Operating costs face numerous challenges: how public hospitals can "calculate this account" and cover nearly 80% of medical services | public hospitals | costs

Since the outbreak of the epidemic, the economic operation of public hospitals has faced unprecedented challenges and pressures. How to strengthen refined management internally, improve the level of medical services, ensure financial and medical insurance support externally, and provide high-quality services to citizens in the context of high-quality development is an urgent pain point that needs to be solved. At the Shanghai Health Economy Youth Forum and the 74th bimonthly lecture of the Shanghai Health and Health Development Research Center, how to strengthen cost control and quality management has become a topic of deep thinking and hot discussion among everyone.

Under the impact of the epidemic, public hospitals have experienced several "declines"

For a long time, public hospitals have played a leading role in providing medical and health services nationwide, covering nearly 80% of outpatient and inpatient services. At the same time, after the cancellation of the markup on drugs and consumables, the price adjustment of medical services has not yet been in place, especially after the COVID-19, the establishment of shelter hospitals, designated hospitals, special beds, fever clinics, and the dispatch of aid medical teams have greatly affected the normal diagnosis and treatment activities.

Zhai Tiemin, a researcher at the Health Development Research Center of the National Health Commission, brought a set of data: in recent years, the surplus rate of public hospital business has decreased, and the scale of negative surplus has expanded; In 2020, the salary level of medical personnel also decreased, and the per capita wage income of in-service employees in public hospitals nationwide decreased compared to 2019; The proportion of drugs in public hospitals is gradually decreasing, reaching a historical low of 29.2% in 2021; The proportion of medical revenue from medical insurance settlement funds is gradually decreasing, with the largest decline occurring in the central region, dropping to 45.5%.

Several "declines" reflect the challenges faced by public hospitals from different perspectives. Zhai Tiemin believes that in addition to the impact of epidemic prevention and control, there are also various factors such as incomplete compensation mechanisms, lack of sufficient and stable investment guarantees for public health funds, and pressure from medical insurance payment and settlement policies. He mentioned that the financing channels for public hospitals can be further expanded, and special medical services can be carried out in a reasonable and orderly manner while ensuring the supply of basic medical services; We can improve the current management methods for public hospitals to accept social donations, encourage the application of third distribution such as charitable donations in the medical and health field, and enhance the enthusiasm of private public welfare donations; Referring to the support policies of elderly care and childcare institutions, water, electricity, gas, heating and other expenses can be implemented according to the prices of residents' living expenses to reduce the operating costs of public hospitals; Internally, it is necessary to further enhance the operational and management capabilities and level of public hospitals, strengthen the construction of an economic management talent team, and promote the efficient provision of medical services and other business work.

Grasping More Service Space, How Second level Hospitals Really "Strengthen Waist"

In recent years, third level public hospitals across the country have frequently conducted learning and training on health economic cost-effectiveness management, but there is still a significant gap between some second level hospitals and county-level hospitals. How is the situation in Shanghai? Li Chen, from the Medical Administration and Management Department of the Municipal Health Commission, admitted, "Whether it is improving business capabilities or building medical institutions, the ultimate goal is to make the people optimistic and affordable about the disease, to make medical institutions spend the least cost, and to make the people pay the least cost to keep the disease safe."

As a core link in the construction of regional medical centers, the management and operation of secondary hospitals not only require investment at the district level, but also cannot do without the planning and layout at the city level. At present, Shanghai has established a medical service system with city level hospitals as the leaders, regional medical center second level hospitals as the backbone, and community health service centers as the network bottom, with a layout of "top-notch, upright, and strong waist". "The large hospitals in the central urban area are overcrowded, and the emergency department is packed with people. This scene is believed to be familiar to many people. However, in the current Shanghai, municipal hospitals should focus on clinical research and innovative development, and give more medical service space to secondary hospitals."

Li Chen said that secondary hospitals, community health service centers, and other medical institutions within the jurisdiction should be coordinated to build a close medical consortium, radiating downwards to solve the vast majority of common and frequently occurring diseases, especially the need to strengthen the five major centers of chest pain, stroke, trauma, pediatrics, and pregnant and postpartum women. "We often say that the level of medical care in a hospital does not depend on the number of experts and academicians, but on whether the emergency department can solve problems. If it can save lives in the emergency department, the public's trust and satisfaction with this hospital will definitely greatly increase in the future."

It is reported that Shanghai currently allocates a district comprehensive hospital based on a population of 300000 to 500000 and an average visit time of 30 to 40 minutes. "For example, Pudong New Area has divided medical institutions into more than ten areas, with every two to three streets and towns as one area. Huangpu District is relatively small, so it is divided into two areas. Although Chongming District has a wide area, its population density is small, and there are islands, so it is divided into three areas." Li Chen introduced that in the future, in addition to coordinating resources with municipal medical institutions and promoting two-way referral services, it is also recommended that district medical institutions set up unified disinfection, logistics, inspection and other management centers to reduce cost savings. "I hope to build a group of regional medical centers with reasonable layout, unified standards, and clear positioning within 3 years, so as to solve the problem of overcrowding in large hospitals and provide good medical services for the people at their doorstep."

Crack the problem of data information and strengthen the management of primary and secondary hospitals

Xu Mingfei, Deputy Director of the Shanghai Health and Development Research Center, mentioned that in the planning and development of public hospitals, perhaps cost saving is more important than open source. Lu Shasha, the head of the Cost Accounting Department of the Finance Department of Fudan University Affiliated East China Hospital, shared her experience. "In terms of cost accounting accuracy, the first layer is two-level cost accounting at the hospital and department level, the second layer is project cost accounting, such as optimizing business processes and improving resource utilization efficiency, and the third layer is disease cost accounting." She admitted that outdated systems, insufficient manpower, lack of complete accounting systems and systems, as well as low accuracy, inconsistent caliber, and information silos in basic data, are the core limitations that plague many public hospitals in doing cost accounting well. To this end, East China Hospital has established a closed-loop management model of "fine accounting, calculation for management and use, and combination of management and calculation". At present, the cost of over 1900 medical projects and over 4800 disease types in the entire hospital has been accounted for, forming a backbone disease accounting framework.

Ye Zheng, the director of the Changfeng Community Health Service Center in Putuo District, mentioned the challenges faced at the grassroots level. "The financial management system of the community health service center is mainly based on accounting and finance, with a relatively weak foundation and extensive asset management. Cost accounting has not penetrated into every department. In response to these shortcomings, we have constructed a new system and refined accounting units using information technology." However, unlike the basic independent setting of clinical departments in second and third level hospitals, the community mainly focuses on general practice and traditional Chinese medicine, with the basic unit being the family doctor team. To this end, Changfeng Community Health has set a relatively fixed "three fixed" system for home medical staff, outpatient positions, and outpatient days, while also considering public health services, which are mainly expenditure oriented and have almost no income, and continuously adjusting indicator templates. "Exploring the balance between public welfare and operational needs is a simple statement, but it is actually difficult." As Ye Zheng said, the ultimate goal of achieving refined management in public hospitals is to promote high-quality development.