The "two-vote system" is a direct way to get rid of medicine to support doctors. Here, it is a unique perspective to analyze the implementation of the two-vote system in China.
What is the two-vote system and why?
In the process of communicating with people in the industry, Arterial Network found that there are different views on the two-vote system in the production, circulation and use of drugs. For example, pharmaceutical companies think that "the two-vote system needs financial processing ability, marketing strategy should be changed, and terminal coverage should be accelerated", while circulation enterprises think that "the process seems simpler after implementation, but the original business system has not changed, and it can only be as compliant as possible at the regulatory level", while hospitals say that "drug income is not the source of profits for hospitals, and drugs can be stripped out of hospitals if there are administrative requirements".
As can be seen from the above, different roles have different views on the "two-vote system", and they often interpret policies from their own interests. The first thing that comes to mind is what policies can affect, and then how to deal with it. Therefore, the system depends on the purpose of the "two-vote system" and the "top design" of the regulatory layer.
The "Implementation Opinions on Implementing the" Two-vote System "in Drug Purchase in Public Medical Institutions (Trial)" issued on February 26th, last year stated the purpose of the two-vote system as follows: "(Two-vote system) is an important starting point to standardize the drug circulation order, compress the circulation links and reduce the false high drug price, an effective means to purify the circulation environment, crack down on" money laundering "and strengthen the supervision and management of the drug market, and it is an effective means to standardize the drug circulation order.
The implementation of the two-vote system involves many interest disputes.
From one point of view, the two-vote system should rectify the order of drug circulation and crack down on money laundering. The ultimate goal is to "reduce the artificially high drug price", which means that the previous circulation system pushed up the drug price. The basis of this goal is that the original circulation system has pushed up drug prices, but the actual situation is far more complicated than this.
From a deeper perspective, the inflated drug price has both defects in system design and industrial and institutional reasons, and the latter two functions are more obvious. Previously, Arterial Network mentioned in the "Fantasy Journey from Medicine Representative to Medicine" that in the public medical system, medicines go through distributors and agents from manufacturers to final consumers, and doctors' prescriptions are finally reflected in the consumption of medicines through centralized bidding, which involves many links and interests, which is very different from the general commodity circulation.
As far as these points are concerned, each type of role has sufficient reasons to make different interpretations of the "two-vote system". For example, pharmaceutical companies believe that their products are not exclusive in the market, and it is inevitable to share benefits in order to achieve terminal coverage; Commercial companies think that they have mastered the resources of medical terminals and also need to gain benefits from the profits of drugs; Medical institutions and doctors think that their regular income is inconsistent with labor, and extra benefits are a compensation mechanism.
A widely circulated profit distribution map illustrates the distribution mechanism of additional benefits for drugs in the upstream and downstream of the pharmaceutical industry chain. Starting from pharmaceutical companies, dealers, bidding departments, hospitals, doctors, unified departments, medical representatives, and ticketing companies are all involved.
The data comes from road network and trunk network.
Then it is necessary to discuss the reasons for the formation of this benefit distribution mechanism. First of all, pharmaceutical companies and commercial companies have obtained "excess" profits, but the bulk of the benefits are distributed to doctors, medical representatives and ticketing companies, which is contrary to the general impression of the outside world. However, judging from the consumption process of drugs, the general consumer goods are not decided by users, but the decision-making power of consumption is in the hands of doctors, who have reason to take away more than one-third of the excess profits.
The "medical representative case", which had been raging before, focused on medical representatives and believed that they were the main promoters of pushing up drug prices. But don't forget who the medical representative works for. It can be said that the abnormal competition in the domestic pharmaceutical industry has led to this unconventional method of increasing sales.
The deeper reason here is that domestic pharmaceutical companies lack competitiveness in products (this abnormal marketing behavior accounts for the vast majority of domestic pharmaceutical companies, at least it is also the initiator). In the case that the technology and products of domestic pharmaceutical companies are not competitive, gray marketing behavior is inevitable.
What is the "two-vote system", that is, the "two-vote system" is implemented in drug procurement in public hospitals-pharmaceutical companies have one vote for circulation enterprises and circulation enterprises have one vote for medical institutions. The most straightforward interpretation is to achieve "book compliance" in the process of drug circulation.
But is it enough just to comply with the book? There may be a question mark. What is "tacit" in the industry is that even if the circulation links are reduced and the brushing behavior is avoided, the interest structure will not change much under the original circulation structure.
Not surprisingly, relevant parties have found countermeasures, such as pharmaceutical companies opening higher, and agency companies absorbing natural persons as employees.
Some commentators even believe that under the new regulatory system, it is necessary to ensure the distribution of the original benefits and meet the regulatory needs, and the ultimate direction can only be to pass on the additional cost of compliance to the final consumers. In short, the biggest obstacle to the "two-vote system" is to break the original interest structure.
What is the situation of the two-vote system in various places?
In traditional Chinese medicine, there are several treatment schemes for "Shen", either using strong drugs to remove the focus or using warm prescriptions to treat the disease slowly. The same is true for cleaning up and rectifying the problems existing in the field of drug circulation, including slow prescription and strong medicine.
The national implementation schedule of the "two-vote system" is that all public medical institutions in the pilot provinces of comprehensive medical reform and the first four batches of 200 pilot cities of comprehensive reform of public hospitals will fully implement the "two-vote system" before the end of 20 17, and encourage other regions to implement the "two-vote system".
According to the statistics of arterial network, as of mid-May, 16 provinces (cities/autonomous regions) have decided to implement the two-vote system, 4 provinces have indicated that they will implement the two-vote system in the rest of this year, and another 12 provinces (autonomous regions) are still waiting for specific time planning.
First of all, we must clarify a concept here. There is a great overlap between the comprehensive pilot provinces and the provinces that need to implement the two-vote system. By comparing the two lists, the scope of implementation of the two-vote system can be clarified.
The first is the pilot province of comprehensive medical reform.
The first batch: Jiangsu, Anhui, Fujian and Qinghai
The second batch: Shanghai, Zhejiang, Hunan, Chongqing, Sichuan, Shaanxi and Ningxia.
The third batch: Guangdong, Jiangxi, Gansu and Jilin (not yet approved)
Then, the two-vote system landed in all provinces and cities across the country.
Implemented in Beijing, Shanxi, Shaanxi, Hebei, Hunan, Gansu, Sichuan, Chongqing, Qinghai, Ningxia, Anhui, Fujian, Liaoning, Hainan, Zhejiang and Tibet.
Implemented during the year: Guangdong, Shanghai, Tianjin and Jilin.
Proposed: Inner Mongolia, Heilongjiang, Hubei, Jiangsu, Jiangxi, Shandong, Henan, Guizhou, Guangxi, Yunnan and Xinjiang.
Here, we select several provinces and cities to discuss the implementation of the two-vote system. Both provinces and cities that have implemented the two-vote system and those that have not yet been specifically planned will be involved. We can see the problems encountered in the implementation of the two-vote system and the attitudes of participants in various industries to the two-vote system.
The first is Fujian. The experience of medical reform in the sample cities of Fujian's national medical reform has also been widely mentioned. Fujian implemented the two-vote system earlier and began to implement the two-vote system policy in 2009. The practice of Fujian's two-vote system is that in the drug procurement of public hospitals, it is clear that the production enterprises directly invite tenders, bypassing the intermediate links, and implementing unified procurement, unified pricing and unified distribution. Clarify the control standard of distribution fee, reduce circulation links, squeeze out the inflated price of drugs, effectively crack down on the behaviors of underwriting the reserve price and money laundering after passing bills in drug circulation, and effectively control the inflated price of drugs.
Fujian has three experiences in implementing the two-vote system, namely, curbing the behavior of hanging tickets and walking tickets; Improve the concentration of drug distribution and reduce the distribution cost; Multi-party governance combined boxing to curb disorderly circulation.
When verifying the two-vote system, Fujian medical reform supervision department has a hard logic, which is to judge whether the implementation of the enterprise is reasonable by the difference between the first vote and the second vote. If there is a big difference between the two votes, it proves that the relevant links have been circumvented in the implementation process, and the regulatory authorities will conduct an in-depth investigation after knowing it.
The second is centralized drug distribution, which divides Fujian Province into several procurement areas, which are co-ordinated by the medical insurance fund, and stipulates that there are no more than 10 distribution enterprises in each procurement area. Through this practice, the number of circulation enterprises in Fujian Province has been reduced from more than 200 to 62, which greatly improves the concentration of drug circulation enterprises and effectively controls the cost of drug circulation. With the support of data, the cost of drug distribution in Fujian Province has been reduced from 5%-8% to 3%-5%, with an average reduction of 2 percentage points.
Third, the medical insurance department should take the lead to control the prescription quantity and quantity from the aspects of policy designation, supervision and management of medical insurance fund, negotiation of medical service price, joint procurement, distribution and settlement, supplemented by the management of medical insurance doctors. At the same time, Fujian plans to change the drug procurement rules from bidding procurement to joint price-limited sunshine procurement.
The second city worth discussing is Beijing. In the "Implementation Plan for Comprehensive Reform of Medicine Separation" issued by Beijing Municipal Government, the two-vote system is stated as follows: the "two-vote system" for drug purchase and sale is implemented (production enterprises issue invoices to circulation enterprises, and circulation enterprises issue invoices to medical institutions).
Beijing medical reform is a bold attempt.
At the same time, encourage and standardize group procurement, medical consortium procurement and regional joint procurement, further improve the participation of medical institutions in centralized drug procurement, and reduce the prices of drugs and consumables.
All drug purchases are carried out on the online centralized drug purchase platform built by the government, and the drug purchase price is dynamically linked to the lowest price of provincial centralized drug purchase.
Publicize the variety, price, quantity and drug adjustment of drug procurement in public medical institutions to ensure that all aspects of drug procurement operate in the sun.
Of course, the main purpose of "sunshine procurement" in Beijing is to reduce the drug procurement price, and its pricing standard is "the lowest price of centralized procurement in China", which means that under the framework of dynamic adjustment, the drug price will continue to decline, which will cause great pressure on pharmaceutical industrial and commercial enterprises participating in Beijing bidding.
Based on the implementation of the two-vote system in Fujian and Beijing, we can basically summarize the specific operation paths of provinces and cities that have implemented the two-vote system. For example, starting with bills and tickets, it requires "the same fare" and the comparison between the two tickets, and starting with medical insurance payment and doctor's prescription management. , curb violations, comprehensively control drug prices by controlling drug prices, and let participants "actively seek change."
What are the remaining problems of the two-vote system?
As mentioned earlier, the main purpose of the two-vote system is to "reduce the inflated drug price". From the cases in Fujian, Beijing and other places, it can be seen that in addition to the two-vote system, the regulatory authorities have supplemented various policies to cooperate with the implementation of the two-vote system and achieved certain results.
Systematically speaking, the high drug price can be said to be a microcosm of the imperfection of China's drug supply and demand system. The interest chain is long and there are many participants. The distribution mechanism has formed a tacit understanding of the industry, which will affect the whole body.
Statistics show that in the drug procurement of public hospitals, the inflated drug price can account for more than 30% of the total price, and the "excess" part is borne by medical insurance funds, patients, insurance and other departments. Especially for the medical insurance fund, it is particularly important to reduce the burden through process control under the current situation that the medical insurance fund is tight or even in deficit (this is also the reason why the medical insurance department participates in the implementation of the two-vote system in Fujian).
From the perspective of controlling inflated drug prices, the two-vote system can never be the only starting point.
Judging from the competition of pharmaceutical companies in China, the main reason for their "sales orientation" is that their products are not competitive and they can only enter the market by changing resources into channels. After the formation of path dependence, this pattern is difficult to change.
Reviewing the history of "medical representatives" can also prove this point. When foreign pharmaceutical companies enter China, commercial bribery is rarely seen-mainly by academic promotion. When domestic pharmaceutical companies began to develop, industrial bribery began to sprout. When domestic pharmaceutical companies began to become the mainstream of the market, commercial bribery in the field of pharmaceutical circulation has become the "hidden rule" of the industry.
After the implementation of the two-vote system, pharmaceutical companies have also found some ways to "break the game". For example, moving the registered place of production enterprises to low-tax areas-making up for the business profits cut off by the two-vote system through tax incentives-ensuring that the distributable profits of the original stakeholders remain unchanged.
Or carry out the so-called sales outsourcing (CSO) to achieve the compliance of bill processing, and form a company with pharmaceutical agents as natural persons, and convert the channel fees into "consulting fees and marketing fees". In fact, this program is still a new form of medicine. Although it seems to be compliant, it retains the original interest system and cannot be implemented to break the drug process premium.
In addition, in the national two-vote system, the definition of "first vote" in the two-vote system is industrial enterprises to circulation enterprises, but the policies issued by different places have different interpretations. For example, Chongqing takes the domestic general manager as one vote, and Zhejiang takes the drug listing license holder as one vote.
In addition, whether primary health care (which also belongs to the public health care system) can increase one vote remains to be explored in actual operation, and the national "two-vote system" also has a great adjustment direction.
In fact, medical institutions and doctors may have different views on the implementation of the two-vote system. Under the background of "separation of medicine and medicine", the supply of medicine has gradually become the burden of hospitals, which are willing to dispense drugs outside the hospital, and some joint pharmacies or designated pharmacies have begun to appear.
Under this pattern, the prescription circulation of joint or designated pharmacies can also become a source of profit, and it is not under the framework of free medical supervision, so it is more hidden and difficult to trace.
Doctors, the beneficiaries of benefit distribution, may have something to say. As far as the current situation is concerned, their workload and interests do not match, and the two-vote system should focus on cracking down on gray interests or compensating their interests.
In fact, for a long time, the regulatory authorities also knew about this compensation channel. However, the existing problem is that it is difficult for the regulatory authorities to bring these interests into the regulatory framework-the treatment of medical personnel is a cliche, and because of its publicity, the treatment of medical personnel is easy to compare with the staffing of other institutions.
Therefore, in the medical reform in Beijing, the medical treatment fee, which reflects the labor value of medical staff, has been increased. At present, the payer of this fee is mainly medical insurance, and the average reimbursement amount of tertiary, secondary and primary hospitals is about 40, 30 and 20 respectively.
Although there is no medical insurance expenditure data released by Beijing Medical Reform, the final direction can only be rising. On the one hand, I want to cut off the extra income of medical staff through the two-vote system, on the other hand, I want to increase medical expenses as compensation. To be sure, there must be an order of magnitude relationship between the two data, so it is difficult to determine the final direction.
To be sure, the two-vote system is only a pilot policy in the process of "medical reform". The ultimate goal of this round of reform is to improve the drug supply system and avoid channel competition bred by gray behavior;
Secondly, improve the treatment of medical staff and put an end to their motivation to rationalize gray behavior; Reflected in the patient level, it is to enjoy valuable medical services with reasonable payment (including medical insurance payment and personal payment).
The road ahead is still far away, and policies such as "three medical linkages" are crucial. As industry participants, we should make clear the node of the two-vote system in medical reform and handle it correctly, which may be the most urgent problem to be solved at present.