In April and June this year, premier li keqiang presided over two executive meetings of the state council, which decided to implement zero tariffs on imported anticancer drugs and encourage the import of innovative drugs. Meeting decided to significantly reduce cancer drug production and import VAT tax, take the government centralized purchasing, will import the innovation medicine especially in urgent need of cancer drugs into the reimbursement list in time, and the use of cross-border electrical business channels, more measures and eliminate the circulation of various unreasonable price, chemical medicine to strengthen the protection of intellectual property rights to innovation, strengthen the quality supervision.

 

Recently, by the China council for the promotion of lingshan charitable joint Beijing new sunshine charity foundation, Beijing disease challenge public foundation hosted "disease medicine, without medicine god" charity salon, public policy research center, deputy director of the institute of economics, Chinese academy of social sciences researcher wang, associate professor qiu month respectively under the state council development research center, is China's drug supply security reform health care, medical innovation and expounded.

 

Pharmaceutical companies are less willing to innovate and less able

 

Wang zhen, deputy director of the public policy research center of the economic institute of the Chinese academy of social sciences

 

As for China's drug supply, there are several characteristic facts: first, China's pharmaceutical innovation capability is relatively low, and the pharmaceutical production enterprises are scattered and scattered. In 2016, there are more than 7,500 large-scale pharmaceutical enterprises in China, plus more than 10,000 below the scale, and the scale is very small.

 

The innovation ability of new drugs is low and can be explained from the perspective of generic drugs. Generics should be applied in accordance with the original research. On March 5, 2016, the general office of the state council issued the "opinions on the consistent evaluation of the quality and efficacy of generic drugs", requiring the conformity assessment of the generic chemical drugs approved before October 1, 2007 in the national basic drugs catalog (2012 edition) to be completed by the end of 2018 to prove that they are consistent with the efficacy of the original drugs. The number I just saw a few days ago, 289 drugs have been assessed for consistency this year. On May 22, the national drug administration announced that only 12 drugs have been approved, which means the rate of approval is very low. Therefore, the quality and efficacy of our generic drugs are much worse than that of the original ones, some of which are only 10%, and the quality is very poor.

 

Look at some statistics, China is the new superpower, but careful comb and will find that the so-called innovation medicine has no substantial, that is to say there is no substantial innovation on chemical structure, most belong to the innovation of the shape, packaging innovation, turned out to be solid, for example, now changed to oral, turned out to be packaged into a box now.

 

Second, the so-called "drug-dependent" medical institutions, which currently rely mainly on drug revenues, now account for about 30 to 40 per cent of the total, a result of years of painstaking efforts. The international average is about 20 percent, and China takes and USES a lot more medicine.

 

The third is the inflated drug price. Hospitals and doctors prefer expensive drugs. In addition, there are also the disappearance of cheap drugs, which used to be very useful and clinically very cheap drugs are no longer available, so there are many examples. Why is this happening? Let's look at the whole process of medicine. When drugs are produced and sold to hospitals, doctors and patients, there is a centralized purchasing link in the process. Suppose it is 100 yuan. Production to circulation 30 percent, low 28 percent, almost within that range. Bidding, public relations of hospitals, including general prescription drugs account for about 10%. Originally there is a drug, plus bonus rate is 15%, now in pushing zero (editor's note: the national development and reform commission in 2006 "about further consolidation of drugs and medical service market price order opinion" regulation: county sell drugs and medical institutions at or above the county level, on the basis of actual 购进价, suitable plus markup percentage for no more than 15%, on the basis of markup percentage bonus income bonus of the pharmaceuticals. In April 2012, the general office of the state council issued a notice entitled "deepening the reform of the medical and health system and major work arrangements for 2012", stating that the reform of public hospitals would eliminate the drug bonus). Finally, there are some kickbacks for relevant personnel. So, that's about a hundred dollars, 20 percent for the production and distribution business, 40 percent for the hospital, and the rest for the rebate, that's what happened in the 1990s. It can be seen from this that a large amount of money is used in the middle link, many of which did not go into production and circulation. Two-thirds of today's drug prices are likely to come from non-production and distribution. The general characteristics are: high drug price, high rebate, high rebate.

 

Why is this happening? What's the problem? Now doctors and hospitals prefer expensive drugs. Why? Where is the root? It comes down to monopoly. First, doctors themselves have an information advantage, which is information monopoly; Second, there is an administrative monopoly in China. Medical services are mainly provided by public medical institutions. In counties, the President and the director of the health bureau are all the same. And then there are other things like implicit financial subsidies and so on, that's monopoly. Under monopoly, there will be high drug prices, high rebates, high rebates.

 

So the government doesn't see it, it has to manage it. In the last two decades, including new health care reform since 2009, the first was price controls, and in 2000 a special document was issued that set a ceiling on the price of medicines entering the health insurance category. What about the business? We need to keep costs down and leave enough room for rebates. So you don't want to and you don't have the ability to innovate. But price controls leave a loophole: any new drug can break the maximum price, so "drug innovation" begins, reinventing old drugs into new ones. In 2007, former director of the state food and drug administration zheng xiaoyu was sentenced to death. Why? Because of the crime of bribery and neglect of duty. Behind this is a large number of drugs to change the face of new drugs, new drugs can be installed to set a new price, these new drugs become the main carrier of rebates and rebates. The higher the price, the more room there is for rebates and rebates.

 

In addition to the government price control there is also a tender procurement, originally called high rebate, the hospital takes 30% off. But this is too high. The government thinks it can't. Provincial-level centralized bidding and purchasing began in 2010, because the price is compared with the price, the low-price medicine will win the bid. But when a low-priced drug is offered, it will be found out which one will not use the low-priced medicine into the prescription as long as it wins the bid. Therefore, drug companies naturally go to raise the price, when bidding will be bidding groups, new drugs are bidding separately, compared with the old drugs have special advantages. Those in short supply are cheap, and companies are less profitable and reluctant to produce them. Hospitals are reluctant to prescribe low-price drugs because of the small rebate space, forming a vicious circle, resulting in frequent "low-price death" phenomenon. Hence all sorts of so-called new drugs. Another kept costs down, and after winning the bid, the drug companies stopped producing. In addition, a large amount of research and development has been invested in Chinese patent medicines that receive kickbacks, and some useless drugs have been prescribed in hospitals. More than 40 percent of our "miracle drugs", or adjuvant drugs, are used.

 

Policy of the last two years is a zero rate of the drug, implement the "two votes", drugs from pharmaceutical factory sell to dealers open an invoice, dealers to sell to the hospital again open invoice, with the replacement of "two votes" common seven, eight, reduce circulation layers of exploitation, and each level dealers shall not exceed two varieties. But by eliminating 15% of the hospital, the entire system will still have to make up for the money by other means, including drug payments.

 

So the biggest problem that needs to be solved is so much government regulation, since the 1980s, more government regulation has been largely ineffective. So my advice is, first of all, let go of access and let the government do less. Second, doctors need to break the public sector and release people. Now the administrative system divides doctors into three grades, six grades and nine grades. Third, the actual purchase price of drugs is 30% to 40% lower than that of the provincial bidding price, which pushes the inflated price down. In this way, patients benefit and hospital doctors benefit.

 

The current administrative regulations do not allow doctors to earn money freely and do not give doctors money. The current health care system must be radically reformed to make doctors feel better about their patients and their ability to earn a good income.

 

The problem of medicine is that medicine is not medicine. The main reason is that our distorted health care system leads pharmaceutical companies to prefer sub-innovation and fake innovation rather than real innovation, because there is no benefit to real innovation.

 

We need to strengthen multi-tiered medical security

 

Qiu yue, deputy researcher of the development research center of the state council

 

I'd like to talk about some of our research results from the perspective of innovation, including security. Second, how to realize the standardization of requirements, what are the influencing factors here? Third, multi-tiered security. What are the current situation and problems?

 

First, our demand for medical innovation cannot be separated from the overall demand for health services. In considering this problem, it is important to take into account the aging population and the current trend of disease transformation. At present, China's aging level has reached more than 20%, which may reach 30% and 40% in 20 or 30 years, which is a very high level of aging. Moreover, China's aging population is different from other countries, with a large base and a fast speed.

 

We now face the dual burden of chronic noncommunicable and infectious diseases, especially chronic diseases, which have brought huge health impairment to society and accompanied by a surge in demand. The number of cases is expected to double in the next 20 years, with major chronic diseases such as diabetes and stomach cancer posing significant challenges, a general trend.

 

Second, this trend will not only increase the quantity, but also raise the demand for quality. Because of the expansion of the middle income groups in society, they demand more services, not just services, but also higher quality services. But as things stand, our cutting-edge drugs are not enough. You can analyze what happens to the requirements throughout the process. In the survey we asked the doctor to do, about 60% of the patients received advice from doctors, but the compliance of patients was not very good, and most of the compliance requirements were not fulfilled. There are two reasons for this. The first is that patients don't know about this medicine or technology at the knowledge level. The second is the cost. About 80 percent of doctors believe that cost is the most important issue, hindering patients from using innovative medicine. So the cost is the biggest barrier that we face in the use of innovative medicine or in the demand for innovative medicine.

 

Solve the problem of cost depends on security, there are two, one is the basic health insurance, there are more than 70% of people think that a very big effect, for social security, nearly 50% of people think the influence is very big, so security is of huge significance for patients, especially in the use of innovative drugs, will influence the decision of the patients.

 

Third, multi-tiered security. The security situation can have a significant impact on the use of drugs especially innovative drugs. In fact, the national health insurance system has undergone tremendous changes since the medical reform reform in 2009, especially the emergence of new rural cooperative medical insurance and urban medical insurance.

 

Although we have basically achieved full coverage, in terms of the proportion of fund payment, if there are some drugs or treatment methods in the policy, the coverage can reach about 60-80%. But if you don't put it in the table of contents, if you put it all together, the reimbursement rate is relatively high for individuals.

 

In this case, is it possible to further improve safeguards? This can be seen from two perspectives. One is basic medical insurance, and the proportion of the country's medical and health input costs in the G D P still presents a basically rising trend, especially after 2000, when compared with the growth rate of fiscal and health input, the annual growth rate in recent years has reached 20%. But in a slowing economy, it is doubtful that there will be enough capacity to cover the coverage of health insurance, especially if basic health insurance is targeted at basic health care. Second, we did a sample survey with the national bureau of statistics last year. About one third of people think that basic insurance cannot meet the demand. Last year commercial insurance payments were only about 6%. Therefore, it should be said that both commercial insurance and multi-tiered medical insurance need to be strengthened. There is still a long way to go.

 

Why is the price so high? For a pharmaceutical company, the cost would not come back until the price of the drug was set a little higher during the patent period. If you look at the market share of Chinese drugs, there are only one or two Chinese enterprises in the top ten, and all the others are foreign companies. Investment in domestic drug research and development has come a step since 2010, but the structure comes from government investment, not corporate investment. Basic research is at the national level, and companies don't need to pay that much for basic investments. However, if the basic investment is finished, enterprises can conduct further research at a small cost, so that the drug price will be relatively lower, which may improve the original pricing.