Behind the "dystocia" of medical insurance bureau: the choice of medical reform again

Source: healthpoint 2018-05-23 last week, CCTV news broadcast the current progress of reform of State Council institutions It was mentioned that in the past two months, institutional reform has been advancing in an orderly manner Up to now, 31 comprehensive departments of 32 newly-built and reorganized departments have implemented centralized office work, and 24 departments that need new brand have been listed The only "dystocia" ministry is the National Medical Security Bureau Although it is said that the location of the National Medical Security Bureau has been determined, centralized office will be realized However, no matter when the leaders of ministries are elected or listed, there is no final conclusion Fortunately, according to the schedule of the institutional reform plan, the health insurance bureau has entered the countdown to its establishment One of the objectives of the establishment of the medical security bureau is to "comprehensively promote the reform of" three medical linkage "of medical treatment, medical insurance and medicine" With the birth of a new institution integrating payment, pricing and purchasing power, people are full of expectations for the reform of the linkage of three medical services, price and salary But will it be really easy to concentrate power in one department and the price of drugs will fall and the linkage of three medical services will become easier? The tardiness of the medical insurance bureau also shows the difficulty of this task Will the price of medicine fall sharply? When talking about the reasons for transferring drug procurement from the health department to the medical insurance department, Fujian has given two kinds of explanations successively The early explanation is: "the hospital only takes care of 'ordering', regardless of 'paying the bill', which completely cut off the capital flow between the hospital and the drug (consumables) suppliers" It is said that the benefits of payment for goods are settled by the medical insurance, and the expression is "ordering" function and "paying the bill" Function should be separated The latest explanation is that "the health and family planning department only" orders food "but not" pays the bill ", and the medical insurance department wants to" pay the bill "but cannot" order food ", resulting in unclear functions and responsibilities of drug bidding units and medical insurance departments in the field of drug procurement It is about the benefits of establishing the medical insurance bureau, expressing the meaning that the" order "function and" pay the bill "function should be combined As a matter of fact, there has been a long-standing dispute over who orders and who pays for the purchase of drugs in public hospitals The generally accepted principle in the industry is that "only when" who orders and who pays for the purchase of drugs ", can we strengthen the control over the price of drugs" The theoretical basis of this statement is Milton Friedman's spending matrix theory According to Milton Friedman, spending your own money and doing your own things care about both price and value; on the contrary, spending other people's money and doing other people's things care neither price nor value Admitting that the buyer cares more about the price is also a kind of progress In fact, it also indirectly admits that the reason why the drug price is still inflated is related to the fact that the Department responsible for purchasing doesn't care so much about the price It also indirectly admits that the interests of all departments of the government are inconsistent and exist However, if considering the interests of the Department, is it good for the medical insurance bureau to reduce the drug price? According to the relevant documents and speeches, the reform of compensation mechanism in public hospitals should take the strategy of "controlling the total amount, making room for space, adjusting the structure and ensuring the connection", which means to reduce the cost of drug consumables, simultaneously increase the price of medical services and the salary of medical staff on the premise of controlling the total amount, that is to say, to control the total amount Optimization and adjustment of hospital revenue and expenditure structure It is not difficult to find that if the drug price drops substantially, the benefits will be transferred to the hospital equally by increasing the price of medical services After 18 years of implementation of centralized drug purchase, the drug price is still unreasonably high, which shows the difficulty of price reduction If the medical insurance bureau reduces the drug price with the efforts of nine cows and two tigers, it will not pay less or benefit from the price reduction Is there any incentive for the medical Insurance Bureau to reduce the price? In the past 18 years, on the one hand, the relationship between quantity and price has been overstated The larger the purchase quantity, the lower the purchase price On the other hand, the bargaining power has been ignored In the past, public hospitals implemented the policy of "pricing drugs at a lower price", but now they generally implement the policy of "zero plus" These policies lead to public hospitals not benefiting from the price reduction, which is one of the main reasons for the false high drug price In fact, the drug purchase price of single private hospitals is much lower than that of all public hospitals in the province, and the bargaining power is more important than the volume price relationship Unfortunately, under the current policy background, the purchase of drugs by the medical insurance bureau is still a matter of spending other people's money and doing other people's business If the agency lacks the power of price reduction, will the specific purchasing agent have the power of price reduction in the future? I think there should be no essential difference in the health insurance for the specific operators I have seen such remarks in a group of medical practitioners: "we can handle health and social security in the future!" Will it be easier for the three doctors to work together? To understand this problem, first of all, what is the linkage of three medical services? What is its goal? In Sanming, Fujian Province, medical insurance lost a lot in the past and the contradiction between doctors and patients was prominent A few years ago, we promoted the "three medical linkage" around medicine, medical insurance and medical treatment, and won the three wins of "medicine price decreasing, medical staff income increasing and medical insurance turning loss into profit" Now, this experience is used for reference by the program " It is not difficult to find out whether the "three medical linkage reform" referred to in the institutional reform plan is still the "total amount control, space creation, structure adjustment, and insurance linkage" mentioned above, or on the premise of total amount control, reduce the cost of drug consumables, improve the price of medical services, and then increase the salary of medical personnel Further analysis found that because the price and salary of medical services are under control for a long time, hospitals and doctors increase their income in disguised form through the drug consumables with relatively low marginal rate of return In fact, under the premise of not increasing medical insurance expenditure and patients' burden, the three medical linkage reform is to replace the high price, overuse and relatively low marginal rate of return drug consumables with the relatively high medical service charges reflecting medical staff value and marginal rate of return The essence of the reform is to optimize the revenue and expenditure structure of the hospital under the condition of total amount control, moderately relax the control of price and salary, or the goal of three medical linkage is to improve the price and salary mechanism It should be said that the above reform is beneficial to hospitals and doctors (unfortunately, doctors in hospitals don't buy the bill, which is rarely applauded) However, because the policy is designed according to the principle of "no increase in medical insurance expenditure, no increase in patients' burden", the above reform will not directly benefit medical insurance and patients So here comes the question As we all know, the medical insurance bureau has concentrated three important powers: fund payment, drug purchase and price management, which is called the strongest in history Among the three key measures of the three medical linkage reform, the medical insurance bureau needs to complete the reduction of drug price, the adjustment of service price and the adjustment of payment policy But will the Department with "strong power" be active in the reform that does not benefit itself? Will "power" bring about the "strength" people want? How to promote the three medical linkage? When it comes to the linkage between the medical insurance bureau and the three doctors, we have to say "Sanming medical reform" Objectively speaking, Sanming medical reform is effective, and the system design is bright However, it has been nearly four years since several ministries and commissions held a field meeting in Sanming in June 2014 to promote Sanming experience So far, no place claims to copy the Sanming model, and in fact, no place has carried out a complete reform like Sanming What's the reason why Sanming mode is "good or not"? Speaking of Sanming mode, you are familiar with the "medical security center" in the management system and the "bird exchange" in the compensation mechanism In fact, Sanming mode has a more important third point, that is, a strong and professional government, a government that understands the "market" of medical medicine, a government that can "move" suppliers, and a government that can make functional departments forget departmental interests Our government ("it's not hard for the boss to come out" is mainly used to balance departmental interests) But at the same time, there are too few government or government leaders who meet the above conditions, which may be the reason for "cheering or not cheering" Just to understand the "market" as an example, most of the leaders in charge come from outside the medical and pharmaceutical industry and are in charge of multiple industries at the same time It often takes 2-3 years, or even longer, to understand the "market" of medical and pharmaceutical industry At that time, it will not be far from the transition Sanming attributed the existing malpractice of the medical industry to "Jiulong water treatment", and the solution strategy was to "divide the relevant powers of the three medical services into one department" However, the medical industry has its particularity Many countries have adopted the internal market-oriented approach of separating service providers from service purchasers in setting up government agencies Britain, which had no separation between the two, also carried out relevant separation reforms We have noticed that the principle of this reform of the party and state organs is "to adhere to the principle that one department is responsible for one kind of matters in principle, and one department is responsible for one thing in principle" It should be said that this principle is consistent with the principle that "the three medical related powers are assigned to one department" However, even so, the reform plan will eventually make the medical insurance bureau independent and the drug administration under the supervision of the market General Administration of science, I think this should not be just the result of balancing the interests of departments In fact, after the health insurance bureau became, three medical linkage faced two options The first is to use "centralized way and administrative means" First of all, we should concentrate the power of decision-making and system design of medical reform to the departments or leaders above the health care Commission and the medical insurance bureau, weaken the interests of the departments and form a joint force This requires that the health care Commission and the medical insurance bureau have a professional and strong common superior Secondly, the reform of reducing drug fee, increasing service price and increasing salary mainly relies on administrative means Forty years of reform and opening-up experience has proved that the management of prices and salaries is not the strength of the government, and the choice of this path will face some challenges The second is to adopt "decentralization and marketization", first of all, we should adhere to the system design of separating medical service providers and purchasers, clearly define the boundaries of the two (at present, the drug procurement which belongs to the responsibility of service providers is assigned to the medical insurance bureau, blurring the boundaries of the two), and improve the contractual relationship between the two; second, we should strengthen the governance role of purchasers in the medical service system It is necessary to guide service providers to adjust the income and expenditure structure and improve the salary system through the reform of medical insurance payment mode; thirdly, it is necessary to establish the price formation mechanism mainly through competition and negotiation At present, more and more attention has been paid to the reform of medical insurance payment In some areas where the current reform of medical insurance payment is being carried out, it has been seen that the actual purchase price of hospitals has dropped substantially, and the proportion of drugs is close to the international level Of course, there are also some disadvantages in separating medical service providers and purchasers One of them is that it is easy to direct funds to disease treatment, which is not in line with the goal of "transforming from disease-centered to health-centered", but it can be improved After the establishment of the medical insurance bureau, the three medical linkage and even the reform of the whole medical system have come to the crossroads of quantity.