Summary of Key Points
The current specialized department setup in hospitals is not convenient for patients. The root cause lies in the legal division system established in 1994 (the "List of Medical Institution Diagnosis and Treatment Subjects"), which was intended for management purposes rather than to enhance patient experience. Today, the spectrum of diseases (with multiple conditions coexisting and a focus on quality of life) has changed, as have patients' needs, yet the payment mechanisms (such as DRG/DIP) still adhere to the outdated practice of calculating costs by department, making collaboration difficult. The solution lies not in dismantling existing departments or review systems but in creating new pathways—using digital guidance, multidisciplinary team (MDT) performance incentives, and virtual accounting pools within hospitals—to improve patient experience and efficiency within the existing framework.
Why Are Hospital Departments Inherentally Not Patient-Focused?
The "List of Diagnosis and Treatment Subjects" issued by the Ministry of Health in 1994 served as the legal basis for hospital departmental organization. Its primary goal was to regulate what hospitals could provide, what certifications they could issue, and how penalties would be imposed for exceeding these limits. For example, there were 34 primary categories (such as internal medicine and surgery) and hundreds of secondary categories, all based on clinical medical disciplines, with no consideration for whether patients would make mistakes in choosing departments or have to travel excessively.
For instance, if you have a headache, you might need to see a neurologist, neurosurgeon, or even an otolaryngologist (if the headache is caused by sinusitis), but the 1994 list only specified which conditions each department could treat, without providing patients with a way to find the right department based on their symptoms. Therefore, patients' complaints that the departmental structure is not patient-centric stem from the fact that this system was never designed with them in mind.
Current Contradictions: Outdated Structures Meeting New Needs and Payment Systems
Changes in Needs: From Treating Single Diseases to Managing Overall Health
In the 1990s, the average life expectancy was 68 years, and hospitals mainly dealt with single diseases (such as pneumonia and acute appendicitis) and infectious diseases. Today, with an average life expectancy of nearly 80 years, patients often have multiple conditions like hypertension, diabetes, and chronic obstructive pulmonary disease (COPD). Patients not only want to be cured but also to live comfortably (e.g., to be able to walk and eat normally after surgery).
However, the old departmental structure was based on the logic of one disease corresponding to one department—hypertension went to cardiology, diabetes to endocrinology, with each department focusing solely on its own condition, without anyone being responsible for the patient's overall health. This is like building a house where the plumber and electrician only work on their respective tasks, without considering the house's functionality as a whole.
Payment Systems: DRG Leads to More Detailed Departmental Segmentation
Medical insurance payment systems like DRG/DIP group patients based on their primary diagnosis and procedures. For example, coronary artery intervention surgery is categorized under cardiology, which carries higher weight and thus more funding. To earn more money, departments further divide their specialties, with each sub-specialty focusing only on its high-weight disease groups, making collaboration less attractive because it reduces the distribution of funds.
Although medical insurance systems are being improved (e.g., DRG 2.0 supports combined surgeries), the pace is not keeping up with clinical needs. The National Health Commission has called for "1+N discipline groups" (such as lung cancer centers that integrate thoracic surgery, respiratory medicine, and oncology), but evaluations and funding are still based on departments, resulting in many of these groups being mere nominal entities with separate operations.
The Key to Breaking the Cycle: Incentivizing Collaboration
The core issue is that collaboration does not yield significant benefits for doctors. Participating in MDTs is not recognized as part of their workload, and departmental collaborations do not result in clear financial rewards. To solve this, we need to address the compensation aspect:
Improving Access: Reducing Patient Mistakes in Department Selection
Add symptom-specific or disease-specific entry points to the existing registration system, such as "headache clinic," "chest pain clinic," or "obesity clinic." This does not require changing the hospital's departmental structure but adds an additional layer of classification during registration. Combine this with intelligent guidance systems; for example, if you enter "headache + dizziness," the system could recommend a neurologist or otolaryngologist, reducing patients' unnecessary travel.
Making Collaboration Rewarding: Incorporating MDTs into Performance Evaluations
The experience at West China Hospital is practical:
- Initial phase: Doctors form MDTs out of enthusiasm.
- Intermediate phase: Relevant department doctors are brought together in the same space, but performance is still attributed to their original departments.
- Later phase: Disease center directors manage the distribution of performance rewards.
Now, this can be simplified with digital systems that automatically trigger MDTs (e.g., patients with stage III tumors must go through an MDT process). The workload from MDTs can be included in both departmental and individual doctor evaluations (e.g., one MDT session might equal 0.5 times the value of a surgical procedure). Funds come from a hospital-specific pool, without affecting existing department budgets, so department directors are more likely to support this.
In-Hospital Accounting: Compensating for Interdisciplinary Efforts
For example, lung cancer patients may need to visit thoracic surgery, oncology (for chemotherapy), and respiratory medicine (for postoperative care). Although insurance payments are distributed by department, hospitals can create a "lung cancer disease chain" virtual pool and give additional funding to participating departments (e.g., an extra 1.03-1.05 percentage of the total payment). This does not require changes to insurance agreements but is a compliant way to encourage collaboration.
How Different Hospitals Can Implement These Changes
- Provincial-level Class-A tertiary hospitals: Fully implement symptom-specific or disease-specific clinics, use AI for guidance, establish physical disease centers (e.g., lung cancer centers), and integrate MDTs into electronic health records. Use CMI (Case Complexity Index) rewards to support collaboration.
- City-level Class-A tertiary hospitals: Focus on key diseases (e.g., chest pain, sleep disorders) and include MDTs in performance evaluations (calculated based on the number of procedures). Pilot high-weight disease chains (e.g., coronary artery disease) using surplus insurance funds.
- County-level hospitals: Simplify symptom-based clinics and schedule regular MDT sessions with fixed teams (e.g., every Wednesday afternoon). Offer small rewards for participating in MDTs without making significant changes to the overall system.
Conclusion
The 1994 departmental system achieved scalability and standardization, but now needs have changed. Instead of forcibly dismantling existing structures or changing laws, it is more effective to use digital tools to improve access, incentivize collaboration with performance evaluations, and compensate for interdisciplinary efforts. These measures can be implemented without waiting for changes in medical insurance policies. Hospitals can take these steps on their own, reducing patients' inconvenience and encouraging doctors to collaborate. While walls may be difficult to remove, corridors can always be built.