High-value consumables are restricted. Is there a hospital that stops some operations?

20 17 12 17, surgical ward of bone and joint tumor in a public hospital in Shandong province. The nurse said 12 months later, how many patients were confiscated in the ward.

The use of high-value consumables is limited to some hospitals. Surgeon: Don't do it unless you can. 20 17 12 16, in the corridor of the inpatient department of a public hospital in Shandong, more than half of the beds are still empty.

Some hospitals restrict the use of high-value consumables. Surgeon: Don't do it unless you can. 20 17 12 2 1, the staff of a public hospital are unpacking disposable medical consumables. A 12-A 13 version

By the end of 20 17, the consumption of sanitary materials in the medical income of 100 yuan (excluding drug income) of public hospitals in the first four batches of pilot cities has dropped below that of 20 yuan. In other words, in 20 17 years, the consumption of public hospitals should be below 20%.

Liu Yun (pseudonym), a 63-year-old Shandong native, has just undergone tumor resection because of advanced colon cancer. In a provincial public hospital in Shandong, she is recovering. When she was uncomfortable, she got up and took a short walk, sitting on a small stool beside the hospital bed, squatting and covering her stomach. "It will be more comfortable."

This is a public action. The operation removed a tumor the size of a goose egg for her, but left a suture wound about 20 cm long on her stomach. Medical papers generally believe that compared with laparoscopic surgery, which has less interference to abdominal cavity and less bleeding during operation, open surgery has slower recovery, easy to lead to wound infection or abdominal infection, and more complications.

She doesn't have to bear such pain and more postoperative risks. The doctor told her that until 2065438+June 2007, 1 1, the hospital was still doing laparoscopic surgery for patients with good cardiopulmonary function and no other inflammation. In that case, only a small incision will be left on the stomach, and the postoperative recovery will be quick.

From 1993 Peking University Third Hospital successfully implemented the first laparoscopic radical resection of rectal cancer in China. Since 15, laparoscopic surgery has long been the first choice for the treatment of gastrointestinal cancer in most large hospitals.

"I first came to this hospital because of the high technology of laparoscopic surgery," Zhang Qing, Li Yun's son, told the Beijing News reporter. Before he was admitted to the hospital on February 5, 65438, the doctor suddenly called him and told him that laparoscopic surgery could not be performed at present, but laparotomy could be performed.

The reporter's investigation found that in this hospital, similar changes include: ordinary hemostatic gauze replaced anti-adhesion hemostatic gauze; The absorption line is limited; The imported stapler disappears, either using domestic stapler or sewing by hand; Suspension of artificial hip replacement; Ultrasonic scalpel is limited; The use of indwelling needles is gradually decreasing.

In addition to Shandong, in Sichuan, Guizhou and other places, there are similar news that medical surgical consumables are limited. A nationwide storm restricting the use of medical surgical consumables swept through at the end of 20 17, which became the "first consumables storm" in the mouth of most doctors.

Public opinion once pointed the finger at medical insurance control fees, which originated from the deficit of medical insurance fund; This speculation has been officially denied. The relevant person in charge of the Guizhou Provincial Health Planning Commission said in an interview with the Beijing News reporter that at present, the medical insurance fund in Guizhou Province is running smoothly, and there is no such thing as "income is not enough".

In June, 20 16, the National Health and Family Planning Commission issued "Several Opinions on Controlling the Unreasonable Growth of Medical Expenses in Public Hospitals" (hereinafter referred to as "Several Opinions"), saying, "Strive to control the growth rate of national medical expenses below 10% by the end of 20 17."

In addition, the Health Planning Commission of Sichuan and Guizhou provinces issued documents on 20 17, 10 and10 respectively to strictly control the unreasonable increase of medical expenses, all of which mentioned "high-value medical consumables".

"When to resume surgery, wait until after New Year's Day."

The challenges facing Liu Yun are not limited to these. The central venous catheter widely used in gastrointestinal surgery was told that it could not be used and was replaced by peripheral venous catheter.

The central venous catheter is inserted from the clavicle, and the peripheral venous catheter is inserted into the arm. Due to the large lumen of subclavian vein, it is quick and convenient to put a central vein catheter to input macromolecular nutrient solution, and there is no need to repeatedly inject needles before leaving the hospital. However, when the peripheral vein catheter is used to input macromolecular nutrient solution, the blood flow velocity is slow and the blood vessels are damaged greatly.

"Too busy", the nurse in Li Yun ward complained that because the blood vessels in the arm are thin, the blood vessels are more likely to contract after long-term infusion of nutrient solution. The nurse has to change the needle to re-needle the patient every 3-4 days, and the patient is alternately bound with both hands.

Central venous catheterization was originally a surgical consumable that anesthesiologists in operating rooms could receive. The nurse in the inpatient department of gastrointestinal surgery of this hospital branch told the reporter around 65438+February 20: "At present, the operating room is not allowed to accept it. If the patient's blood vessels are not good after evaluation, the doctor who performs surgery in the department will take the puncture bag (which contains the central venous catheter) to the operating room. "

65438+In mid-February, the reporter visited several provincial public hospitals in Shandong Province and found that the number of patients in obstetrics, endocrinology and other internal medicine wards who used less surgical consumables did not change much. In the hand-foot surgery and orthopedic wards where surgical consumables are used more, some doctors were asked if they would still wave their hands when performing surgery. "Don't do it without surgery."

At present, the cardiologist in Li Yun's hospital can only put one stent during interventional surgery. The person in charge of the medical department of the hospital told the reporter that if the blockage is serious and he wants to put two stents, the doctor's usual answer is, I'm sorry, transfer to another hospital. If you want to put an imported stent, "Sorry, you go to a foreign hospital."

The joint clinic of this hospital is surrounded by many people who come to see the "old problems" during the Spring Festival. Liu De (a pseudonym), a 54-year-old welder, bends over and squats all the year round. His right hip hurts badly, and he often can't sleep in the middle of the night and can only sit for one night. In February 65438, he was diagnosed as "avascular necrosis of the femoral head", and the doctor told him that he needed to replace the artificial hip joint, but only after New Year's Day.

In the joint department, artificial joints (artificial knee joint, artificial hip joint, etc. ) is almost the only necessary surgical consumables. But in some cases, immediate surgery is not needed. As of mid-February, 65,438+has registered nearly 30 patients on the patient register shown to reporters by the joint nurses in this hospital. These patients can't be operated at present, and there are only less than 10 patients in dozens of beds in the ward. "When to resume the operation, wait until after New Year's Day," the joint nurse replied.

The reasons for the restrictions are confusing. For patients interviewed in the joint department, doctors gave different explanations, such as "insufficient beds", "negotiating with pharmaceutical companies for the second time to reduce the cost of orthopedic consumables, but no agreement has been reached", "medicine can be taken first" and "pharmaceutical companies do not supply".

"Now the hospital has been in a meeting all day to discuss this matter, and we are all devastated," a joint doctor of the hospital revealed in the middle of June 5438+February, and the operation stopped for nearly half a month from June 65438+February 1. "The superior has restrictions on the hospital. The hospital has indicators for each department, and each department can only reduce the number of patients. "

The use of surgical consumables was stopped on a large scale. The relevant person in charge of the hospital said, "Not before, it started on 20 17." This statement has been confirmed by the relevant person in charge of many public hospitals in Shandong Province.

High-value consumables are limited to "hardest hit areas"

In fact, before Shandong, Guizhou and Sichuan provinces were pushed to the forefront of public opinion as early as 1 1.

1 1 In June, an internal notice signed by the Affiliated Hospital of Guizhou Medical University was circulated on the Internet. The notice requires that "some medical consumables in orthopedics, intervention, neurosurgery, operating room, ophthalmology, cardiology and other departments should be stopped; Stop using all hemostatic and anti-adhesion materials, staplers, cutters, patches and biological patches, medical glue, punctures, disposable negative pressure drainage devices, etc. Except for some special departments, the use of all sutures except silk thread is restricted; Suspend the warehousing procedures for high-value consumables. "

A number of WeChat official accounts published related articles in the circle of friends, mentioning "stopping some medical consumables" such as a 3A hospital in Guizhou and Sichuan Cancer Hospital, "increasing the number of patients who use low-value consumables and strictly controlling the admission of patients who need high-value consumables".

Some limited consumables in the whirlpool are mostly high-value medical consumables. There is no special classification standard for them, and they are usually consumable medical devices that are vital to safety. Their production and use must be strictly controlled and limited to certain specialties. The price is generally above 1000 yuan. For example, the ultrasonic scalpel needed in laparoscopic surgery, some steel plates in orthopedics, guide wires, dressings and cardiac interventional stents used in other departments all belong to high-value medical consumables.

The person in charge of the medical department of the above-mentioned hospital takes gastrointestinal surgery as an example. All expenses (including nursing expenses and hospitalization expenses) are less than 1000 yuan, of which the labor cost for surgery is usually around 1000 yuan, but the price of an ultrasonic scalpel for laparoscopic surgery (not needed for open surgery) is around 6000 yuan.

The price of high-value medical consumables has been "falsely high". In addition to the high cost, there are also reasons such as price increase, abuse and waste in the sales process. In order to avoid nosocomial infection, the blades of ultrasonic scalpel used in domestic hospitals are generally disposable, but they can be used after disinfection in Europe and America.

High-value medical consumables belong to sanitary materials. 201May 17, "Guiding Opinions on Comprehensive Reform of Urban Public Hospitals" issued by the General Office of the State Council began to take the proportion of 100-yuan medical expenses and medical materials income as the macro-assessment indicators of hospitals. It is mentioned that by the end of 20 17, the consumption of sanitary materials in the 100-yuan medical income (excluding drug income) of public hospitals in the first four batches of pilot cities will fall below that of 20 yuan. In other words, in 20 17 years, the consumption of public hospitals should be below 20%.

Jinan, where several provincial public hospitals in Shandong are located, belongs to the first four pilot cities mentioned above.

The consumption ratio of 20% is called "one size fits all" policy by most doctors interviewed.

According to the person in charge of the medical department of Liu Yun's hospital, the average consumption in Shandong Province accounted for about 40% in 20 17, and his hospital has exceeded 40%. Due to the different characteristics of surgery, the consumption ratio of each department varies greatly. For example, in the joint department, one operation exceeds 60%, so the hospital will control the number of relatively high-consumption operations and simply stop related operations in June 5438+early February.

Pressure index of medical expenses growth

Some medical surgical consumables are restricted for different reasons, and the reporter has not yet received a reply from the Shandong Provincial Health Planning Commission. Zhu Hengpeng, deputy director of the Institute of Economics, China Academy of Social Sciences, who has been studying medical insurance for many years, analyzed that the growth rate of medical expenses in public hospitals in 2065,438+07 10% may bring great pressure to major public hospitals, especially at the end of the year.

In June of 20 16, the National Health and Family Planning Commission issued "Several Opinions on Controlling the Unreasonable Growth of Medical Expenses in Public Hospitals" (hereinafter referred to as "Several Opinions"), demanding that the average growth rate of medical expenses in 20 17 years be controlled below 10%. According to the statistical bulletin on the development of health and family planning in China in 20 16, the reporter calculated that the growth rate of medical expenses in 20 16 was about 13%.

At the same time, the "Several Opinions" mentioned that the state will rank and report the growth of medical expenses in public hospitals in various provinces (autonomous regions and municipalities) and the Corps.

According to the internal document of Emergency Notice of Sichuan Provincial Health and Family Planning Commission Office on Strengthening Responsibility Investigation and Strictly Controlling Unreasonable Increase of Medical Expenses (hereinafter referred to as Emergency Notice), the average growth rate of total medical expenses in public hospitals in Sichuan Province is 13. 15%.

The Beijing News reporter called the Sichuan Provincial Health Planning Commission Office and confirmed that this document did exist and was issued by the Sichuan Provincial Health Department. 20 17 120.

The emergency notice dated 2017110/010 pointed out that the purchase and use of expensive and self-funded medical devices must be strictly controlled for medical institutions whose medical expenses have increased by more than the prescribed proportion. "Among them, if the total medical expenses increase by more than 10%, from now on, the proportion of expensive and self-funded drugs purchased by tertiary hospitals must be less than 3%, and that of secondary hospitals must be less than 2%. The bid-winning drugs that exceed the planned purchase limit must not be purchased, and the use of imported high-value medical consumables must be strictly controlled."

On 20 1 10, official website, the Health and Family Planning Commission of Guizhou Province, issued the Policy Interpretation on Controlling Unreasonable Growth of Medical Expenses in Public Hospitals, which mentioned that the Health and Family Planning Commission of Guizhou Province issued the Policy Interpretation on Controlling Medical Expenses on 201710/9.

According to the interpretation of this policy, there are eight main measures to control the unreasonable increase of medical expenses, the third of which is "reducing the inflated price of medical consumables" and "implementing online sunshine procurement of high-value medical and health materials". Encourage the use of domestic high-value medical consumables with high quality, low price and high cost performance under the premise of ensuring quality. "

According to the person in charge of the medical department of Shandong Li Yun's hospital, the National Health and Family Planning Commission first interviewed the relevant person in charge of Guizhou Province and Sichuan Province, which ranked first and second from the bottom. "We are the third in Shandong."

In fact, the problem of unreasonable increase in medical expenses has always existed. Before the cancellation of drug addition, medical expenses accounted for a large proportion of medical expenses. After the cancellation of drug addition, the cost of health materials accounts for a higher proportion of medical expenses in public hospitals.

The above-mentioned emergency notice of Sichuan Province also made it clear that the drug control fee will be linked to the annual assessment target, hospital grade assessment, employee performance assessment, and key drug use procurement. Among them, public hospitals that fail to meet the standards will be deducted 20% from the total annual employee performance and 40% from the dean's performance.

Regarding the hospital's behavior of stopping using some medical consumables, the Sichuan Provincial Health Planning Commission replied to the reporter that there has never been a policy or document to stop using some medical consumables, and stopping using some medical consumables is purely an individual behavior of some hospitals. The head of the medical department of a provincial public hospital in Shandong visited by the reporter also made it clear that "the government did not say that it would stop using consumables".

At the same time, the Sichuan Provincial Health Planning Commission said that once it was found that the hospital refused to consult and treat patients on the grounds of controlling medical expenses and rectifying medical consumables, the Provincial Health Planning Commission would seriously deal with it.

The reporter noted that there is no statement in the above-mentioned documents that "the use of consumables should be stopped".

It is understood that many public hospitals in Shandong Province are negotiating with many pharmaceutical companies to reduce the profit margin of consumables. The result is uncertain. Some domestic medical device companies agreed to reduce prices, and the imported medical device giants and hospitals were "deadlocked". The reporter learned through various channels that the staplers used in gastrointestinal surgery in one of the public hospitals in Shandong Province are all made in China at present, and the artificial joints made in the joint department are expected to decrease by about 15% on the basis of the price reduction in September 2065438+2007.

"There is no such thing as having no money."

In the Zhihu, an answer pointed out that medical insurance fee control was the main reason to limit the use of consumables, which once pointed to the deficit of medical insurance fund. It is reported that a third-class first-class hospital in Guizhou Province is facing the pressure of medical insurance fund.

Local officials immediately rumored that there was no deficit in the medical insurance fund. Guizhou's statement is that the online news is untrue, and the medical insurance fund in Guizhou Province is running smoothly, and there is no such thing as "income is not enough to cover expenditure".

According to the Statistical Communiqué on the Development of Human Resources and Social Security over the Years issued by Ministry of Human Resources and Social Security (hereinafter referred to as the Statistical Communiqué), the national medical insurance has a balance every year, and the accumulated balance in 20 15 years reaches 976.5 billion yuan. According to the latest data in the annual report of China Social Insurance Development 20 16, in 20 16, the accumulated balance of employees' basic medical insurance fund reached 777.2 billion yuan, and the balance of urban residents' basic medical insurance reached 33/kloc-0.0 billion yuan.

"Every year, the income of the fund grows faster than the expenditure of the fund, and it continues to be in a state of income exceeding expenditure, indicating that the accumulation of the fund is increasing year by year. The ability of employees' medical insurance fund to pay has been significantly enhanced, and the situation of residents' medical insurance fund has been generally stable, and there has been no so-called lack of money. "Dr. Guan Bo from the Institute of Social Development of China Macroeconomic Research Institute analyzed.

The relevant person in charge of the above-mentioned hospital where Li Yun is located revealed that the hospital's medical insurance fund spent almost the first 10 month, "it is impossible to have a balance".

At present, the medical insurance departments in Shandong, Beijing, Shanghai, Guangzhou and other regions have adopted the method of total prepayment. This is to curb the excessive growth of medical insurance fund expenditure and stabilize the level of medical insurance.

The total advance payment is simply to give the hospital a quota at the beginning of the year. According to the analysis of some articles, due to the lack of the ability and enthusiasm of meticulous management, managers of public hospitals all over the country generally adopt the practice of decomposing the total indicators into departments and even doctors.

Zhu Hengpeng, deputy director of the Institute of Economics of China Academy of Social Sciences, once analyzed in 20 12 that the total prepayment method, which determines the total prepayment at the beginning of the year and actually pays the settlement at the end of the year, gives the medical insurance agency greater autonomy, and at the same time, to a great extent, transfers the risk of medical expense fluctuation to the hospital.

For example, the person in charge of the medical department of a public hospital in Shandong Province, the provincial hospital receives patients from the whole province every year, and patients from other cities are reimbursed after seeing the disease. The hospital has to pay in advance, and the medical insurance in other cities will make up this part of the money next year, dragging on. "If medical insurance doesn't give us money, we can't give money to medical device companies. If you can't give money to pharmaceutical companies, you have to drag it. Now even the patients can't get it. We have to pay for it ourselves. The more we collect, the more we lose. "

The head of the legal department of another provincial public hospital visited by the reporter denied that medical insurance was directly related to the limited use of consumables. He explained to reporters that these two things were not related, but just coincidences. "Now is the end of the year, and the money given by medical insurance is flawed. The National Health and Family Planning Commission also said that high-value consumables are not allowed. "

The above-mentioned statistical bulletin also mentioned that although the overall balance of the medical insurance fund is seen from the national data, deficits have already appeared in some areas, such as Tianjin, Qinghai and Fujian. The person in charge of the medical department of the above-mentioned hospital confirmed the above statement, "It is losing money every year, and the whole of Shandong is losing money."

Must I use it or choose it?

"Technology once returned to 20 years ago", doctors in different fields in Zhihu expressed their dissatisfaction with the limited use of consumables. Over the years, due to the characteristics of "saving time", "accuracy" and "convenience", many consumables have become surgeons' assistants.

Take the stopped stapler as an example, it takes less than 5 minutes to sew a gastric cancer incision, while manual sewing takes half an hour or more. Tension-free hernioplasty, the hernia patch used is softer and more resistant to bending and folding than ordinary patches, which can reduce the recurrence rate of hernia and relieve postoperative pain. The use of consumables such as laparoscopy can greatly reduce the amount of bleeding of patients and reduce the risk of surgery. Coronary artery bypass grafting (CABG) and heart valve replacement make it possible to perform major operations that used to require a small incision to open the chest. Absorbable suture can be degraded and absorbed by human body after being implanted into human tissue, which is seamless and painless.

Doctors who have worked 10 years or more think that "there is nothing necessary and unnecessary in clinic, and most of them pay attention to evidence." If large-scale research shows that the use of instruments can make the prognosis good and the success rate high, it is necessary to use them. "

Gong Xiaoming, who used to be an obstetrician and gynecologist at Peking Union Medical College Hospital, gave an example. For example, after the wound is coated with glue, you can take a bath directly. It takes a week to take a bath for a wound that has not been stitched with glue. "But can't the patient recover without the wound adhesive?" No, consumables sometimes just make medical quality better. "

He further explained that for some consumables to improve the quality of surgery, doctors need to find a balance between quality, satisfaction and cost. At present, his operations in private hospitals are generally charged according to the package. The more fixed-price consumables are used, the greater the loss of the hospital, so doctors will naturally find a balance between various factors.

Some interviewed doctors also expressed "doubt" about the help brought by some of the above medical devices. A doctor said, "there is no conclusion that stapler is necessary, but it is the general trend." Some hospitals use it, and some manufacturers are selling it, so it is gradually popular, and there are vested interests in it. " The doctor said that experienced surgeons, hand stitching "is still beautiful."