Encircle the medical chaos! "Four killer maces" in the name of health reform stars are in place

Recently, Zhan Jifu, director of Sanming Municipal People's Congress, who has not been away from the pharmaceutical industry for a long time, told his peers on a forum that there are four trumps to deal with the disorder of pharmaceutical consumables: first, if the manufacturer dares to bribe hospitals and doctors, it will not let the pharmaceutical consumables of this manufacturer go on the unified platform of the whole country; Second, determine the national maximum sales price limit for drug consumables Some hospitals that exceed the price limit will pay the bill, and those that do not exceed the price limit will keep the hospital balance; third, drug consumables will not be allowed to enter the national medical insurance catalog; fourth, determine the national medical insurance payment settlement price (payment standard) The time has come to April 2019 Let's see how many Assassin's maces have been implemented in Zhan Jifu's mouth to rectify the drug mess? How many have achieved results Under the background of drug review and approval system reform, under the background of "two vote system" and "business to value added system", it is urgent to carry out policy formulation and accelerate the implementation of drug price procurement in the new situation Drug purchase is undoubtedly an important task of the medical security bureau Not long ago, there was a "notice on convening the Symposium on the construction of national drug consumables bidding and purchasing platform" in the industry On March 5, this year, the state health insurance bureau organized relevant leaders from all provinces and cities to have a discussion on the construction of national drug consumables bidding and purchasing platform The content of the meeting includes the introduction of the overall demand plan for the construction of the national pharmaceutical machinery bidding and procurement platform, and listening to the opinions of all provinces on the overall demand, including data demand, business function demand, monitoring and supervision demand, statistical analysis and decision support demand, data sharing demand, price management demand, etc As early as October 2014, the statistical information center of the national health and Family Planning Commission and the Department of Drug Administration jointly issued the notice on the pilot work of the construction of the comprehensive management information system for the national drug supply guarantee The original intention of the notice is not complicated It is to connect the provincial drug procurement platform with the national drug administration platform, standardize the construction, unify the drug coding, etc., and realize the centralized drug procurement data Exchange and sharing on national and provincial platforms Including drug bidding, procurement, distribution and settlement The original intention at that time also had a certain vision, that is, "the national drug control platform is an information platform After docking with the provincial drug centralized procurement center, the future national classified procurement, national drug price negotiation mechanism and other negotiation prices will be publicized on this platform." It is not difficult to see that the positioning of national management platform is "data management and control" platform, and the biggest impact on pharmaceutical enterprises is that the procurement (bid winning) prices of all parts of the country are reflected in the national management platform, which has the basic role of data comparison and analysis for the provinces to carry out bidding procurement At present, the national procurement platform is expected to be implemented Its positioning should be based on the national management platform or part of the national management platform, and on the premise of strengthening basic data management, the comprehensive platform of "combination of bidding and procurement" If the platform is built successfully, it will be an effective "grab" and "sharp tool" for the drug price management after the establishment of the medical insurance bureau But the positioning is relatively clear, that is, "unifying drug data standards, building a large platform with large data and large capacity and an efficient regulatory procurement platform" As for whether the national management platform and the national mining platform will be integrated in the future, it depends on how to distinguish the positioning of the two platforms in the future, as well as how much the data of the two platforms will contain in the future To determine the so-called maximum sales price limit of drugs in China is the creative proposal of Fujian ten standards (the sunshine purchase rules of drugs joint price limit based on the implementation of medical insurance payment and settlement price in Fujian Province) The definition itself is: the part of the hospital that exceeds the price limit pays the bill, the part that does not exceed the price limit, and the balance of the hospital is retained (that is, the meaning of encouraging the hospital to negotiate twice or even three times) However, since the launch of No.7 and No.70 documents in 2015, the centralized drug purchase has become "zero", and the so-called "no second price negotiation" has basically disappeared in the context of creative drug purchase in various cities and counties The so-called provincial bid price has actually evolved into a provincial maximum sales price limit Taking Zhejiang, a pharmaceutical Province, as an example, in 2014 and 2015, after the bidding, in addition to regular provincial online transaction price linkage (the lowest price in the country) and drug procurement organized by pilot cities Ningbo and Wenzhou separately (second bargaining), since 2016, in the context of Zhejiang becoming a new upstart in the pilot province of medical reform, the bargaining in various regions of Zhejiang is like "sesame blossoming, saving and increasing" , the price reduction rate is lower than that one time In some places and cities, the price of a product regulation has been reduced by as much as 50% In the meantime, the relatively silent medical institutions in the past began to go to the front desk to grasp the power of drug procurement: first, to form a consortium to carry out group procurement, such as Gansu and Guangxi Second, the hospital openly managed the pharmacy, forcing the enterprise to rebate the commercial company of the contractor again Third, hospitals carry out price negotiation procurement, such as Guangxi and Hainan For local drug procurement, it is better to carry out price negotiation on the premise of provincial shortlist in a fair way than to carry out secondary price negotiation on the basis of provincial bid price, but in essence, this is a different continuation of "secondary price negotiation" At the same time, under the background that the medical insurance cost has gradually become the operating cost of the hospital, the hospital, in line with the principle of "saving control, keeping the surplus for itself", has full motivation to bargain on its own Therefore, the maximum sales price limit in Fujian is just a saying, and this practice of "saving and retaining, generating income and self spending" has been widely carried out all over the country 3 It is a kind of "industry anti-corruption" high-pressure deterrent practice that drugs are not allowed to enter the national medical insurance catalogue, as director Zhan said But in the long run, we can see the new trend of the development of the pharmaceutical industry through the frequent introduction of relevant policies in recent years That is to improve the product quality through the consistency evaluation of generic drugs, then further optimize the industrial structure, and encourage the dominant enterprises to become bigger and stronger Therefore, the dynamic adjustment of the medical insurance catalog and the obligation to encourage domestic innovative drugs should be obligatory Seriously considered by the decision-maker At the same time, not long ago, the government's task in 2019 was clear and "do a good job in the prevention and treatment of common chronic diseases, and include outpatient drugs such as hypertension and diabetes into the medical insurance reimbursement." Therefore, products like hypertension and diabetes will have great hope to adjust this catalogue Similarly, the access of medical insurance catalog is directly related to drug purchase The author has long emphasized the view that: in terms of access channels of medical insurance catalog, according to the provisions of the plan, transfer in can be divided into two ways: regular access and negotiation access Under the premise of meeting the effectiveness and safety, if the price is equivalent to or lower than the existing varieties in the drug catalog, the price can be adjusted by regular access Regulations and methods shall be included in the catalogue, and patent exclusive drugs with high price or great influence on medical insurance fund shall be admitted through negotiation According to this trend, there is no doubt that the so-called effectiveness and safety should first depend on whether they pass the consistency evaluation, and then on whether there is evidence-based basis in clinical practice Thirdly, the cost is lower than that of others In the future, products in the same treatment field will be referred to the same kind, and the exclusive varieties with unlimited scenery will be compared with the same kind of products, after all, Fujian sunshine has dared to purchase First of all, some products in the same field of treatment were combined and grouped in the tenth bid Therefore, it is worth pondering and paying attention to whether there will be a concept of future drug procurement, packaging and merger procurement behind this "conventional way" 4 To determine the payment and settlement price (payment standard) of national medical insurance According to the 2016 draft of relevant national medical insurance payment standard, the ultimate goal of establishing the payment standard is to help gradually establish a market-oriented drug price formation mechanism, On the other hand, relevant policies continue to emphasize that the formulation of medical insurance payment standards should "improve the drug use behavior of medical institutions and patients, and promote the use of drugs with definite curative effect and reasonable price on the premise of ensuring medical quality by designated medical institutions" From the original intention of the formulation of medical insurance payment standard, on the one hand, we should resolutely implement the requirements of reducing "drug proportion" and "medical insurance fee control", on the other hand, we are worried that "there is no good medicine at a low price" Therefore, the drugs with "accurate curative effect and reasonable price" have become the active ones to be used In this hesitation, as far as the relevant provinces are concerned, the medical insurance payment will inevitably start to go wrong In the 16 + 1 belt purchase in Anhui Province, medical insurance compensation can be obtained for the drug price difference reduced by the hospital belt purchase; in 2017, Fujian sunshine purchase, 1719 varieties pay zero payment for the settlement price of medical insurance payment Facts have proved that the erratic payment policies of medical insurance in all provinces do not take into account all aspects, but bring more confusion and confusion to the payment policies of medical insurance It's no wonder that the health insurance payment standard is still hard to produce Because the relevant departments have set the payment standard for medical insurance drugs for a long time, which is not the so-called "medical insurance pricing", but refers to the base number of medical insurance funds to pay for drugs, and plays a guiding role in drug prices The payment standard is not the absolute amount paid by the fund The specific amount of drug reimbursement is directly related to the proportion of fund payment In my opinion, if the standard is not a price, it is certainly not a settlement reimbursement price If the standard only plays a guiding role of price, then as a "standard" which is not based on price, what does it guide? Taking the national minimum online transaction price just linked in Zhejiang Province as an example, 1804 out of 5240 product regulations have been lowered in terms of medical insurance payment standards Its foundation is the actual purchase price of drugs, and the standard guides the irreversible trend of price downward Therefore, the basic attribute of medical insurance payment standard is still not separated from the category of price setting With the incessant negotiation of consortium purchase and the explicit deduction and price reduction of some single hospitals in various regions of the country, the so-called medical insurance payment standard has become the profit task of earning the difference under the operation of medical institutions In such a simple and crude declining drug payment standard background, who will protect the interests of patients? Who will protect the interests of pharmaceutical companies with spiraling drug prices? Medical insurance payment standard, and how much should not bear the weight Therefore, in the expectation of all the people in the industry, the establishment of the medical security bureau is welcomed, and the real big move for the implementation of the consistency evaluation: 4 + 7 Therefore, the latest transitional policy on the medical insurance payment standard circulated in the industry is also welcomed, namely: （1） If the price of non selected drugs at the end of 2018 is more than twice the price of selected drugs, the payment standard will be no less than 30% reduction of the original price in 2019, and the payment standard will be adjusted to the price of selected drugs in 2020 or 2021 We will encourage non selective enterprises to reduce their prices on their own initiative and converge on payment standards Each pilot city can also explore ways to guide patients to use the selected varieties by adjusting the proportion of self payment on the basis of comprehensive consideration of local reality （2） The price of non selected drugs at the end of 2018 is twice of the price of selected drugs and the price of selected drugs