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Some hospitals limit the length of hospitalization for insured persons, and tell them that they must be discharged from the hospital if they are hospitalized for 15 days with medical insurance.
In fact, the medical insurance policy has never restricted the length of hospitalization, the number of hospitalizations and related expenses.
The emergence of this situation has nothing to do with hospital performance appraisal, medical insurance control fees and hospital economic benefits.
Professionals believe that regulatory assessment should be flexible, and it is recommended that medical insurance pay according to the characteristics of medical services used for diseases.
For a period of time, patients have reported that they were sick and hospitalized, and were persuaded to leave the hospital before they recovered.
The reason given by the hospital was that “you must be discharged after 15 days of hospitalization with medical insurance”.
In response, many local medical insurance departments did not stipulate that patients must be discharged after 15 days of hospitalization.
Wang Ying, a Sichuan native who works in Guangzhou, had this experience not long ago.
Due to a sudden cerebral hemorrhage, she has been hospitalized in Guangzhou since the end of November 2020.
By the end of March this year, within four months, she had been in four hospitals in Guangzhou and was "discharged" three times by the hospital.
In the case that the patient has not recovered, the hospital repeatedly handles the admission and discharge procedures for the patient, and even the phenomenon that the patient has to be transferred to the hospital to continue to receive the unfinished treatment is called "disintegration of hospitalization."
Decomposing hospitalization is indeed illegal, why does the hospital do this?
How to solve this problem?
Was "discharged" 3 times in 4 months
In early April this year, Wang Ying, who had worked in Guangzhou for more than a decade, returned to his hometown in Sichuan to recuperate.
Recalling his wife's treatment in Guangzhou, her husband Gao Qiang said that frequent hospitalizations, discharges and admissions made them exhausted.
Gao Qiang told reporters that when they were "transferred" for the first time, the hospital told Wang Ying that they could only live for half a month on the grounds that the beds were tight and the hospital stay could not be reimbursed. For this reason, they had to be transferred to other hospitals.
In the subsequent two transfers, the reason for the hospital was that the hospital stay exceeded 30 days and the medical insurance could not be reimbursed.
The condition of the last hospitalization was "relatively better." There was no need to transfer to other hospitals. The hospital told her that after the hospitalization period expires, she can continue to be hospitalized through discharge in the morning and admission in the afternoon.
Among the 4 hospitals that Wang Ying moved around, there were provincial hospitals, municipal hospitals, public hospitals and private hospitals.
The car for each transfer is provided by the hospital, and the car and other transfer fees are paid by the patient.
"The number of hospital transfers is too large, which is not conducive to recovery, and it will also incur a lot of expenses. In addition, during the epidemic prevention and control period, the hospital only allows one family member to accompany it, which is more tossing." Gao Qiang said.
In fact, it is not uncommon to decompose hospitalizations.
According to media reports, at the end of 2019, an 89-year-old man in Guangzhou was admitted to the hospital for acute stroke. After the acute period, he was repeatedly in critical condition due to complications such as pneumonia. During this period, he was forced to move to 4 hospitals and had to be discharged and admitted repeatedly; In January of this year, a patient in Wuhan suffered a sudden cholecystitis and was admitted to the Department of Hepatobiliary Surgery in a tertiary hospital. On the 13th day of hospitalization, the doctor suddenly asked her to leave the hospital and told her to be admitted a few days later.
In this regard, medical insurance departments in many places have clarified that medical insurance policies have never imposed restrictions on the length of hospitalization, the number of hospitalizations and related expenses.
The length of stay of the patient and the cost of treatment shall be determined by the medical institution based on the patient’s condition.
Related to hospital performance appraisal and medical insurance control fees
The reporter's investigation found that the phenomenon of "discharge after 15 days of hospitalization with medical insurance" occurred repeatedly, which has nothing to do with hospital performance appraisal, medical insurance control fees, and hospital economic benefits.
Liao Cangyi, an assistant professor at the School of Politics and Public Administration of China University of Political Science and Law, said that although the state does not explicitly limit the length of hospitalization and the number of hospitalizations, in the assessment of the quality of medical services by the health industry authorities, the length of hospitalization and the number of hospitalizations are important indicators.
Hospitals need to speed up bed turnover to improve operational efficiency, and the performance appraisal baton of the competent department has undoubtedly strengthened the hospital's attention to the length of stay.
At the National People's Congress this year, a "Recommendation on Solving the Problem of "Decomposing Hospitalization"" submitted by Shen Jinqiang, deputy director of the Standing Committee of the Chongqing Municipal People's Congress, and chairman of the Chongqing Municipal Committee of the China Democratic National Construction Association, attracted attention.
Shen Jinqiang believes that the main reason for the decomposition of hospitalization lies in the setting of some assessment indicators.
In the assessment of the hospital by the health department, there are indicator requirements such as the average length of stay, the average cost of hospitalizations, and the utilization rate of beds. The medical insurance agreement includes the average cost of hospitalizations within the scope of the medical insurance policy, the number of days between two hospitalizations, etc., if it exceeds If the agreement stipulates, the payment will be refused by the medical insurance, and the hospital will bear it on its own.
Professor Zhai Shaoguo, the vice dean and professor of the School of Public Administration of Northwest University, agreed with this.
In his opinion, some hospitals and doctors have performed illegal operations to decompose the hospitalization in order to successfully pass the assessment and obtain the medical insurance fund payment, which has caused unnecessary troubles for patients and brought pressure on the medical insurance fund to pay.
Regarding the forced discharge of patients, the National Medical Insurance Bureau has explained that in order to prevent excessive medical treatment, the health department will evaluate the average hospital stay in the hospital to reflect the hospital's service efficiency for inpatients.
This limitation is a consideration of the average condition of the entire hospital, not a single patient.
Some patients have been in the hospital for a long time, and some hospitals adopt a “one size fits all” approach to require patients to be discharged and then re-admitted. This is unreasonable.
When the hospitalization expenses of the insured person exceed the disease settlement standard or the average fixed settlement standard, it is also unreasonable for some hospitals to discharge the patient in order to ensure that a single medical treatment does not lose money.
It is recommended to assess and pay for different diseases
The "Regulations on the Supervision and Administration of the Use of the Medical Security Fund" that came into effect in May this year clearly stated that the medical insurance administrative department shall order corrections and interview the person in charge for the decomposition of hospitalization and other violations of laws and regulations. Fines of more than 1 time and less than 2 times the amount of loss, etc.
Zhang Yang, who worked in Shanghai's medical insurance department, used to be a doctor. He believes that in the face of the performance appraisal indicators set by the competent department, the hospital has a mechanical understanding in the process of implementing policies and regulations.
At the same time, he suggested that relevant departments assess and pay for hospitals according to the type of disease.
In this way, the hospital has no need to resolve the hospitalization response to the assessment.
“Decomposing the problem of hospitalization requires the joint efforts of health and health departments, medical insurance departments, and medical institutions to resolve it.” Zhai Shaoguo suggested optimizing the assessment standards for medical institutions, optimizing medical insurance payment methods, and choosing different medical insurance payment methods according to the characteristics of medical services. Especially for cases with high treatment costs, long treatment cycles, and complicated complications, we will strengthen the single discussion of special diseases, and minimize the strict restrictions on payment by item.
Liao Cangyi suggested that the supervision and evaluation of indicators such as "15 or 30 days readmission" should be clearly defined and interpreted by the health and medical insurance departments.
In his view, the supervision and assessment should be flexible. If medical institutions do require treatment due to disease, reasonable treatment and humanistic treatment, and need to extend hospitalization, even if the length of hospital stay exceeds the prescribed length of stay, they should consider exempting the supervision and assessment.
He specifically reminded that patients should strengthen their awareness of rights protection, and should promptly complain to the health and medical insurance departments when they encounter problems such as decomposition and hospitalization.
(Some interviewees have pseudonyms)