Looking at the medical reform during the 14th Five Year Plan from the perspective of "one pill"

Innovative drugs in the past five years have been included in the review, and a large number of "zombie drugs" are facing elimination. In 2020, the adjustment of the national medical insurance drug catalog will enter the countdown. This unprecedented adjustment will be an upgraded guarantee for the 1.4 billion people's medicine basket.

Since this year, the medical field has been turbulent. The coronary stents that fell into the "millennium era" started the national procurement of high-value medical consumables; A total of 112 countries have fully implemented the centralized procurement of drugs, with an average price reduction of 54%; The record keeping system for medical representatives was formally implemented to end the "sales with money"; Drug circulation is moving towards the "last mile" in the Internet field

One pill affects people's livelihood. As we move towards the "14th Five Year Plan" medical reform in the deep-water area, how can we continue to reverse the false high price of drugs and the phenomenon of using drugs to supplement medicine, and how can we take the drug reform as a breakthrough to let the people spend less money and enjoy better health?

On December 14, Yuan Hongwei, a physician of Chaoyang District People's Hospital, Changchun City, Jilin Province, diagnosed and treated patients. Photographed by Zhao Dandan, reporter of Xinhua News Agency

"Three Axes" of Centralized Purchase: Drug Price Reduction Will Become Normal

Recently, Yuan Hongwei, a physician of Chaoyang District People's Hospital in Changchun City, Jilin Province, found that a kind of metformin hydrochloride tablet whose price was too low to believe had appeared in the system when he was prescribing the medicine. Only when he asked, he knew that it was the selected drug of the state.

At the beginning of December, the third batch of 55 kinds of drugs organized by the state to purchase collectively were launched in public hospitals across the country. Metformin hydrochloride is one of the "star drugs" - a first-line hypoglycemic drug for type 2 diabetes. In the fierce competition among 44 pharmaceutical enterprises, the average price of a 0.5g tablet is only 6 cents.

Chen Shuyun, a citizen of Changchun in his 60s, took metformin hydrochloride tablets for a long time due to illness. Her daughter told the reporter that her mother had prescribed Gehuazhi in the hospital before, each box of which was 10g in size. She needed to take 6 boxes every month, which cost a total of 140 yuan.

Not long ago, she went to the hospital again to prescribe medicine for her mother, and found that the price of each box of 25g metformin hydrochloride tablets was 3.56 yuan, which cost 8.5 yuan per month, only 6% of the previous cost.

"The doctor explained to us that the quality of cheap drugs is recognized by the state and can be used safely. Parents are not distressed by the drugs, and the children's burden is lighter," said Chen Shuyun's daughter.

This is a photograph of metformin hydrochloride tablets taken in the pharmacy of Chaoyang District People's Hospital, Changchun City, Jilin Province, on December 14. Photographed by Zhao Dandan, reporter of Xinhua News Agency

How did you get cheap medicine for a few cents? The answer is centralized purchase with quantity.

Ding Yilei, Deputy Director of the Department of Medicine Price and Bidding Procurement of the National Medical Security Bureau, said that "with volume" is the core of the reform, and the governance is to drive up prices in the circulation link. The national and local medical insurance departments are the spokesmen of "quantity", holding the account book to directly "group purchase" with manufacturers.

How fierce is the centralized purchase of drugs and high-value medical consumables this year? The National Health Insurance Bureau gives an account:

The price of small stents was reduced by 93% - the average price of the first batch of coronary stents purchased by the state in a centralized manner fell from 13000 yuan to 700 yuan. Compared with 2019, the average price reduction of the same products of the same enterprises reached 93%. According to the latest purchase volume, it is expected to save 11.7 billion yuan.

The "centralized drug collection" has been reduced in half - patients have been able to use three batches of 112 cheap drugs brought about by the national centralized drug collection in national public hospitals, with an average price reduction of 54%, and the maximum price reduction of some drugs has exceeded 95%, covering diabetes, hypertension, anti infection, anti-tumor and other treatment fields, all of which are drugs with large clinical use.

The drug cost was saved by 53.9 billion yuan - calculated according to the agreed purchase volume of the national centralized purchase, the annual drug cost decreased from 65.9 billion yuan to 12 billion yuan, saving 53.9 billion yuan. If the reimbursement rate is 60%, it can save 21.6 billion yuan for patients and 32.3 billion yuan for medical insurance funds.

People can't help asking why the price of drugs can be reduced so much? Can cheap medicine be used safely?

"The core of price reduction is to make drugs better, not just cheap." Ding Yilei said that the "three axes" of the centralized procurement system is to use demand orientation to curb clinical abuse; The second is to use competition rules to guide drug prices to return to reasonable intervals; The third is to promote a clean and healthy atmosphere in the pharmaceutical industry with the volume rule.

To sort out the history of China's pharmaceutical reform, from the zero price difference and two ticket system reform of drugs at the circulation end, to the clinical prescription supervision and key drug monitoring directory at the user end, to the drug consistency evaluation and marketing licensor system at the production end, the reform of "one drug" is like a delicate operation, with the goal of gradually returning the drug market to the normal value system, At the same time, the drug price will be greatly reduced, not just the price "dropped".

The reporter noted that the national organization of centralized drug purchase has formed a normalized mechanism from procurement, payment, advance payment collection to landing use, quality control, etc. At present, the centralized purchase of local drugs, including more varieties of non overrated drugs, has become a burning fire.

Ding Yilei said that as long as the number of drugs that meet the conditions for centralized purchase or their amount reaches a certain level, the country will be triggered to organize centralized purchase. It is expected that two batches of drugs will be collected annually. This means that more low-cost drugs and medical consumables are on the way.

Change of medical pattern: "vacate the cage and replace the bird" for medical reform

Clear out the zombie medicine. Please come in with the lifesaving medicine. The annual adjustment of the medical insurance catalogue is also a dynamic adjustment of the medical pattern.

The reporter observed that new drugs from January 1, 2015 to August 17, 2020 were included in the review scope of this catalog adjustment, which can be said to open the "gate" to encourage innovation to the maximum; Some magic drugs, zombie drugs and drugs with obvious abuse that have been criticized by the masses for a long time will be removed from the list to make room for life-saving drugs with high clinical value.

The medical reform in deep-water areas is manifested in medicine, which is rooted in medicine. Therefore, one "medicine" affects the whole body.

Looking at the changes in the medical pattern in the year 2020, from the epidemic situation at the beginning of the year that made Internet medicine catch the fast train, to the mid year "price cutting tide" spread to pharmacies and non-public medical institutions, to the end of the year coronary stent price plunge, and the in-depth adjustment of the medical insurance catalog, the effect of its linkage reform is gradually emerging.

The People's Hospital of Shanglin County, Guangxi Province has been collecting goods since January 1 this year. Previously, the drug revenue accounted for about a quarter of the hospital's total revenue, which dropped to about 15% after the collection of drugs. However, Pan Maohua, the president, said that at present, there are not enough varieties of centralized procurement.

Why does the president want more cheap drugs when drug income drops?

Pan Maohua said that this move has greatly promoted rational drug use and optimized the income structure of medical business. "In the past, there were too many drugs prescribed, and some people would scold them if they didn't understand. Now doctors are more concerned about rational drug use when prescribing drugs. In addition, the medical insurance surplus saved by centralized purchase can be retained, and the money used for hospital development and staff income can be increased along with it, which has stimulated the enthusiasm of medical personnel. The hospital has also entered a benign development of cost reduction, structure optimization, and management promotion."

Where has the saved medical insurance fund gone? That's the answer——

Ding Yilei said that, in essence, the reform of centralized procurement has freed up the "old cage" of high drug prices, difficult sales with gold, and strained doctor-patient relations, and replaced it with the "new bird" of returning public hospitals to public welfare, purifying the ecological environment of the pharmaceutical industry, and promoting industrial transformation and upgrading.

Lv Sheng, director of the medical price and bidding procurement department of the Medical Security Bureau of Guangxi Zhuang Autonomous Region, introduced that while Guangxi actively promoted the implementation of centralized drug collection in grass-roots hospitals, it also reduced the transaction cost of the purchase of the selected products and significantly shortened the payment collection time of medical institutions and production enterprises through information system transformation, medical insurance fund prepayment and other means, Effectively improved the local medicine industry ecology.

According to the data from the National Health Insurance Bureau, the proportion of sales expenses in operating income of some selected enterprises has dropped from 40% to 5% to 10%; Some over evaluated generic drugs effectively replace the original drugs; Some selected pharmaceutical enterprises have significantly increased their R&D investment.

For ordinary people, the supply side reform effect of medical services is also emerging.

The first-line drugs for hepatitis B, tenofovir dipivoxil and entecavir, used to be expensive, and initially each person spent between 13000 yuan and 18000 yuan annually. In 2019, the national medical insurance department reduced the prices of these two drugs through centralized procurement, and the annual cost per person was only 200 yuan.

"Centralized purchasing not only reduces the burden of patients who take medicine for a long time, but also benefits the people who can't afford to take medicine in the past." Jia Jidong, director of the Liver Disease Research Center of Beijing Friendship Hospital affiliated to Capital Medical University, said that taking entecavir as an example, the patient selection rate rose from about 20% at the beginning to nearly 80% after centralized purchasing, and the situation of not treating or not adhering to treatment due to economic reasons was greatly reduced, It has greatly promoted the prevention and treatment of hepatitis B.

However, the historical documentary of professors from the School of Pharmacy of Peking University also reminds that centralized procurement and drug price reform cannot become an island of policy. Only by truly realizing the linkage of the three medical services, "vacating the cage" and "changing the bird" can we ensure that the space vacated will not be occupied by other interests, and realize the reasonable return of drug prices.

New "medicine" formula of medical reform: innovation leads high-quality development

In Jiulong Village, Mingliang Town, Shanglin County, Nanning City, villagers had to go to the big hospital to get medicine as long as they swiped their medical insurance cards. This is because the village clinic has not connected to the direct medical insurance settlement system, and the identification of chronic diseases must also go to the hospital above the second level.

Today, all villages with clinics in Guangxi have access to medical insurance. Villagers can swipe their cards at their doorstep, and can also recognize their faces, which is very convenient. Some diseases can also be recognized by the first level designated hospitals with qualifications.

"The cheapest medicine must be available at the grass-roots level and can be reimbursed. This is of great significance for the implementation of hierarchical diagnosis and treatment." The village doctor Meng Meise has a deep feeling, like the commonly used amoxicillin granules, which has now been reduced to more than one yuan per box. The villagers will not complain that the car fare is more expensive than the drug fee.

"In the previous reform, we have always focused on the unit price of drugs, but in fact, the drug price problem may be just a symptom, not a cause." Gu Xuefei, director of the medical security research office of the Health Development Research Center of the National Health Commission, said that the problems people criticized in the past, such as the high price of drugs and supporting medicine with drugs, were basically the problems of inappropriate doctor incentive mechanism and inadequate medical security. If you want to prescribe new "medicine", you have to come up with new "tactics".

In the health room of Shinan Village, Pinggui District, Hezhou City, Guangxi, a doctor sees a doctor for villagers (photographed on November 13, 2019). Photographed by Lu Bo'an, a reporter from Xinhua News Agency

From the opening of the door to the normalization of centralized purchase of drugs and consumables, to the negotiation of updating the medical insurance catalogue, and the rules of access to competitive pricing; From the newly revised drug management law, which focuses on the control of fake and substandard drugs, to the "out" of the medical representatives who undertake sales tasks... 2020 is a year of innovation for the medical field.

It has become the consensus of all parties to look forward to the "14th Five Year Plan" and lead high-quality development in the pharmaceutical field with innovation.

Hu Yinglian, professor of the Central Party School (National School of Administration) and director of the China Pharmaceutical Regulatory Research Association, said that under the challenges of aging population and increasing number of chronic disease patients, especially the test of COVID-19, China's drug governance has entered a new stage. In the past, the focus was on the scale and quantity of the pharmaceutical industry, and the focus was on people's health, ensuring the quality and safety of drugs and promoting innovation.

Gu Xuefei said that during the "14th Five Year Plan" period, it is urgent to take "one pill" as a breakthrough, through the innovation and implementation of various mechanisms, to truly establish an integrated medical and health service system centered on people's health, as well as a health value oriented medical insurance payment system.

In the Shinan Village Health Center, Pinggui District, Hezhou City, Guangxi, doctors use the "Village Medical Access" system to swipe the patient's ID card to settle medical expenses (photographed on November 13, 2019). Photographed by Lu Bo'an, a reporter from Xinhua News Agency

The "Internet+medicine" that shines brightly during the epidemic may become an overtaking tool for a new round of medical reform. At present, Beijing, Shanghai, Fuzhou, Ningbo and other places have incorporated Internet hospitals into their new infrastructure development plans. New policies such as "Internet+" medical insurance payment, health information sharing and mutual recognition are also being explored.

Experts believe that Internet hospitals, as the "standard configuration" of offline entities, will become the general trend of medical reform during the "14th Five Year Plan" period, but drugs are high-risk products in the Internet medical service scene, so the promotion process should be cautious.

Hu Yinglian said that in the next five to ten years, the development and security of the medical field must be well coordinated, and the bottom line must be kept, as well as the top line. We should coordinate the policy objectives of drug quality and safety, medical insurance fund safety, and anti-monopoly economic safety to prevent and resolve major risks. At the same time, we will use efficient regulatory governance to boost the high-quality development of the pharmaceutical industry, so that Chinese people can fill their own medicine cans with more good medicines.