Medicine changes medicine changes Anhui mode lost

Source: new century weekly 2011-12-28 new year is coming For the new round of medical reform launched in 2009, the time of submitting the three-year plan target is approaching However, Anhui model, known as "the most thorough sample of medical reform" and "return to public welfare system innovation", is facing severe challenges In the past three years, Anhui medical reform has made great progress: in November 2009, it took the lead in introducing the implementation plan of basic drug system nationwide, and in April 2011, it achieved "full coverage of basic drugs" in the province one year ahead of the original plan The medical reform office of the State Council praised Anhui model as "a new way for the national medical reform" and "worthy of learning from other provinces, regions and cities in the country" In the middle of November, 2011, CCTV reported that it had fired continuously at the "inflated drug price" In an interview with CCTV on the evening of November 20, Sun Zhigang, director of the medical reform office of the State Council, said that "supporting doctors with drugs" has increased the burden on the people In areas where the basic drug purchase system has been implemented, the drug price has been successfully reduced The positive model he cites is the Anhui model The so-called Anhui model is a comprehensive supporting reform with the basic drug system as the core It requires grass-roots medical institutions to sell only 584 kinds of "essential drugs" with "zero price difference", and simultaneously carry out "comprehensive reform at grass-roots level" under the leadership of the government, including the reform of hospital management system, drug bidding, purchase and distribution system, personnel system, distribution system, security system, etc Specifically, the logic of Anhui model is: drugs are selected through the "two envelope system" of provincial bidding; local governments subsidize the profit loss after "zero price difference"; re position the functions of medical institutions, manage by "two lines of revenue and expenditure", and replace the previous "prescription linked" salary distribution model with performance evaluation The ultimate goal is to establish a new mechanism from the perspective of drug price reduction, to completely replace the mode of "supporting medical institutions with drugs" and to solve the problem of "expensive medical treatment" In the view of policy makers, the above logic is closely linked The implementation of the basic drug system will force the reform of the medical security system, the national drug production and supply system, the basic medical service system, and the medical public health service system, which can be described as "taking one lead and moving the whole body" However, since the implementation of this reform, it has encountered many doubts and negative resistance at the grass-roots level, and the timetable has been repeatedly delayed On November 21, 2011, Li Yaoguang, director of the second division of the medical reform office of the State Council, told the media that there are still nine provinces and cities that have been slow to implement the new mechanism in implementing the bidding system for essential drugs, and Beijing, the capital, is also among them In addition, the other two core systems of Anhui model - "zero price difference" and "two lines of income and expenditure" are not effectively implemented in many provinces Sun Zhigang, director of the State Council's medical reform office, publicly criticized in June 2011 that some provinces simply implemented zero price differential sales of drugs and failed to implement comprehensive reform as required by the State Council The problem is that while the medical reform office of the State Council urges all regions to vigorously promote the Anhui model, the Anhui model itself is undergoing subtle changes On September 1, 2011, Anhui Province issued and implemented the opinions on consolidating and improving the comprehensive reform of grass-roots medical and health system (WZB [2011] No 61, hereinafter referred to as "No 61 document") Reading this document carefully, we can find that its key word is two words - "adjustment" The document is known locally as the "new thirty" Its core is to ensure the increase of investment and financial sustainability The main two adjustments include a substantial supplement to the previously strictly restricted catalogue of essential drugs, and a performance appraisal of medical personnel that "reflects more work, more pay for outstanding performance", etc In the view of many scholars, the essence of this adjustment is "callback" to the pattern before reform In addition to the 1154 regulations in the catalogue of essential drugs, Anhui mode adjustment launched the catalogue of "additional distribution", with a total of 5488 regulations A person in charge of a pharmaceutical enterprise told reporters that this means that the adjustment of the Anhui model is not surprising Before this round of adjustment, reporters in dozens of villages and towns in Anhui Province have found that: after the implementation of the basic drug system, the total medical burden of patients has not really decreased; the phenomenon of "eating the pot of rice" and shirking the responsibility of patients in medical institutions has not been avoided; the drug rebate, which was rarely seen at the rural level, appears in a concealed form; whether the government financial investment can be sustained, These may be the reasons for the adjustment of Anhui model The first item of the adjustment measures requires the grass-roots government to change the operation compensation mechanism of medical and health institutions, bring the basic expenditure into the budget management, turn over the revenue to the finance and specify the use Shen Weiguo, director of the development and Reform Commission of Anhui Province and director of the office of the leading group of medical reform, said at the provincial Conference on consolidating and improving the basic medical reform on August 8, 2011 that this is "to ensure the normal operation of the basic medical and health institutions" Among all the adjustments, the biggest difference is the supplement of the catalogue of essential drugs The measure also has the effect of expanding cash flow for primary medical institutions The so-called essential drugs are the concepts put forward by the World Health Organization in 1977 They refer to the drugs that can meet the basic medical and health needs, have appropriate dosage forms, ensure supply, be equipped at the grass-roots level, and be equitably accessible to the people Its main characteristics are safety, necessity, effectiveness and low price Its original intention is to pursue social equity and ensure everyone's enjoyment On August 18, 2009, China officially announced the implementation opinions on the establishment of the national essential drug system, the measures for the administration of the National Essential Drug Catalogue (Provisional) and the National Essential Drug Catalogue (for the use of primary medical and health institutions), marking the formal implementation of the establishment of the national essential drug system In August 2009, 307 kinds of essential drugs were selected from the first national essential drugs catalogue (Basic Edition) But soon after the catalog was released, it was expanded due to the "insufficient use" of local reports Subsequently, in the provincial "supplement" list of essential drugs issued by each province, each province added 188 varieties on average In Anhui, 277 varieties were added, with 584 kinds of essential drugs in total After the first bidding, there were 1154 specifications In addition to the 1154 items of basic drugs, the adjustment of Anhui Province launched the catalogue of "additional matching" basic drugs, with a total of 5488 items, almost covering all the drugs in the Anhui Medical Insurance catalogue and the new rural cooperative medical insurance catalogue According to No 61 document, all central health centers can "reasonably expand the scope of drug use", that is to say, "on the premise of ensuring that the proportion of basic drugs used is not less than 70% of the purchase amount, they are allowed to appropriately add some clinical drugs from the new rural cooperative medicine catalog and the medical insurance catalog in addition to the basic drugs and provincial supplementary drugs The purchase amount of additional drugs shall not exceed 15% of the total monthly purchase amount " According to the relevant documents of the State Council on the reform of the basic drug system, the drugs in the catalogue of basic drugs shall be priced through the "two envelope" system This is also one of the most controversial and characteristic signs of Anhui model At the end of 2010, it was written into the guiding opinions on establishing and standardizing the bidding system for purchasing essential drugs issued by the general office of the State Council, which became a national policy However, it is surprising that the drugs listed in the "additional distribution" catalogue can only be purchased according to the provincial bidding price of medical institutions above the county level before the reform Xie Ruijin, director of the Anhui Provincial Department of health policy and regulation, told reporters that the current adjustment plan is only transitional policy because Anhui has no tender plan this year However, a person in charge of a pharmaceutical company, who declined to be named, commented: "after the adjustment, the principle of basic drugs is not followed, and the" two envelope "bidding is also abandoned, which means that the Anhui model cannot be implemented any more." In his opinion, although the drugs in the catalogue must be sold at a low price, the grass-roots medical institutions can make profits by selling the drugs out of the catalogue, and continue the mode of "supporting doctors with drugs" Another notable adjustment is to open the income gap of medical staff, "increase the proportion of incentive performance pay, reflect more work, excellent performance pay"; and "deduct performance pay and Dean's reward according to relevant regulations for the illegal behaviors such as excessive medical treatment, prevarication of patients, arbitrary charges and so on" Shen Weiguo, director of the development and Reform Commission of Anhui Province and director of the office of the provincial medical reform leading group, publicly explained that the move was "to mobilize the enthusiasm of the president and medical staff" In fact, long before this document was issued, some regions had made similar adjustments, so that doctors' salaries were directly linked to business volume A surgeon in a township hospital in Anhui Province told reporters that a few months ago, the Health Bureau set an assessment target of 200000 yuan of profit for the hospital in 2011 However, the quantity assessment has the suspicion of giving birth to a "big prescription", which is exactly what the Anhui model should try to avoid According to Gu Xin, a professor at the school of government management of Peking University, these adjustments are likely to make the grass-roots units return to the situation before the implementation of the Anhui model, "in fact, they are nibbling at the Anhui model a little bit." However, Zhao yuebin, deputy director of the Health Bureau of Feixi County, said the adjustment was a positive move: "to measure the success of a reform, it depends on whether problems can be found in time and whether there is courage to make breakthroughs." According to the explanation of Anhui Province, the reason for the above adjustment is that "there are some new situations and problems in the process of system transformation" Previously, the official figures had been optimistic Among them, drug price reduction is the biggest highlight of Anhui model According to the data provided by the Department of health of Anhui Province, from September 20, 2010 to September 20, 2011, the basic medical and health institutions in Anhui province implemented the basic drug system, showing a trend of "four drops and one rise": the average outpatient drug cost, antibiotic utilization rate, the average outpatient fee and the average inpatient drug cost decreased by more than 20%, and the number of outpatient increased by more than 10%, The burden of medical treatment for the masses was significantly reduced There are many such cases in reality In March 2010, Guo Chengzhang, who worked in Danyang, Jiangsu Province, went back to his hometown, Dingyuan County, Anhui Province, to seek medical care In Danyang hospital, the average cost of hernia surgery was 5000 yuan, and after the reimbursement of 30% of the new rural cooperative medical system, he had to pay 3500 yuan at his own expense However, in Zhangqiao town hospital, Dingyuan County, the total cost of surgery was less than 1000 yuan, and the reimbursement was 75%, Personal expenses are less than one tenth of the former However, on the other hand, the decrease in drug prices did not make Anhui's primary medical institutions like a city, especially the inpatient areas In March and April this year, reporters visited dozens of Anhui township hospitals and found that most of the wards were empty In a township hospital in Feixi County, Hefei City, a nurse told reporters that more than 20 beds were sometimes full before the reform, and the number of patients decreased every day after the reform On the day of the interview, only one patient was hospitalized According to the summary report of medical work of Health Bureau of Feixi County in 2010, the number of inpatients of primary medical institutions in the county decreased by 57.4% in 2010, and the proportion of reimbursement decreased from 20% in 2009 to 10.5%; the number of inpatients of county-level medical institutions in the county decreased by 5.1%