I'm guessing you've probably seen this kind of news.
He was hospitalized for more than 60 days and spent 1.4 million yuan in medical expenses. Not only is the total cost frightening, but two days after the patient's death, the hospital is still prescribing laboratory tests.
Among the more than 9,700 yuan of medicines, auxiliary drugs such as traditional Chinese medicine injections and nutrients account for most of them. The real cure is only 1,000 yuan.
A hospital has problems such as excessive diagnosis and treatment, excessive inspection, over-prescribing drugs, repeated charges, application charges, and over-standard charges, involving a total of 218,200 yuan of illegal medical expenses, of which 187,000 yuan is used in violation of medical insurance funds.
Medical chaos happens from time to time. In media reports, doctors who treat and save lives also seem to have become the enemies of patients.
On the other hand, the news about adjustment and reform has not stopped.
For example, improve the medical insurance system. For example, expand the scope of centralized drug procurement. Another example is the establishment of a dynamic adjustment mechanism for the price of medical services.
However, how is the reform that has never been interrupted? Can it solve the medical chaos? What is the medical reform, what is the medical reform, what impact will it cause, and what does it mean to me?
Well. These issues deserve special attention. Because birth, old age, sickness and death are big things for everyone.
But I'm not in the industry after all, so I don't know enough. So, I found Mr. Zhang Xiaoping and had an in-depth chat with him.
Mr. Zhang Xiaoping is the secretary general of the DTP Committee of the China Medical Materials Association, the CEO of Keycloud Technology, and the general manager of Xiaokang Online, and has been engaged in the medical and health service industry for more than 20 years. Whether it is macro thinking in the pharmaceutical industry or summarizing practical theories, he has expertise.
From the pharmaceutical reform measures in the second half of 2023, we talked about the possible impact in the future, and talked about the doctor-patient relationship. After chatting, I felt that I had gained a lot, and I also had a more systematic understanding of the purpose and impact of medical reform.
Therefore, I have also compiled the content of this conversation and shared it with you. Hope it helps you a little.
Let's start with the phrase "medicine for medicine".
One of the purposes of medical reform is to eliminate the "use of medicine to maintain medicine"
Yes. Medicine for medicine.
In 2012, the Ministry of Health proposed to abolish the mechanism of "supplementing medicine with medicine" and deepen the reform of public hospitals. In 2017, Xinhua News Agency published a commentary mentioning that it would eliminate the use of medicine to support medical care and return public hospitals to public welfare. In the report of the 19th National Congress of the Communist Party of China, it was also proposed to "completely cancel the use of medicine to maintain medicine".
Whenever there is news involving health care reform, the term always seems to come up.
But what exactly is medicine for medicine, and what are the consequences?
Cultivating medicine with medicine is a medical institution that increases income through drug sales. To put it simply: the more drugs are sold, the higher the hospital's income.
The origin of this incident can be traced back decades.
After the reform and opening up, with the rise of medical technology, our financial investment was insufficient, and we had to push the hospital to the market and be responsible for our own profits and losses.
Among them, there is such a rule: hospitals are allowed to sell drugs as a markup. That is: to use medicine to maintain medicine.
Truly. When more than half of a hospital's income needs to generate its own income, although it is helpless to use medicine to support medicine, it does allow many hospitals to survive.
Isn't that great?
It's pretty good. But after it solved the problem of food and clothing, it left another question, about "human nature".
There is really no money, you can rely on it to solve the problem of food and clothing, everyone understands.
But when the operable space becomes more and more "abundant", will you use it to solve the problem of affluence?
For example, which drug has a higher profit and which one to use. For example, prescribing more adjuvant drugs that cannot have a real therapeutic effect will increase drug sales. For example, which company promises more "kickbacks" and gives more bribes, which one to use. Another example......
Therefore, the most direct consequence of using medicine to maintain medicine is excessive medical treatment. Minor illnesses can be cured, and major illnesses can be cured for a long time.
And this will cause a huge waste of medical resources.
According to a 2015 report by People's Daily Online, the waste of medical resources due to the indiscriminate prescribing of drugs and inspections by medical institutions may exceed 20% every year. If coupled with drug rebates, inflated drug pricing, arbitrary charges, etc., the proportion of waste and loss of medical insurance funds is not less than 50%.
In addition to the waste of medical resources, doctors are not compensated for their labor.
Because medical institutions rely on medicine to support medical treatment, most of the doctor's income also falls on the sales of drugs.
As a result, countless doctors have to sell their high-tech labor at low prices to earn bonuses from patients' "drug buying" behavior. The effort and the income are not proportional.
However, what doctor does not want to be upright and make money with his knowledge and skills?
In the end, it is the patient who pays.
When you go to the hospital, it seems that you have to do several tests every time. What about the drugs prescribed? Useful, not much. It's useless, so much that it seems like you'll never be able to eat it all.
It costs a lot of money, but it may not cure the disease. Even those who are not sick have seen that they are sick, causing additional harm, and their trust in doctors is becoming less and less.
Humanity does not stand the test. It's time to stop using medicine to maintain medicine.
This is also an important reason why the state vigorously promotes "medical reform" and eliminates the use of medicine to support medical treatment.
So, how to break it?
Reduce the price of medicines, improve treatment, and grasp anti-corruption
Teacher Zhang Xiaoping said:
In three steps. The first step is to reduce the price of drugs. The second step is to improve the treatment of medical personnel. The third step is anti-corruption.
The first is to reduce the price of medicines. Squeeze the water out of the price of drugs and use it to improve doctors' salaries, benefits and bonuses.
It does not increase the expenditure, so it does not increase the burden of medical treatment on the people, and it also solves the income problem of medical staff.
After the current work is done, it is necessary to intensify anti-corruption efforts and further standardize the use of drugs. On the premise that the income is reasonable, of course, it is not possible to "generate income" in other places.
Three steps down, theoretically, can completely break the "medicine to maintain medicine".
Does that sound reasonable?
In fact, this method also has a name, called the Sanming model, which is named after the successful model of medical reform in Sanming City, Fujian Province.
Let's take a look at Sanming City first, how to do it.
According to People's Daily Online, the key points of Sanming's medical reform include:
Carry out joint price limit procurement of drug consumables on a regular basis, reduce inflated prices, use 80% of the space freed up by price reductions to adjust the price of technical services, and include the increased price of technical services in the scope of medical insurance payment, which will not increase the burden on the people in general.
This is to reduce the price of medicine.
At the same time, we will deepen the reform of the remuneration system. On the basis of dynamically adjusting the price of medical services, the requirements of the "two allows" should be implemented, and the total salary of hospitals should be approved based on the income of medical services, and the salary level of medical staff should be gradually increased. Realize the "target annual salary system for all employees and the annual salary calculation work division system", and cut off the direct connection between individual salary and department income.
This is to mention the treatment.
Strengthen the supervision and management of medical institutions. Monitor and analyze the operation of the hospital, and evaluate the secretary of the party committee and the president of the hospital every year from the aspects of medical direction, hospital development, hospital management, service evaluation, and safety construction. Strengthen the supervision of medical services, strictly manage the use of drugs by medical institutions, and standardize the centralized procurement of drug catalogs. Build a close-knit county-level medical and health community.
This is to grasp the anti-corruption.
So, what is the result? According to a report by Xinhuanet:
After the reform that began in 2012, the proportion of drug consumables income in 22 public hospitals above the county level in Sanming decreased from 60.08% to 32.51%, the proportion of medical service income increased from 18.37% before the reform to 41.46%, and the average annual salary of on-the-job employees in the hospital increased from 42,200 yuan before the reform to 133,700 yuan.
The results are remarkable. It seems that further promoting the experience of Sanming's medical reform may be a feasible plan.
So, how do you change that? Let's take a few examples.
Excuse me, have you seen the news and videos of health care negotiations?
(Picture from CCTV News in 2021)
The negotiator of the Health Insurance Bureau said that this price, from the perspective of enterprises, is indeed painful, because the drop has been very large. However, there is still a certain distance before we can talk further.
Therefore, the representatives of pharmaceutical companies left the table to report and discuss. When I came back later, I reported the number again, saying that I had done my best.
But, it still doesn't work. The negotiator of the Health Insurance Bureau said, "We will follow the reserve price." You can step in, and we'll keep talking.
In this way, the whole negotiation lasted an hour and a half. In the end, a drug for the treatment of rare diseases was cut from 700,000 yuan to 33,000 yuan per injection.
(Picture from CCTV News in 2021)
There are many more similar ones. A drug for the treatment of diabetes was eventually cut from 15 yuan a piece to 5.39 yuan a piece, and the average price of a heart stent dropped from 13,000 yuan to 700 yuan......
Some "sky-high medicines" were cut into "cabbage prices" and "floor prices". The strength is so great that many netizens call it "soul bargaining".
Behind the "soul bargaining" is actually the country's efforts to lower the price of medicine at the source.
The relevant policy is called: national discussion and centralized procurement.
What do you mean?
The state talks about centralized procurement and the two-invoice system
The national negotiation is a negotiation between the state and pharmaceutical companies, mainly for innovative drugs. For example, if you have a new class of drug on the market, the NHSA will negotiate with you to determine a low enough price to be included in the reimbursement scope of the medical insurance.
In response to the national medicine, the National Health Insurance Bureau has also issued a "dual channel" policy: it can be reimbursed in hospitals or designated pharmacies.
For the "dual channel" policy, Mr. Zhang Xiaoping commented that this can be said to be one of the most revolutionary policies since the medical reform.
Because in this way, the hospital is no longer as high as before. The doctor who prescribes medicine will not be constrained. Patients will also gradually get used to the separation of medicine.
Once the pharmaceutical family is separated, the scene of seeking medical treatment and medicine in the mainland for decades will change and bring more impact.
It turns out that this is the national talk, and it is a dual-channel policy. So, what is centralized procurement?
Centralized procurement is centralized procurement, mainly for drugs that are already on the market and are in the medical insurance catalog.
For example, if 10 pharmaceutical companies all produce a certain drug, then you will compete and win the bid according to certain rules, and the lowest price will be preferred.
If the centralized procurement does not win the bid, it may have an impact on its sales in hospitals, and even be removed from the medical insurance catalog.
In this way, the price of drugs can be kept low enough and innovation can be encouraged.
What do you mean?
In the past, many domestic pharmaceutical companies were imitating foreign companies. Which of their drugs sells well, we will imitate them.
But in the future, if you don't have the technical content, just imitate, and want to be within the scope of medical insurance reimbursement, you must enter the competitive logic of low prices until there is no way to reduce it.
So what to do? Innovation. Develop new drugs, enter the national negotiation process, and ensure their profit margins.
The price at the source has gone down, and the circulation link must also be pressed out of the water.
How to press? Two-vote system.
The two-invoice system means that only two invoices are issued in the circulation of drugs.
The first time is from a production enterprise to a distribution enterprise, and the second time is from a distribution enterprise to a medical institution.
Teacher Zhang Xiaoping said that this is to minimize the circulation links in the middle and reduce the additional costs caused by multi-level agents and transfers.
Whether it is a national negotiation and centralized procurement, or a two-invoice system, the purpose is to reduce the price of medicine.
After squeezing out the water in the drug price, the proportion of medical insurance funds used for drug expenses may be saved.
After saving, it can increase the proportion of medical services in medical insurance funds, and increase the salary and bonus benefits of doctors.
How to improve it? Change the payment system. For example, DRG, DIP.
What do you mean?
DRG and DIP payment system
Traditional medical insurance payment is based on "elements".
Open the list of treatments, what tests have been done today, what treatments will be used tomorrow, and each one has a corresponding cost.
But in doing so, it leaves a lot of room for "waste". Today, add a test, and tomorrow, add an auxiliary medicine, and God knows it.
So what to do?
Pay directly for the "results". DRG and DIP are essentially ways to pay for treatment results.
Among them, DRG (payment by disease diagnosis-related group) is paid according to the type of disease. According to the patient's disease type, treatment method, and condition, the group is delineated, and then the fee is implemented according to the relevant payment standards.
Here's an example. Xiao Zhao suffered from appendicitis and went to the hospital. The hospital assigned him to appendicitis, surgical treatment, and young men, and implemented the relevant standards, reimbursing 7,000 yuan.
The 7,000 yuan is the cost calculated according to the "result". The hospital will pay in advance.
If the cost exceeds 7,000 yuan, the hospital will bear the extra part. If it is less than 7,000 yuan, the hospital can use the savings and surplus for its own use.
Sounds pretty good. However, what if the situation is extreme, such as an 80-year-old with multiple complications, who cannot find a suitable group, or if there is a new treatment and the group has not yet been established?
DIP (Pay by Disease Score) is here. It is a big data-based scoring payment method, through the exhaustive combination of disease diagnosis and treatment methods, more detailed grouping, scoring, and calculation of specific costs based on the score. Broadly speaking, the more difficult the treatment, the higher the score, and the higher the cost.
Both DRG and DIP are standardized and more systematic payment methods, which can better reflect the labor value of medical staff and motivate medical staff to improve high-quality medical services.
At the same time, under the premise that the total amount is determined, the drug has also changed from a source of profit to a treatment cost. This can also force the hospital and compress the water during the treatment process.
Understood. Unexpectedly, behind the pharmaceutical reform, so many policies need to be used to support it, and so many complex links need to be involved.
However, no matter how complicated it is, this thing has to be done. Even though, it may cause "labor pains" for some people.
Who?
Aftermath
Teacher Zhang Xiaoping said, for example, pharmaceutical companies. Pharmaceutical companies may have to transform quickly.
Because under the centralized procurement policy, if you still rely on generic drugs, you must enter low-price competition.
As a result of the competition, only 3 out of 10 pharmaceutical companies may win the bid. Under pressure, pharmaceutical companies have to make changes to a greater or lesser extent.
How to change?
If the drug does not win the bid, it has to turn to multiple channels to push out the generic drugs that fail to bid, such as online, such as pharmacies.
But in addition, it can also choose to vigorously innovate, come up with good enough innovative drugs, enter the national negotiation process, and enter the medical insurance. Either rely on quality to speak, build a brand, and let some patients who are not price sensitive, but pay great attention to quality, buy.
Because with the advancement of medical reform, as before, the "channel" that relies on hospitals or doctors to sell drugs may be gradually blocked.
Or, simply do over-the-counter drugs, health products, vigorously market, and add brands.
So, for pharmaceutical companies, there are actually two markets. One to b, one to c.
The business of prescription drugs is biased towards the logic of to b, because the medical institutions have a great influence on what drugs are used in the end, which is also the market that the policy is mainly aimed at.
Rather than prescription drugs and health products, it is more inclined to the logic of to c. It is a more market-oriented business, which needs to be branded, open up channels, and let consumers pay.
Equally challenging are pharmacies.
It turns out that many pharmacies may only sell retail drugs, such as over-the-counter drugs, such as health supplements.
But now, because of the adjustment of the dual-channel policy, a large number of patients may buy prescription drugs in pharmacies.
Then, how to transform into a professional pharmacy and provide more professional full-course services may be a key problem faced by many pharmacies.
In any case, under the top-down system adjustment, many changes will definitely occur.
In the midst of change, there will be many people who are not used to it.
But no matter how unaccustomed you are, this important matter of people's livelihood must be done. And for the industry, it's not necessarily a bad thing.
Because, under the norms of the system, there will be more and more "good money" that will stand out.
Expectation.
Finally, I would like to share some data with you.
According to the information of the National Health Commission, as of 2022, the average price reduction of 7 batches of selected drugs in centralized procurement has exceeded 50%, and the average price reduction of 2 batches of consumables has exceeded 80%, saving a total of about 300 billion yuan. In 2020 and 2021, the proportion of personal expenditure in total health expenditure fell to 27.7% for two consecutive years. By the end of 2023, the state has organized 9 batches of 374 drugs and 4 batches of high-value consumables for centralized procurement.
Every time it comes to medical reform, there may always be some people who will be skeptical. Say, it's been doing it for so many years, is it okay?
Distrust may come from real experiences in the past. Disappointment accumulates and hurts trust. Understand.
However, when we look back today, the pace of medical reform has actually come a long way.
And in the future, we will definitely continue on this road.
Because, doctors who treat diseases and save people should not have a game of interests with patients.
When ordinary people seek medical advice and medicine, there should not be too many intermediate links to make a hindrance.
I hope you can keep your faith in it.
I also hope that the day when the goal will be achieved will come sooner.
Blessing.
Viewpoint / Liu Run