How does the logic of "4 + 7" centralized purchase "exemption" drug proportion control change?

Breaking through the red line of drug proportion policy is changing from "exception" to normal, and clinical drug management methods such as drug proportion control seem to be facing a new round of changes in 2019 On January 17, 2019, the State Council issued the "4 + 7" pilot procurement scheme with volume One of the highlights is that in order to implement the responsibilities of medical institutions and ensure the volume of the winning varieties, all relevant departments and medical institutions are required not to affect the reasonable use and supply guarantee of the selected drugs on the grounds of cost control, drug proportion, and the requirements of the specifications and quantities of the varieties of drugs used by medical institutions This means that the procurement of 25 winning varieties in 11 cities will break through the red line of policy According to the data of the Ministry of Commerce and the data of the sample hospitals, it can be estimated that the market scale of the pilot cities accounts for about 30% of the total scale of the country Although only 22 varieties of the pilot cities have won the bid, the subsequent relevant policies are further pushed forward, and the impact cannot be underestimated In fact, this is not the first time that the red line of drug proportion policy has been broken On November 29, 2018, the medical insurance bureau, the Ministry of human resources and social security and the health and Health Commission jointly issued a document requiring 17 kinds of negotiated anticancer drugs included in the category B scope of the medical insurance drug catalog, and not to influence the supply and rational drug demand of the negotiated drugs on the basis of the total amount control of medical insurance, the total cost control, "drug proportion" and the basic drug catalog of medical institutions At the local level, there are also some extension actions in the near future On January 18, 2019, Anhui Medical Insurance Bureau, health care Commission and human resources and social security department jointly issued a policy notice on "17 + 13 + X" anticancer drugs Based on the 17 anticancer drugs included in the medical insurance catalog through negotiation by the National Medical Insurance Bureau, Anhui Province selected 13 organizations with large amount of Anhui province's existing medical insurance catalog for provincial-level belt procurement, and X anticancer drugs will be timely selected for belt procurement in the future 。 In view of these "17 + 13 + X" anticancer drugs, Anhui Province requires all health and medical security departments not to be included in the "drug proportion" and the "three fees" (materials, drugs, inspection and test costs) for assessment According to the information obtained from different sources by e-drug managers, the policy of canceling the proportion of controlled drugs is also being studied at the national level Officials close to policymakers say it will be cancelled in 2019 Of course, there are voices in the industry that the policy of controlling the proportion of drugs will not be cancelled However, there is no doubt that the drug proportion control policy may change greatly in 2019 under the condition that the exemption of drug proportion control appears in the policy several times in a row 1 According to the guidance on pilot comprehensive reform of urban public hospitals issued by the general office of the State Council, the proportion of drugs in the pilot city public hospitals (excluding Chinese herbal pieces) will be reduced to about 30% by 2017 Another goal is to comprehensively push forward the comprehensive pilot reform of urban public hospitals in 2017, which also means that all public hospitals across the country need to reduce the proportion of drugs to less than 30% According to the statistics of China Health Yearbook, the proportion of public hospital drugs in 2017 was 36.2% Assuming that the next step will be 30%, the current drug revenue of public hospitals is 800 billion yuan If 6.2% of drugs are squeezed out, it means that in the future, drugs will face at least 50 billion yuan of drug control pressure As the main means to achieve cost control, drug proportion has been regarded as the key policy to change the situation of "medical care with drugs", but under the current level of drug proportion control, there have been obvious problems in clinical medication The key point is that it is easy to pass on the pressure of cost control to patients by reducing drug use in one size fits all way In reality, the more prominent situation is that many public hospitals in the last two months of the year, when the proportion of drugs reaches 30%, they will no longer continue to prescribe drugs, and drug discontinuation incidents occur from time to time, which makes the interests of patients be infringed But in 2019, the total drug control policy no longer seems to be effective At the same time, the policy focus of reducing the burden of drug price is also shifting to "4 + 7" volume procurement, auxiliary drug catalog and new base drug catalog 25 varieties won the bid in the "4 + 7" pilot procurement policy, with an average decrease of 52% and a maximum decrease of 96% According to relevant estimates, the procurement cost of 25 selected drugs in 11 cities dropped to 1.9 billion yuan, saving 5.9 billion yuan If the conditions are mature and extended to the whole country, it is estimated that the purchase cost of 25 drugs can be reduced to 6 billion yuan, saving 19 billion yuan The health and Health Commission also issued a notice on the new version of basic drugs, requiring that the proportion of basic drugs should be increased, that public medical institutions should set up scientific indicators for the use of basic drugs in clinical departments, and that the proportion of basic drugs used and the proportion of prescriptions should be increased year by year New clinical drug use management rules are emerging, and the original drug use control methods such as drug proportion, cost control, drug proportion, drug varieties, specifications and quantity of medical institutions are gradually diluted in the "4 + 7" pilot volume procurement, and anti-cancer drugs are included in the medical insurance, which seems to indicate that the logic of drug control is changing 2 The logic of medical cost control is changing At the second joint meeting of security cooperation held in October 2018, the relevant people of the National Health Insurance Bureau said frankly that the decline of the proportion of drugs did not lead to the decline of medical costs From the perspective of expression, the proportion of controlled drugs has little effect on the cost saving of medical insurance The reason is that the drugs are controlled, but the cost of consumables, diagnosis and treatment is rising For example, the relevant personnel of the medical insurance bureau pointed out that through big data analysis, 80% of the inpatients used traditional Chinese medicine injection, 70% of the patients used traditional Chinese medicine injection, 26% of the patients used two traditional Chinese medicine injection, and 8% of the patients used three traditional Chinese Medicine injection However, if the traditional Chinese medicine injection is related to the diagnosis of disease, one injection can be related to 180 diagnoses, and the supervision of such magic medicine should be strengthened For example, simply speaking, the proportion of drugs does not play a pre-set role However, through data analysis, we can find out some "magic drugs" that occupy high medical insurance funds, and strictly control or kick them out of the medical insurance catalog, so as to achieve the purpose of rational use of drugs and control of medical expenses, rather than extensive total control of the proportion of drugs At the end of 2018, the national health and Health Commission has started to take action against the "magic medicine" occupying high medical insurance funds, and issued the document of the national catalog of auxiliary drugs to be published, which explicitly requires the provincial health and health administrative departments to organize the medical institutions above the second level within their jurisdiction, use the common name of the auxiliary drugs in their own institutions, and rank the amount of annual use from more to less to form the auxiliary drugs The catalogue shall be submitted to the provincial health administrative department On January 19, Liu Yuehua, deputy researcher of the Health Technology Evaluation Office of the health development research center of the national health and Health Commission, made it clear that "auxiliary drugs" will be the focus of the reform in 2019, at the "2019 new year outlook meeting of China's pharmaceutical industry" jointly sponsored by e-medicine managers and 50 people's Forum on investment in China's medical and health industry Specifically, the selection method of the catalogue will pay attention to the actual clinical value According to the results of clinical evaluation of drugs, "positive list" and "negative list" were issued Specifically speaking, on the one hand, there are so many auxiliary drugs who are effective and positive, which I should buy, or which are indispensable to deal with the adverse reactions of a certain disease Or drugs for children or special diseases It is a positive list, a list that encourages priority procurement A negative list is also needed If the enterprise's own drugs are proved to have no effect by evidence-based evidence, or not to have better effect than other drugs, then it is a negative list with low value and no priority to purchase, so as to ensure that we can control the reasonable demand of auxiliary drugs in clinical At the same time, the draft of the overall work plan of the national comprehensive clinical evaluation of drugs (2018-2020) formulated by the national health and Health Commission was released in October 2018 According to the document, China will establish a comprehensive evaluation system for clinical medication, and about 100 evaluation bases will be built from 2020 The comprehensive clinical evaluation of drugs for many years was put forward, and there was a clear framework and schedule in this draft Previously, in an interview with relevant media, the director of the Department of pharmacy management and clinical pharmacy of Peking University School of pharmacy said that the implementation of the comprehensive clinical evaluation of drugs "will promote the control of drug proportion to return to the law of medicine" The application of drug evaluation results will accurately find out the rational use method, way and time of drugs for patients, establish a precise drug use model, and complete the revision Good medication guide This seems to indicate that the extensive management mode that originally defined the red line of 30% drug proportion is gradually fading out of the historical platform, and the clinical monitoring and control of drugs are also changing to the direction of refined management.