Recently, Zhang Yu, a doctor from Peking University Third Hospital, exposed the shady treatment of cancer on the Internet, which caused a heated discussion among the public about ineffective medical treatment. According to the investigation of medical institutions in Zhejiang and Hunan, the reporter learned that the current ineffective medical situation is grim due to improper guidance of hospital economic interests, lack of medical literacy of patients, and control of medical risks, and experts suggest that systematic governance is urgently needed.
Nodules are cut or not. Chronic diseases are repeatedly used as "hardest hit areas"
Jiang Zhilei, who works in an Internet company in Hangzhou, was diagnosed with thyroid nodules at the beginning of this year. The medical report suggested that he go to nail surgery for further examination. However, after Jiang Zhilei re-examined in two 3A hospitals in Zhejiang, the doctor gave a completely different treatment. "Two doctors are experts in various hospitals. One asked me to operate and the other asked me not to care about it." Faced with such a result, Jiang Zhilei is very confused.
He consulted some friends around him, and many people said that they had thyroid nodule resection to avoid developing into malignant tumors and threatening their health in the future. During the National Cancer Prevention Publicity Week, Zhejiang Cancer Prevention Office released a set of data showing that the incidence of thyroid cancer in Zhejiang Province is obviously on the rise. The incidence rate was 2.75/100,000 in 2000 and soared to 37.15/100,000 in 2016.
However, the data also showed that the standardized mortality rate of thyroid cancer was 0.23/100,000 in 2000, 0.25/100,000 in 2012 and 0.25/100,000 in 2016. "Although the incidence rate has risen rapidly, the mortality rate of thyroid cancer has remained basically stable for more than ten years. With the continuous improvement of the resolution of ultrasound technology, more and more concealed papillary thyroid microcarcinoma can be found, even including patients who have not yet developed clinical symptoms, so there is no need to panic about the high incidence of thyroid cancer. " The relevant person in charge of the Zhejiang Cancer Prevention Office said that many of the thyroid nodules were "everything" and were ineffective medical treatment.
In addition to thyroid nodules, breast nodules, lung nodules, etc. all have the problem of "everything". Repeated medication for chronic diseases is another "hardest hit" for ineffective medical care. A staff member of the medical insurance department in Hunan said that during the audit of the medical insurance department, it was found that ineffective medical care was common, and some patients with chronic diseases with respiratory diseases were overtreated and repeatedly used drugs by the hospital during hospitalization.
"We once found that a patient with emphysema incurred a total of 220,000 yuan in medical expenses (including medical expenses) during his three-month hospitalization, of which 160,000 yuan was reimbursed for medical insurance. We found that more than 60,000 yuan of his expenses were wasted on excessive medical care and ineffective medical care. The hospital repeatedly used drugs and gave drugs to patients in violation of limited indications." The staff member said.
The book "Ineffective Medical Care" written by German writer Yuge Blake shocked the European medical community, which also listed cases of gallbladder stones, heart stents, intervertebral discs and other operations, and bluntly said that a considerable number of diseases have better results than treatment, and sometimes treatment will cause more harm.
Ma Jin, a professor at School of Public Health, Shanghai Jiaotong University, investigated the gynecology department of a third-class hospital in Shanghai, and estimated the waste of resources caused by invalid hospitalization from two aspects: direct economic burden and bed use efficiency. It is found that the hospital’s gynecological admission inefficiency rate is 12.40%, and the hospitalization inefficiency rate is 22.93%. Excluding invalid hospitalization and invalid hospitalization days can save nearly 18% of the direct economic burden. "We followed up with the international scale to do over-medical research in some areas and found that over-medical care accounts for about 20%-30% in medical institutions." Ma Jin said.
The biggest pressure of the dean is that the three major factors of income generation make it difficult to contain ineffective medical care.
At present, the medical and health needs of the people in China are entering an expansion period. The emergence and growth of ineffective medical care have brought great pressure on medical insurance funds. Serious waste and a large number of patients can’t get effective treatment exist at the same time. It is difficult to contain ineffective medical care mainly due to the following three factors:
Improper guidance of hospital’s economic interests. Although public hospitals should adhere to public welfare, they are not completely supported by finance, and almost all public hospitals have to support themselves. During the period of tight epidemic prevention and control in COVID-19, many domestic public hospitals were in debt and even defaulted on doctors’ salaries, so hospitals had the internal driving force to make money.
A person in charge of a 3A hospital said that the biggest pressure of the dean now is to generate income, otherwise the normal operation of the hospital can’t be maintained. In addition, the evaluation of the hospital’s strength is mainly based on the overall medical income, the number of beds and the utilization rate. These indicators will be passed to the department director and then to every doctor, which will have a negative impact on the diagnosis and treatment behavior to a greater or lesser extent.
The patient lacks medical literacy. The person in charge of a 3A hospital in Hunan mentioned that for many critically ill patients, the possibility of survival after a series of routine rescues is extremely small, but family members still strongly urge emergency department medical staff to continue to rescue. Many times, medical staff only "perform rescue" at the end, which is equivalent to ineffective medical treatment and a waste of medical resources.
It’s not entirely the doctor’s judgment that the nodule is "all over", and a clinician of nail and breast surgery is blunt. "We will analyze several development trends from a medical point of view after discovering that the patient has thyroid nodules, but many patients will strongly demand ‘ Doctor, please cut it off for me to avoid future troubles ’ Although I suggested that I can closely observe the follow-up, the patient will say that there is psychological pressure like carrying a time bomb. "
Control of medical risks. The person in charge of the medical department of a 3A hospital said that science and technology have their limitations, diagnostic technology is sometimes difficult to assess the risk of a disease, and there are also vague areas in the guidelines and norms of diseases, and individual situations vary from person to person, so overtreatment or ineffective medical care is actually a vague definition.
For example, when a breast nodule is found, the patient does not make any treatment according to the doctor’s advice. If the nodule has bad changes when it is checked again at intervals, the patient may in turn question the doctor’s original judgment. "Why didn’t you do puncture at that time?" Why was it not surgically removed at that time? " Causing contradictions and disputes between doctors and patients.
Radical ineffective medical treatment is a system engineering, government hospitals, doctors and patients need to work together.
In recent years, China has successively launched a series of medical reform measures, such as DRG medical insurance payment reform, centralized drug procurement, medical insurance fund supervision, medical insurance drug list adjustment, etc., to reduce the proportion of ineffective medical care and promote the return to reasonable medical care. Experts said that radical treatment of ineffective medical care is a systematic project, and systematic governance needs to be further strengthened.
Improve the feasibility of diagnosis and treatment norms, formulate corresponding laws and regulations to clarify the definition of invalid medical care and protect the rights and interests of doctors. Experts interviewed said that at present, the guidelines for diagnosis and treatment of many diseases need to be updated and improved, and some vague content definitions need to be improved to avoid large deviations from different doctors in the implementation process. At the same time, he said that the definition of ineffective medical care is not clear at present, and relevant medical regulations should be formulated to clarify its boundaries. On the one hand, doctors’ behavior should be standardized, on the other hand, doctors’ rights and interests should be protected, so that doctors can give advice to patients according to scientific basis in the process of diagnosis and treatment.
Improve the incentive mechanism, pay attention to cost control, and improve the "income under the sun" of medical staff. Experts suggest that the salary of medical staff should be improved scientifically, so that the "income under the sun" of medical staff is in line with the labor they have paid, so as to avoid their "sword going sideways" to seek drug kickbacks, medical device kickbacks, testing kickbacks, etc., and also to reduce the problems of ineffective medical care and excessive medical care under the interest-oriented mechanism.
In addition, the assessment indicators of hospitals should also be adjusted accordingly. For example, hospitals with better cost control can be appropriately rewarded when paying medical insurance funds. "A reasonable incentive mechanism and the reform of medical insurance payment methods are key factors. Management means should not only strengthen supervision, but also make correct guidance." Ma Jin said.
Establish a health-centered concept and improve the health literacy of the masses. Zeng Saizhen, director of pediatric emergency department of Hunan Provincial People’s Hospital, pointed out that during the epidemic period, the number of patients admitted to infectious diseases, pediatrics and respiratory medicine in many hospitals was greatly reduced, because many people developed the good habit of wearing masks and washing their hands frequently during the epidemic period, and the habit of preventing diseases was developed, and the number of sick people naturally declined.
Experts believe that the new medical reform is from disease-centered to health-centered, which requires public hospitals to undertake not only medical security tasks, but also health communication tasks. Health departments, medical institutions and media should strengthen health communication, improve people’s health literacy, let people develop good health habits, and cultivate people’s scientific medical habits, which can alleviate the ineffective medical problems of some patients and their families who run to the hospital because of excessive anxiety and minor pains.