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It is not realistic to expect that the last mile problem of innovative drugs will be solved immediately

 Last Update: 2021-04-27
 Source: Internet
 Author: User

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After the anti-cancer drugs entered the medical insurance, Xiaosi, a reader at 8:00, felt that "prescribing drugs every month is a war.

She found out in 2016 that she had cancer.

At the end of 2018, after the prices of anti-cancer drugs have been drastically reduced and medical insurance has been widely introduced, she found that “prescribing drugs is difficult to get to the sky”.

First, the self-pay pharmacy on the first floor of the hospital no longer supplies them.

Moreover, hospital pharmacies are not always available.

Even when the pharmacy is in stock and the chief doctor is in the consultation, these medicines may not be available.

In Xiaosi's view, "I am afraid, worried, and helpless, just like cancer.

Two months ago, 8:00 Jianwen also reported on such a case exclusively, which triggered a heated discussion in the society: The patient’s family member Xiao Zhang discovered that more than 500,000 yuan of his father’s treatment and medication costs belonged to the drugs in the medical insurance catalog, but the hospital asked for it.

Among these drugs, the specific antibiotic Fengweiling, which was included in the National Medical Insurance List in 2019, accounted for a large proportion of the amount.
The hospital explained to Xiao Zhang that it had not purchased this medicine, and since then it has not made temporary purchases in accordance with Xiao Zhang's requirements.

The encounters between Xiaosi and Xiao Zhang point to the same problem: after a drug is included in the medical insurance list, it may not be available in every hospital.
For various reasons, many hospitals have no incentive to purchase these drugs, and they also impose various restrictions on their use.
Among them, the most likely to cause concern and controversy are the higher-priced varieties.
Some innovative drugs are particularly prominent, which is also known as the "last mile problem of innovative drugs.
"

Blindly criticizing hospitals and doctors is unsolvable.
Where does this problem that has become more and more intense in the past five years originate?

Is the rate at which the drugs in the catalog enter the hospital slowing down?

Many innovative drugs have not entered the hospital for a long time after entering the catalog.

During the two sessions, the topic of how innovative drugs get through the "last mile" of entering the hospital once again sparked multi-party discussions.
Yao Shukun, a member of the National Committee of the Chinese People's Political Consultative Conference and former vice president of the China-Japan Friendship Hospital, submitted the "Recommendations on Smoothing the Mechanism for Rapid Access of Class 1 New Drugs to Medical Institutions and Improving Patient Access.
He found that among those drugs that “have been covered by medical insurance but cannot enter the hospital”, there are many Class 1 new drugs among them.

According to the survey data of the Chinese Pharmaceutical Association, the proportion of oncology innovative drugs included in the National Medical Insurance Catalogue from 2018 to 2019 is only 15%-25% by the third quarter of 2020.
More than 75% of patients cannot get regular prescriptions from the hospital.

The patient organization "Dongdong Oncology" recently launched a survey and found that although the country included the first PD-1 drug at the end of 2019, among the 353 patients in 26 provinces, municipalities and autonomous regions across the country, only through out-of-hospital The percentage of purchasing PD-1 is 64%.
The organization is concerned about the future hospital admission speed of the four PD-1 drugs that enter the 2020 medical insurance catalog.
It put forward hopes at the end of the research report: "Reduce unnecessary processes and restrictions" and "Encourage the opening of green channels.
"

The slow admission of PD-1 is not an isolated case.
The ovarian cancer drug olaparib, which entered the national medical insurance list at the same time, was admitted to the hospital for nearly one year after being included in the medical insurance, and the proportion of hospital admissions was only 26.
76%.

The public's demand for innovative drugs is extremely urgent.
Many patients hope that as soon as the new medical insurance catalog is promulgated, they will be able to buy any of the newly added drugs in the hospital, but this is not realistic.

"On March 1, the new medical insurance catalogue was implemented, and 119 domestically-made new drug varieties were admitted.
By March 12, it was more than ten days.
We had received several inquiries, and we were all asking one question: why is medical insurance available? New drugs can't be prescribed from your hospital?" Zhang Lan, director of the Pharmacy Department of Xuanwu Hospital of Capital Medical University, said in a live broadcast hosted by the People's Daily health client.

According to Yao Shukun, the vice president of the China-Japan Friendship Hospital, most of the new tumor treatment drugs that will be admitted to the medical insurance catalog in 2020 may take six months or more to land.

An industry researcher pointed out to the eight-point health news that there are policy advantages for the drugs in the medical insurance catalog to enter the hospital.
However, it seems that the time from entering medical insurance to entering the hospital for innovative drugs has become longer and longer.

"One or two years ago, the common policy requirement was that the negotiations ended in November and the implementation would be implemented before March.
But now, the regulations in some provinces have been changed to: implementation within a year or longer.
"The direct reason is that more and more drugs are entering the medical insurance catalog, and the capacity of hospital pharmacies is limited, and the policy dividend for entering the hospital for innovative drugs has gradually decreased.

So, has the speed of landing (entering the hospital) of a drug after being included in the medical insurance catalogue slowed down compared with the previous years?

A senior industry observer gave a negative answer.
She pointed out that the landing is actually faster than before.
In the past many years, after the national medical insurance catalogue was finalized, the provincial capitals had to make some additions and reductions to determine the provincial medical insurance catalogue, and the progress of medicines entering the hospital was relatively slow.
She believes that more innovative drugs have been included in medical insurance in the past two years, and the speed of admission of these drugs to hospitals under the preferential policies has also increased everyone's expectations for the speed of implementation of all medical insurance drugs.

Is it possible that a hospital has all the medicines in the medical insurance catalog?

In recent years, the national medical insurance catalogue has been adjusted more frequently, and the types of drugs included in it have also increased significantly.
This has brought new problems to the implementation of the drugs, and the pressure on all parties has also increased sharply.

The problem can be seen from simple figures: In 2000, the National Medical Insurance Catalogue contained 1,535 types of drugs, and in 2019 it increased to 2,709 types, and in 2020 it will continue to increase to 2,800 types.

According to many media reports, the health and health commissions in many places have clear restrictions on the performance evaluation indicators of public hospitals: ≤1500 tertiary hospitals and ≤1200 secondary hospitals, which is the same as the number of products in the medical insurance catalog.
The gap is huge.

But does a hospital have such a large capacity?

"If a large tertiary hospital has 2,000 kinds of medicines, it would be too much.
" The aforementioned industry researcher told 8:00 Jianwen that the storage capacity and management capacity of the hospital pharmacy are limited, and the cost of increasing the quantity is quite high.
"The same medicine may be There are also different dosage forms.
Some medicines have special requirements for storage, such as refrigeration.
The staff of the pharmacy also keeps checking, and they find that medicines with a near expiry date must be returned to the company.
"

In addition, the inclusion of new drugs is not just as simple as entering the pharmacy.
Any drug that is not widely used in clinical practice is a challenge for doctors.
"After a new drug appears, doctors will have a process of understanding; for the hospital, how to better use the limited resources and dig out its maximum effectiveness also takes a certain amount of time.
If there is no diagnosis and treatment ability, Even the admission is irresponsible for the patients and the medical insurance fund.
" Li Xiaobei, president of Beijing Chest Hospital, said during the "two sessions".

The implication is that not all hospitals have the ability to diagnose and treat new drugs.

The proportion of medicines and the cost of medical insurance control jointly restrict the purchase of hospitals

"If there are other forms of drive or policy encouragement, the hospital may be willing to put 2500 kinds of medicine in its own pharmacy; but if not, it may put less, which is enough for the hospital.
" The aforementioned senior industry researcher pointed out.

The reality is that, driven by policies, hospitals generally will first consider the national centralized procurement of drugs that have won the bid, followed by the basic drugs, and then the national negotiated drugs.

However, under the "zero drug addition" system, the use of drugs cannot bring profits to hospitals, and drug storage and management are cost items.
Therefore, hospitals are faced with pharmacies that have full quota all the year round and often lack the introduction of new drugs, especially high-priced drugs.
power.

At the same time, multi-use drugs, especially high-priced drugs, may have a negative effect on the hospital's performance appraisal.

A major influencing factor is the proportion of drugs.

Although the performance appraisal standard of public hospitals released in January 2019 has cancelled the appraisal standard for the proportion of drugs and replaced them with relevant indicators of rational use of drugs, in practice, most regions still regard the proportion of drugs as a key assessment item.

The person in charge of the medical insurance service department of a tertiary hospital pointed out to Badian Jianwen that the requirements for medicines entering the hospital, such as the proportion of medicines, were set up in the past to solve the problem of undesirable driving force caused by the addition of medicines.

The State Council’s pilot medical reform guidelines issued in 2015 proposed the elimination of the “medicine supplementation” mechanism, and clearly required that the proportion of medicines in public hospitals in 100 pilot cities fell below 30% in two years.

He believes that the situation has fundamentally changed after the drug addition was cancelled.
"Because a large number of innovative drugs are more expensive, the cost of their storage after entering the hospital has increased.
The hospital even considered prescribing as little as possible from the previous to the current one.
" He said, considering from this perspective, Some statistics have been outdated as a means of hospital performance management.

"Innovative drugs can be included in the statistics of the proportion of drugs, but it is not necessary to use this data to link performance.
" He suggested.

In addition to the proportion of drugs, medical insurance control fees are also a major concern for some hospitals when they decide to purchase high-priced drugs.

"After a medicine enters the hospital, it may not only bring about the cost of the medicine, but also the corresponding medical expenses.
" The aforementioned industry researchers listed, for example, a kind of oncology medicine covered by medical insurance.
If a hospital has it, the relevant patients Will come to be hospitalized and incur other expenses related to this disease.

She introduced that some regions have encouraged hospitals to purchase innovative drugs that are covered by medical insurance, but they have not taken into account the related medical expenses that follow.
"Therefore, the more new drugs a hospital buys, the more likely it is that various indicators will exceed the quota.
" In this way, some hospitals that have actively purchased innovative drugs will have less motivation.

"In terms of policy, the multi-sectoral linkage mechanism is not in place.
The price of new drugs is expensive.
However, whether it is in the internal performance evaluation of the hospital, or the amount of capital used by the supervision department of the Health Commission, or the proportion of drugs in the system The assessment is non-sticky.
Therefore, in terms of related policy guarantees, even if it is a bit looser compared to the past, it has not taken a big step forward.
" The deputy dean of a tertiary hospital told 8:00 Jianwen.

Why does the hospital control temporary purchases?

Due to various considerations, hospitals do not formally purchase some medicines in the medical insurance catalog.
However, for special cases where the pharmacies do not have stocks that are actually needed clinically, there is an institutional solution, namely: clinical applications for special medications can be urgently purchased if they meet the conditions.

"If a drug is used in a small amount, the hospital generally does not purchase it.
If necessary, we will make a temporary purchase order.
" An oncologist at a general hospital in Guangzhou told Jianwen at 8 o'clock.

However, temporary purchases are also firmly controlled within a certain range by the hospital.

"Some hospitals require doctors above the director level to have this authority.
Some hospitals will stipulate that a doctor can only apply twice a year.
" A senior industry researcher pointed out.

The aforementioned oncologist from a comprehensive Grade-A general hospital in Guangzhou told 8:00 Jianwen: "I once applied for a temporary purchase of a chemotherapy drug in our hospital, but the signing procedure made my head big and it was too troublesome! I never want to use it in our hospital anymore.
With this kind of medicine, let the patient go directly to the cancer hospital.
"

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