Entering August, the centralized procurement of drugs, which had been silent for a long time, became lively again. First, the procurement policies of Anhui and Fujian attracted a strong rebound from pharmaceutical companies, and then Zhejiang, Jiangxi, Ningxia and other places successively solicited opinions on the province's centralized drug procurement plan, and all interested parties rushed to express their opinions.
In addition, the national version of the centralized drug procurement method for public hospitals is being intensively revised and improved, and its internal draft for comments also appears in the media from time to time. Obviously, the centralized procurement of drugs is about to usher in a major adjustment.
However, the experience and lessons of previous adjustments have proved that a single institutional change cannot achieve the desired results. The next step in drug procurement reform must bypass this vicious circle.
Source of Policy
Liu Zheng, who has been engaged in drug procurement for more than 20 years, is now somewhat confused. He is a staff member of the drug procurement department of an eastern province. When he talks about the current procurement policy, he seems to have no idea. "Low-cost drugs, double envelopes, quality stratification, hanging net procurement ...... Now the policy, information chaos, say bad."
It has been more than 20 years since the centralized procurement of drugs began in the 1990 s. Since 2000, this work will be adjusted every four or five years. At first, it is to implement centralized bidding and procurement of drugs with prefectures and cities as the unit and medical institutions as the main body of procurement, and entrust intermediary agencies. Starting from 2006, the centralized online drug procurement led by the government and taking the province as the unit has been gradually implemented. Since 2010, with the establishment of the essential drug system, the procurement of essential drugs at the grass-roots level has begun to build a new mechanism characterized by "the integration of recruitment and procurement, the linkage of quantity and price, and the double envelope system. In 2014, classified procurement was also known as a policy hotspot.
There is also something unchanged in the constant changes. Since the start of centralized drug procurement, correcting unhealthy tendencies in the industry and cracking down on commercial bribery has always been one of the core objectives of this policy.
Song Ruilin, executive director of the Pharmaceutical Policy Research Center of the Chinese Pharmaceutical Association, said that in the early 1990 s, the drug supply system, which was dominated by three-level pharmaceutical stations, gradually disintegrated, drug production, supply, sales, and price management were liberalized, and the number of pharmaceutical companies surged. Excess production capacity and fierce market competition. On the other hand, the medical service system is also in the process of transformation, and public hospitals begin to pursue profits and seek expansion and development.
In this context, enterprises use various means to seize the market promotion, "high pricing, high kickbacks, large prescriptions, large inspections" began to appear. In addition, at this time, the labor insurance system for employees is also undergoing reform and adjustment, the security capacity is weakened, the public's dissatisfaction with the medical system is increasing, and medical disputes are also frequent. In order to alleviate social contradictions, the relevant departments began to rectify the order of drug circulation. In the process of controlling unhealthy tendencies in the field of pharmaceutical purchase and sale, all localities began to think about and explore centralized drug procurement and standardize the drug management of medical institutions.
"So, centralized procurement of drugs from the beginning of the establishment with multiple tasks." Song Ruilin said. And this top-level design has laid the groundwork for the entanglements between the stakeholders of all parties in the future. In the subsequent public opinion war on drug procurement, it is often seen that all parties in the debate are expressing their demands: enterprises talk about market economy, the government talks about anti-corruption and rectification, and hospitals talk about clinical needs. It seems lively, but in fact it is not the same thing.
In this regard, Liu Zheng's feelings are more direct. "The discipline inspection department slowly faded out of the procurement process two years ago, but now it is back." He said that his province began to be led by the county (city) discipline inspection department to organize the second negotiation of drugs. "Although the drug procurement policy does not allow it, it is difficult to say anything."
Quantity and price are not linked
Due to the responsibility of correcting unhealthy tendencies in the industry, drug procurement is naturally considered by relevant departments to need to strengthen control. Some places have also taken the reform of drug procurement as a starting point to promote the overall reform of the medical system, further enhancing the administrative color of this link.
In the view of the pharmaceutical industry, the hand of the government is not omnipotent, and excessive intervention can not achieve the desired effect. The most typical manifestation of this is the price-to-volume linkage of drug purchases.
The so-called quantity-price linkage is an important measure to ensure the price of purchased drugs. Through the preparation of the procurement plan, the specific dosage forms, specifications and quality requirements of the procurement are clearly defined, the procurement quantity is clearly defined, the whole procurement process is completed at one time, the purchase and sale contract is signed, and the payment time is strictly stipulated. In this way, pharmaceutical supply enterprises can more accurately calculate the quantity of supply and market share before bidding, easy to calculate the cost and reasonably determine the quotation, give full play to the advantages of bulk procurement.
However, in the current drug procurement of public hospitals, even if companies win the bid, various medical institutions do not sign future drug consumption with these companies. This bidding only means that this company is eligible to enter the hospital, but whether it can be sold in each hospital and how much it can sell, it still needs the company to conduct public relations with hospitals and doctors one by one.
Some experts told reporters that this mode of separation of recruitment and procurement and disconnection between quantity and price deviates from the original intention of the design of the centralized procurement system, but will promote the spread of commercial bribery. This is also considered to be the biggest drawback of the current centralized procurement of drugs in hospitals.
The reason for this situation is that, on the one hand, it is related to the monopoly position of public hospitals. It is very risky for enterprises to negotiate prices with hospitals and achieve volume-price linkage. Even if the pharmaceutical company promises the price, the hospital does not fulfill the promised purchase volume, and the company can do nothing about it. On the other hand, in the bidding and procurement, the bidding subject and the procurement subject are out of touch, and the purchaser is unwilling to perform, or there is a big difference between the total amount of procurement promised and the actual amount of procurement.
In the view of medical institutions, even if the government uses administrative means to promote the linkage between quantity and price, it is only wishful thinking. A physician at a tertiary hospital said, "What drugs to use and how much to use is the natural power of the profession of doctors, and the government can use mandatory administrative powers to deprive hospitals of the right to purchase drugs, but it is impossible to deprive doctors of the right to prescribe. If the drug varieties and quantities determined by the government are not in the doctors' interest, it will be difficult to implement them in practice."
What makes the administrative department feel headache is that under the system of supplementing medicine with medicine, even if the quantity and price are finally linked, it is difficult to fundamentally solve the commercial bribery in the link of drug purchase and sale. The phenomenon of secondary bargaining has been changed and quietly exists in the form of rebates, cash rebates, purchase order fees and other hidden forms.
"drug reform" alone does not work
In the view of many experts, the change of centralized procurement and bidding mode alone can not solve the problem of high drug prices and drug costs.
Professor Song Hua of Renmin University of China has made an empirical study on the centralized bidding procurement system from both macro-performance and micro-performance. The result of the research and evaluation is that micro-performance is better achieved, and through centralized bidding, buyers and sellers have a better grasp of the demand and supply information of the industry. But macro performance has not been achieved. The so-called macro performance refers to reducing the transaction cost of drugs and reducing bribery and corruption in drug transactions. Centralized bidding and procurement have not reduced these behaviors.
Wang Liejun, an associate researcher of the Social Development Research Department of the Development Research Center of the State Council, said in an interview with the media that my country's centralized drug procurement was implemented when the order of drug production and circulation was chaotic and the compensation mechanism of medical institutions was unreasonable. With regard to policy design issues, all parties hope that the price of drugs will be high, so as to make more profits, rather than lowering the purchase price.
Because of this, my country's centralized drug procurement was almost mandatory at the beginning, and it also bears multiple missions such as regulating the drug purchase behavior of medical institutions, rectifying the order of drug circulation, regulating drug prices, and reducing the medical expenses of the masses. Therefore, the centralized procurement of drugs in my country was implemented from the beginning when the incentive mechanism was not smooth. This is the biggest problem and a problem that has not been completely solved so far.
"Since 2006, the centralized procurement with the province as a unit of bidding and price-limiting has been alienated. 'The goal of centralized procurement is to reduce the price', which is wrong in itself." An expert who studies drug circulation policy told reporters that a complete drug circulation and supply chain, from production enterprises to prescription doctors, involves production, bidding, circulation, use, public hospital compensation, etc., relying solely on the reform of a centralized procurement platform, it is difficult to fundamentally change the current situation.
Medical reform should focus on solving the problems of the medical system. The medical system has been straightened out. Drugs are just ordinary commercial transactions and will naturally return to normal. In his view, the real difficulty of reform is how to correctly handle the redistribution of power and interests in the field of drug circulation. And this is the crux of the problem.
Supporting reform linkage is crucial
In Song Ruilin's view, although the current centralized drug procurement system has many problems, it has not yet found a better system.
In fact, according to the World Health Organization, the goal of drug procurement is to obtain a sufficient quantity of essential drugs at the lowest procurement cost, meet the needs of daily patients, and have the best cost-effectiveness ratio, and select suppliers with quality assurance and timely delivery capabilities. Form a drug procurement system that can effectively manage and supervise the behavior of all parties in procurement. An expert involved in the formulation of drug bidding policy said that drug bidding should eventually return to the most essential purpose, which is to obtain the best drugs at the lowest cost. To do this, the linkage of external supporting reforms is crucial.
Wang Liejun said that if the hospital's drugs become its cost and are no longer a tool for making money, the hospital will have the motivation to purchase the best cost-effective drugs; if the drug procurement can fully realize the volume-price linkage or single source commitment, then the suppliers are also willing to supply drugs at a lower price, which realizes the original intention of centralized procurement.
After the incentive mechanism in drug procurement is straightened out, centralized drug procurement can be more diversified. In addition to centralized procurement organized by government organizations, hospitals can also be allowed to voluntarily organize centralized procurement, allowing intermediary organizations to participate, and further promote the specialization of drug procurement. The government can do a good job of supervision.
"in fact, this is a policy put forward or even advocated by the centralized bidding and procurement policy of drugs in 2001, but due to the incompatibility of incentives caused by other systems of the pharmaceutical system, it has not been able to be carried out." Wang Liejun said that when the medical reform reforms these problematic systems, the mission of centralized drug procurement will not be so much, and the pressure on the government will not be so great.
An official from the Department of Pharmaceutical Affairs of the National Health and Family Planning Commission revealed to reporters that in the next step, public hospital drug procurement will strengthen the linkage with medical insurance payment methods and price reforms, and give full play to the leverage of medical insurance and prices, including exploring the formulation of medical insurance payment benchmark prices; Encourage medical insurance agencies to negotiate prices with medical institutions and drug suppliers, and rationally adjust medical service prices; "In cities where public hospital reform pilots are implemented, centralized procurement of drugs will be more explored."