Sun Lihua, Professor, School of Business Administration, Shenyang Pharmaceutical University, and Cai Jiangan, Senior Researcher of Health Policy, Ministry of Health and Welfare, Massachusetts, USA Zhou Shenglai, Associate Dean of Beijing Anzhen Hospital, Capital Medical University, has aroused much discussion on the topic of canceling “taking medicine for medical treatment”. After the Ministry of Health set a four-year deadline for this reform, how can it be achieved? The hospital does not have drug income. How will financial compensation follow? Although Beijing has just confirmed on the 12th that it will pilot “dividing medicine” at 5 public hospitals, local exploration has also come one after another. However, starting from the 300 pilot county-level public hospitals in 2012, the reform should be made public at the county level within 2 years. It is not easy for hospitals to be fully implemented in public hospitals in the country for another two years. So, where is the main difficulty in the middle? How will the value orientation of hospitals and doctors change after the “prescription of medicines”? If prescription dispensing becomes possible, how will this affect the hospital drug structure? How to change the retail terminal? With these unknowns, this issue of the "Medicine Economics" has invited domestic senior experts and hospital administrators to make in-depth interpretations for readers.

Landed to take root "Pharmaceutical Economic News": 3 years of new medical reform, "drugs to medical care" has been criticized. Today, the “available for medicine” program has been cancelled and the schedule has been launched. How do guests look at this New Deal?

Gu Ke: It is necessary to cancel the "doctoring for medicine". However, in the present, the difficulty will be many. At present, the Ministry of Health has only given the set goals for four years. The ideal is very full, but the reality is very edgy. The means and measures for reform are not seen. On the other hand, current policies of medical institutions are market-oriented when it comes to patients, and once it comes to human resources expenditures, equipment purchases, etc., it becomes a planned means. This is the contradiction in public hospitals. status. As a result, public hospital reform can only oscillate between "re-administration" and "de-administration." Therefore, the reform must be cut to the point. In fact, there will be more problems with financial compensation. Because the money that the hospital runs comes mainly from financial compensation, the eyes of hospitals and doctors must look upwards. If the eyes are old, the time for the eyes to look at the patient may be limited. If we can't even look at patients, can we be patient-centered and patient-centered? Looking back at the distorted income structure of medical institutions, the current price of medical services is low, and if you want to eliminate the use of medicine to provide medicine, reform designers must first bravely face the adjustment of medical service prices.

Sun Lihua: Abolished the “medicine-based medicine” mechanism that has been implemented for a long time and involves adjustments of multiple interests. To truly land, and solve the problems caused by the reduction of economic returns of medical institutions, it will directly affect the success or failure of this reform. At the same time, it also affects the rationality of the state's fiscal expenditure and whether the future medical institutions can develop healthily. Therefore, reforms need comprehensive and in-depth analysis and demonstration.

Cai Jiangnan: In China, the government really wants to promote a reform. Any deep-seated conflicts can be solved. However, in the absence of complete systemicity, first of all, 300 pilot counties across the country canceled “taking medicine to support medical care.” The specific implementation plan for advancement is not yet clear, and the cancellation of “doing medicine to support medicine” is not only The hospital itself is a systematic reform of the Finance, Development and Reform Commission, and People's Insurance and other departments. The Ministry of Health alone cannot solve all problems. Japan, South Korea, etc. also took a long time to carry out the reform of "taking medicine to support medicine". It took China in as little as 4 years to make it difficult.

Zhou Shenglai: It is good to cancel the original intention of “taking medicine to support medicine”, but to really separate the medicine and end the situation of “taking medicine to support medicine”, we must rely on deepening the reform of the system. If you do not move the original system and do not touch on deep-seated problems, you can only solve the surface problems.

"Pharmaceutical Economic News": When it comes to the elimination of "the use of drugs to support medical care," one unavoidable reality is the issue of compensation mechanisms. For example, to instigate the large-scale hospital terminal market that has reached a scale of more than 500 billion yuan at present, how can the central and local financial compensation be matched? Where are the main difficulties in the middle?

Sun Lihua: I disapprove of using the term “compensation”, which misleads people into thinking that medical institutions can't always survive on their own, do not need to use medicine to “nurture” or “make up”, or need the government to “compensate”. “Practice with medicine” is a product under the planned economy system. The reason why the problem is becoming increasingly prominent is because there are external interventions in this model that do not meet the objective requirements of the market economy in the pricing of medical services or the source of salaries of medical institutions. To cancel the use of drugs for medical treatment, it is necessary to cancel corresponding unreasonable interventions or measures. For example, under the basic maintenance of the current price level of medical services, the wages of public non-profit hospitals will be fully funded from financial sources; the financial sector of profit-making hospitals will be responsible for salaries, but the prices of medical services will be set according to the objective requirements of the market economy. Appropriately gradually release and so on. In my opinion, the elimination of "taking medicine to support medical care" should not focus on how to measure and compensate for the reduced medical income of medical institutions. It should not be on the basis of the existing medical system that should be reformed. Simple compensation for income gap. What's more, the scientific and rationality of the existing compensation quota accounting method has yet to be considered. A new hospital economic operation mechanism that meets the requirements of the market economy system and the objective requirements of different medical institutions and the sources of personnel wage sources should be designed.

Zhou Shengsheng: Financial compensation is the basis of the hospital. However, it is very important how to make up for what the standard is. In fact, in order to truly solve the problem of “taking drugs to support medical care”, the country must first carry out profound reforms in medical prices. Currently, the only thing that has not been mobilized in medical reform is the price of medical services. This price issue is the key to industry distortions: doctors take kickbacks, “doctors use medicine”, and so on. The reason is that the price system of medical services violates the law of value, reflecting the knowledge of doctors and nurses. The service price of labor is far below the cost.

More importantly, the return of medical services must also be scientific and reasonable. Reforms can't stop at "taking medicine to support medical treatment" instead of "taking medicine to support medical treatment." This is just a major adjustment of the hospital's income structure. At present, public hospitals still have strong incentives for profit-taking. If medical prices increase, drug prices have not fallen, or have fallen less, this has served to reduce the score. This "a rise and fall" also test the policy makers' wisdom.

The reform of the payment method is a breach of the “Pharmaceutical Economic News”: In addition, the reform of the payment method is also a key safeguard link for the elimination of “the use of drugs for medical treatment”. From the current point of view, in the case of changing payment methods, medicines are turned from profit sources to costs, and hospitals try to control expenses as much as possible in the case of disease. For example, the DRG has introduced the payment reform for disease-specific groups in Shanghai and the total advance payment reforms in Shanghai. What is your solution to this problem?

Cai Jiangnan: The most feasible way and way to cancel the “prescription for medicine” is to start from the perspective of medical insurance, and reform the payment method and the structure of medical insurance calculation. At present, there are many exploration methods for payment in China, such as disease-based payment in Beijing and total advance payment system in Shanghai. However, under the premise that it is difficult to withdraw medicine for medical treatment, there will be a gradual retreat of payments by project. process. In addition, it is obviously not feasible to separate medicines in hospitals. In the absence of supporting systems, many hospitals now come up with this kind of exploration and have come up with strategies. Prior to this, the society reflected that in order to deal with the separate medical income loss, a few hospitals opened their own pharmacies near hospitals and induced patients to go. These pharmacies buy drugs. This phenomenon also exists. I think we should start from a different perspective and start with medical insurance. The current medical insurance does not play its due role. It is like a cashier's role. Medical insurance does not play the role of accounting and supervision like the management of insurance funds. According to foreign practice, medical insurance is not capped. Within the scope of medical insurance coverage, the relevant benefits must be guaranteed, so that they have strong accounting and supervision enthusiasm, but the domestic medical insurance only pays for the overall funding. How much money is on hand will be responsible for payment. If medical insurance funds are paid out each year, it will not be able to do so, so the risk of medical insurance will be passed on to hospitals and patients. In addition, if the medical service fee is appropriately increased to balance the value of medicines and medical services, only the structural adjustment of the medical insurance in terms of internal accounting will not involve an external interest game. Such a reform is operable.

Sun Lihua: The reform of the medical insurance payment method is very necessary, but it is difficult to obtain the same results as the developed countries with this reform alone. The reason is that the coverage of medical insurance at home and abroad, and the varieties and proportions of reimbursement are still quite different. The improvement of its effectiveness depends to a large extent on the increase in the proportion of the cost of medicines under the medical insurance payment method to the total cost of medicines. Judging from the current mode of operation of pharmacy trusteeship and other modes of operation, it does not really eliminate the use of drugs to supplement the medical treatment. Although medical institutions no longer operate drugs, they still participate in the distribution of drug income, or return profits from pharmaceutical manufacturers and suppliers, etc. The connection between the hospital and drug revenue has not been completely cut off. These models are micro-adjustments built under unfavorable mechanisms to be reformed, and the effectiveness of controlling drug costs is not significant. The real need for reform is the new design mentioned earlier. Although it is a new design, it is not predestined to mean that it will be difficult to change. The new design is scientific, reasonable, and effective. It is necessary to improve the management level. Otherwise, it will be trapped in the passive state of “headaches and foot acupuncture” and “treating the symptoms and not curing the symptoms” for a long period of time.

Zhou Shenglai: When it comes to the reform of payment methods, I think it should be based on the reform of medical service fees. At present, the hospital's services, medicines and consumables are all priced by the NDRC. Because the price of medical services is too low, it does not reflect value. Therefore, the most critical thing in China's medical reform is to change this practice that is contrary to economic laws and laws of value. This is the core point of the problem. Looking at the flu in the Taiwan region of China, the physician’s medical treatment fee is 500 TWD and the prescription fee is 50 TWD. The mainland needs more than 200 yuan for medicine, but the registration fee is only 1 renminbi. The medical service fee does not increase in price, and it actually violates the law of value, causing kickbacks and the proliferation of red packets. Since the basis and criteria for disputes between the supply and demand sides should be price, the payment method must be changed first. Otherwise, the payment method reform may also be in a form.

Gu Ke: At present and in the long run in the future, under the circumstances that it is difficult to promote separation of administration and office and separation of government affairs, the reform of the medical insurance payment can only be accelerated. The core of the Medicare payment reform is to use a combination of packaged payments to replace the predominant project-based payment system. After the Medicare payment reform determines the package payment model, it negotiates the two parties to pay the bill and collect the money, and then writes the agreement: If you do it, I will give you the money; if you breach the contract, you will deduct the money. In fact, regardless of whether the total amount is paid in advance or according to the type of disease, it is the same in a certain degree: as long as the corresponding fees and certain medical service standards are provided, the issue of zero-law, drug price and other details will be determined by the hospital itself. Under the agreement, in order to guarantee existing resources and even obtain more resources, the hospital will inevitably apply various methods and form a benign competition mechanism, so that the quality of medical services will continue to be improved and ultimately benefit patients. This will also be a gradual process. The first year will not be good, and the second year will be improvement.

Directly to the hospital drug structure "Pharmaceutical Economic News": Looking deeper, the elimination of "drug-based medicine" will inevitably affect the hospital's operation and the doctor's prescription behavior, which makes prescriptions with the outside world become more realistic. In this regard, how do you think the future hospital's medication structure will change? More importantly, the elimination of “doing medicine to support medicine” will also directly affect the pricing system for medicines. From overseas experience, what kind of thinking do you think we will bring?

Sun Lihua: The elimination of “doing medicine to support medicine” does have a great impact on hospital operations and doctors' prescription behavior. However, this effect should be conducive to the rational use of medicines and facilitate the realization of reform goals, but the premise is that the aforementioned new The design is scientific and reasonable. As for the future impact on the proportion of imported drugs and domestic drugs used in hospital terminals, it should not be an absolute increase or drop. The final result of a scientific and rational and comprehensive supporting measure should be to promote the use of a higher proportion of drugs that are highly compliant with “safe, effective, and economical use of drugs”, not because of obvious differences between imported and domestic identities. Otherwise, it can only indicate that the corresponding design or measure is not scientific and reasonable.

Any drug-related work and reforms should be designed around the overall goal of drug management (guaranteeing and improving people's drug safety, effectiveness, economy, and appropriateness). This objective is consistent with the objective requirements for drug pricing and the elimination of the new requirements for drug pricing by “taking medicine to support medical care”. Both focus on the consideration of economic factors. The value-based pricing method will be a reasonable choice for drug pricing.

Cai Jiangnan: After the abolition of “the use of drugs to support medical care”, doctors have no incentive to make prescriptions, and they need more cost-effective drugs. In the future, the drug supply chain, including circulation, will change. In the past, hospitals were purchasers of medicines and had incentives to use prescriptions, but foreign countries were different. The United States adopted a highly market-oriented pricing method, but this marketization was priced by pharmaceutical companies themselves, and the role of the government was weak. Drug prices High is inevitable. This is also the drawback of US drug pricing. The United Kingdom, Japan, and Germany have chosen universal health care, and the government has a strong lead. The government and the enterprise are in full negotiation. For example, new drugs must provide economic analysis of drugs. This shows the economic analysis of drugs and drug value evaluation. However, the pricing of Chinese medicines is very deformed, such as the bidding of medicines, the hospital's drug additions, and the monopoly of prescriptions. Dislocation policy packages have made medical reform unsustainable and the interests of hospitals have been distorted. There are no monitoring mechanisms such as legislation. Media and other aspects of supervision.

The elimination of “taking medicine for medical treatment” is not only a matter of money, but more importantly it stimulates the perversion of the medical industry. For example, if the “prescription for medicine” is cancelled, the monopoly of prescribing rights will not break, and social retail terminals will compete with the hospital in drug sales and supervise each other. Coupled with the off-site supervision of medical insurance institutions, it also promotes the coordination of the reform of medical institutions.