Liabilities are trillions!Where will the debt of public hospitals go?

In 2020, the asset -liability ratio of my country's government office governments reached about 45.75%, and the warning line of 50%was not far away.

On July 6, the National Health and Health Commission announced the results of the "national examination" of the second and third public hospitals in 2020. Among them, about 40%of hospitals in 2020 were losses, of which 7.51%of the asset -liability ratio exceeded 100%, and 49.53%of the asset -liability ratio exceeded 50%, pushing the debt problems of public hospitals to the table again.

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For a long time, debt has been an indispensable part of most public hospital operations. It is reported that from 2005 to 2014, the liability size of my country's public hospitals rose rapidly at an average annual debt compound growth rate of 20.5%of debt, and as the debt growth, the asset -liability ratio continued to rise.

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Asset -liability ratios (total liabilities/total assets) are mostly used to measure the debt repayment capacity of institutions, and it is generally believed that more than 50%is high risk. According to the latest "2021 China Health Statistical Yearbook", in 2020, the total liabilities of my country's government office hospitals were about 1.764 billion yuan, and the asset -liability ratio reached about 45.75%.

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90%of county -level hospitals have debt,

The central government has arranged 2.5 billion yuan for grassroots debt

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In fact, the asset -liability ratio is not an absolute "negative indicator".

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Wu Min, deputy director of the Department of Medicine Economy and Management of Nanjing Medical University, told the "think tank in the medical community": From an economic point of view, especially for enterprises in the market economy, only the company's own business conditions can obtain loans from banks. In other words, the better its debt ratio, the higher the operating conditions.

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On the one hand, high debt means that companies have obtained more funds that can be used for their own development, and on the other hand, it also means a certain financial risk. "The situation of the hospital is similar, but unlike ordinary enterprises, high debt may cause the hospital to put profit attributes in front of the development of public welfare attributes. This is unwilling to see the government and the people," she said. The debt ratio is a 'double -edged sword'. "

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The context of hospital debt development basically follows her views -in 1999, the concept of "hospital liabilities" was first clarified in the "Hospital Finance System" jointly promulgated by the Ministry of Health and the Ministry of Finance. Policy permits.

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Later, the scale and asset -liability ratio of public hospitals increased for many years. By 2009, the asset -liability ratio of public hospitals had increased from 19.31%in 2002 to 31.99%, and the total liabilities reached 368.7 billion yuan. Some scholars commented in the paper: debt development has become the basic characteristic of the development of my country's health.

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Among them, county -level hospitals are recognized as the "hardest disasters" of debt. According to China News Network in 2011, 90%of county -level hospitals in the country had debt. The total liabilities in 2008 were 40.6 billion yuan, with an average of more than 26 million yuan per county hospital liabilities.

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A report from Guangzhou Daily in 2012 shows that of the 192 county -level hospitals in Guangdong Province, 188 average liabilities reached 48.26 million yuan, and only 4 have no debt.

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The main purpose of public hospitals' debt construction is to expand scale and allocate equipment, so as to "grab patients" and seek development, but blindly pursuing scale is not good. Some research team surveyed 19 public hospitals and found that from 2001 to 2005, the total value of the total assets and equipment assets of these hospitals increased by 90%and 104%respectively, but the average growth rate of their outpatient and residents was only the only growth rate 3.6%and 3.7%.

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Another study pointed out that from 2016 to 2018, the asset -liability ratio of 5 public hospitals in a cities in a city in Northeast China exceeded the early warning line, reaching more than 80%, up to 127.87%. At the same time, the labor cost of the hospital has increased the labor costs of hospitals year by year, and the proportion of administrative logistics personnel exceeding 15%or even 20%is a common phenomenon. And more configured an administrative logistics personnel, the annual funding expenditure will offset business income of 250,000 to 300,000 yuan.

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In 2011, the Central Finance even arranged 2.5 billion yuan at one time to support the debt of the grassroots medical and health institutions in various regions. Sun Zhigang, then deputy director of the National Development and Reform Commission and the director of the Office of the State Council's Medical Reform Leading Group, mentioned the reason for this in an interview with Xinhua News Agency-

As of the end of 2010, the long -term liabilities of township health centers and community health service agencies were 5.5 billion yuan and 3.50 million yuan, respectively. With the comprehensive implementation of the basic drug system in the grass -roots medical and health institutions, the gradual eradication of the "medicine supplementing medicine" mechanism at the grassroots level, the primary medical and health institutions have lost the main source of debt repayment. Operation, comprehensive reform of the grass -roots medical and health institutions.

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Public hospital debt scale is trillions,

Unified caliber is difficult

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The "medical tank of the medical industry" was informed that a region in South China had thought of the debt resolution of public hospitals. To this end, the expert group discussed the matter, but the first meeting was controversial.

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The dispute is mainly at 2 points. First, the state has banned public hospitals from the construction of a public hospital from 13 years. These hospitals do not comply with the debt caused by relevant provisions. Instead, there are still the government's "bottom". Will it play a reaction to encouragement?

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Second, the debt of public hospitals has developed to this day, and the amount is too large, and the government has been unable to resolve it 100 %. So, which debts can be resolved by the government, which cannot be, and how to give a unified caliber?

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"The use of debt in the hospital can be divided into 2 categories. Category 1 is the loss of losses in its own inconvenient support. It has to rely on borrowing to maintain normal business activities. The other class is the hospital used to expand reproduction. The typical approach is to cover the new. Building, buying large medical equipment, etc. "Participating in the discussion of an expert said," The quality of these two practices is difficult to define. The former hospital's ability is not good. "

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Faced with the increase in public hospitals with a trillion -dollar scale of the year, the national level has not yet introduced a specific solution policy at the national level. In 2014, the "Opinions on Strengthening Local Government Debt Management" issued by the State Council made it clear. The debt borrowed by public institutions is included in the debt that the government should repay, and the general debt and special debt should be included in budget management by procedures.

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In 2016, when the former National Health and Family Planning Commission responded to the proposal of the Twelfth National People's Congress No. 1537 to resolve the debt of the county -level public hospitals, it would further strengthen the regional health planning and strictly control the construction standards and scale of public hospitals. Public hospitals prevent new debts from blind expansion.

"But I think debt is not all caused by blind expansion," said an industry expert, "Hospital -level review system, including the latest 'national examination' performance indicators involving many indicators. If public hospitals want to develop, they must meet these indicators. , Whether it is the improvement of medical technology, the introduction or cultivation of talents, these require a lot of capital investment. "

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Insufficient government investment is a major reason for the development of hospital liabilities. It is reported that the human cost and the cost of drug equipment that the hospital have been affordable has risen year by year, but the price of medical services has always implemented a relatively low government guidance price. Before proposing the establishment of a dynamic adjustment mechanism, it was only adjusted once every 5-7 years.

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"The current medical service price still cannot reflect the value of medical staff. Taking peritoneal cancer surgery as an example, 7 medical staff is required for about 4 hours of labor, but the government pricing of this operation is only 1705 yuan." Liu Muyu, a medical management expert, said "This is the underlying logic of most hospitals to survive in loans. This is a structural issue."

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After the public hospitals across the country began to cancel the drug bonus nationwide, the hospital's income was further reduced, and the cost caused by drug storage and other. In addition, the cost of medical insurance costs often lags behind and settled. Summarize.

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On the other hand, Liu Muyu believes that with the gradual improvement of government funds and the medical insurance system since the new medical reform in 2009, it has stimulated the needs of the people's medical treatment, and it has also stimulated the development of hospitals, building new buildings, and buying large -scale medical equipment. idea.

"Should a new device buy, which price to choose which manufacturer, the rationality of this decision has basically rely on leaders' shooting. Many leaders can not consider the depreciation cost of the equipment when shooting. , Maintenance costs, etc., there is a certain blindness. "Yang Yue (pseudonym), deputy head of the accounting department of a provincial and county -level hospital in central China.

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After all, public hospitals belong to public institutions, and there is no saying in bankruptcy. No matter how good, there is a government. Some hospital managers therefore "there is no fear" is another reason for the blind liabilities of public hospitals.

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In the exchange with his peers, Yang Yue learned that the annual income of county -level public hospitals was about 100 million yuan, and the annual loss of more than 40 million yuan, "but new equipment is still bought. The lack of management talents and other phenomena are still common in county -level public hospitals. "

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She believes that the important reason is that the financial status of public hospitals lacks strong supervision. At present, only the "national examination" scores and ranking of second- and third -level public hospitals involving asset -liability ratios and medical surplus ratios involving the ranking. "But some deans feel that the ranking of the hospital can not go up anyway. I simply‘ lie down ’. The‘ National Examination ’indicator cannot constitute a constraint on it.”

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In addition, although the five departments such as the Ministry of Human Resources and Social Affairs, the "Guiding Opinions on Deepening the Reform of the Public Hospital's Salary System" jointly released by the Ministry of Human Resources and Social Security, stated that since the date of printing, the new debt will still be added to the regulations. Public hospitals, before the repayment of the new growth period of debt, strictly control the salary level of members of the hospital leadership team.

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"But whether it has risen or not, there is no supervision and implementation of relevant departments. After all, the salary of the hospital's leadership team is universally issued by the hospital." She said, "The debt issues of public hospitals are the same. Many departments such as bureaus, even the Development and Reform Commission, and Audit Bureau may involve it. Whoever supervises it requires the central government to introduce a implementable guidance policy. "

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Louder fund loans and government special bonds

Chenggong Hospital is currently the mainstream financing model

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Speaking of which, the "liability history" of public hospitals is also the process of its financial management step by step.

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In the early days, because most of the public hospitals had stable cash flow and good expected income, banks were willing to lend to hospitals, and fixed asset loans and mobile capital loans were available. "If the cash flow of the hospital is better, you should take a credit loan. If the hospital's operating conditions are not so good, the guarantee is reinforced." A insider insiders in the central branch of a state -owned bank said.

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By December 2010, the government began to introduce restrictions. The Ministry of Finance and the former Ministry of Health jointly issued the "Hospital Financial System" and stipulated that in principle, the hospital shall not borrow non -current liabilities. The departments (or organizers) are approved with relevant departments, and the government is responsible for repayment in principle.

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Beginning in 2012, supervision has become extremely strict. First of all, the "Twelfth Five -Year Plan" period released in March deepened the reform plan and implementation plan for deepening the pharmaceutical and health system "stipulated that" the public hospitals should be prohibited from the construction of debt ", and then the Development and Reform Commission, the Ministry of Finance, the Ministry of Health, and the CBRC jointly issued the" Regarding the urgent notice of strictly prohibiting county -level public hospitals from borrowing new debts "and prohibiting public hospitals from borrowing new debts.

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The hospital's fixed asset loan was banned. The hospital could only apply for a mobile fund loan from the bank and could not obtain long -term debt from the bank. "Short -term flow funds loans generally do not exceed 1 year, and they need to be repaid monthly. This year's loan will be repaid this year, next year will be repaid next year." Yang Yue said.

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Loans also mean constant interest. The long -term loan's mouth was blocked, and there was no new source of funds for a while. According to industry insiders, public hospitals began to drag the money to cope with the supplier of medicine or equipment.

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"So after the purchase of normalized drugs, it also has a certain impact on the cash flow of the hospital," said Min Min said. "First, the hospital cannot choose the pharmaceutical factory by itself, and the second is that the government requires that the hospital must generally be within 60 days. Payment, you can no longer be as arrears of the drug factory as before. "

At the same time, in order to alleviate the operating pressure of public hospitals, since the successful issuance of the country's first medical and health bond 600 million yuan in 2018, in 2019, the General Office of the State Council released the "About "Notice of the issuance of special bonds and supporting financing of local governments", since, the form of special bonds for local governments has been continuously used to support hospital construction.

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"The interest of special bonds is relatively low, around 2.9 to 3.23, but there are certain requirements for the asset status of the hospital. There are more can loans to 200 million in county -level hospitals, and less can be loaned to about 20 million. The period can be divided into 10 years, 15 years or 30 years, and the hospital may not have the pressure to pay interest. "Yang Yue said," But how to pay the capital after expiration, if there is no supervision, it also needs to be considered Question. After all, 10, 15 or 30 years expire, the leaders of the loan are basically not in office. "

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She heard that some public hospitals that were difficult to sustain due to debt, medicines and other related suppliers even "held" the hospital's charging offices, and automatically paid the patient's money to the hospital into the supplier's account. "Many hospitals themselves themselves themselves themselves The management is not good, so it is expected that the government's full amount of debt is unrealistic, and the amount of liabilities in some hospitals is no longer able to afford its finances. "

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However, since the government accounting system was fully implemented in public hospitals on January 1, 2019, this situation has become less and less. "The new accounting system requires full budget management. How much money does it cost within the year must make a budget form before the year, and strictly follow the budget expenditure. Including about 17 years, the state requires a total accountant to set up a total accountant to be responsible for responsible for responsibility In terms of operation management. Generally speaking, the financial management of public hospitals is becoming more and more stringent, and it is more and more refined. "Wu Min said.

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Yang Yue also said that since 2020, the country has issued several successive policies documents including high -quality development, public hospital economic management years, and internal control management measures in public hospitals. "I have been engaged in accounting for accounting for 20 years. This situation is rare, indicating that the national level has realized that there are economic risks in public hospitals and urgently need to strengthen the level of operation and management. "

Source: medical tank in the medical world

Author: Tian Wei

Responsible editor: Song Kunlun

School pair: Zang Hengjia

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