Centralized drug procurement (hereinafter referred to as "centralized drug procurement") is an important measure to deepen the reform of the medical and health system in the mainland, through large-scale procurement to achieve the purpose of reducing inflated drug prices, reducing the burden of the masses, standardizing procurement channels, and correcting unhealthy trends in the industry. This paper investigates the implementation status of centralized drug procurement in medical institutions in Haidian District, Beijing, analyzes the existing problems and causes, and puts forward countermeasures and suggestions, in order to provide reference for the formulation of relevant policies, the introduction of follow-up measures, and the optimization of service management.
1. Progress of centralized drug procurement
In January 2019, the "Notice of the General Office of the State Council on Printing and Distributing the Pilot Program for the Centralized Procurement and Use of Drugs Organized by the State" (Guo Ban Fa [2019] No. 2) was promulgated to carry out the pilot work of centralized procurement and use of drugs organized by the state in accordance with the overall idea of "national organization, alliance procurement, and platform operation". The first batch of pilot projects was carried out in 11 cities including Beijing and Tianjin, and 25 varieties of selected drugs were selected. Since then, the scope of regions, medical institutions, and types of drugs covered by centralized drug procurement has continued to expand, gradually promoted from pilot cities to the whole country, and expanded from public medical institutions to some private medical institutions, and it is clearly proposed that by 2025, more than 500 varieties of national and provincial drugs will be procured in various provinces (autonomous regions and municipalities directly under the Central Government).
Beijing has built a unified procurement platform, the Beijing Medical Insurance Public Service Platform Procurement Subsystem (hereinafter referred to as the "Procurement Platform"), to promote the implementation of centralized procurement of selected drugs by medical institutions and standardize online procurement behavior. On the basis of the national centralized procurement and volume bidding model, the city has taken the lead in establishing a variety of new centralized procurement models such as volume linkage, volume negotiation and order-based procurement of shortage drugs, and gradually improved the three-level procurement system of national organizations, regional alliances and Beijing Municipality, so as to realize the coverage of drugs in the three major fields of chemical drugs, biological products and Chinese patent medicines. Haidian District has implemented the results of 9 batches of 374 varieties of centralized drug procurement organized by the state, and 4 batches of 115 varieties of drug procurement organized by the inter-provincial alliance and the city itself.
Second, the implementation status of centralized drug procurement in medical institutions
Based on the platform procurement data of medical institutions in Haidian District to complete the first to fifth batches of state-organized centralized drug procurement, combined with the discussion and interview content of the staff engaged in drug procurement in some medical institutions in Haidian District, the current situation of the implementation of centralized drug procurement in medical institutions was investigated in depth, especially the problems and reasons existing in the implementation of the centralized procurement policy were summarized and analyzed.
(1) Participation in the centralized procurement of drugs by medical institutions in Haidian District
As of March 31, 2024, there are 1,370 medical institutions in Haidian District, including 559 non-profit medical institutions (including 213 government-run medical institutions and 346 non-government-run medical institutions) and 811 for-profit medical institutions. There are 366 designated medical institutions for medical insurance, including 329 non-profit medical institutions (including 203 government-run medical institutions and 126 non-government-run medical institutions) and 37 for-profit medical institutions.
In the first to fifth batches of state-organized centralized drug procurement, the amount of selected drugs purchased by medical institutions in Haidian District was 404.77 million yuan, accounting for 21.48% of the total amount of drugs, and the use of selected drugs was 272.36 million (bottles, boxes and other corresponding packaging units), accounting for 52.63% of the total drug usage. There are 326 medical institutions with more than 10 varieties of drugs included in the centralized procurement and procurement. Most of the community health service stations are managed and procured by the higher-level community health service centers, and do not undertake the task of centralized procurement. Some medical rescue centers that only provide public health services, school health stations that only provide internal services, and infirmaries of publicly-funded medical units do not participate in the centralized procurement of drugs.
(2) Problems existing in the process of medical institutions implementing centralized drug procurement
According to statistics, the problems existing in the process of implementing centralized drug procurement in medical institutions are mainly reflected in: 1. Use but do not report", do not report the quantity, do not purchase the selected products but purchase non-selected products; 2. "Report but not use", the amount has been reported but the selected drugs have not been implemented into the hospital or have not been purchased in the hospital; 3. "Poor completion", the amount that has been reported but the agreed purchase volume has not been completed; 4. "Conservative reporting", the purchase volume of the agreed agreement is completed, but the use of non-selected drugs accounts for a relatively high proportion; 5. "Offline procurement", failure to carry out sunshine procurement as required, offline procurement settlement with enterprises, and some cases of failure to implement the price policy according to the centralized procurement price; 6. "Failure to settle the payment on time", failing to settle the payment in time with the selected enterprise within the specified time limit; 7. "One-size-fits-all" use of centralized procurement drugs, ignoring the needs of special patients, etc.
(3) Cause analysis
1. Centralized procurement of drug supply
1.1 Drug supply interruption
In the first to five batches of state-organized drug centralized procurement, there are phenomena such as drug supply interruption and the priority supply of medical institutions with large amounts of selected enterprises. Manufacturers have seen a decline in profits and an increase in demand due to the selection of drugs, which has affected the supply and quality of drugs. The selected enterprises plan the production volume of the next year according to the national reporting data, if the medical institutions generally "conservatively report the volume", the actual demand is much greater than the reporting results, and the inaccurate reporting of medical institutions indirectly leads to insufficient supply of enterprises.
1.2 Poor delivery management
Some distributors are not highly motivated to deliver and have a long time cycle; Due to the small scale of some first-level and below medical institutions, the cooperative distribution business is limited and the drug varieties are not fully covered, and a small number of centralized procurement drugs have no supply in the corresponding distributors.
2. Policy provisions
2.1 Adjustment of the list of medical insurance drugs
Due to policy reasons such as the adjustment of the scope of limited payment of drugs, the use of such drugs has declined. For example, in the 2022 Beijing Municipal Medical Insurance Drug Catalogue, "glucosamine" was adjusted to "limited work-related injury insurance" due to the limited payment scope, and medical institutions generally reported the amount of uncompleted tasks.
2.2 Restrictions on antimicrobial drug indicators
According to the Administrative Measures for the Clinical Application of Antimicrobial Drugs, the clinical application of antimicrobial drugs in medical institutions is included in the assessment index system of medical institutions, and the use of antimicrobial drugs by patients is assessed, which affects the completion of the task of antimicrobial selected drugs in medical institutions.
2.3 Special provisions during the new crown pneumonia epidemic
Due to the regulations during the epidemic period, medical institutions that do not have the ability to receive fever, cough and other suspected symptoms of new crown pneumonia purchase such drugs in small quantities; During the special period, due to the large demand of patients and the availability of goods, the selection of drugs was not carefully considered; Some medicines are distributed by the health department.
3. Procurement process
3.1 The online procurement function needs to be improved
The in-hospital procurement system of medical institutions cannot be connected with the procurement platform, which repeatedly increases the workload of procurement and warehousing; Medical institutions have operational problems such as centralized procurement and procurement, and cannot be responded to and resolved in a timely manner by calling the platform maintenance and relevant departments; There are errors in the data on the task volume and completion of some medical institutions.
3.2 The procurement process is complex
There are many processes involved in the centralized procurement of drugs, the cycle is long, the volume and procurement are not on the same platform, the accounts used are different, and medical institutions need to invest a certain amount of manpower and material resources to participate in all aspects of procurement, especially for some grassroots medical institutions, it is more difficult to implement, resulting in delays in the work of centralized procurement and reporting.
4. Clinical medication
4.1 The packaging, specifications, and dosage forms of the selected drugs are inconvenient for dispensing and use
The packaging volume of some selected drugs in centralized procurement is large, which is not conducive to dark storage after dismantling; Some of the selected drugs in centralized procurement are large doses, and the commonly used clinical specifications are small doses, which cannot be further split and adjusted.
4.2 Medication habits
Due to individual differences, some patients are dependent on specific brands of drugs, and changing drugs may affect patients' treatment effectiveness and compliance. For example, for psychotropic and anticoagulant drugs, the drug habits of clinical medical personnel are limited by factors such as the specifications of the selected drugs, clinical application plans, and actual efficacy, and the original drugs with wide clinical applications are usually used.
5. In terms of medical groups
5.1 Some patients have low willingness to use the selected products
At the same time, Haidian District has a developed economy, and the insured have a high level of knowledge and economy, so they tend to use the original drugs.
5.2 Patients' medical treatment fluctuates greatly
The proportion of patients seeking medical treatment in other places in tertiary medical institutions is relatively high, and the number of patients receiving medical treatment in other places is closely related to the number of patients seeking medical treatment in other places. For example, during the new crown epidemic, due to the epidemic prevention and control regulations, the number of patients in the tertiary medical institutions in Haidian District generally declined, which affected the completion of the centralized procurement task of the medical institutions.
6. Management of medical institutions
6.1 Objective differences in medical institutions
First, the scale is different. Tertiary medical institutions are usually large in scale and have many patients, and the centralized procurement work involves in-hospital procurement, medical insurance, prices, information, clinical and other departments, which has high requirements for close linkage within the institution. The medication compliance of patients in secondary and lower medical institutions is not as good as that of tertiary medical institutions, and they are usually smaller, with multiple positions and high personnel mobility, which makes it difficult to quickly adapt and adjust to new procurement processes.
Second, the attributes are different. In the early stage of the implementation of centralized procurement, only public medical institutions were required to participate, which was not mandatory, and after the implementation of the relevant requirements of centralized procurement was included in the scope of agreement management, the proportion of non-public medical institutions designated by medical insurance to participate in centralized procurement increased. Non-public medical institutions are highly profit-seeking, have a large right to choose independently, and have high requirements for payment collection by medical institutions in centralized procurement, while non-public medical institutions have high pressure to collect money and have weak enthusiasm for participation.
The third is to undertake other support tasks. Haidian District has accumulated troops, universities, scientific research institutes and other units. Military medical institutions are responsible for the medical treatment of officers and soldiers in the military system, military retired cadres, etc., and should be guaranteed as much as possible, according to needs, the proportion of military medical treatment is significant, and the use of centralized procurement of non-selected drugs is more common; The internal infirmaries of publicly-funded medical units are mainly protected by the public-funded medical population, and medical expenses do not use medical insurance funds, and the incentives for centralized procurement are not very attractive to such medical institutions.
6.2 Failure to establish and improve the normalization and institutionalization working mechanism of the unit
Medical institutions do not pay enough attention to the reform of centralized drug procurement, extensive management, do not improve the internal management system and performance appraisal methods, fail to adjust the drug catalog and product regulation restrictions of medical institutions in a timely manner, and do not do a good job in monitoring and analyzing the use of centralized procurement of drugs and medical consumables.
6.3 Procurement behavior is not standardized
The statistics of the centralized procurement task volume are subject to the procurement data of the procurement platform, and the medical institutions have irregular procurement behaviors such as illegal offline procurement, resulting in the non-inclusion of this part of the task volume. If medical institutions and online enterprises do not complete the confirmation of the procurement process, it will affect the calculation of the amount of centralized procurement tasks.
6.4 The understanding of the centralized procurement policy is not in place
Failure to do a good job in the training, interpretation, and guidance of public opinion for medical personnel. The staff did not grasp and understand the policies in place, did not fully understand the rules of centralized procurement, and did not pay attention to the implementation of the centralized procurement tasks of medical institutions. Ignoring the key link of volume reporting, "underreporting", "misreporting" and "conservative reporting" often occur, and it is fortunate that they can purchase low-cost drugs without participating in the volume reporting.
6.5 Lack of attention to rational drug use
In order to ensure the completion of the agreed procurement volume, some medical institutions have adopted administrative measures such as restricting doctors' prescription authority, stopping non-selected varieties with the same or similar pharmacological effects, and including doctors' performance appraisals to intervene in clinical drug use, which increases the risk of clinical irrational drug use.
6.6 Miscellaneous
low degree of informatization; Business adjustment, reconstruction and expansion, closure of medical institutions, etc.
7. Supervision and management of government departments
7.1 The regulatory mechanism is not perfect
At present, the regulatory mechanism is not perfect, and the coordinated supervision work of the departments has failed to achieve efficient linkage in ensuring the admission of selected drugs into the hospital, quality standards, and stable supply.
7.2 Single means of supervision
The district-level medical insurance department in Haidian District does not have the authority to recruit and purchase platforms and other systems, and cannot dynamically grasp the progress of the completion of the centralized procurement policy of medical institutions and urge medical institutions to complete the volume reporting and other operations as required.
7.3 Policy publicity is not in place
The lack of publicity of the centralized procurement policy has led to the lack of confidence of some doctors and patients in the quality of drugs of centralized procurement varieties.
3. Promote the implementation of centralized drug procurement by medical institutions
Measures and Recommendations
(1) Improve policy support
1. Compile guidelines and specifications for centralized procurement
According to the different subjects involved in centralized drug procurement, for the selected enterprises and medical institutions, the full-cycle operation guidelines and code of conduct for centralized procurement are formulated, the list of main responsibilities is clarified, and the requirements of each link of centralized drug procurement are refined, so as to provide a strong starting point for the implementation and supervision of drug centralized procurement policies.
2. Improve supporting measures for centralized drug procurement
Further integrate centralized procurement batches, unify the implementation time, and reduce the management pressure of medical institutions; Improve incentive and restraint measures, increase the proportion of medical insurance fund balance retention, and explore the part of the medical insurance fund saved by remote medical personnel to retain the balance of medical institutions.
3. Optimize the rules for centralized procurement and procurement
Strictly control the screening of drug varieties and specifications, combine the prescription management measures, the National Essential Drug Catalog, the National Medical Insurance Drug List and other relevant documents, comprehensively determine the selected drug varieties, and refer to the clinical drug guidelines and drug dosage, specifications, packaging and other factors to select the selected drugs with high quality and low price, suitable for clinical use.
4. Establish and improve the adjustment mechanism for the centralized procurement of drugs by medical institutions
Explore the channels for medical institutions to adjust the amount of centralized procurement tasks between medical institutions under special or specific circumstances, balance the diversity of clinical drug use, guide medical institutions to solve the problem of index adjustment through reasonable compliance negotiation, and accelerate the completion of the overall centralized procurement task in Beijing.
(2) Pay close attention to assessment and supervision
1. Establish an evaluation system for centralized procurement of drugs
Continue to carry out real-world research on centralized procurement drugs, and explore the establishment of a comprehensive evaluation system for the clinical efficacy and safety of centralized procurement drugs based on research results, focusing on drug quality standards and adverse reactions.
2. Improve the assessment mechanism for centralized procurement of drugs
Optimize the evaluation indicators for the implementation of centralized procurement by medical institutions, and comprehensively consider health-related policies, changes in disease spectrum, drug policy adjustments and other factors under the premise of rational drug use. Publish the assessment rules for medical institutions in a timely manner, and strengthen the use and management of centralized procurement drugs by medical institutions.
3. Strengthen the guarantee of drug supply
Strengthen the evaluation and supervision of drug supply, smooth the feedback channels of medical institutions, and report to the procurement platform in a timely manner in case of drug shortages, drug quality, distribution enterprises and other problems. Establish a two-way supervision mechanism for distribution enterprises by medical institutions and procurement platforms, and rectify the non-standard distribution enterprises reflected by medical institutions in a timely manner.
4. Strengthen supervision and inspection of medical institutions
Adopt methods such as self-inspection and self-correction, on-site inspection, data analysis, and system monitoring, issue a list of problems and data, regularly supervise and remind, strengthen the supervision of the implementation of centralized procurement by medical institutions, and timely adopt interviews, notifications and other methods to improve the supervision of centralized procurement.
(3) Deepen the consensus on centralized procurement
1. Increase training and publicity
The medical insurance department actively provides policy training and system operation guidance related to volume procurement for medical institutions, and helps medical institutions actively adapt to changes in centralized procurement by organizing online and offline training, producing learning videos, operation manuals, etc. Further increase the publicity of the centralized procurement policy, and improve the awareness and acceptance of doctors and the masses on centralized procurement of drugs.
2. Promote departmental linkage
Establish a cross-departmental coordination mechanism for medical insurance, medical care, and medicine, and strengthen information sharing and communication. Establish a joint supervision and linkage disposal mechanism, actively cooperate and cooperate, refine the division of responsibilities for the admission of selected drugs, quality standards, and stable supply, and promote collaborative supervision.
3. Strengthen the internal management of medical institutions
Combined with the requirements of the implementation documents of each batch of centralized procurement, medical institutions refer to the Chinese Expert Consensus on the Management of Centralized Procurement of Drugs Organized by National Organizations of Medical Institutions by the Chinese Pharmacists Association, etc., and strictly implement sunshine procurement from the aspects of organization and leadership, quantity measurement, catalog management, monitoring and analysis, etc., so as to realize the refined management of the whole process of centralized drug procurement in medical institutions.
(4) Enhance technical support
1. Optimize the procurement process
Further improve the functions of the procurement platform, optimize and reengineer the procurement process, highly integrate the volume reporting, procurement and other platforms, effectively realize data docking, open up the whole process of drug procurement, inventory management and use of medical institutions, and improve procurement efficiency.
2. Promote intelligent supervision
Build a comprehensive procurement platform with intelligent monitoring, empower various regulatory departments, and strengthen the construction of a comprehensive supervision system. Use advanced technologies such as big data and artificial intelligence to conduct in-depth analysis and mining of procurement data to discover potential risks and abnormal behaviors. Improve the accuracy and efficiency of supervision through a data-driven approach.
Author | Beijing Haidian District Medical Insurance Bureau
Source | China Medical Insurance
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