How to manage the drug price after the "4 + 7" breakthrough?

Recently, the author received a "4 + 7" which was forwarded by an old leader Why doesn't it matter? 》After reading the article, I was shocked This article has also attracted wide attention, with more than 100000 readers in just three days After reading this, the writer thinks he should write something After several days of thinking, I wrote down the following feelings: The so-called "4 + 7" means that 11 cities (including 4 provincial cities and 7 sub provincial cities) such as Beijing launched the pilot work of centralized drug procurement and use led by the state health insurance bureau, commonly known as "4 + 7" drug volume procurement In 2019, the price of those drugs with "4 + 7" volume purchase appeared a "cliff" drop The sharp drop in the price of these drugs has benefited many patients; at the same time, it has also made the public see a black curtain unprecedented in human history The author still borrows "4 + 7" to break the sky, why not? 》Part of the data and data in this paper prove how dark this black curtain is The following are part of the original content of the author (Muran, Jiangsu pharmaceutical alliance): Let's take a look at the bid winning results of volume procurement: the bid winning price of atorvastatin calcium tablets of Qilu pharmaceutical decreased from 3.81 yuan to 0.12 yuan, a decrease of 96.85% (meaning that the original bid winning price was 3175% higher); the bid winning price of entecavir 0.5mg/tablet of Suzhou Dongrui decreased from 9.47 yuan to 0.18 yuan, a decrease of 98.10% (5161% higher); the bid winning price of tenofovir dipivoxil 300mg / tablet of Chengdu Beite decreased from 9.47 yuan 14.33 yuan decreased to 0.47 yuan, a decrease of 96.72% (virtual height of 3048%) It is particularly noteworthy that in the past, foreign-funded original research drugs supported by brands and quality also saw a huge decline: AstraZeneca's gefitinib 250mg / pill dropped 76% again after 55% price reduction in national negotiation, and the bid price decreased from 500 yuan to 54.7 yuan, with a cumulative decrease of nearly 90% (virtual high of 914%); Sanofi's clopidogrel 75mg / pill's bid price decreased from 16.8 yuan to 2.55 yuan, with a decrease of 84.8% (virtual high of 658%); Lilly's pemetrexed injection 100 Mg / branch decreased from 3060 yuan to 809 yuan, with a decrease of 73.56% (virtual high of 378%) 4 + 7 can be said to have opened a dark curtain unprecedented in human history It is not surprising that it has been left unattended since it was opened and evolved 10 years ago Next are CCTV, Xinhua news agency, people's daily and other reports: In 2010, the bidding price of asparagus tablets was 1300% higher than the actual price, and the kickback accounted for 40% of the bidding price; in 2011, GlaxoSmithKline bribes, its vice president in China Liang Hong admitted that the price of commercial bribes can only be apportioned to the drug price, and the cost of drugs is only 30 yuan, and the final price of drugs sold to patients can be 10 or dozens of times of the cost price; in 2013, Zhangzhou medical corruption case, 100% of the public hospitals in the city involved in the case, and 50% of the drug price is public Customs fees; in 2016, six large public hospitals in Shanghai and Hunan had a false high bid price of 600% - 1000%, 30% - 40% rebate, and 10% commission for medical representatives; in 2017, the deputy director of a department in a top three hospital in Nanjing was investigated by the Commission for discipline inspection due to a lover's report, and then involved up to 618 doctors and medical representatives involved in drug rebate; on May 21, 2019, helezhong, Wanning City, Hainan Province Hua Sheng (pseudonym), a doctor of the mental health center, reported to Hainan SAR that many doctors in the hospital, including himself, had received kickbacks from drug dealers, but the management of the hospital ignored the situation On May 23, 2019, a woman in Henan reported receiving kickbacks due to her husband Ji Feng (a doctor in the First Affiliated Hospital of Zhengzhou University) cheating In the past 10 years, the price of clinical drugs in public medical institutions in China has been more than 10 times higher, some of which are more than 100 times higher The price includes 60% of the underground transaction costs According to the current annual purchase amount of drugs in public hospitals, the underground costs are 720 billion More than that, under the influence of drug proportion assessment, in order to achieve the goal of not affecting the standard, not affecting the large prescription and drug abuse, the most simple and effective method is to "enlarge the denominator", that is to say, under the condition that the drug cost remains unchanged or even increases, the cost of inspection, consumables, diagnosis and treatment will be greatly increased This requires an increase of 1 trillion in expenses for consumables, inspection, diagnosis and treatment, and a waste of about 600 billion underground expenses How terrifying is the figure of the underground transaction cost of the above two items, about 1.3 trillion? We can simply make a comparison: in 2017, China's poverty alleviation fund was 140 billion yuan, and in 2017, China's defense expenditure was 1044.397 billion yuan If the U.S side imposed 25% tariffs on China's 560 billion US dollars, it would exert pressure of 980 billion yuan on Chinese goods at most That is to say, the waste caused by over medical treatment (over medication and over inspection) exceeds the military expenditure of the country, exceeds the loss caused by the Sino US trade war, and is 10 times of the poverty alleviation fund Therefore, it is no exaggeration to say that the waste of funds caused by the inflated drug price and the rampant kickbacks endangers national security! It can be said that since the new health care reform, China's drug prices are inflated and kickbacks are rampant, which has created a human catastrophe If it's not a big surprise, what else can it be? What causes the corruption of medicine and then leads to the false high price of medicine? In 2013, after CCTV reported that 90% of doctors in public hospitals of all municipalities and counties in Zhangzhou City, Fujian Province were bribed by drugs, and 50% of the commercial drug price was used for "public relations expenses", the author wrote three consecutive review articles (one of which was published by China Health Magazine) The title of one of the articles is "the primary reason for Zhangzhou's" losing the whole line ": three" ordering by yourself and paying by others " The author believes that the reason why drug dealers can use 50% of the drug price to provide drug rebates to 90% of doctors in all public hospitals in Zhangzhou is because of the institutional corruption caused by three "ordering by themselves and paying by others", which leads to the high drug price for a long time, even worse Here are some parts of the article: Under the planned economy system, the production, supply and marketing of drugs in China are strictly controlled by the government, so the medical corruption is most effectively controlled However, the medical service industry not only needs to curb corruption, but also to improve efficiency Otherwise, the ultimate goal of medical reform cannot be achieved: it is not difficult for the masses to see a doctor cheaply Therefore, the medical industry must implement a fully competitive market system like other industries However, due to the complexity and particularity of the medical industry, its market system and mechanism are far less perfect than other industries, so the medical industry has become a high incidence area of corruption cases The author analyzes that there are many reasons for the occurrence of medical corruption in China, but one of the most important reasons is the unreasonable mechanism of "ordering by yourself and paying by others" in the three links of using, purchasing and bidding First of all, in the use of drugs, it is an unreasonable mechanism of "ordering by yourself and paying by others" In other industries, because the demander (consumer) orders and the demander pays the bill - "he orders and pays for himself", the market law can play a normal role; in the medical industry, the supplier (Doctor) orders and the demander (patient, government and unit) pays the bill - "he orders and others pay", so the market law fails (if any industry orders and others pay for himself) Market rules will fail It is precisely because "order by yourself and others will pay the bill", so whether or not the government controls the "price difference rate" (including "zero difference rate", the same below) of drugs in hospitals, drug manufacturers and drug dealers will use the impulse of "high pricing and large rebate" to "bill and commission" for doctors, and doctors will also have the impulse of overusing drugs for patients and using high priced drugs Why does the medical service industry have "billing Commission", while other service industries such as diet do not? The basic reason is: the former is "order by yourself and others will pay", while the latter is "order by yourself and pay by yourself" Just imagine that if the salesmen and the waiters of the restaurants in the shopping malls have the same right to order "dishes" for consumers as doctors, the manufacturers and the businessmen will also use "high pricing, big rebate" means to "bill and commission" for the salesmen of the shopping malls and the waiters of the restaurants Then the corruption of "bill Commission" will also breed and spread in shopping malls and restaurants For example, in the catering service industry, before the issuance of the "three public funds" document under the central control, the business of high-end restaurants was very popular, and even the most expensive dishes were ordered This is because there are many people who are spending money from others (the public) In addition, the restaurant owner will also send a lot of red envelopes to the order takers and the order signers who consume the public funds during the Spring Festival This is the "high pricing, big rebate" in the catering service The manifestation of the industry; however, after the issuance of the central control "three public funds" document, many high-end restaurants are facing the crisis of closing down or even closing down, so they have to reduce the price of dishes, attract customers through small profits and high sales, so that many ordinary people can also enter the high-end restaurants for consumption The reason for this great situation is that there are fewer people who spend other people's money in high-end restaurants and more people who pay for their own money It is because of "let the ordering person pay the bill himself", that the improper marketing means of "high pricing and big rebate" in high-end restaurants naturally lose its existence value Secondly, the purchase of drugs is also an unreasonable mechanism of "ordering by yourself and paying by others" Because the medical market of our country is basically monopolized by the public hospitals (including the public primary medical institutions), and the decision makers of the public hospitals are not the property owners of the public hospitals (the property owners are generally the government), so the orderers of the drug procurement of the public hospitals are not the buyers Because it is others who pay the bill, whether or not the government implements the drug "price difference rate" control, whether or not the government allows the second drug price negotiation, it is also possible for pharmaceutical factories and drug merchants to "high pricing, large rebate" to the hospital leaders for public relations, so the hospital leaders may order food at random (that is, purchase drugs with high quality and low price) Because it is someone else who pays, government officials and other hospital managers may also be involved in drug procurement and want to take a share of it, so there is a corruption case Why don't pharmaceutical companies and drug dealers use "high pricing, big rebate" to conduct public relations in private hospitals? The reason is obvious: the boss of the private hospital is both the orderer and the buyer in the drug purchase As long as the boss has no water in his head, he will never accept the "high pricing, big rebate" public relations of the pharmaceutical factory and the pharmaceutical manufacturer Why so many years, corruption cases occur frequently in public hospitals, but there is no case report in private hospitals Even in the case of Zhangzhou public hospitals and their doctors "total annihilation", there is no media report about the case of a Zhangzhou private hospital and one of its doctors and managers This is not that the private hospitals do better than the public hospitals in moral and honest education, but because the private hospitals' drug purchase is the boss who "orders the dishes and pays the bill himself", so the boss will try to avoid the middle link, directly purchase from the manufacturers, and use the "base price" (i.e the price without water) to bargain Because it is a "base price" deal, then pharmaceutical companies and drug dealers are unable to use drug kickbacks to public relations with doctors and other managers of private hospitals Thirdly, in the drug bidding process, it is still an unreasonable mechanism of "ordering by yourself and paying by others" In order to prevent public hospitals from accepting the public relations of "high pricing and big rebate" from pharmaceutical companies and drug dealers in drug procurement, the government adopted centralized bidding procurement