The hospital outpatient service "slimming" why is it so hard 
 
 
The 2015-05-22 06:42:02 | source: health | share 

    Level 3 general hospital outpatient clinic visits, reduction is put forward in the urban public hospital reform guidance documents clear objectives. However, ordinary outpatient service is an important source of income of large hospital, the majority of patients and widespread of the grassroots medical institutions of medical level a lack of confidence, how to do big hospitals are willing to put, grassroots medical and health institutions, patient and willing to take a live? 

- chief reporter yan 龑 / 
 
 
CFP for figure 

    Recently enacted on reform of the urban public hospital comprehensive guidance ", explicitly proposed to "build a reasonable medical order", and required by the end of 2015, to make an appointment referral accounts for the proportion of public hospital outpatient medical consultations to increase to more than 20%, reduce the level 3 general hospital outpatient clinic visits; By 2017, the city level 3 general hospital outpatient clinic visits of medical and health institutions significantly lower proportion of the total outpatient visits. Compression, as it were, large general hospital outpatient service has become a tough health-care reform, Beijing, anhui and other places also first to carry out the relevant exploration. But in practice, the reform is faced with challenges, to reform the city or vanished, or quiet caution, or slow. Big hospital outpatient service "swelling", where is the difficulty? Is there a suit the recipe?
 
    Define difficult --
 
    Ordinary outpatient is not clearly defined
 
    National center for health statistics state family planning commission data show that in 2014, China's total diagnosis and treatment for 7.602 billion. Among them, the total hospital diagnosis and treatment for 2.972 billion, in tertiary hospital diagnosis and treatment for 1.398 billion. Some big 3 armour hospital daily MenZhenLiang high, easily broken people.
 
    Health experts said that at present, our country grading diagnosis system is not sound, disorder in patients with medical treatment, disease "winner-take-all" big hospital size, outpatient packed. The government a lot of investment of the construction of the urban secondary hospitals and grassroots medical institutions and "do not have enough to eat," idle resources. Actively expand scale, at the same time, the big hospital in our country medical service system in more and more big hospital patients, grassroots health institutions shrinking, a vicious cycle of doctors and patients are less and less.
 
    Around this situation is constantly trying to compress or even cancel the large general hospital outpatient service of direct power. However, what is the average outpatient service? Distinguish between the discretion of the standards is the registration fee, or the ease of disease diagnosis and treatment? Amount of compression is to reduce the amount of average outpatient service visits or decrease the number of visits the doctor? In the first try to explore some provinces and cities, are each have a different understanding.
 
    Xiamen city in fujian province is taken out method. Out of doctor of vice director of emergency, the above expert outpatient service, health, medical clinic, cadres and outgoing health clinics, outpatient patients see a doctor, other outpatient service is average outpatient service.
 
    Beijing health and family planning commission, head of a think, tertiary hospital subject classification is very fine, and similar Yu Quanke outpatient service of average outpatient service, can be sent to the grassroots, early screening function to achieve its common diseases. At present, in the big hospital outpatient constitute of Beijing city, the Beijing municipal health care patients (70%), prescription of these patients were 45%, these MenZhenLiang can be decentralized to the grassroots. "Compression average outpatient service, therefore, should first to simply get medicine outpatient surgery." Beijing 3 armour hospital a doctor told reporters, in some key large hospital outpatient department, pure take medicine up to 20% of patients, so the hospital had to in key department triage send a doctor specialized prescriptions. This part of the patients should first be shunt to the community, but only if the community drug must be complete, can keep up with the pace of the large hospital drug use. 
 
    Also have experts, ordinary outpatient service can be defined as: use of mainstream medical technology, provide regular hospital service, using the general medical facilities to provide services of medical treatment process. Nothing to do with disease severity and size of medical institutions, its main purpose is to relieve patients suffering.
 
    From the point of the exploration and the expert's opinion, what is the average outpatient service, and which the clinic should be stripped from the big hospital, there is no unified standard and specifications. Therefore, the concept of fuzzy, defines standard is not unified, and compressed the first problem of the average outpatient service.
 
    "Lean" difficult --
 
    To earn money by "meager profit but high turnover" big hospital
 
    According to international experience, the ideal situation is: ordinary outpatient exit from the hospital, grassroots health institutions become the only option of average outpatient service, hierarchical diagnosis will follow; Big hospital also don't have to spend a lot of manpower and material resources of average outpatient service, so as to focus more on the diagnosis and treatment of difficult diseases. But the ideal is plump, reality is always very skinny.
 
    The reporter understands in the interview, in a big hospital income structure, the outpatient service business income typically account for about 30% ~ 30%. In xiamen, a 3 armour hospital, for example, in 2014, the hospital medical income 2.1 billion yuan, the outpatient service income of more than 700 million yuan, accounting for about 37% than that. In addition, the drug income of outpatient department generally accounted for about 50% of the drug income to the hospital, outpatient amount of inspection and test cost is high. More importantly, enough outpatient visits is at the core of maintaining a hospital.
 
    A health expert said that in the current hospital compensation mechanism, the outpatient service is still a big hospital important and stable source of income. In the case of interests mechanism adjustment is not clearly, no dare to give up the clinic hospital. "According to rough statistics, 50% of the large hospital outpatients in fact can be solved at the grassroots level, but the big hospital operation support to rely on outpatient service revenue, if MenZhenLiang compressed 10%, large hospital dean would feel 'flesh aches."
 
    An unnamed tertiary hospital outpatient department director, told reporters that although the big hospital complaining MenZhenLiang is too big, but actually they are not willing to see MenZhenLiang decline. Although some cities have begun pilot hospitals to cancel the drug addition, but premise condition is set up such supporting policies to support outpatient medical service charge income. After the media has a Beijing hospital outpatient visits by decomposition to increase the number of outpatient cases, also from the side proved the outpatient income is an important source of the hospital. In addition, the "hospital registration room does not directly create value, logistics, etc. Service personnel, but also from the current outpatient service income" into ", in the case of "not enough", big hospitals must won't compress MenZhenLiang ".
 
    Practice hard --
 
    "Carrots and sticks" is only a temporary solution
 
    In recent years, many places in the compression on the large general hospital outpatient service activity.
 
    In 2011, shenzhen city is put forward, the medical institutions of the city can be divided into 13 networking groups, each group established a tertiary hospital as a "leader", responsible for the complicated and severe disease in the region of specialized medical services, and gradually cancel the average outpatient service. It's a pity that this goal has not come.
 
    In compression ordinary outpatient service process, measures throughout the intervention by the means of administration is + policy encourages guidance, is the "carrot and stick" policy. But in reality the new problems appear constantly, more have suffered the recessive resistance. A anhui hospital managers admitted that if forced to limit the number of big hospital outpatient service can lead to patients through various channels to find relationship or find scalpers pour, see a doctor difficult problem. "Limit the direction of the large general hospital outpatient service is right, but not radical, administrative intervention is only a temporary solution."
 
    Compression of zhejiang province people's hospital, dong-sheng huang believes that the large hospital implementation of average outpatient service is difficult, the most direct reason is that the hospital gate is wide open, was hospitalized completely according to their own subjective intention, see a doctor to the big hospital has become a habit. "In our hospital opened network, telephone and so on eight kinds of way to make an appointment, and open all the source, the purpose is to let patients can hang up the number as soon as possible. At this point to limit, can convenient measures to counter and make an appointment?"
 
    Dong-sheng huang believes that even slow patients should also be of average outpatient service for structural analysis, not "one size fits all" to sink to the grassroots. Patients with chronic kidney disease, for example, in addition to simply fill it back, over a period of time needs a testing and examination; Mounting bracket of postoperative patients with anticoagulant drugs after a period of time, needs to evaluate condition and the attending doctor for review. These tests need to go back to the big hospital to complete, so the compression big hospital outpatient service, prior to solve these problems.
 
    Health development research center, deputy director of hospital reform and management laboratory er-dan huang pointed out that some of the current policy is "stumble right leg left leg". Health care, for example, different ground convenient reimbursement policy of promoting the flow of the patients, but also give relief "3 big cities such as pressure big hospital to see a doctor difficult problem.
 
    Change is difficult --
 
    It is seems to be the means, the implementation goal
 
    "Big hospital doing big business profit path is definitely right. It should be said that compress large general hospital outpatient service is the development direction of medical service system in our country." School of public health, Peking University health science professor wu Ming told reporters.
 
    How to promote grassroots service capability to ensure large hospital distribution of patients in the community can meet lived, is also a big realize hierarchical diagnostic difficulty. Anhui a, head of the administrative department of health told a reporter, at present, the city he has cancelled the balance at the grass-roots level two lines system, is committed to upgrading by doctors treatment, to mobilize grassroots doctors work enthusiasm. In addition, the city also enforce counterpart support, to put an end to the doctor through the motions, during the period of counterpart support, temporarily to big hospital doctors practicing sites registered in the community. Under the condition of invariable in former unit revenues, the government each month to the doctor again 1000 yuan to 2000 yuan of special subsidies.
 
    Many hospital dean said, because the compression is actually moved hospital cheese of average outpatient service, so as soon as possible, establish a new compensation mechanism is essential, otherwise after compression outpatient big hospital became a madrassa reflected, soon dried up. In this regard, the experience of xiamen city is: on the one hand, improve medical staff labor value, high gold content of the service price, guide the large hospital notice difficult critically ill outpatient service and high level operation, only this year, more than 1000 service charge should be adjusted; On the other hand, adjust the structure of financial investment, cancel the original subsidies for MenZhenLiang and into according to the number, the number of cases in the ICU and emergency rescue patients and hospital quantity indicators such as subsidies.
 
    In fact, for 20% of the city public hospital comprehensive reform in filing the reservation referral targets, health under the state council, an official said, the figure is a guiding principle, it is difficult to by executive order in real operation to reduce MenZhenLiang mandate a big hospital. Therefore, national health commission is on a control unreasonable medical expenses increased public hospital file, aims to control cost measures such as reversed transmission big hospital compression general outpatient service.
 
    Many respondents said, compress large general hospital outpatient service, "seems to be a means, it is ultimately the reform goal of". Because compression outpatient service is the comprehensive reform system, not individual, must be reimbursement ratio and improve the basic medical and health institutions, promoting community first, optimizing the structure of social security and settlement, increase health care spending and raise the level of financing support.
 
 
    link
 
    Hierarchical diagnosis and treatment of international traffic
 
    Compress large general hospital outpatient service, is the objective law of development of medical service system. From the international perspective, this approach is not new. Reporters interviewed the national institutes of health and family planning commission hospital management Dong Siping, new liu jing, vestbo several experts, through carding part of the national health service system and found: although the medical service system in these countries will inevitably have some differences, but with a diagnosis is the common action.
 
    English: take a hierarchical medical service system. When residents health problems, the first will be near and community hospitals (clinic) family doctor appointment. Family doctor is Britain's national health service (NHS) of the main force, accounted for more than 50%. The community hospital is the first level, the NHS costs accounted for about 75% of the NHS budget. When the severity of disease is not the family doctor can control, hospital patients will be referred to the region, namely the secondary medical institutions. Regional hospital is usually the region's medical center, for comprehensive general hospitals, responsible for emergency, serious illness, and the surgical treatment and allocate medical resources as a whole. The third level is a teaching hospital. Teaching hospital for emergency treatment and major treatment of knotty disorder. Patients with emergency personnel will often approached to general hospital or disease related specialized subject hospital.
 
    United States: the function of hospital to undertake other basic diseases treatment and advanced treatment, common outpatient service is not available, only can be directly to the big hospital emergency department patients. The medical service system is mainly composed of family doctors, public hospitals, private non-profit and private for-profit medical institutions into medical institutions. Family doctor is a primary health prevention health care providers, the gatekeeper is medical services. Established by the family doctor's clinic quantity and widely distributed. Private hospital is the main part of the American hospital, the medium income in its service object is the crowd. Private for-profit medical institutions to provide high level and high quality of medical treatment service.
 
    Germany: medical service system is divided into open doctors, hospitals, rehabilitation facility and care level 4. Most practitioners are gp, set up clinics in the community, to provide primary health care services. Patients to the gp first option first commonly, if severe and referral to the higher level hospital. Hospital main disease treatment and hospitalization services, referral to rehabilitation facility, after waiting for patients to improve care institutions or general clinic treatment.
 
    Canada: unless it's injury accident or emergency, the patient must first to see the family doctor, by the family doctor for a simple disposal. If necessary, the family doctor to referral to medical tests to check, or referral to a specialist for treatment. Family doctors are gp, can be in private clinics, community health care center or hospital departments. If the patients without family doctor's referral, hospital or a specialist will not overcharge. The family doctor of the registration fee and the fee paid by the government health insurance plan; Family doctors to prescribe medicine by patients themselves to the pharmacy to buy.
 
    Australia: gp is the gatekeeper of medical service system, set up clinics in the community. Needs to gp first place to accept patients with primary care services, if necessary can be hold by the gp referral to a higher level of hospital treatment, get better before referral to hospital for subsequent treatment at a lower level.
 
    Cuba: a family doctor system, family doctors not only responsible for the patients, but also for each and every one of the district health responsibility, fully grasp each resident's health. Family doctor to cure the patient referral to the provincial hospital and central hospital, but still track and grasp of the patient's illness development.