Since CCTV continuously paid attention to the issue of high drug prices in the near future, drug price, a socially sensitive topic, has again become the focus of public opinion.
According to Zhu Hengpeng, an expert in health economics and a researcher at the Institute of Economics of the Chinese Academy of Social Sciences, the high drug price is a long-term phenomenon that must be found in the system design.
He pointed out: In recent years, in order to reduce the medical burden on patients, the government has implemented a series of regulatory measures in the pharmaceutical industry to regulate the behavior of hospital doctors, regulate medical services and drug prices, but these have become the root cause of the high drug prices, and the result has been counterproductive.
Some links in the formation of high drug prices
One indisputable fact is that the high drug prices mainly occur in the second and third-tier public hospitals.
Zhu Hengpeng divides the drugs used in public hospitals into three categories: The first type is life-saving drugs, which are necessary for hospitals to carry out their daily operations. Whether they are purchasing varieties or purchasing prices, hospitals have little negotiation space, but the amount of medication is small and the amount is also small. Not much; the second category is the treatment of drugs, but also the necessary drugs, the hospital selection of procurement when the leeway is not large, but the negotiation space for the purchase price is larger; the third category is available medicine, such drugs The typical characteristic is that "it is impossible to cure people and cure diseases." It is entirely up to the hospital to decide whether or not to purchase or purchase such drugs.
In Zhu Hengpeng's view, it is the third type of medicine that has become the "hardest hit area" where drug prices are high. "Prices of generic drugs are not high, and high-priced drugs are mainly new drugs and special drugs, and almost all are individually priced."
The formation mechanism of drug prices in China is based on the self-reported production costs of pharmaceutical companies. After being accounted for by the Price Division of the National Development and Reform Commission or the local price departments, each type of drug will generate a “maximum retail priceâ€, which is the so-called “ceiling priceâ€; After the centralized bidding and organization of expert assessments, a “bid price†is generated; the bid price is the purchase price of the hospital.
The policy explicitly stipulates that the hospital must purchase at this price, and must not negotiate with the supplier to lower the purchase price, and increase the purchase price by 15% on the basis of the bid price, resulting in a “hospital retail priceâ€.
In the case of 2 ml and 0.3 g of clindamycin phosphate injection, widely reported by the media a few days ago, the drug's factory price per item is about RMB 0.6. The winning price in Beijing is RMB 11 and the retail price of the hospital is RMB 12.65. From the ex-factory price to the retail price, despite the fact that the price has more than doubled 20 times, it has still not exceeded the maximum retail price set by the price department and there is no violation.
In the eyes of people in the industry, it is precisely because some drugs "ceiling price" and the bid price is set too high, so that the drug price is possible to become a virtual high, and then derived from a multi-link fertilizer chain of interest.
Taking the above clindamycin phosphate injection as an example, the medical agency takes the drug from the drug factory at a price of 0.6 yuan, and sells it to a pharmaceutical representative at a price of 4 yuan, earning a difference of more than 3 yuan in the middle.
In order to ensure that medicines can be bid at a high price, most of the spreads in this part will be spent on tender public relations on the bidding office and its competent departments and supervisory departments, as well as the assessment of experts who bid on the price, and the agency companies must open up all links!
As the bidding department only bids and does not purchase, it is the hospitals and doctors who really decide on the sale of drugs. In order to promote the quantity of drugs to be taken in hospitals, medical representatives are required to work as doctors and hospitals.
The medical representative took medicine at a price of 4 yuan, and the hospital's nominal purchase price was 11 yuan. The distribution of the difference of 7 yuan in this period is that the doctors, nurses, and pharmacy coordinators, etc., who are related to prescriptions, give marketing remuneration to the hospital (known in the industry as dark cover), and may also involve the director of the department of pharmacy and the deputy supervisor. The dean, the dean, and even the head of the health bureau. Occasionally, hospital finance personnel must also be targeted for timely recovery of sales receipts. These are the medical rebates that are widely criticized by the outside world.
In addition, the drug regulatory department in charge of the approval of new drugs, the price department that sets the maximum retail price, and the medical insurance department and pharmaceutical company that are responsible for the medical insurance directory management may all be public relations, and thus become a part of the high drug price interest chain.
Price control and drug prices are high
Drug prices are vaunted, and the price departments and the tendering departments cannot escape the responsibility of inspection. In the case of the “Astronomical Asparagus Film†of the Hunan Xiangya No. 2 Hospital, which has drawn extensive attention, the Hunan Provincial Price Bureau once admitted in the notification: “The staff of the Bureau does have issues of poor supervision, incomplete information collection, and insufficient work. When pricing, important information such as the ex-factory price and the purchase price of the pharmaceutical company was not known, resulting in a high bidding price.†The tendering department only collected the guided bidding prices of other provinces for reference by experts.
In Zhu Hengpeng's view, the highest retail price and high bidding price are only necessary conditions for the high drug prices, not sufficient conditions. Under the current medical control system, hospitals and doctors must favor high-priced drugs.
The first is the regulation that the hospital retail price increase cannot exceed 15%. In the absence of fiscal subsidies, hospitals must find ways to do well in their nutrition. A 15% increase in drug prices is their legitimate profit. This kind of game rules make the hospital must favor high-priced drugs. Take the asparagus slice as an example. If the purchase price is 15 yuan, the maximum legal increase for the hospital is 1.25 yuan. If the purchase price is increased to 185 yuan, the legal fare increase will be close to 28 yuan.
Zhu Hengpeng once stated in an article that under the regulation that the rate of increase cannot exceed 15%, hospitals generally have rebates and rebates in addition to legitimate increases in profits. The dark buckles in actual operation have become an important source of hospital profits.
Followed by the price control of medical services. For a long time, the price of doctors' medical services has been artificially depressed, and the registration fee is only a few yuan at most, which is far from reflecting the value of their labor. When doctors can't obtain income from medical treatment fees, when they can start taking medicines, they will of course choose to receive rebates and push up drug prices. In other words, the high price of some medicines is not actually medicine profits, but medical service remuneration.
Zhu Hengpeng repeatedly emphasized that when discussing the issue of high drug prices, it is necessary to clarify two issues: First, why can hospitals sell drugs at high prices and pharmacies cannot? Why do second- and third-tier hospitals sell drugs at high prices and basic hospitals and social clinics cannot? Second, why are hospitals selling drugs at high prices?
He believes that the answer to the first question is that public hospitals have an administrative monopoly in the medical services market, making it a monopoly of pharmaceutical retailers through monopoly prescription rights. This is a necessary condition for public hospitals to be able to sell drugs at high prices. Health centers and clinics do not have such monopoly power and there is no condition for selling drugs at high prices.
At the same time, Zhu Hengpeng further analyzed that only this kind of monopoly on medical services does not necessarily lead to public hospitals selling drugs at a high price. On the contrary, if there is no government regulation of the prices of medical services, hospitals tend to increase their fees for treatment. Not selling drugs at high prices. Artificially lowering the price of medical services has caused hospitals to sell drugs at high prices.
“In a nutshell, the administrative monopoly position allows public hospitals to sell drugs at high prices, and the government artificially reduces the price of medical services and leads to the system of using drugs to provide medical care. This makes hospitals have to sell drugs at high prices.†Zhu Hengpeng said, “This makes some room for fare increases. For small drugs, hospitals are unwilling or even unable to sell them, otherwise it will be difficult to obtain enough proceeds from drug sales to keep the hospital running."
Under the above-mentioned benefit incentive mechanism, there is a market for high drug prices and no market for low-cost drugs. “Some low-priced medicines have low profit margins and there is no room for public-equipment kickbacks. Doctors do not prescribe and hospitals do not purchase. Even if they win the bid, there will be no sales. This is known as the “dead standard†in the industry.†Zhu Hengpeng told reporters.
Zhu Hengpeng said that this can also explain the disappearance of some low-priced drugs. When the country repeatedly lowers the maximum retail price of certain drugs, manufacturers will introduce alternative new drugs, and then seek individual pricing rights, evade government price controls, and raise drug prices. For hospitals and doctors, sales of such high-priced new drugs apparently can bring greater benefits to themselves. Therefore, some price-cutting drugs are expelled from the hospital market. This is what the industry calls "death price cuts."
How to treat the zero difference
Only the right medicine can solve the problem. According to the "source of the disease" it finds. In the short term, it is difficult to substantially increase the cost of medical services, Zhu Hengpeng suggested that the state liberalizes the control over the rate of retail drug retailing in public hospitals so that hospitals can independently choose drug suppliers and allow hospitals to autonomously administer medicines within the scope of provincial procurement catalogues. Negotiations are initiated, and the actual purchase price is negotiated independently, and the actual retail price is determined independently under the guidance of the highest retail price in the country.
“Under this new mechanism, public hospitals are not driven by the interest in purchasing high-priced drugs and will certainly choose a lower purchase price from the market. Even if the price increases are 100% or even 200%, because there is no room for dread and rebate, The new retail price will also be lower than the current price." Zhu Hengpeng said.
Zhu Hengpeng analysis believes that in this case, any act of the doctor accepting kickbacks and raising the purchase price will squeeze the profit margin of the hospital to allocate the difference price, thus affecting the overall revenue of the hospital. Hospital administrators cannot tolerate the existence of such behavior.
Of course, hospitals adopt this model and must support the follow-up of the pay system that directly links hospital income with doctors' income. If the public hospital adopts a pot-ease-average income distribution system, even if the price increase rate control is cancelled, the incentive for doctors to receive drug rebates still exists.
Zhu Hengpeng emphasized that the elimination of the regulation of drug price increase is absolutely not a zero difference system. In fact, zero spread is a more stringent price increase control. “In the past few years, I have discovered at the grass-roots level that the effect of the zero spread is that the hospital’s loss of medicine sales revenue is difficult to make up for, and it will seriously dampen the enthusiasm of doctors.â€
The prescription prescribed by Zhu Hengpeng was approved by Gu Kai, professor of medical reform and Professor of the School of Management of Peking University. Gu Kezeng once wrote an article pointing out that “for the stubbornly high drug prices in public hospitals, one prescription can be eased, that is, the elimination of drug addition control,†and the zero difference price is only an ineffective “pharmaceutical prescriptionâ€.
While cancelling the rate control of drug price increase, Zhu Hengpeng and Gu Jie also unanimously called for the reform and improvement of the Medicare payment mechanism as soon as possible, and the implementation of a compound payment method focusing on head-to-head payment, in-patient payment on a case-by-case basis, and total advance payment.
In layman's terms, the patient is packaged in a hospital and the mode of capping the total amount of hospital visits and the retention of hospital balances are implemented. Under this model, medicines become a cost input for medical institutions rather than a source of profit. Doctors certainly do not use high-priced medicines and make big prescriptions. "He even hopes that patients can be cured without prescribing medicines."
In the medium and long term, Zhu Hengpeng also suggested that the number of public hospitals should be streamlined, and private hospitals should be vigorously developed to break the administrative monopoly position of public hospitals while vigorously developing chain pharmacies, giving pharmacies and hospitals the same qualifications as prescription drug sales, through various types of medical institutions. Full competition, allowing patients to use their feet to vote, thereby inhibiting the growth rate of medical expenses.
According to Zhu Hengpeng, an expert in health economics and a researcher at the Institute of Economics of the Chinese Academy of Social Sciences, the high drug price is a long-term phenomenon that must be found in the system design.
He pointed out: In recent years, in order to reduce the medical burden on patients, the government has implemented a series of regulatory measures in the pharmaceutical industry to regulate the behavior of hospital doctors, regulate medical services and drug prices, but these have become the root cause of the high drug prices, and the result has been counterproductive.
Some links in the formation of high drug prices
One indisputable fact is that the high drug prices mainly occur in the second and third-tier public hospitals.
Zhu Hengpeng divides the drugs used in public hospitals into three categories: The first type is life-saving drugs, which are necessary for hospitals to carry out their daily operations. Whether they are purchasing varieties or purchasing prices, hospitals have little negotiation space, but the amount of medication is small and the amount is also small. Not much; the second category is the treatment of drugs, but also the necessary drugs, the hospital selection of procurement when the leeway is not large, but the negotiation space for the purchase price is larger; the third category is available medicine, such drugs The typical characteristic is that "it is impossible to cure people and cure diseases." It is entirely up to the hospital to decide whether or not to purchase or purchase such drugs.
In Zhu Hengpeng's view, it is the third type of medicine that has become the "hardest hit area" where drug prices are high. "Prices of generic drugs are not high, and high-priced drugs are mainly new drugs and special drugs, and almost all are individually priced."
The formation mechanism of drug prices in China is based on the self-reported production costs of pharmaceutical companies. After being accounted for by the Price Division of the National Development and Reform Commission or the local price departments, each type of drug will generate a “maximum retail priceâ€, which is the so-called “ceiling priceâ€; After the centralized bidding and organization of expert assessments, a “bid price†is generated; the bid price is the purchase price of the hospital.
The policy explicitly stipulates that the hospital must purchase at this price, and must not negotiate with the supplier to lower the purchase price, and increase the purchase price by 15% on the basis of the bid price, resulting in a “hospital retail priceâ€.
In the case of 2 ml and 0.3 g of clindamycin phosphate injection, widely reported by the media a few days ago, the drug's factory price per item is about RMB 0.6. The winning price in Beijing is RMB 11 and the retail price of the hospital is RMB 12.65. From the ex-factory price to the retail price, despite the fact that the price has more than doubled 20 times, it has still not exceeded the maximum retail price set by the price department and there is no violation.
In the eyes of people in the industry, it is precisely because some drugs "ceiling price" and the bid price is set too high, so that the drug price is possible to become a virtual high, and then derived from a multi-link fertilizer chain of interest.
Taking the above clindamycin phosphate injection as an example, the medical agency takes the drug from the drug factory at a price of 0.6 yuan, and sells it to a pharmaceutical representative at a price of 4 yuan, earning a difference of more than 3 yuan in the middle.
In order to ensure that medicines can be bid at a high price, most of the spreads in this part will be spent on tender public relations on the bidding office and its competent departments and supervisory departments, as well as the assessment of experts who bid on the price, and the agency companies must open up all links!
As the bidding department only bids and does not purchase, it is the hospitals and doctors who really decide on the sale of drugs. In order to promote the quantity of drugs to be taken in hospitals, medical representatives are required to work as doctors and hospitals.
The medical representative took medicine at a price of 4 yuan, and the hospital's nominal purchase price was 11 yuan. The distribution of the difference of 7 yuan in this period is that the doctors, nurses, and pharmacy coordinators, etc., who are related to prescriptions, give marketing remuneration to the hospital (known in the industry as dark cover), and may also involve the director of the department of pharmacy and the deputy supervisor. The dean, the dean, and even the head of the health bureau. Occasionally, hospital finance personnel must also be targeted for timely recovery of sales receipts. These are the medical rebates that are widely criticized by the outside world.
In addition, the drug regulatory department in charge of the approval of new drugs, the price department that sets the maximum retail price, and the medical insurance department and pharmaceutical company that are responsible for the medical insurance directory management may all be public relations, and thus become a part of the high drug price interest chain.
Price control and drug prices are high
Drug prices are vaunted, and the price departments and the tendering departments cannot escape the responsibility of inspection. In the case of the “Astronomical Asparagus Film†of the Hunan Xiangya No. 2 Hospital, which has drawn extensive attention, the Hunan Provincial Price Bureau once admitted in the notification: “The staff of the Bureau does have issues of poor supervision, incomplete information collection, and insufficient work. When pricing, important information such as the ex-factory price and the purchase price of the pharmaceutical company was not known, resulting in a high bidding price.†The tendering department only collected the guided bidding prices of other provinces for reference by experts.
In Zhu Hengpeng's view, the highest retail price and high bidding price are only necessary conditions for the high drug prices, not sufficient conditions. Under the current medical control system, hospitals and doctors must favor high-priced drugs.
The first is the regulation that the hospital retail price increase cannot exceed 15%. In the absence of fiscal subsidies, hospitals must find ways to do well in their nutrition. A 15% increase in drug prices is their legitimate profit. This kind of game rules make the hospital must favor high-priced drugs. Take the asparagus slice as an example. If the purchase price is 15 yuan, the maximum legal increase for the hospital is 1.25 yuan. If the purchase price is increased to 185 yuan, the legal fare increase will be close to 28 yuan.
Zhu Hengpeng once stated in an article that under the regulation that the rate of increase cannot exceed 15%, hospitals generally have rebates and rebates in addition to legitimate increases in profits. The dark buckles in actual operation have become an important source of hospital profits.
Followed by the price control of medical services. For a long time, the price of doctors' medical services has been artificially depressed, and the registration fee is only a few yuan at most, which is far from reflecting the value of their labor. When doctors can't obtain income from medical treatment fees, when they can start taking medicines, they will of course choose to receive rebates and push up drug prices. In other words, the high price of some medicines is not actually medicine profits, but medical service remuneration.
Zhu Hengpeng repeatedly emphasized that when discussing the issue of high drug prices, it is necessary to clarify two issues: First, why can hospitals sell drugs at high prices and pharmacies cannot? Why do second- and third-tier hospitals sell drugs at high prices and basic hospitals and social clinics cannot? Second, why are hospitals selling drugs at high prices?
He believes that the answer to the first question is that public hospitals have an administrative monopoly in the medical services market, making it a monopoly of pharmaceutical retailers through monopoly prescription rights. This is a necessary condition for public hospitals to be able to sell drugs at high prices. Health centers and clinics do not have such monopoly power and there is no condition for selling drugs at high prices.
At the same time, Zhu Hengpeng further analyzed that only this kind of monopoly on medical services does not necessarily lead to public hospitals selling drugs at a high price. On the contrary, if there is no government regulation of the prices of medical services, hospitals tend to increase their fees for treatment. Not selling drugs at high prices. Artificially lowering the price of medical services has caused hospitals to sell drugs at high prices.
“In a nutshell, the administrative monopoly position allows public hospitals to sell drugs at high prices, and the government artificially reduces the price of medical services and leads to the system of using drugs to provide medical care. This makes hospitals have to sell drugs at high prices.†Zhu Hengpeng said, “This makes some room for fare increases. For small drugs, hospitals are unwilling or even unable to sell them, otherwise it will be difficult to obtain enough proceeds from drug sales to keep the hospital running."
Under the above-mentioned benefit incentive mechanism, there is a market for high drug prices and no market for low-cost drugs. “Some low-priced medicines have low profit margins and there is no room for public-equipment kickbacks. Doctors do not prescribe and hospitals do not purchase. Even if they win the bid, there will be no sales. This is known as the “dead standard†in the industry.†Zhu Hengpeng told reporters.
Zhu Hengpeng said that this can also explain the disappearance of some low-priced drugs. When the country repeatedly lowers the maximum retail price of certain drugs, manufacturers will introduce alternative new drugs, and then seek individual pricing rights, evade government price controls, and raise drug prices. For hospitals and doctors, sales of such high-priced new drugs apparently can bring greater benefits to themselves. Therefore, some price-cutting drugs are expelled from the hospital market. This is what the industry calls "death price cuts."
How to treat the zero difference
Only the right medicine can solve the problem. According to the "source of the disease" it finds. In the short term, it is difficult to substantially increase the cost of medical services, Zhu Hengpeng suggested that the state liberalizes the control over the rate of retail drug retailing in public hospitals so that hospitals can independently choose drug suppliers and allow hospitals to autonomously administer medicines within the scope of provincial procurement catalogues. Negotiations are initiated, and the actual purchase price is negotiated independently, and the actual retail price is determined independently under the guidance of the highest retail price in the country.
“Under this new mechanism, public hospitals are not driven by the interest in purchasing high-priced drugs and will certainly choose a lower purchase price from the market. Even if the price increases are 100% or even 200%, because there is no room for dread and rebate, The new retail price will also be lower than the current price." Zhu Hengpeng said.
Zhu Hengpeng analysis believes that in this case, any act of the doctor accepting kickbacks and raising the purchase price will squeeze the profit margin of the hospital to allocate the difference price, thus affecting the overall revenue of the hospital. Hospital administrators cannot tolerate the existence of such behavior.
Of course, hospitals adopt this model and must support the follow-up of the pay system that directly links hospital income with doctors' income. If the public hospital adopts a pot-ease-average income distribution system, even if the price increase rate control is cancelled, the incentive for doctors to receive drug rebates still exists.
Zhu Hengpeng emphasized that the elimination of the regulation of drug price increase is absolutely not a zero difference system. In fact, zero spread is a more stringent price increase control. “In the past few years, I have discovered at the grass-roots level that the effect of the zero spread is that the hospital’s loss of medicine sales revenue is difficult to make up for, and it will seriously dampen the enthusiasm of doctors.â€
The prescription prescribed by Zhu Hengpeng was approved by Gu Kai, professor of medical reform and Professor of the School of Management of Peking University. Gu Kezeng once wrote an article pointing out that “for the stubbornly high drug prices in public hospitals, one prescription can be eased, that is, the elimination of drug addition control,†and the zero difference price is only an ineffective “pharmaceutical prescriptionâ€.
While cancelling the rate control of drug price increase, Zhu Hengpeng and Gu Jie also unanimously called for the reform and improvement of the Medicare payment mechanism as soon as possible, and the implementation of a compound payment method focusing on head-to-head payment, in-patient payment on a case-by-case basis, and total advance payment.
In layman's terms, the patient is packaged in a hospital and the mode of capping the total amount of hospital visits and the retention of hospital balances are implemented. Under this model, medicines become a cost input for medical institutions rather than a source of profit. Doctors certainly do not use high-priced medicines and make big prescriptions. "He even hopes that patients can be cured without prescribing medicines."
In the medium and long term, Zhu Hengpeng also suggested that the number of public hospitals should be streamlined, and private hospitals should be vigorously developed to break the administrative monopoly position of public hospitals while vigorously developing chain pharmacies, giving pharmacies and hospitals the same qualifications as prescription drug sales, through various types of medical institutions. Full competition, allowing patients to use their feet to vote, thereby inhibiting the growth rate of medical expenses.
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