The "two-vote system" is a direct way to eliminate the use of medicines to support medical care, so analyzing the implementation of the two-vote system in the country is a unique perspective for interpreting the "health care reform".
What is the two-ticket system and why?
In the course of exchanging views with industry insiders, Arterial Network found that each link in the production, circulation and use of drugs has a different view of the two-invoice system. For example, pharmaceutical companies believe that "the two-ticket system puts forward requirements for financial processing capabilities, to change the marketing strategy to accelerate the coverage of the terminal", the circulation of enterprises believe that "after the implementation of the process seems to be simpler, but the original business system has not changed, can only be done at the regulatory level to try to achieve compliance! ", the hospital said "drug revenue is not a source of profit for the hospital, if the administrative requirements, can be divested from the hospital drugs.
The above can also be seen, different roles for the "two votes system" of different views, and often from their own interests in the interpretation of the policy, the first thing that comes to mind is what the policy can affect, and then how to deal with. So the system to see what the purpose of the "two-ticket system" should also look at the regulatory layer of the "top-level design".
December 26 last year, the promulgation of the "on the public medical institutions in the implementation of drug procurement," the implementation of the "two-ticket system" (for trial implementation) "for the two-ticket system for the purpose of the two-ticket system is expressed in this way "(two-ticket) is to regulate the order of the circulation of medicines, compression of the circulation link to reduce the price of medicines, an important hand, is to purify the circulation environment, is the important hand, is to purify the circulation environment, is the important hand. Important hand, is to purify the circulation environment, combat "money laundering", strengthen the supervision and management of the pharmaceutical market an effective means to protect the urban and rural residents of the safety of medicines, safeguard the people's health of the inevitable requirements."
The implementation of the two-ticket system, involving a lot of interest entanglements
Article by article, the two-ticket system to reorganize the order of the circulation of medicines, to combat money laundering, the ultimate goal is to "reduce the high price of medicines", meaning that the previous circulation system pushed up the price of medicines. This goal was established on the basis of the original circulation system pushed up the price of drugs, but the actual situation is far more complex than this.
From a deeper perspective, high drug prices have both system design flaws, but also industry and institutional reasons, and the role of the latter two is more obvious. Previously, the arterial network in the "from the transformation of pharmaceutical representatives, see a drug's fantastic journey" has mentioned, in the public health care system, drugs from the manufacturer to the hands of the final consumer, to go through the dealers, agents, and through the centralized bidding, and ultimately by the doctor's prescription embodied in the consumption of medicines, involves a lot of links, involved in a wide range of interests, and the general flow of commodities there are big differences.
On these points, each type of role has enough reasons to make different interpretations of the "two-ticket system". For example, pharmaceutical companies believe that their products are not exclusive to the market, and to achieve the coverage of the terminal will inevitably share the benefits; commercial companies believe that they hold the resources of the medical terminal, but also need to gain from the profits of the drugs; medical institutions and doctors believe that their regular income is not in line with the payment of labor, and the additional benefits are a compensation mechanism.
A widely circulated benefit distribution mapping illustrates the distribution mechanism of extra benefits of medicines upstream and downstream of the pharmaceutical industry chain, starting from pharmaceutical enterprises, distributors, bidding departments, hospitals, doctors, unified party departments, medical representatives, and overbilling companies are all involved.
Data from the Internet, collected and organized by Arterial Network
So here it is necessary to explore the reasons for the formation of this benefit distribution mechanism. First of all, the drug companies and commercial companies get "excess" profits, but the bulk of the benefit distribution is in the doctors, medical representatives and overbilling companies, which is also contrary to the general impression of the outside world. But from the consumption process of this particular commodity, not to the general consumer goods by the user to decide, the decision-making power of consumption is in the hands of doctors, so doctors have reason to take more than one-third of the excess profits.
Previously, the "case of medical representatives" has been a hot topic, the focus of the contradiction in the medical representatives, that is, to push up the price of medicines is the main pushers. But don't forget who the reps are working for. It could be argued that the abnormal competition in the domestic pharmaceutical industry has led to this unconventional method of increasing sales.
The deeper reason here is the lack of competitiveness of domestic pharmaceutical companies in the product (this abnormal marketing behavior of domestic pharmaceutical companies account for the vast majority, or at least the originator), in the case of domestic pharmaceutical companies are not technically and product competitiveness, gray marketing behavior can not be avoided.
What is the two-vote system, that is, in the public hospital drug procurement in the implementation of the "two votes" - from the pharmaceutical enterprises to the circulation of a vote, from the circulation of a vote of the enterprise to the medical institutions, the most straightforward way to interpret is that the circulation of drugs to achieve the process of The most straightforward way to interpret this is to say that the process of drug distribution should be "book-compliant".
But only to do book compliance is enough, may want to play a question mark. The industry "unspoken" is that even if you reduce the circulation of the links to avoid the invoicing behavior, but in the original circulation structure, the interest structure will not have much change.
The most unsurprising thing is that the related parties have already found countermeasures, such as the high opening of the pharmaceutical enterprises, the agency to absorb the natural person as employees.
There are even comments that under the new regulatory system, both to ensure that the original distribution of benefits, by the need to meet the regulatory needs, the ultimate point can only be to comply with the extra costs passed on to the final consumer, in a word, the "two-ticket system," the biggest obstacle is to break the original structure of interests.
The two-ticket system around the landing situation
The Chinese medicine on the "disease" there are several treatment programs, or fierce medicine to get rid of the lesions, or the warm side of the slow treatment of disease. For the circulation of drugs in the problem of cleanup and remediation is the same, there is a slow party also have a strong medicine.
"Notice" on the two-ticket system in the national implementation of the time schedule is, by the end of 2017, the comprehensive health care reform pilot provinces and the first four batches of 200 public hospitals comprehensive reform of the pilot city of all public health care institutions to fully implement the "two-ticket system", to encourage the implementation of the "two-ticket system" in other areas. ".
And according to arterial.com, as of mid-May, 16 provinces (municipalities/autonomous regions) across the country have already determined to implement the two-ticket system, four provinces said they will implement the two-ticket system for the rest of this year, and another 12 provinces (autonomous regions) are still waiting for specific time planning.
Here we have to first clarify a concept is that there is a big overlap between the integrated pilot provinces and the provinces that need to implement the two-invoice system, and looking at the two sets of lists in comparison can clarify the scope of implementation of the two-invoice system.
First, the integrated medical reform pilot provinces
First batch: Jiangsu, Anhui, Fujian, Qinghai
Second batch: Shanghai, Zhejiang, Hunan, Chongqing, Sichuan, Shaanxi, Ningxia
Third batch: Guangdong, Jiangxi, Gansu, Jilin (yet to be approved)
And then, the provinces and cities where the two-ticket system is already in place nationwide
Already implemented Beijing, Shanxi, Shaanxi, Hebei, Hunan, Gansu, Sichuan, Chongqing, Qinghai, Ningxia, Anhui, Fujian, Liaoning, Hainan, Zhejiang, Tibet
Implemented within the year: Guangdong, Shanghai, Tianjin, Jilin
Still to be planned: Inner Mongolia, Heilongjiang, Hubei, Jiangsu, Jiangxi, Shandong, Henan, Guizhou, Guangxi, Yunnan, Xinjiang
Here we select Here we pick a few provinces and cities to discuss the implementation of the two-vote system, which has been implemented and is still to be specifically planned for the provinces and cities will be involved, you can see the two-vote system in the implementation of the level of the problems encountered, as well as the attitude of the various industrial participants on the two-vote system.
First is Fujian. Fujian national healthcare reform sample city, its healthcare reform experience has also been widely mentioned, Fujian to carry out the two-ticket system is also earlier, since 2009 to implement the two-ticket system policy. The practice of Fujian's two-invoice system is that in the procurement of drugs for public hospitals, it is clear that manufacturers bid directly, bypassing the intermediate links, and implementing unified procurement, unified pricing, and unified distribution. Clear distribution fee control standards, reduce the circulation link, squeeze out the water of drug prices, effectively combat the circulation of drugs at the bottom of the price of underwriting, money laundering and other behaviors, and effectively control the inflated prices of drugs.
The implementation of the two-ticket system in Fujian has three points of experience, respectively, is to curb the hanging ticket, ticket behavior; improve the concentration of drug distribution, reduce distribution costs; multi-party governance combinations to curb the circulation of chaotic direction.
Fujian health care reform regulators in the verification of the two-ticket system has a hard logic, that is, through the first ticket and the second ticket price difference to determine whether the implementation of the enterprise is reasonable, if the price difference between the two tickets is very large, then it proves that the relevant links in the implementation of the process of circumvention, the regulator is aware of it, it will be investigated in-depth.
The second is to centralize the distribution of medicines, the province of Fujian will be divided into several procurement area, distribution area and health insurance fund co-ordination, the provisions of each procurement area of the distribution of no more than 10 enterprises. Through this approach, Fujian province's distribution enterprises from the original more than 200 reduced to 62, significantly increasing the concentration of drug distribution enterprises, effectively controlling the cost of drug distribution. Supported by data, the cost of drug distribution in Fujian province has been reduced from the previous 5%-8% to 3%-5%, an average reduction of 2 percentage points.
The third is led by the medical insurance department, from the medical insurance fund policy designation, medical fund supervision and management, medical service price negotiation, joint purchasing and distribution and settlement, supplemented by the management of medical insurance physicians to control the amount and volume of their prescriptions. At the same time, Fujian intends to change the rules of drug procurement from bidding to joint price-limit sunshine procurement.
The second city worth discussing is Beijing. In the Beijing Municipal Government issued a comprehensive reform of the implementation of the separation of medicine program, about the two-invoice system is so expressed: the implementation of the purchase and sale of drugs "two-invoice system" (production enterprises to the circulation of the enterprise to open an invoice, the circulation of the enterprise to the health care institutions to open an invoice).
Beijing's healthcare reform is a bold attempt
At the same time, it encourages and standardizes group purchasing, medical consortium purchasing and regional joint purchasing to further increase the participation of medical institutions in centralized purchasing of medicines and reduce the prices of medicines and consumables.
Drug purchases are all conducted on the government-built online centralized drug procurement platform, and drug purchase prices are dynamically linked to the lowest prices of centralized drug purchases at the provincial level nationwide.
Disclosing the varieties, prices, quantities, and changes in drug adjustments in public medical institutions ensures that all aspects of drug procurement operate under the sun.
Of course, the main purpose of Beijing's "sunshine procurement" is to reduce the price of drug procurement, and its pricing standard is the "national centralized procurement of the lowest price", which means that under the framework of dynamic adjustment, the price of drugs will continue to fall, which will give the pharmaceutical industry and commercial enterprises participating in the bidding in Beijing a great deal of money. This will put a lot of pressure on the pharmaceutical industry and commercial enterprises participating in Beijing's bidding.
Comprehensive implementation of the two-ticket system in Fujian and Beijing to see, basically can be summarized in the implementation of the two-ticket system of provincial and municipal specific path of operation. For example, from the ticket ticket to start, the requirement of "ticket goods money" consistent, the two votes compared, and from the direction of health insurance payment, doctor prescription management, etc., to curb irregularities, coupled with the excess from centralized purchasing to sunshine purchasing, the overall control of the drug price, through the control of the drug price of the way to reshape the interest space of the drug, so that the participants "take the initiative to seek change".
What problems are still left unresolved with the two-ticket system?
As mentioned earlier, the main purpose of the two-ticket system is to "reduce the inflated prices of medicines", as can be seen from the cases implemented in Fujian and Beijing, in addition to the two-ticket system, the regulatory authorities also supplemented by a variety of policies to fit the implementation of the two-ticket system, and has achieved certain results.
Systematically, high drug prices can be said to be a microcosm of the imperfect system of supply and demand of drugs in China, the interest chain is long, many parties involved, the distribution mechanism has formed a tacit understanding of the industry, pulling one hair and affecting the whole body.
Data show that public hospitals in the procurement of drugs, inflated drug prices can account for more than 30% of the total price, the "excess" part of the medical insurance fund, patients, insurance and other sectors. Especially the medical insurance fund, in the current situation of medical insurance fund tension or even deficit, can through the process of control to reduce the burden is particularly important (this is also the implementation of the two-ticket system in Fujian, the implementation of the process of the medical insurance sector to participate in the reason).
From the point of view of controlling the inflated prices of drugs, the two-ticket system can never be the only hand
From the competitive situation of China's pharmaceutical enterprises, the main reason for their "sales-oriented" is the lack of competitiveness of the product, and can only enter the market through the exchange of resources for the channel. And after the formation of path dependence, this pattern is difficult to change.
Reviewing the history of the "pharmaceutical representative" can also support this point, in the foreign-funded pharmaceutical companies to enter China, seldom seen commercial bribery - its main academic promotion, until the domestic pharmaceutical companies began to develop, the industry began to bribery began to pull seedlings. To the domestic pharmaceutical enterprises began to become the mainstream of the market, the pharmaceutical distribution of commercial bribery has become the industry's "unspoken rules".
After the implementation of the two-ticket system, pharmaceutical companies have found some ways to "break the ice". For example, they have moved the registration of their manufacturing enterprises to areas with low tax rates to make up for the business profits cut off by the two-invoice system through tax incentives, and to ensure that the distributable profits of their original stakeholders remain unchanged.
Or the so-called sales outsourcing (CSO) to achieve compliance with the bill processing, the pharmaceutical agent natural person to form a company, the channel costs into "consulting costs, marketing costs" and so on. This set of processes is actually still a change of soup but not a change of medicine, although it seems to be compliant, but the original interest system is preserved, to break the drug process premium can not be implemented.
Additionally, the national two-ticket policy on the two-ticket system, "the first ticket" is defined as the industrial enterprises to the circulation of enterprises, but the separate policies issued by different parts of the different interpretations of this, for example, Chongqing will be the domestic general agent as a vote, Zhejiang, the drug listing licensee as a vote, and so on.
Additionally, such as primary health care (also belonging to the public health care system) can add a vote, these are to be explored in the actual operation, the national "two votes system" there is also a great direction of adjustment.
In fact, for the implementation of the two-vote system, medical institutions, doctors may have different views. In the context of the "separation of medicine", the supply of drugs has gradually become a burden on hospitals, hospitals have the will to transfer drugs outside the hospital, some joint pharmacies or designated pharmacies began to appear.
Under this pattern, the flow of prescriptions from joint or designated pharmacies can also be a source of profit, and is not under the public healthcare regulatory framework, making it more secretive and difficult to track.
The main beneficiary of the profit distribution - doctors - may have more to say, given the current situation, there is a mismatch between the amount of their labor and the benefit of the two-ticket system to focus on combating the gray benefit or compensation for their interests.
In fact, for a long time, the regulator is also aware of this compensation channel. But the problem is that it is difficult for the regulator to bring this benefit under the regulatory framework - the treatment of medical staff is a cliché, and because of its public nature, the treatment of medical staff can easily be compared with that of other institutionalized staff.
So in Beijing's healthcare reform, the fee for medical treatment has been raised to "reflect the value of medical staff's labor". The current payer of this fee is still mainly health insurance, with the average reimbursement for tertiary, secondary and primary hospitals at around 40, 30 and 20 respectively.
While there is no data on health insurance spending released by Beijing's health care reform, the ultimate point can only be up. On the one hand, look, through the two-ticket system and other ways to want to cut off the extra earnings of medical personnel, on the other hand, want to raise the consultation fee as compensation, you can be sure that there is absolutely a size and magnitude of the data of the two, so it is difficult to determine the final direction.
What is certain is that the two-ticket system is only a pilot policy in the process of continuing to push forward the "health care reform". The ultimate goal of this round of reforms is to improve the supply system of medicines and avoid channel competition that is fostered by grey behaviors;
The second is to improve the treatment of medical personnel and eliminate their incentives to rationalize grey behaviors; and, at the patient level, to pay a reasonable amount of money (both in terms of health insurance payments and personal payments) to enjoy valuable medical services.
The road ahead is still far, "three medical linkage" and other policies for the key, as industry participants, should be clear about the two-ticket system in the health care reform in the node, the correct response, which may be the most important issue to be resolved at this time.