The source of false high drug price: rebate becomes rigid demand

Source: caixin.com is expensive to see a doctor on September 6, 2016 Where is it? The high price of medicine is what we call it Expensive medical treatment includes many factors, but the high drug price is a fact, and it has always been the focus of the government's attempts to control High drug price can be divided into two levels: "high drug unit price" and "high total drug cost" According to the 2015 statistical bulletin on the development of China's health and Family Planning Undertakings issued by the health and Family Planning Commission, out-patient medicine accounts for 48.3% and in-patient medicine 36.9% of China's total medical expenses, while those in developed countries such as Britain and the United States account for only about 10%, so there should be a large space for China's medicine expenses to fall In addition, relevant research shows that more than 60% of domestic drug prices are spent on logistics and public relations, while the proportion of medical insurance fund waste and loss is about 50%, which is shocking A lot of people think that it is the root of high drug price to raise medicine with medicine, which must be eliminated But since ancient times, doctors have been raising medicine with medicine Why has it suddenly become a problem in recent years? Why did street vendors sell pancakes to support their families, which never caused the public to "eat breakfast expensive"? Zhan Jifu, a star of Sanming medical reform and the new deputy director general of Fujian Provincial Department of finance, thinks: "if the 3 million medical representatives of the whole country don't disappear and change careers, it's impossible for ordinary people not to take unjust drugs, not to open unjust knives, not to spend unjust money", which means that eliminating medical representatives can stop the high price of drugs In this regard, Liu Qian, the author of medicine, points out:“ Medical representatives are not the culprit of high drug prices or medical malpractices, but the root of medical malpractice lies in the cultivation of medicine These theories are not new Similar theories have been popular for a long time, but they are far away from the facts 1、 The pharmaceutical representatives have no ability to push up the drug price, the elasticity of drug demand is low, the consumption needs to rely on the doctor's appointment, there is a third party to pay, the final consumers have no bargaining power, and the drug price is largely subject to the centralized bidding process and public relations in the circulation process, which makes the formation mechanism of drug price confusing, but it has little to do with the pharmaceutical representatives Zhan Jifu said: "the bidding price of drug procurement at provincial level is several times or even dozens of times of the factory price, and the final price paid by patients is also several times or even dozens of times of the factory price" This has proved that high drug price is closely related to bidding, so how can we put the responsibility on the medical representatives? Many medical representatives are really important participants in the implementation of drug rebate, but only supply when there is demand Medical representatives can't determine the drug price, but only a link in the circulation It can't be the reason why the drug price is falsely high To make the medical representatives disappear is just to make the soup boil down, and it can't fundamentally solve the problem of the drug price falsely high 2、 It is not the reason for the high price of medicine to raise medicine with medicine "the system of raising medicine with medicine" is often considered as the reason for the high price of medicine, so there is a policy of "zero margin", but it is not a system arrangement, but a contingency choice for hospitals and doctors in the reality of unbalanced financial compensation and administrative control of medical service price The so-called medical care by drugs generally refers to the medical care by drugs, but in fact, the bigger problem is the medical care by drugs, and the proportion of drug rebate collected by doctors is several times higher than that of hospitals No matter whether the hospital can get direct benefits from drug sales or not, doctors can get benefits through kickbacks This kind of gray income has reached hundreds of billions of yuan every year Too many people are involved in it The structure of benefits is intertwined and hard to return This has long been an open secret, but many experts in the industry seem reluctant to face the reality There is a saying that when the zero difference rate of drugs is not implemented, doctors are also generating income for the hospital while collecting kickbacks, so the hospital will turn a blind eye to it and even encourage it Once the zero difference rate of drugs is implemented, the hospital loses the profit of drug management, and will not allow doctors to collect kickbacks again This view is naive The zero difference rate of drugs does not mean that hospitals will not be able to make profits from drug sales Even if hospitals cannot legally increase prices to make money, they are also able to make profits in private by asking for rebate and rebate In fact, after the implementation of the zero difference rate system, the main factors considered by many hospitals are still the level of rebate and rebate There are also some hospitals with zero margin implemented pharmacy trusteeship, and then collected fees from the trusteers In addition, it is the bottom line of many doctors (especially department backbones) that can withdraw the deduction, and many directors also participate in it The motivation of hospitals to touch the bottom line is insufficient Therefore, it is impossible to eliminate the zero difference rate, which is just a contingency choice of hospitals and doctors under the current system, and is one of the many adverse results of the current medical system, rather than the real reason for the high drug price 3、 Centralized bidding is not the culprit of high drug prices The current bidding system is indeed responsible for pushing up drug prices, which seems strange Common sense tells us that unified bidding can generally reduce procurement costs Why does drug bidding push up drug prices? The secret lies in the separation of bidders and payers, as well as the real dilemma of China's medical industry The essence of centralized bidding is to concentrate the power of drug purchase on a few officials The view that everything can be solved through "government supervision" needs to assume that all government officials are moral models who do not eat fireworks, otherwise they will not be able to escape the temptation of corruption, and administrative power supervision will inevitably make supervision an objective pleasure park for rent-seeking Thousands of pharmaceutical companies across the country are competing for bids There are only a few people in the drug bidding office, plus only a few dozens of evaluation experts In order to win the bid, pharmaceutical companies need to pay bribes, and the officials of the bidding office are often bought by pharmaceutical companies, which is inevitable However, the problem of bidding is not only the corruption of officials In the reality of administrative medical system, it is difficult to rationalize the income structure of hospitals and doctors, which leads to the rigid demand of drug rebate Only high drug price and high rebate can make the medical industry survive in the current system If the bidding price does squeeze out the water of drug price, the medical system may be in trouble, which is the deep reason behind the phenomenon of high drug price Medicine is also a kind of commodity, and the "reasonable price" of commodity can only be achieved through full and fair market competition Even if the bidding can really reduce the price of drug bidding to a reasonable range, the hospital also needs to have other benefits to compensate If the compensation is still set by the government, the price of the medical industry will continue to be distorted, and the problems of the medical industry will not be solved Doctors are high-tech talents It's difficult to keep doctors only by the salary of institutions Once the drug rebate disappears, the real income and expected income of doctors will also drop sharply, and doctors may lose a lot, which may bring unpredictable consequences to the medical industry Therefore, there are deeper reasons behind the false high price of drug centralized bidding These problems can not be solved only by anti-corruption, and centralized bidding is not the real source of high drug price There is a view that as long as the hospital is allowed to negotiate twice after bidding and the 15% mark up limit is broken, the hospital will have the motivation to reduce the purchase price of drugs and distribute this part of profits to doctors in the way of sunshine income In this way, the problem of rebate, high drug price and waste of medical insurance funds can be solved at one stroke, or the government can directly increase doctors' wages, "high salary and low cost" ” 。 But the reality is: if the doctor's legal income is very high, it may be difficult for the hospital's administrative staff and other employees of public institutions to balance At the same time, the public hospital can make profits freely and distribute them freely When making losses, it is necessary to guarantee the doctor's income financially This is determined by the nature of the business unit, which is obviously unreasonable Therefore, in the case of the unchanged personnel system , such so-called sunshine distribution schemes are difficult to be implemented or sustained In addition, high salary and integrity are always illusions As long as there are opportunities and risks, few people will refuse possible benefits, unless there is an effective restraint mechanism and a good legal environment 4、 The two ticket system can't solve the problem that the drug price is too high The factory price of drugs is very low After many circulation links increase the price level by level, they can be sold dozens of times in the hospital Therefore, streamlining the circulation link is considered to reduce the drug price Recently, the State Council issued a document to implement the "two vote system" in the pharmaceutical industry The two ticket system can reduce the intermediate link, or it is conducive to the timely traceability of drugs and improve the safety of drug use, but it may only be wishful thinking to expect that the two ticket system can reduce the drug price "Two vote system" is not a new thing Guangdong Province tried out "two vote system" ten years ago, but it has not been implemented for various reasons In essence, the two vote system is to achieve two goals, one is to reduce the price increase in circulation, the other is to promote the tax bill compliance to control the high return It is impossible to reduce the price of drugs only by reducing the circulation links, because the terminal price of drugs does not depend on the production and circulation costs, but depends on the supply and demand game or bidding procedures No matter how many circulation links are in the middle, it is impossible to affect the terminal price, but only affect the distribution of interests in the circulation links The "two vote system" is more likely to increase the operating costs and legal risks of operators' high opening and high return by promoting tax bill compliance, so as to achieve the purpose of operators' initiative to reduce the invoice price, which may not really be achieved, and is likely to backfire Under the condition that the compensation mechanism of public hospitals is not perfect and the price of medical services is under administrative control, the demand for drug rebate is rigid In the face of higher operating costs, enterprises are more likely to choose to further increase the invoice price to cover the increased costs, which is not only unable to reduce, but also likely to continue to push up the drug price 5、 Medical ethics is not the key to solve the problem of high drug prices Many people believe that the existence of drug rebate is due to the corruption of doctors' medical ethics, which is not the truth Doctors are also human beings Their behaviors are highly dependent on institutional incentives It may be a moral problem for individual doctors to do so, but the common phenomenon can not all be attributed to the moral factors of individual doctors Doctors are high-tech and high-risk occupations The average income of doctors in the world is very high Qualified doctors should get higher income However, the reality of the establishment management of public institutions has hindered the improvement of doctors' legitimate income In fact, it is a helpless choice for the medical industry to support doctors with drugs Although the drug rebate is illegal, it has objectively stabilized the doctor team without directly increasing the financial burden, which is a weird reality Some doctors have commented that the so-called good doctors only passively collect drug kickbacks, but will not actively and deliberately prescribe large prescriptions for patients in order to get kickbacks If doctors in public hospitals want to refuse kickbacks, they will often be isolated, or even be difficult to stand in the Department because they affect the interests of their colleagues This is the real portrayal of the current Chinese medical industry Drug rebate will not only lead to patients and doctors