pilot cities in public hospitals in the first 100 yuan of medical income (excluding drug income) in the consumption of sanitary materials down to less than 20 yuan. That means the ratio of consumption in public hospitals should be below 20 percent in 2017.
Li Yun (a pseudonym), a 63-year-old native of Shandong, just underwent an operation to remove a tumor from her moderately advanced colon cancer. In a provincial public hospital in Shandong, she was half lying down to recuperate, and when it was hard to get up and move in small steps, she sat on a small stool next to her bed, curled up and covered her stomach, "so that it would be more comfortable."
It was an open heart surgery. The surgery removed a goose-egg-sized tumor but left a stitched wound on her stomach about 20 centimeters long. Medical papers generally agree that open surgeries have slower post-operative recovery and are prone to wound infections or abdominal infections and more complications than laparoscopic surgeries, which cause less interference with the abdominal cavity and less intra-operative bleeding.
She didn't have to endure such pain and more postoperative risks. Doctors told her that until November 2017, this hospital was performing laparoscopic surgeries for patients like her with intact heart and lung function and no other inflammatory conditions. That way, only small incisions would be left on the stomach and recovery after surgery would be quick.
Fifteen years after the nation's first laparoscopic radical rectal cancer surgery was successfully performed at Peking University Third Hospital in 1993, laparoscopic surgery has long been the preferred surgical modality for treating cancers of the gastrointestinal area in most major hospitals today.
"Originally was rushing to this hospital laparoscopic surgery technology is very high only to come," Li Yun's son Zhang Qing told the Beijing News reporter, December 5 for admission before the doctor suddenly called to tell him that laparoscopic surgery can not be done at present, can only be done to open surgery.
The reporter investigated and found that in this hospital, similar changes are: ordinary hemostatic gauze instead of anti-adhesion hemostatic gauze; absorbable thread is limited; imported anastomosis disappeared, either the use of domestic anastomosis, or manual suture; artificial hip joints to suspend replacement; ultrasonic scalpel is limited to the use of; retention needles are gradually reducing the use of.
In addition to Shandong, in Sichuan, Guizhou and other places, there are medical surgical supplies are limited to similar news. A nationwide storm of restrictions on the use of medical surgical supplies swept through the country at the end of 2017, becoming what most doctors refer to as the "first consumables storm".
Public opinion once pointed the finger directly at the health insurance fee control, from the health insurance fund deficit; such speculation by the official denial, the Guizhou Provincial Health Planning Commission relevant person in charge of the previous interview with a reporter from the Beijing News, said that at present, Guizhou Province, the operation of the health insurance fund is stable, there is no "income does not cover expenditure".
The National Health and Family Planning Commission issued a "Several Opinions on Controlling Unreasonable Increases in Medical Costs in Public Hospitals" (hereinafter referred to as the "Several Opinions") in June 2016, saying it was "striving to reduce the increase in medical costs nationwide to less than 10 percent by the end of 2017."
In addition, the Sichuan and Guizhou Provincial Health Planning Commissions issued documents in October and November 2017, respectively, to strictly control unreasonable growth in medical costs, which both mentioned "high-value medical consumables."
"When to resume surgery, wait for the notice after New Year's Day"
The challenges faced by Li Yun do not stop there. A central venous catheter, commonly used in gastrointestinal surgery, was told to be unavailable and replaced with a peripheral venous catheter.
Central venous cannulation is inserted through the clavicle, while peripheral venous cannulation involves sticking a needle in the arm. Because the subclavian vein lumen is larger, central venous cannulation is fast and easy to enter large-molecule nutrient solutions, and there is no need to be re-tipped before discharge, while peripheral venous cannulation enters large-molecule nutrient solutions with slower blood flow and more damage to the blood vessels.
"Too busy," complained the nurses in Li Yun's ward, because of the thin blood vessels in the arm, a long infusion of nutrient solution makes the blood vessels more prone to atrophy, the nurses have to change the needle every 3-4 days to re-lap the patient, and the patient also rotates between the two hands to be lanced.
Central venous cannulae were originally surgical supplies that anesthesiologists in the operating room could receive, and nurses at the hospital division's inpatient gastrointestinal surgery department told reporters around Dec. 20, "Currently, the operating room has been prevented from receiving them, and if, after an assessment that the patient's blood vessels are not good and so on, the doctor doing the surgery in the department will bring his own puncture kit (which contains a central venous cannulae) to the operating room."
In mid-December, the reporter visited a number of provincial public hospitals in Shandong Province, found that the use of surgical supplies less internal medicine inpatient wards such as obstetrics, endocrinology, the number of patients did not change much. Hand and foot surgery, orthopedics, such as the use of surgical consumables more wards, a doctor was asked if they still do surgery straight wave, "surgery can not do not do it".
Li Yun's hospital cardiology patients to do interventional procedures can currently only put a stent, the hospital's head of the medical department told reporters, if the blockage is very serious, want to put 2 stents, the doctor's usual response is, sorry, transfer, if you want to put an imported stent, "I'm sorry, you go to an overseas hospital."
The hospital's joints clinic, sitting around a lot of people rushed to see the "old problems" before the Spring Festival. 54-year-old Liu De (a pseudonym) is a welder, often bent over and squatting work, the right buttock pain intolerable pain in the middle of the night, often unable to sleep, can only sit all night. December, he was diagnosed with "ischemic necrosis of the femur", the doctor told him he needed to replace the artificial hip joint, but only until after New Year's Day.
In the joint department, artificial joints (artificial knees, artificial hips, etc.) are almost the only necessary surgical supplies. But there are some cases where immediate surgery isn't necessary. As of mid-December, the hospital's joint department nurses showed reporters the patient register has registered nearly 30 patients who are currently unable to have surgery, while the dozens of beds in the wards are occupied by fewer than 10 patients. "When to resume doing surgery, after New Year's Day and so on notice," the joints nurse replied.
The reason for the restriction is confusing. Interviewed arthritis patients get doctors have different explanations, "beds are not enough", "is the second bargaining with the drug companies to reduce the cost of orthopedic consumables, not yet negotiated", "at present you can also take medication to maintain the first ", "drug companies do not supply."
"Now the hospital all day in the meeting to discuss this matter, we also collapse," the hospital's an arthroscopist in mid-December, revealed that from December 1, the operation stopped for nearly more than half a month. "The higher-ups have targets for the hospital, the hospital is stuck with targets for each department, and each department can only accept fewer patients."
Massive stopping the use of surgical supplies, the hospital responsible person said, "not before, this is the beginning of 2017." And this statement was corroborated by the relevant person in charge of a number of public hospitals in Shandong Province.
High-value consumables have become a restricted "disaster area"
In fact, in Shandong Province, Guizhou Province and Sichuan Province as early as November has been pushed to the forefront of public opinion.
In November, an internal notice addressed to the hospital attached to Guizhou Medical University circulated on the Internet. The notice required, "stop orthopedics, intervention, neurosurgery, operating room, ophthalmology, cardiology and other departments and other departments part of the medical consumables; stop the use of all hemostatic and anti-adhesion materials, anastomoses, cutters, patches and biopatches, medical adhesive, puncture devices, disposable negative pressure drainage devices; in addition to some special departments, limit the use of all other sutures in addition to silk threads The use of; suspend the high value consumables into the warehouse procedures."
Multiple WeChat public number released a related article to brush the circle of friends, mentioning such as a tertiary hospital in Guizhou, Sichuan Cancer Hospital, "stop using part of the medical consumables", "increase the admission of patients using low-value consumables, strict control of the admission of patients needing high-value consumables to hospital admission ".
Some of the consumables in the vortex that have been restricted are mostly high-value medical consumables. They don't have a particular categorization standard, and are usually expendable medical devices that are critical to safety, whose production and use must be strictly controlled, and whose use is limited to certain specialties. The price is usually over $1,000. For example, the ultrasonic knife needed for laparoscopic surgery, some steel plates for orthopedics, and guide wires, dressings, and cardiac interventional stents used in other disciplines are all high-value medical consumables.
The head of the medical department of the above hospital to gastrointestinal surgery, for example, all the costs (including nursing and hospitalization fees) a *** less than 10,000 yuan, of which the cost of doing the surgery of the labor is usually about 1,000 yuan, but an ultrasound knife used in laparoscopic surgery (open surgery is not required), the price of about 6,000 yuan.
The price of high-value medical supplies has always been "inflated". In addition to the cost is really high, but also because of its sale in the link layers of price increases, abuse, waste and other reasons, in order to avoid hospital infection, surgery in the use of ultrasound knife head is generally disposable in Chinese hospitals, used up to throw, but the knife head in Europe, the United States and other places can be sterilized to continue to use.
High-value medical consumables belong to the health materials. on May 17, 2015, the General Office of the State Council issued the "guidance on the pilot comprehensive reform of urban public hospitals" began to start the cost of 100 yuan of medical income health material costs and health material income accounted for the ratio of the macro-assessment of hospitals as an indicator. It is mentioned that by the end of 2017, the sanitary materials consumed in 100 yuan of medical income (excluding drug income) of public hospitals in the first four batches of pilot cities fell to less than 20 yuan. That is to say that in 2017, public hospitals consume less than 20% of the ratio.
Jinan, where several provincial public hospitals in Shandong investigated by the reporter are located, belongs to the first four batches of pilot cities mentioned above.
The 20 percent consumption ratio was called a "one-size-fits-all" policy by most of the doctors interviewed.
The head of the medical department of Li Yun's hospital, mentioned above, revealed that the average consumption ratio in Shandong Province in 2017 was about 40%, while his hospital has exceeded 40%. Due to the different characteristics of surgery, each department's consumption ratio varies greatly, such as arthropathy will exceed 60% once the surgery, so the hospital will control the number of arthropathy and other consumption ratio is higher than the number of surgeries, simply stop the relevant surgery in early December.
The pressure of medical cost growth indicators
Part of the medical surgical consumables limit the use of the reasons for the parties said differently, the reporter also did not get the Shandong Provincial Health Planning Commission reply. And years of research on health care, the Chinese Academy of Social Sciences, deputy director of the Institute of Economic Research, Zhu Hengpeng analysis, 2017 10% of public hospitals medical cost growth rate of the target may be to the major public hospitals have brought great pressure, especially at the end of the year.
The National Health and Family Planning Commission (NHFPC) issued a "Several Opinions on Controlling Unreasonable Growth of Medical Expenses in Public Hospitals" (hereinafter referred to as the "Several Opinions") in June 2016, which called for the average growth rate of medical expenses in 2017 to strive to be controlled at less than 10 percent. According to the 2016 Statistical Bulletin on the Development of China's Health and Family Planning Program, the reporter calculated that the growth rate of medical costs in 2016 was about 13 percent.
Meanwhile, the Several Opinions mentioned that the state will rank and inform the growth of medical costs in public hospitals in all provinces (autonomous regions and municipalities) and corps.
According to an internal document circulating on the Internet, "Emergency Circular of the Office of the Sichuan Provincial Health and Family Planning Commission on Strengthening Accountability and Strictly Controlling Unreasonable Growth in Medical Costs" (hereinafter referred to as the "Emergency Circular"), the average increase in the total medical costs of public hospitals in Sichuan province was 13.15 percent.
New Beijing News reporter called the Sichuan Provincial Health Planning Commission office to confirm that this document does exist, for the Sichuan Health Office issued 2017120.
The Emergency Notice, dated Nov. 10, 2017, states that medical institutions whose medical costs have increased by more than a specified percentage must strictly control the procurement and use of expensive, self-financed medicines and equipment. "Among them, where the total medical cost growth ratio exceeds 10%, from now on, the procurement ratio of expensive, self-financed drugs must be less than 3% for tertiary hospitals and less than 2% for secondary hospitals, must not exceed the upper limit of the planned procurement volume of the purchasing of the winning drugs, and must strictly control the use of imported high-value medical consumables."
The official website of Guizhou Provincial Health and Planning Commission released a "Policy Interpretation on Controlling Unreasonable Growth of Medical Expenses in Public Hospitals" on November 1, 2017, which mentioned that Guizhou Provincial Health and Planning Commission issued the "Emergency Notice on Controlling the Unreasonable Growth and Excessive Growth of Medical Expenses" (Guizhou Health and Planning Letter [2017] No. 150) on October 19, 2017, which clearly the objectives and requirements of cost control.
This policy interpretation says that there are eight main measures to control the unreasonable growth of medical costs, of which the third is to "reduce the inflated prices of medicines and consumables" and "implement the online sunshine purchasing of high-value medical and health materials. Under the premise of quality assurance to encourage the use of high-quality, low-priced, cost-effective domestic high-value medical supplies."
The above-mentioned Shandong Li Yun's hospital medical department responsible person revealed that the National Health Planning Commission first looked for the ranking of the bottom first and second Guizhou, Sichuan Province, the relevant person in charge of the interview, "our Shandong is the third."
In fact, the problem of unreasonable growth in medical costs has always existed, before the abolition of the drug markup, the cost of drugs accounted for a large proportion of medical costs, after the abolition of the drug markup, the cost of sanitary materials accounted for the proportion of medical costs in public hospitals is high.
The above from Sichuan Province, "Emergency Notice" also made it clear that the medical control costs and annual assessment of the target, hospital level assessment, staff performance appraisal, the use of key drugs procurement linked. Among them, public hospitals that fail to meet the target, the total annual employee performance is deducted 20%, and the performance of the director is deducted 40%.
For hospitals to stop the use of some of the medical supplies behavior, the Sichuan Provincial Health Planning Commission to the reporter's response is that never issued a request to stop the use of some of the medical supplies policy and documents, stop the use of some of the medical supplies purely some of the hospitals of individual behavior. The reporter visited a provincial public hospital in Shandong Province, the head of the Department of Medical Services also made it clear that "the government did not say to stop the use of consumables".
Meanwhile, the Sichuan Provincial Health Planning Commission said that once the hospital was found due to the control of medical costs, medical supplies remediation, the refusal of patients, refusal to treat patients affecting the normal needs of patients, the provincial health planning commission will be seriously dealt with.
The reporter noted that the above document does not "stop using consumables" statement.
It is understood that a number of public hospitals in Shandong Province and a number of pharmaceutical companies are bargaining, compression of the profit margins of consumables, the results are not yet determined, part of the domestic medical equipment companies agreed to reduce prices, while imported medical equipment giants and hospitals are "deadlocked". The reporter learned through multiple channels, one of the public hospitals in Shandong Province, gastrointestinal surgery using anastomosis are currently domestic, while the joints of domestic artificial joints are expected to be reduced from September 2017 price cuts on the basis of a further 15% or so.
"There has not been a so-called no money situation"
Knowledge, there are replies pointing directly to the medical insurance fee control is the main reason for the restriction of consumables, the spearhead once pointed to the shortfall of the medical insurance fund. There is news that a third-rate hospital in Guizhou province is facing pressure to wear out its bottom due to the medical insurance fund.
Officials from all over the world immediately started rumors that there was no shortfall in the health insurance fund, and Guizhou's claim that the rumors were untrue was that the health insurance fund in Guizhou province was running smoothly, and did not "outstrip its revenues".
According to the Ministry of Human Resources and Social Security's "Statistical Bulletin on the Development of Human Resources and Social Security Career" (hereinafter referred to as the "Statistical Bulletin"), the national medical insurance from the past years, there is a surplus every year, and in 2015 the accumulated surplus reached 976.5 billion yuan. The latest data in the Annual Report on the Development of Social Insurance in China 2016 showed that the accumulated balance of the basic medical insurance co-ordination fund for employees reached 777.2 billion yuan in 2016, while the balance of basic medical insurance for urban residents was 33.01 billion yuan.
"Every year, the fund's income grows faster than the fund's expenditure, and it continues to be in a state where income is faster than expenditure, which shows that the accumulation of funds is increasing year by year. The payment capacity of the employees' medical insurance fund has increased significantly, and the situation of the residents' medical insurance fund has also been generally stable, with neither of them experiencing the so-called out-of-money situation." Dr. Guan Bo of the Institute of Social Development at the China Academy of Macroeconomic Research analyzed.
And the above mentioned person in charge of Li Yun's hospital disclosed that the hospital's medical insurance fund has been spent almost all of the first 10 months, and "it is impossible to have a surplus".
At present, the medical insurance departments in Shandong, Beijing, Shanghai, Guangzhou and other regions have adopted the total prepaid medical insurance payment method. This is to curb the momentum of excessive growth in health insurance fund expenditure and stabilize the level of health insurance protection.
Total prepayment simply means giving hospitals a fixed amount at the beginning of the year. An article analyzed that managers of public hospitals around the world have commonly adopted the practice of breaking down the total amount target to departments and even to doctors due to the lack of ability and motivation for fine-tuned management.
Zhu Hengpeng, deputy director of the Institute of Economics at the Chinese Academy of Social Sciences, analyzed in 2012 that the payment method of total prepayment, which determines the total prepayment amount at the beginning of the year, as well as the actual payment and settlement at the end of the year, provides greater autonomy to health insurance agencies, while largely transferring the risk of fluctuating medical costs to hospitals.
Shandong Province, a public hospital in charge of medical services, for example, the provincial hospitals receive patients from the province each year, patients from other cities, see the doctor to reimbursement to go back, the hospital to advance funds, the next year, other cities of the health insurance will make up for this part of the money, the more delayed the more delayed. "Health insurance does not give us money, we have no way to give money to medical equipment companies, no way to give money to the pharmaceutical companies, we have to drag, now is even patients can not be collected, the money to pay out of pocket, the more you collect, the more you lose."
The reporter visited another provincial public hospital regulations department in charge of the denial of the direct relationship between medical insurance and limited supplies. He and the reporter explained that the two things are not related, just coincidental. "It is the end of the year, health insurance to the money shortcomings, the National Health Planning Commission and said that high-value consumables do not allow the use."
The aforementioned Statistical Bulletin also mentioned that although the overall health insurance fund has a surplus in terms of national data, some regions have already experienced deficits, such as Tianjin, Qinghai, Fujian and other regions. The head of the medical department of the said hospital corroborated the above statement, "Every year is in the red, the whole Shandong is in the red."
Necessary or optional
"Technology once returned to 20 years ago," the doctors from different areas of knowledge **** the same expression of dissatisfaction with the limited use of supplies. Over the years, many consumables have become the surgeon's assistant because of their "time-saving", "precision" and "convenience" properties.
Taking the discontinued anastomosis as an example, it takes less than five minutes to close an incision for stomach cancer, while it takes half an hour or more to do it by hand. Tension-free hernia repairs, which use hernia patches that are softer and more resistant to bending and folding than typical patches, can reduce hernia recurrence rates and alleviate postoperative pain. The use of consumables such as laparoscopy can greatly reduce patient bleeding and minimize surgical risk. Coronary artery bypass grafting and heart valve replacement allow major surgeries that used to require an open chest to be solved through a small incision. Absorbable sutures can be degraded and absorbed by the body after being implanted into human tissues, eliminating the need to remove sutures and eliminating pain.
The aforementioned doctor, who has been practicing for more than 10 years, believes that "there is no such thing as clinically necessary and non-essential, and most of the talk is evidence-based, so if large-scale studies show that using the device can lead to a good prognosis and a high rate of success, using it is very necessary."
Gong Xiaoming, who used to work as a doctor in the Department of Obstetrics and Gynecology at the Peking Union Medical College Hospital, cited the example of a wound adhesive that can be used to take a shower directly after applying it to a wound, and a wound that is not closed with adhesive stitches needs to be bathed after a week, "but without the wound adhesive, the patient can't recover, can he? Nope. Consumables some times just make the quality of care a little bit better."
He further explained that for some of the consumables that improve the quality of surgery, doctors need to find a balance between quality, satisfaction and cost. At present, his surgery in private hospitals usually implement package charging, the more consumables used in a fixed price situation, the more the hospital loses, so that doctors will naturally find a balance between various factors.
The doctors interviewed also expressed "skepticism" about the help of some of the medical devices mentioned above. One doctor said, "There is no conclusion that anastomosis must be used, but the use of anastomosis is a general trend, some hospitals use it, and there are manufacturers marketing it, so it has gradually become popular, which includes vested interests." The doctor said that experienced surgeons, manual suturing "as beautiful as ever".