These six things will happen after 4 + 7

▍ special writer: Geng Hongwu On November 20, 2019, the premier of the State Council again presided over the executive meeting of the State Council, deployed to deepen the reform of the medical and health system and further promote the centralized purchase and use of drugs, so as to better serve the public to see a doctor In half a year, the two meetings of the State Council have deployed the same issue, which shows that the state attaches great importance to the centralized drug procurement, and also highlights the affirmation of the state on the current centralized drug procurement This executive meeting stressed that promoting centralized purchase and use of drugs is an important part of deepening medical reform, and plays a positive role in reducing the "virtual high" drug price and reducing the burden of the masses The meeting called for further progress in this work Further implementation of the requirements will lead to the evolution of centralized procurement from 4 + 7 to 4 + N, including the further expansion of the number of varieties of centralized procurement, the extension of the scope of products to high value consumables, and the extension of the scope of application from public medical institutions to medical insurance agreement institutions In 2018, the State Council carried out major system reform and newly established the National Medical Security Bureau In May, the National Medical Security Bureau was officially listed In July, the three plans were announced, which clarified the relevant functions of each department and office In August, the first "pilot drug centralized procurement" Symposium and "generic drug volume and price procurement Symposium" were organized and held In September, the symposium was again hosted and the joint venture was determined Meeting the procurement requirements and operation methods, and publishing the list of 31 consistency evaluation varieties of the first batch of volume procurement, this discussion caused a small shock in the pharmaceutical industry On November 14, 2018, the fifth deep reform meeting of the Central Committee for comprehensive deepening reform deliberated and approved the pilot program for centralized drug procurement organized by the state; the next day, Shanghai Sunshine pharmaceutical procurement network released the document for centralized drug procurement in 4 + 7 cities; on December 6, 31 varieties were quoted and negotiated, the results were published on July 8, and 25 products were to be selected On December 7, 2018, the national leading group of medical reform held a national organization drug centralized procurement and use pilot work deployment meeting in Beijing Sun Chunlan, vice premier of the State Council and leader of the leading group of medical reform of the State Council, pointed out that centralized drug procurement is an important measure to deepen medical reform and solve the problem of difficult and expensive medical treatment We should adhere to the combination of market mechanism and the role of the government, explore cross regional alliances to focus on volume procurement, volume price linkage, and the integration of bidding and procurement, do a good job in ensuring the use, quality, stable supply, and timely payment collection, so as to promote the return of drug prices to a reasonable level and the transformation and upgrading of the drug industry The vice premier particularly stressed that the drug reform involves the adjustment of multiple interests in production, circulation and use The pilot areas and relevant departments should improve their political positions, consolidate their responsibilities at all levels, carefully organize and implement them, strengthen publicity and guidance, and promote the medical reform to develop in depth with the stability and order of the pilot work, so that the reform results can be more transformed into people's sense of access On December 8, 2018, the State Medical Security Bureau held a press conference to announce that the 4 + 7 pilot project will achieve four goals: first, drug price reduction and quality improvement; second, industry transformation and upgrading; third, deepening reform of public hospitals; fourth, reducing burden and increasing efficiency of medical security On January 11, 2019, the National Symposium on medical security work was held in Beijing, and Han Zheng attended the meeting He pointed out that: we should do a good job in the pilot work of centralized purchase and use of drugs organized by the state, and effectively reduce the burden of drug costs on the masses On January 17, 2019, the notice of the general office of the State Council on printing and distributing the pilot program of centralized drug procurement and use organized by the state (GBF [2019] No 2 document) was issued, which clarified the guiding ideology, objectives, operation methods, etc of 4 + 7 volume procurement On April 3, 2019, the premier of the State Council presided over the meeting of the State Council, which stressed that we should further promote the national drug centralized procurement pilot, drug shortage monitoring and response, and medical assistance We will improve the centralized procurement system, strengthen the quality supervision and supply guarantee of winning drugs, and reduce prices for the benefit of the people We will conscientiously summarize the experience of the pilot projects and push them forward in a timely and comprehensive manner In order to solve the price imbalance and other problems, 4 + 7 volume procurement expanded from 11 cities to 25 provinces, and changed from one to three On September 24, 2019, the bid was opened in Shanghai On that night, the Shanghai joint procurement office released the results of the national pilot of centralized procurement and use of drugs and the national pilot of expanding production The 25 "4 + 7" pilot drugs expanding procurement of the alliance was all successful, The price is not higher than the "4 + 7" pilot selection price; a total of 77 enterprises participated, generating 45 enterprises to be selected and 60 products to be selected Compared with the lowest purchase price of the alliance region in 2018, the average decrease is 59%; compared with the price level of "4 + 7" pilot selection, the average decrease is 25% On September 30, 2019, nine ministries and commissions jointly issued the implementation opinions on the pilot drug centralized procurement and use in national organizations to expand the regional scope (medical insurance Fa [2019] No 56), which put forward clear requirements for the implementation of provinces and cities in the next step Subsequently, several provinces issued supporting documents for nationwide expansion and landing of "4 + 7" volume procurement Shandong, Jiangsu, Jiangxi, Anhui, Liaoning and other places also conducted pilot projects in the field of 4 + 7 external products and consumables in accordance with the 4 + 7 volume procurement spirit On November 15, 2019, the national health and Health Commission issued the notice of the leading group of the State Council on deepening the reform of the medical and health system on further promoting the experience of deepening the reform of the medical and health system in Fujian Province and Sanming City In the task of strengthening the reform of centralized procurement of drug consumables, it was pointed out that before the end of December 2019, all provinces should fully implement the reform and trial of centralized procurement and use of drugs organized by the state Purchase and use policies for 25 drugs In 2020, according to the national unified deployment, expand the scope of centralized procurement and use of drugs by national organizations As stated at the beginning of the article, on November 20, 2019, the premier of the State Council again presided over the executive meeting of the State Council, which proposed four important measures to promote the centralized purchase and use of drugs, and defined the direction for the next step The biggest characteristic of "centralized procurement of drugs organized by the state" is "procurement with quantity" Volume purchase is not a new term for the pharmaceutical industry It was clearly stated in the centralized purchase document as early as 2010, and it has been used in the centralized purchase scheme in many provinces Then why did the previous volume purchase not get the effect it should have, and this volume purchase can make the selected price of drugs fall to the "floor price"? First of all, the general policy of centralized drug procurement organized by the state is the first medical reform measure since the establishment of the state health insurance bureau and approved by the Deep Reform Commission of the Central Committee for the first time In the overall design and implementation, we should start with the problems, study them carefully, and focus on the implementation and strict supervision; Secondly, it has changed several important mechanisms in the previous centralized procurement, one is "medical insurance settlement in advance" to solve the problem of long-term arrears of payment of medical institutions; the other is the unconditional opening of accounts and the integration of recruitment and acquisition of selected product medical institutions to ensure that all medical institutions use the products according to the quantity, and the supervision mechanism of medical insurance restricts the non use of medical institutions; Thirdly, this is the largest pharmaceutical procurement alliance in the history of alliance procurement scale It is the largest pharmaceutical procurement alliance in China so far In the face of volume, any bidding enterprise can't take it lightly Choosing among production enterprises means having market share, and failing to choose means having market share of zero (although there are still 30% markets in theory, there are several varieties in practice In a sense, the 4 + 7 pilot and expansion are not only price competition, but also survival competition According to the principle of economic prisoner's dilemma, in order to survive, the competition will be extremely fierce The results are also true, with an average decrease of 52% and a maximum decrease of 96% in the 4 + 7 pilot area, and an average decrease of 25% and a maximum decrease of 78.35% in the 4 + 7 expansion based on the selected price in the pilot area It can be seen that the goal of 4 + 7 pilot and expansion in price discovery, quality assurance and ecological change has been basically achieved, and effectiveness is the hard truth Of course, the 4 + 7 expansion is not perfect I think there are still some aspects that can be improved First, the policy of choosing the region in turn among the three selected varieties has led to differences in prices and varieties in different provinces, obviously resulting in institutional inequity; second, the method of determining distribution costs by percentage is obviously not reasonable, especially for the distribution guarantee in remote areas will be tested; third, the use of quantity still needs time to observe, because the guarantee of quantity is not only Only relying on the "political position" can be sustained, which depends on stable clinical needs and the approval of doctors I believe that in the future, the country will continue to improve the problems exposed in the current pilot and expansion With more and more products passing the consistency evaluation, the following six aspects are basically clear from the current policy trend First, it has entered a new stage of "national joint mining" After 4 + 7 pilot and expansion, the conditions for the nationwide combined mining have been mature In 2019, the National Health Insurance Bureau launched the work of drug classification and coding, which will take three years to establish a new health insurance information system, and the national drug control platform is also under construction In the future, the national level platform will undertake more national centralized procurement work, such as negotiation, volume procurement, etc Second, price reduction is still the goal of centralized procurement with volume From the aspect of national policy, the false high drug price is still the main problem at this stage Price reduction becomes the main target After the 4 + 7 pilot and expansion, policy makers are more convinced that there is a serious problem of inflated prices of products formed by centralized procurement in the past 20 years In the future, there are standards that can be followed for volume procurement It is not so much that volume plays a role, but rather that "survival right" forces enterprises to change From the design of 4 + 7 centralized purchase rules, we can see that the right to survive is the most important game weight Third, foreign enterprises will enter the competition slowly From the collective silence of foreign-funded enterprises in the pilot to the active participation and selection of some foreign-funded enterprises in the expansion, I believe that in the future, more foreign-funded enterprises will participate in the centralized procurement of national organizations From the observation of the policy direction by the collective of foreign-funded enterprises, they must be aware of the irreversible trend of the policy trend The awakening of foreign-funded enterprises may make the future volume procurement more competitive Fourth, "barefoot" has always had the opportunity to subvert the market Practice has proved that there is no "General Chang Shengjun" in front of the volume purchase rules Five enterprises lose Jingzhou in the process of expanding, the reasons are different, but the impact is the same, that is, low price For barefoot, the only way to obtain the largest number of hospitals with the lowest market cost is to design the volume purchase rules Therefore, in the future volume purchase, barefoot is the most worry free, and the impact on the price cannot be ignored Fifthly, the generic pharmaceutical market is the game paradise of "the powerful" Under the dual policies of consistency evaluation and volume purchase, the industrial pattern of the generic drug market will change dramatically From the current ranking of enterprises through the drug consistency evaluation and the 4 + 7 volume purchase of the selected enterprises, the future generic drug market will be the comparison of the strength of enterprises, and giant generic drug enterprises may appear The pattern will gradually form in the evolution of policy.