National drug collection three batches after the trend of September 01, 2020 Source: Health News.

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The first batch: On September 30, 2019, the results of the alliance's regional centralized procurement were announced. There were 25 selected drugs, with an average price reduction of 59%.

Second batch: January 21, 2020, the second batch of national centralized procurement results announced, there are 32 selected drugs, the average price reduction reached 53%, the highest drop reached 93%.

The third batch: August 24, 2020, the third batch of national collection selection results announced, there are 55 selected drugs, an average price reduction of 53%, the highest drop of more than 95%.

Professor Hu Shanlian, School of Public Health, Fudan University

Multi-party win-win situation gradually formed.

It can be seen that from the third batch, the national organization of drug centralized procurement into the normal operation, centralized procurement rules, policy system, working mechanism has been basically finalized, and further consolidated and improved. Compared with the second batch of centralized procurement, the third batch of procurement rules are only fine-tuned and optimized, and the maximum number of enterprises that can be selected is further increased from 6 to 8.

For patients, the collection brings more good news. From the data of the third batch of drug collection, it can be seen that the average price reduction of the selected varieties is 53%, and the highest drop is more than 95%, which continues the strength of the first two batches of collection in terms of "price cutting. In terms of the coverage of purchased varieties, the third batch of collection involves a total of 55 varieties, close to the sum of the number of varieties collected in the first two batches. The total number of varieties collected in the three batches has exceeded 100, with generic drugs commonly used accounting for about 50%, and the benefits of patients continue to expand.

Although more than 100 varieties account for only a small part of the entire drug catalog, after the enthusiasm of all parties is mobilized, the motivation of enterprises to pass the consistency evaluation will become greater and greater, and it can be expected that the scale of drug collection will continue to expand like a "snowball.

For the health insurance sector, with the drug collection towards normalization, institutionalization, the continuous promotion of health insurance reform has played a positive role.

For example, the reform of the health insurance payment system requires the development of health insurance payment standards, but because the true cost of drugs is difficult to verify, so that health insurance payment standards can only be based on historical data, and the historical sales prices of drugs often contain "moisture". However, after the centralized procurement of drugs, we have seen that the market commitment obtained by pharmaceutical companies has greatly reduced the cost of sales and circulation, and it is easier to give prices close to the true cost in the centralized bidding, thus the health insurance department has an additional way of price discovery.

In addition to this, the collection of drug price cuts, according to estimates can save about 22.9 billion health insurance funds. This also ushered in space for subsequent reforms such as price adjustments for medical services. As more and more varieties enter the collection channel, it is believed that it will play an increasingly important role in promoting health insurance reform.

Medical institutions to implement zero-margin sales of drugs, drug collection originally on the hospital operations. However, with the continuous improvement of the collection of supporting documents, the enthusiasm of medical institutions to use the collection of varieties is being mobilized.

The "Opinions of the National Medical Security Administration on the State Organization of Drug Centralized Procurement and Use of Pilot Medical Insurance Supporting Measures" issued in March 2019 pointed out that the incentive and restraint mechanism and risk-sharing mechanism of "balance retention and reasonable sharing of overspending" should be improved to encourage medical institutions to use selected drugs. It is required that "when the medical insurance department formulates the total amount control index of the annual medical insurance fund in 2019, the designated medical institutions that reasonably use the selected varieties, fulfill the purchase and sale contract, and complete the centralized purchase of drug consumption shall not reduce the total amount control index due to the decrease of the drug cost of the centralized purchase of varieties."

Shortly before the start of this round of drug collection, the National Health Insurance Bureau and the Ministry of Finance once again jointly issued the "guidance on the retention of medical insurance fund balances in the centralized procurement of drugs organized by the state" (Medical Insurance issued No. 26 of 2020). This is another important supporting document for the national drug collection work. The document makes it clear that the difference between the cost of drugs after the price reduction and the budget fund paid by medical insurance will be returned to public medical institutions in accordance with a certain proportion. This will greatly mobilize the enthusiasm of medical institutions to give priority to the use of selected varieties.

From a corporate point of view, it is undoubtedly good news that their own varieties stand out in the collection. For example, the cost of corporate capital has fallen sharply. In the past, it was a very common phenomenon for medical institutions to default on drug payments. Some public hospitals can even have a repayment period of several years. This will result in a longer capital flow cycle and financial pressure for pharmaceutical companies. These capital costs are included in the price of the drug, which is ultimately paid for by health insurance and patients.

The medical insurance department takes the lead in the volume of procurement, using a certain percentage of the medical insurance fund as the volume of procurement funds, pre-allocated to medical institutions, while the health administration will be medical institutions return cycle into the assessment. This fundamentally solves the problem of "triangular debt" between hospitals, drug suppliers and medical insurance departments, reduces enterprise costs and improves operational efficiency.

In addition, in the centralized procurement negotiations, the lower limit of drug sales has been locked, on the one hand, enterprises can arrange production plans accordingly, to avoid insufficient production capacity or waste, on the other hand, can also significantly "cut off" marketing costs.

However, the benefits of these selected enterprises also mean that the living space of the unselected enterprises will be compressed. In the long run, with the normalization of volume procurement, the concentration of the generic drug industry is bound to continue to increase. This is conducive to improving the level of drug quality supervision and the overall profit margin of enterprises in China, and promoting the sound development of China's pharmaceutical industry.

Chen Hao, Senior Economist, Pharmaceutical Policy and Management Research Center, Tongji Medical College, Huazhong University of Science and Technology

The incentive mechanism related to the arable is worthy of attention.

This time the national organization of drug collection, there are some fine-tuning from the rules. In the winning rules, a 50% drop was added to the pre-winning rules, and the "parachute" rule of 0.1 yuan's pre-winning rules and the "fuse" rule of automatic elimination if the quotation exceeds 1.8 times the lowest price were retained. The number of selected enterprises for the collection of drugs has increased from a maximum of 6 to 8, which is not only to ensure stable supply, but also to guide enterprises to continue to strive for consistency evaluation and participate in competition. Compared with the previous two, the biggest point of this band purchase is the incentive mechanism for medical institutions to use the selected drugs.

Judging from the previous two batches of collection, whether for hospitals or enterprises, the margin outside the market share of band procurement is still considerable. The original research pharmaceutical enterprises and other unelected enterprises can continue to compete for this part of the margin market outside the collection ring. But this drug collection a relatively large change, is the introduction of the collection work related to the health insurance fund balance retention policy.

This policy rewards medical institutions based on their progress in the use of selected drugs. Driven by the matching balance retention policy of drug collection, medical institutions will declare the dosage according to the actual demand as far as possible, and will take the initiative to increase the use of the selected varieties. This will obviously squeeze the non-winning market, forcing those enterprises that do not win to participate in the collection and strive for selection.

The problem can be seen from the data distributed by the joint mining office. Some of the varieties of hospitals reported more than enough, even slightly more than the use of previous statistics. Under the incentive of balance retention, the behavior of the hospital's full amount of reporting has many positive meanings.

On the one hand, many clinical drugs are not purchased in all varieties, and there is still the possibility of substitution between products for medical staff. If the hospital fully or even over-reports the dosage, it will encourage doctors to replace non-selected varieties with similar functions with selected products. Replacing non-collection varieties with collection varieties is conducive to squeezing the activity space of irregular drug marketing behavior.

On the other hand, the hospital retains only one selected species, which also brings management convenience to the hospital. Especially when dealing with the proportion of selected varieties and non-selected varieties, it often involves medical ethics, drug choice, prescription distribution and other aspects, it is difficult to find a balance. For hospitals, a simple solution is to report in full and use in full. While maximizing the balance and retention rewards, it also reduces the troubles of these problems and reduces management and administrative costs.

In addition, after the national organization of drug collection, the price of some drugs has dropped significantly, which may stimulate some unmet demand in the past. For example, Sildenafil Citrate Tablets (Viagra), the previous retail price of the drug in the hospital was about 90 yuan to 100 yuan. After centralized procurement negotiations, the price was reduced to 2.08 yuan per tablet, with a price reduction of more than 90%. This huge drop is likely to stimulate a huge demand for use, so that the actual use will exceed the previous year's usage. There are many similar varieties, and hospitals will also have such considerations.

Of course, there are some products that are not reported in sufficient quantities, or even far from reaching the previous dosage. The main reason is that some hospitals have concerns about the selected products, or there is a strong demand for the original research varieties, so they retain the share of continuing to purchase the original research drugs. In addition, some varieties of balance retention incentives, after calculation is actually not outstanding enough.

At present, I am more concerned about whether the balance retention is a long-term mechanism. From the current collection of drug balance retention funds calculation method, this incentive mechanism is "transient", because with the proportion of selected drugs used to increase, the actual cost of hospital use of drugs will be more and more close to the collection of drug health insurance funds budget, the balance of the space will naturally shrink. How to maintain a long-term incentive mechanism and make medical institutions continue to have the motivation to use the selected drugs is a problem worthy of discussion.

Another concern is the relationship between the retention of the medical insurance balance of the collection of drugs and the retention of the balance of the medical insurance funds under the total prepaid system of medical insurance.

In recent years, in the context of the reform of medical insurance payment methods, we emphasize the implementation of medical insurance fund balance retention in hospitals under the premise of the total budget of medical insurance, in order to encourage hospitals to fine management and control costs. Relatively speaking, this is a large balance retention policy. And the collection of drug health insurance balance retention mechanism, is specific to the collection of selected drugs used as the basis for the small balance retention policy.

It can be considered that the funds retained in the balance of the drug collection are still part of the total budget of the medical institution or the total advance amount. Taking the summary of the remaining retention policy as an incision is conducive to the implementation of the large balance retention policy, but at the same time, the total amount of medical insurance in medical institutions does have a balance, which is also a prerequisite for the collection of drug medical insurance fund balances.

Chen Qiulin, Director of the Health Economics Research Office, Institute of Population and Labor Economics, Chinese Academy of Social Sciences.

The behavior of parties is being reshaped.

The smooth development of centralized drug procurement in the third batch of national negotiations on drugs sends a very clear signal that the drug collection system is viable. The scope of drugs has been expanded batch by batch, the negotiation rules have been gradually improved, and the social acceptance has been steadily improved, which shows that centralized procurement with volume is not only feasible in theory and in line with the market law, but also oriented to the problems we are facing in practice, which is in line with the needs of reform and development.

The rate of development of the collective mining system is "visible to the naked eye.

The most obvious thing is that there are more varieties. The first two centralized mining were 25 species and 32 species respectively, and this time it was 55 species. Under the influence of the collection system, the enthusiasm of enterprises to carry out consistency evaluation is high, and the variety of over-evaluation and participation in the collection competition is increasing. The collection of data collection has widely adopted information-based means to be more accurate and efficient.

In the process of centralized mining, more and more demands for reform and development are integrated. For example, the commitment of medical institutions in the use of antibiotics is lower than that of general drugs. This is in line with the general direction of limiting the use of antibiotics in future reforms. The upper limit of the number of selected enterprises has also been increased from a maximum of 6 to 8, considering that there are more over-rated enterprises in some varieties, increasing the number of selected enterprises can enable more enterprises to develop through the centralized procurement platform. These details fully reflect the flexibility and vitality of the centralized procurement system.

The change in mindset of the relevant businesses is an important sign.

First of all, pharmaceutical manufacturers have begun to gradually adapt to the national drug centralized belt procurement. This is a major change in this collection. After the previous two tenders and one expanded "actual combat training", enterprises are more familiar with the centralized procurement procedures and rules, and have more confidence in the transparency and fairness of the centralized procurement system. Although the sharp price reduction still makes the enterprise very "flesh painful", but for the final result, the enterprise can treat and accept it with a more peaceful state of mind. Whether it was the entry/exit of the company or the precipitous fall in the final price, the market did not show the same mood swings as it did at the end of the first collection.

Second, the market's doubts about the collection policy are gradually fading. When launching the first batch of centralized procurement, many companies participated with a tentative heart. The basic idea is "look at it first, and the policy may change in the future." However, after three consecutive batches of centralized procurement, most enterprises have begun to accept the fact that centralized procurement has formed a normalized mechanism and the scale of centralized procurement will continue to expand. Judging from the performance of this centralized purchase, they are already seriously studying and thinking about how to adjust the enterprise development strategy in the future to adapt to the new reform situation.

This round of procurement is clearly designed with the question of how to share the benefits with the hospital. The landing of centralized procurement results depends to a large extent on the use of hospitals and doctors, and the change of drug use behavior is a key link in the centralized procurement system. In the past, only in a few places such as Shanghai, the medical insurance funds saved in the process of use can be rewarded by the way of balance retention. This time, we see that this benefit-sharing mechanism has entered the supporting policy of centralized procurement. It can be seen that the fundamental purpose of the national drug centralized procurement system is not to reduce the price of drugs, but to reshape the behavior of various participants in the medical field-including corporate behavior, doctor behavior, hospital behavior and patient behavior.

For now, such a goal is gradually being achieved. From a production point of view, the benefits of different pharmaceutical manufacturers in centralized procurement are different, with mixed emotions. One category of pharmaceutical companies has benefited the most. The quality of products of such enterprises meets the requirements, but the market has not yet been opened everywhere. At this time, if you stand out in the centralized procurement, you can skip the long and difficult process of developing the market and directly get the "admission ticket" to enter the hospital ". It is an important direction of the system to standardize the field of drug circulation and reduce the marketing cost of enterprises.

From the point of view of drug use, hospital drugs are sold at a zero-difference rate, and the results of the collection have little impact on the hospital, so the main impact is on doctors and patients. The results of centralized collection may violate the medication habits of doctors and patients, but the incentive mechanism of balance retention can encourage them to change their medication behavior. From the patient's point of view, there is indeed a problem of changing medication habits at the beginning, but mainly some OTC oral drugs, the patient's feeling will be more obvious. For a large number of intraoperative medication, intravenous medication, the patient's direct feeling is not obvious. Therefore, the impact on patients is limited, and the rebound of patients on the change of drug varieties is not sharp.

In general, it is worth looking forward to the reshaping of the behavior of enterprises, hospitals and patients through the linkage of policies. Such a result will eventually be conducive to drug collection and other health care reform policies.