Summary of Key Points
The DRG/DIP 3.0 version is about to introduce a policy for "primary care diseases," which aims to ensure that the same medical conditions are reimbursed equally whether treated at large hospitals or primary care facilities. This is intended to encourage primary care hospitals to treat more common and frequently occurring illnesses, thereby reversing the current situation where large hospitals handle both minor and serious cases. However, large hospitals may continue to attract patients through cost control measures or by forming medical alliances, so balancing their interests is crucial for the success of the policy.
I. The Primary Care Disease Policy: Using Equal Reimbursement to Encourage Large Hospitals to Treat Minor Illnesses
The logic behind the policy is straightforward: In the past, large hospitals received more reimbursement from medical insurance for treating common illnesses like colds and hypertension due to their higher status, which led them to prefer treating these conditions. Now, the reimbursement rates for these same diseases will be standardized, with the same amount paid whether treated at community hospitals or tertiary hospitals.
Large hospitals have higher costs, including salaries for doctors and expensive equipment. If treating minor illnesses does not generate enough profit or even results in losses, they may be less inclined to do so, prompting patients to seek care at primary care facilities. This is just the first step; in the future, prices for outpatient services and examinations are also expected to be standardized to promote more services to be provided at the grassroots level.
The policy also has targeted approaches: for complex surgeries (such as heart bypass), the price difference between large and secondary hospitals will be increased to 30%-40% to encourage large hospitals to focus on treating serious illnesses, while for simpler surgeries and routine examinations, the price difference will be reduced to 10%-15% to make them more accessible at primary care levels.
II. Current Situation: Large Hospitals Still Attracting Patients, While Primary Care Facilities Are Facing a Shortage
Data shows that the number of inpatients at tertiary hospitals is still increasing (8.57%) in 2024, although this is the lowest rate in the past eight years. However, the number of inpatients at secondary and primary care facilities is declining—by 3.07%, 3.85%, and 0.11%, respectively.
Why? Large hospitals have a better reputation and better facilities, so patients are willing to wait in long queues to be treated there. As a result, primary care hospitals have many empty beds, while large hospitals are overcrowded, leading to a waste of resources. The policy aims to direct patients with minor illnesses back to primary care facilities, allowing large hospitals to focus on treating serious cases.
III. How Large Hospitals Will Respond
Large hospitals are not going to give up treating minor illnesses easily. They have several strategies:
1. Cost Reduction: With the implementation of DRG/DIP, hospitals need to reduce the length of hospital stays (e.g., reducing the time from 3 days for a cold to 1 day), which can lower costs and still allow them to make a small profit from treating minor illnesses.
2. Bypassing the Policy through Medical Alliances: Large hospitals can turn primary care facilities into their own branches, ensuring that patients are still counted as their patients and that they can receive the full reimbursement amount from medical insurance. For example, in Taiwan, attempts to limit the number of outpatient visits at large hospitals were circumvented when large hospitals acquired smaller hospitals and moved their outpatient services to the branches, rendering the policy ineffective.
Therefore, even with equal reimbursement, large hospitals may still try to treat minor illnesses, undermining the policy's effectiveness.
IV. Lessons from Abroad
Taiwan’s "reasonable outpatient volume" policy is a case in point: Medical insurance reimburses only half of the costs for outpatient visits exceeding a specified limit. The goal was to reduce the number of outpatient visits at large hospitals, but they managed to increase the number of outpatient services by expanding beds, hiring more doctors, and even acquiring smaller hospitals, effectively bypassing the policy.
This shows that price controls alone are not sufficient; it is necessary to consider the interests of large hospitals. If they have no other sources of profit, they will find ways to continue treating minor illnesses.
V. The Key to the Policy’s Success: Balancing the Interests of Large Hospitals
To encourage large hospitals to abandon treating minor illnesses, incentives are needed. For example, increasing the price difference for complex surgeries to allow them to make more money from treating serious illnesses, or providing other incentives (such as research funding) to focus on treating difficult and complex cases.
If only the reimbursement for minor illnesses is reduced, large hospitals may find ways to circumvent the policy. The key is to ensure that both primary care and large hospitals have viable options and are motivated to perform their respective roles.
In summary, the direction of the primary care disease policy is correct, but its implementation requires addressing the concerns of large hospitals. Otherwise, they will continue to attract patients, and the goal of tiered healthcare will not be achieved. Balancing the interests of all parties is the crucial factor for the policy to be successful.