□ Our reporter Liu Zhiyue
□ Liu Huan, a trainee reporter of this newspaper
On the surface, everything seems to be business as usual.
In the early morning of May 12, the orthopaedic clinic of Tongji Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology (hereinafter referred to as Wuhan Tongji Hospital) was full of patients waiting to be called. Chuan, some are from Honghu, Hubei, and more are locals from Wuhan, Hubei.
What is different from the past is that the doctor only "sees a doctor" and does not issue a list or medicine.
A reporter from the "Rules of Law Daily" saw at the scene that some patients really needed medication. The doctor wrote the name of the medicine on the paper and asked the patient to buy it by himself.
Not long ago, on April 20, the National Medical Security Administration reported that an unannounced inspection of Wuhan Tongji Hospital found that the hospital had the problem of collusion and false records of high-value orthopedic medical consumables, and defrauded the medical insurance fund to pay more than 23.3436 million yuan.
Wuhan Municipal Medical Insurance Bureau ordered the hospital to rectify according to law, fined a total of more than 59,245,600 yuan, and ordered the hospital to suspend medical services involving the use of medical insurance funds in the orthopedics department for 8 months.
This 700-word bulletin has attracted widespread attention from all walks of life.
As a prestigious tertiary hospital in China, what does it mean for Wuhan Tongji Hospital to be investigated for fraudulent insurance?
Why is there such a huge amount of insurance fraud at a time when the high pressure on insurance fraud continues to be maintained?
How to strengthen the supervision of medical insurance funds?
With these questions, the reporter conducted an investigation and interview.
Fraud and insurance are severely punished
For a long time, private and primary medical and health institutions and pharmacies have been regarded as the hardest hit areas for fraud and insurance fraud.
"The investigation and punishment of Wuhan Tongji Hospital this time shows that large tertiary hospitals do not have fraud and insurance fraud as some people thought before." Zhang Zhongmin, director of the Legal Affairs Department of Zhongnan University of Economics and Law, said that fraud and insurance fraud occurred, regardless of Private hospitals, grass-roots medical and health institutions, pharmacies, or large tertiary hospitals will be severely punished by the law.
According to the report of the National Medical Insurance Administration, clues to the problem of the case have been transferred to relevant departments such as public security, market supervision, drug supervision, health, discipline inspection and supervision.
At present, the loss of the medical insurance fund has been fully refunded, and the fines have been fully implemented.
It is worth noting that in addition to the orthopaedic problems, the unannounced inspection also found that Wuhan Tongji Hospital was suspected of illegally using 91.0741 million yuan of medical insurance funds in other medical activities in 2021.
In this regard, some industry analysts believe that the medical reform has been going on for many years, but well-known public hospitals still rely on the gray income of the departments to increase their profits, which shows that all parties within the hospital have not paid attention to fraud and insurance fraud.
"This incident has caused Wuhan Tongji Hospital to suffer heavy losses in the short term, but it will help its healthy development in the long run. If it were not for this supervision and punishment, the spread of fraud and insurance fraud may lead to more serious consequences." Zhang Zhongmin believes that, The severe punishment of Wuhan Tongji Hospital this time is a "good start to the initiation of legal supervision" of public hospitals.
On April 19, Tongji Hospital responded on its official website, "Completely accept, comprehensively and thoroughly rectify, and draw inferences from one case to another, and resolutely prevent similar incidents from happening again."
Earlier, some media reported that the head of the Orthopedics Department of Wuhan Tongji Hospital had been taken away by relevant departments.
On May 12, the reporter logged in to the appointment registration system of Wuhan Tongji Hospital and found that the director of the orthopaedic department of the hospital had a consultation on the morning of May 17, and the number had been fully booked.
Difficulty in local regulation
According to statistics, from its establishment in 2018 to 2021, the National Medical Insurance Bureau has recovered a total of 58.3 billion medical insurance funds.
"Since the establishment of the National Medical Insurance Bureau, it has achieved remarkable results in combating fraud and insurance fraud. However, from a national perspective, there is still a long way to go to form an atmosphere of 'don't dare to cheat, can't cheat, and don't want to cheat'." Zhongnan, who has long studied the supervision of medical insurance funds Yu Changyong, an associate professor at the School of Public Administration at the University of Economics and Law, said.
Judging from the report of the National Medical Insurance Bureau, the investigation and punishment of Wuhan Tongji Hospital for defrauding medical insurance funds was found by unannounced inspection of the hospital based on the clues reported.
The so-called unannounced inspection is an unannounced inspection without prior notice to the inspected object.
According to statistics, in 2021, the National Medical Insurance Administration will organize 30 groups of unannounced inspections, and find out 558 million yuan of suspected illegal funds.
Two days before the National Medical Insurance Administration issued a notification on the unannounced inspection of Wuhan Tongji Hospital, the Wuhan Municipal Medical Insurance Bureau issued a notification on the illegal use of medical insurance funds by Wuhan Tongji Hospital on April 18.
Comparing the two reports, the reporter found that the Wuhan Municipal Medical Insurance Bureau's report did not involve some key information: it did not mention the unannounced inspection by the National Medical Insurance Bureau; on the issue of fraudulent insurance in Tongji Hospital, it only pointed out that "there is a settlement with false consumables and product regulations." , and did not mention that the hospital "is suspected of illegally using 91.0741 million yuan of medical insurance funds in other medical behaviors in 2021"; in the follow-up processing, it only said that "the clues of the case will be transferred to the relevant departments in accordance with laws and regulations."
Some experts pointed out that for a long time, in the daily inspections of local medical insurance departments, supervisors often encounter hospital leaders with higher administrative levels. The difficulty of its supervision can be imagined, and it also reflects the difficulty of local supervision of medical insurance.
At the same time, the particularity of medical service behavior also increases the difficulty of local supervision of medical insurance.
Yu Changyong introduced that there is a complex principal-agent relationship in the medical service field, in which the doctor is both the agent of the patient and the agent of the medical insurance. In addition, the medical service behavior has a high degree of professionalism, high information asymmetry and high degree of uncertainty. The uncertainty of treatment results determines that the field of medical services is a field with high incidence of moral hazard, and it is difficult to supervise.
Local regulation is also easily constrained by interests.
"The distribution of medical resources is unbalanced, high-quality medical resources are concentrated in the top three hospitals, and local regulatory authorities are often subjectively unwilling to oppose medical institutions." Yu Changyong said frankly.
According to public reports, when Wuhan Tongji Hospital exchanged consumables, the steel plate implanted in the body was 200 yuan, but the hospital wrote 600 yuan.
The reporter combed and found that the current targeted laws and regulations on the supervision of medical insurance funds mainly include the Social Insurance Law, the regulations on the supervision and management of the use of medical insurance funds, and the fraud provisions in the criminal law.
"Because medical service behavior is highly professional and lacks standardized treatment paths and methods, doctors have great discretion, which brings difficulties to the accurate definition of violations of laws and regulations." Yu Changyong said.
After several years of exploration by the National Medical Insurance Bureau, unannounced inspections have been gradually standardized and institutionalized, and a relatively mature working mechanism has been formed.
However, problems such as weak supervision and insufficient supervision capacity of local medical insurance departments are still relatively prominent. At the same time, medical insurance departments are not the direct superiors of medical institutions, and their supervision authority is limited.
"Medical insurance funds involve the vital interests of the general public, and local regulatory authorities should not be timid and dare not take action." Yu Changyong said.
Deepen reforms and solve problems
Fraud and insurance fraud in the medical field is a worldwide problem.
Statistics show that the global loss of medical insurance funds due to fraudulent insurance accounts for about 4.6% of medical insurance fund expenditures.
"If this standard is followed, in 2021, China's medical insurance fund losses due to fraudulent insurance fraud will exceed 110 billion yuan, while only 23.418 billion yuan of medical insurance funds will be recovered in 2021." Yu Changyong said.
It is imperative to further strengthen the supervision of medical insurance funds.
Yu Changyong believes that it is necessary to adhere to the general idea of classified supervision and focus on key points. "Efficient supervision of medical insurance funds is the unity of objective supervision ability and subjective supervision willingness."
From the perspective of improving the supervision ability, Yu Changyong suggested that to speed up the legislation of medical insurance fund supervision, the national level needs to introduce laws and regulations such as the Medical Insurance Law as soon as possible, improve law enforcement standards, standardize law enforcement procedures and clarify discretionary benchmarks, so as to provide a strong foundation for medical insurance fund supervision. legal weapon.
In addition, it is necessary to strengthen the construction of the medical insurance fund supervision team, strengthen the training of medical insurance laws, regulations and policies, and take the improvement of the professionalism of the medical insurance fund supervision team as the starting point to improve the supervision ability of medical insurance funds; increase the publicity and publicity of cases of fraudulent insurance by medical insurance funds. Form a powerful public opinion offensive.
From the perspective of enhancing supervision willingness, the supervision of medical insurance funds should be included in the performance assessment of local governments, so that the supervision of medical insurance funds should become the internal driving force and active behavior of the medical insurance administrative department.
"It is worth reminding that the most fundamental and effective means to deal with fraudulent insurance fraud is to use the reform of medical insurance payment methods, the reform of medical service prices and other mechanisms to reasonably compensate the value of doctors' labor services, enhance doctors' self-discipline, and allow doctors to rely on Medical skills make money openly and aboveboard, rather than relying on fraud and insurance to make illegal profits." Yu Changyong said.
Near noon, there are still patients waiting outside the orthopaedic clinic of Wuhan Tongji Hospital.
"I have seen it in other hospitals, but I still think of Tongji to see it, and I feel at ease." An out-of-town patient told reporters.