Addressing Overdiagnosis: How to Treat the Excessive Testing of Hormones in Elderly Patients
Recently, the National Healthcare Security Administration (NHSA) reported typical violations found during inspections of seven hospitals, highlighting issues such as overdiagnosis, excessive charges, and duplicate billing. Alarmingly, some hospitals conducted nearly clinically insignificant hormone tests on over 2,500 patients aged 60 and above. Additionally, there were instances where short-term hospitalized patients underwent multiple “glycated hemoglobin” tests in a single day, akin to measuring height multiple times within the same day. The total amount involved in the reported violations from these seven hospitals reached nearly 90 million yuan.
With the coverage of health insurance extending to over 95% of the population and the continuous expansion of designated medical facilities and pharmacies, there has been an unprecedented rise in the number of patients seeking medical care across regions. This increased demand has heightened the complexity of healthcare cost settlements, posing challenges for medical supervision. Although regulatory measures for healthcare insurance have been continuously upgraded, fraudulent practices such as medical fraud persist. The findings from this report indicate that a significant portion of healthcare funds is being drained through unnecessary tests and treatments, largely driven by the expansion of medical facilities that induce demand for services.
The Context of Overdiagnosis in Hospitals
Despite a gradual decline in the growth rate of hospital beds nationwide, the total number of beds has surged from 3.71 million in 2011 to 8 million in 2023, with an especially pronounced increase in large public hospitals with more than 800 beds. As the number of beds increases, larger hospitals continue to attract more patients to support their expansion. This cycle of meeting service demands, continual expansion, and induced patient demand ensures that large hospitals sustain their growth momentum.
With the implementation of centralized procurement and negotiations for healthcare insurance, hospitals have increasingly relied on medical materials and services to offset the shortfall in pharmaceutical revenue. Consequently, this has led to two troubling trends: first, minor ailments are being treated as major conditions, with outpatient services being converted to inpatient checks and treatments, significantly escalating medical costs; second, hospitals intensify competition to enhance their testing capabilities, resulting in excessive diagnoses and charges, while simultaneously increasing their debt burden.
Strengthening Healthcare Insurance Regulation
In response to these violations, it is inevitable that healthcare insurance regulation will be further strengthened, with a gradual establishment of a reward and punishment system for designated medical facilities and practitioners. According to the Regulations on the Supervision and Management of Healthcare Insurance Funds, the State Council is required to establish a credit management system for designated medical institutions and personnel, supervising and managing them based on their credit ratings. Daily inspection results and administrative penalties will be included in the national credit information sharing platform.
While a credit evaluation system for responsible personnel was established in the Guidance on Establishing Management Systems for Healthcare Insurance Payment Qualifications released in October, a comprehensive credit evaluation for medical institutions is still lacking. Future policies may focus on enhancing this aspect, thereby creating an integrated reward and punishment system for healthcare institutions.
However, healthcare insurance regulation should not merely resemble a “cat-and-mouse” game with external pressure to resolve problems; rather, it requires a transition from regulation to governance. As technical capabilities and healthcare management abilities improve, developing a clinically recognized pathway for both healthcare insurance regulation and medical services will be crucial to solving these issues.
Future Directions: Standardized Clinical Pathways
With the nationwide rollout of Diagnosis-Related Groups (DRG) and Disease-Based Payment (DIP) systems, enhanced scrutiny over medical tests is expected, potentially leading to the establishment of a regulatory framework based on standardized clinical pathways. As clinical pathways are defined, standardizing treatment processes and bundled payments will create pressure to reduce the misuse of diagnostic tests and treatments. For instance, for a heart surgery, detailing the clinical treatment plan, including necessary tests, surgical medications, and prescriptions, in conjunction with data analysis from payers, will help identify abnormal practices—such as excessive use of certain drugs or repeating tests—indicating potential misuse.
Moreover, post-DRG reform, healthcare insurance can externally drive medical institutions towards self-reform, particularly in public hospitals, which will place greater emphasis on cost accounting. In this process, it is also crucial to avoid situations where medical institutions refuse complex patients due to DRG/DIP reforms; necessary adjustment and supplementary payment mechanisms must be established. By continuously increasing the proportion of service revenue in medical institutions and implementing effective regulation, we can gradually correct current issues related to fraud and waste.
Conclusion
Strengthening healthcare insurance regulation is a long-standing concern in the market. Enhanced regulation will have a clear impact on the development of medical services and pharmaceutical expenses. In the future, while reinforcing regulation, efforts to alter the economic incentives of hospitals—particularly through the separation of technical costs and enhancing the value of services provided—will ultimately reduce regulatory costs and improve hospital efficiency.
The challenges in healthcare need a multifaceted approach that prioritizes patient care while ensuring the integrity of the healthcare system. Addressing overdiagnosis and unnecessary treatments is vital for both patient welfare and the sustainability of healthcare resources.
