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中国基本药物制度建立的探索与体会-胡善联
发表于:2010-8-15 | 来源于:卫生论坛
中国基本药物制度建立的探索与体会

复旦大学公共卫生学院    胡善联

 

[摘要]

2009年8月《关于建立国家基本药物制度的实施意见》及一系列配套文件的公布,标志着中国国家基本药物制度的启动。提出了2020年全面实施规范的、覆盖城乡的国家基本药物制度的目标。

建立基本药物制度是一项系统工程,包括对基本药物的遴选、生产、流通、使用、定价、报销、监测与评价等环节。主要内容包括基本药物的遴选,制定基本药物目录并动态管理;保证基本药物有充足的生产,坚持质量优先、价格合理;建立以政府为主导,以省为单位集中招标采购、统一配送、零差率销售;对基本药物实行政府定价,切实保障低收入人群基本药物的可及性;对政府指导价的药品加强成本审核,对企业自主定价的药物加强市场购销价格的调查,对流通环节实际加价率进行监控,对非基本药物实行差别差率和差比价的政策、坚决打击商业贿赂;提高企业的现代医药物流经营和管理能力。基本药物全部列入医疗保险药品报销目录,报销比例要明显高于非基本药物报销比例的5%-10%;利用信息系统做好基本药物制度的监测和评价。

一年来,基本药物制度取得了重大进展,有30%以上的县市区已实施基本药物制度。基本药物招标采购后,药价平均降幅为25%—50%。实施基本药物政策后,表现在基层医疗卫生机构的门、急诊量和住院人次明显增加,病人流向趋向于基层的比例明显增加。人均门诊和住院费用同比下降。

一年来,各地在探索基层医疗机构实行基本药物政策的补偿模式方面创造了经验。如采用预拨与结算相结合的方式,落实财政补偿资金;探索对村卫生室和乡村医生每月定额补助;取消药品加成收入后,由地方财政和医保基金分别负担;或通过设立药事服务费得到医保报销;或采取以奖代补的方式等。对其他各类医疗机构也要将基本药物作为首选药物,并确定使用比例。用绩效工资鼓励医生使用基本药物。

但在实施基本药物制度中也遇到不少困难。表现在基本药物品种少,不能满足群众需求;实施基本药物零差率销售后,基层医疗卫生机构药品收入下降,而不少地区的财政补贴又没有到位。慢性病患者不得不回到大医院看病买药,增加新的医患矛盾。在加强对医务人员的培训,规范使用基本药物,教育公众转变用药习惯方面也缺乏有效措施。没有充分利用市场机制开展价格竞争,推动基本药物的生产、流通和招标采购,以致出现了基本药物招标价格高于市场价格的扭曲现象。综上所述,政府应加大对基本药物的质量、采购、使用等监督力度。

建立国家基本药物制度是医改的重点,也是难点。基本药物制度是一项全新的制度。基本药物制度的实施涉及到多部门的利益,包括医药行业、政府财政、物价、医疗保险与卫生部门、医务人员和患者。总之,要创造基本药物制度可持续性发展的基础和条件,并不断完善。

 

Exploration and Experience of Establishing Essential Medicines System

in China

 

Hu Shanlian. MD. MSc. Professor. School of Public Health, Fudan University

 

[Abstract]

The promulgation of “The Implement opinion on establishing national essential medicine system” and a series of policy document issued on August, 2009, showed the launch of China essential medicine system. The target of national essential medicine policy is to establish a comprehensive and universal coverage of NMP by the year of 2020 in China.

The establishment of essential medicine system is a systematic engineering, which contains a cycle of selection, production, distribution, utilization, pricing, reimbursement, monitoring and evaluation. The main contents include: the selection of essential medicines, formulation of essential medicine list and its dynamic management; issuance of the production and insistence the priority of quality and reasonable pricing; establishing government-oriented and province-run pooled procurement, unified distribution and zero mark-up on the sale; pricing setting by the government to ensure the access of essential medicine in the lower income population. For those drugs that their price are set by the government reference price should be strengthening on cost auditing, on the other hand, if the price of some drugs is set freely by the manufacturers that will be monitored on the market and supervision on the real mark-up price during the process of distribution. For those non-essential medicines that will be conducted differential price, the price should be compared between strengths and dosage. Commercial bribe should be avoided. The management capacity of modern logistic distribution system of pharmaceuticals should be strengthening. All EM should be list in the various medical insurance reimbursement schemes. The reimbursement ratio of essential medicines must be higher than that of non-essential medicines (5%-10%). The monitoring and evaluation of essential medicine system should be made through information system.

After one-year implementing essential medicine system, a great achievement has been made in China. More than 35.7% of cities and counties has been implemented NMP. The average price of essential medicines has been declined about 25%-50% of original price before the bulk purchasing. The number of outpatient and inpatient is significantly increased. The patient flow tends to be reasonable. The average cost per ambulatory visit and admission to the hospital is declined accordingly.  

Much best practice has been created on the exploration of compensation model of essential medicine policy, such as by using the combination of budgeting and accounting method to make the financial reimbursement. Using government subsidies supports the construction of village posts and the income of village doctors, or even establishing prescription fee compensated by medical insurance for community health centers. After eliminating the drug markup, local government and medical insurance fund should be reimbursed respectively. Other secondary and tertiary hospitals should also be used essential medicines as the first choice and identified a certain amount of proportion. Doctors are based on pay-for- performance in the utilization of essential medicines.

However, the implementation of essential medicine policy is also facing many problems. Since the items of essential medicine used in urban community and rural township health center only allow 307 items, the number is not enough to meet the need of patients. After implementing zero mark-up policy on drug sale, the drug revenue in grass-root health facilities is declined significantly. The financial support is not subsidized timely. Many patient have to purchase non-essential medicine back to the hospitals, it exacerbates the contradiction between doctor and patient. Lack of effective measurements on strengthening the training of medical professional on using essential medicines and changing the behaviour of rational use of drug in patients. The distortion of price between bulk procurement price and market price showed that the market competition force has not been fully used in the procurement and distribution process. Government needs to supervise more on the quality, procurement and utilization of essential medicines.   

Finally, NMP is a key point and an innovative system in China. To some extent, it is one of the systems more difficulties for operation. Because it is an interest related to multiple sectors and stakeholders, including pharmaceutical enterprises, government finance, price and health sectors, medical professionals and patients. In sum, the foundation and condition of the sustainable development of essential medicine system is need to create and improve continuously.


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