How to balance the price and quality when the average price reduction of coronary stent collection exceeds 90%
● Behind a small coronary stent is the rapid development of innovation and medical security in China’s medical field. Only by developing and innovating can we get "bargaining power" and better protect people’s health.
● In this centralized procurement by the national medical insurance department, the main reason why coronary stents were selected for "operation first" is that coronary stents are widely used in clinical practice and belong to a kind of high-value consumables with relatively high moisture content.
● There is indeed a problem with domestic drugs and consumables, that is, if the government’s centralized purchase price is not set, the price will be artificially high; If the centralized purchasing price is too low, there may be quality problems and innovation stagnation. Therefore, we should think about how to find a balance between the two.
□ Our reporter Zhao Li
□ Intern Sun Yifei of this newspaper
Recently, a "combing the quotations of the state-organized centralized purchasing companies for coronary stents" has set a new low for the price of coronary stents: the average bid price is around 700 yuan.
The average price dropped from 13,000 yuan to 700 yuan — — The first batch of coronary stents purchased by the state in a centralized way opened a shocking "floor price" in Tianjin. Compared with 2019, the average price reduction of the same product of the same company reached 93%.
Xinhua News Agency commented that a small coronary stent is behind the rapid development of innovation and medical security in China’s medical field. As a cardiologist said, since the introduction of domestic stents, the price of imported stents has plunged from the sky-high price of 40,000 yuan to about 10,000 yuan. After 20 years’ development, domestic stents have become the first and only high-end medical devices with domestic enterprises playing a leading role in the domestic market. This is the premise of the shocking low price in this centralized purchase, and it also shows that only by developing and innovating can we get "bargaining power" and better protect people’s health.
Significantly reduced price of coronary stent
Reduce the gray space of sales
On November 5th, the national centralized procurement of coronary stents was opened in Tianjin. There was no group bidding for 26 stent products from 11 companies, and the price was fierce on the spot. None of the 10 selected products surpassed 800 yuan.
Jiwei Medical’s EXCROSSAL product has the lowest bid price, which is 469 yuan/piece. The price of the other winning products from low to high is Aili of Yisheng Technology, with a price of 549 yuan; Firebird 2 of minimally invasive medical treatment, quoted in 590 yuan; GuReater of Lepu Medical, quoted at 645 yuan; Resolute integrity of Medtronic, quoted at 648 yuan; Firekingfisher of Minimally Invasive Medical, quoted in 750 yuan; Helios from Kelly, Jin Rui, quoted 755 yuan; PROMUS PREMIER and PROMUS Element Plus of Boston Medical are both quoted at 776 yuan; NOYA from Wanrui Feihong, the price is 798 yuan.
The price drop of this centralized purchase has exceeded the expectations of the National Medical Insurance Bureau. According to the data provided by the National Medical Insurance Bureau, the price of stents has dropped from an average price of 13,000 yuan to 700 yuan. Compared with 2019, the average price of the same product of the same enterprise is reduced by 93%, the average price of domestic products is reduced by 92%, and the average price of imported products is reduced by 95%. According to the intended purchase volume, it is expected to save 10.9 billion yuan.
It is worth noting that the mainstream products commonly used in clinical practice in medical institutions are basically selected, covering more than 70% of the intended purchases of medical institutions.
Liu Zhaoping, a professor of cardiology at the First Hospital of Peking University, said that the winning products basically covered stents that were widely used in clinic, which could completely meet the clinical use and the needs of patients.
At the collection site, a medical representative said that it is more than this price to make eyelashes now.
Sun Feng, a special researcher at Peking University International Research Center for Pharmaceutical Management, analyzed that the current centralized purchasing quotation is only a simple bracket price, and there is no doctor’s service fee and hospital site fee, which are two different price manifestations.
Sun Feng hopes that through this price reduction, on the one hand, the burden of patients can be reduced, on the other hand, the medical service cost of doctors can be increased, the labor value of doctors can be reflected, doctors can have legitimate income, and the gray space of coronary stent sales can be reduced, which is conducive to improving the service quality of doctors and the healthy development of the medical equipment sales industry.
Zhong Dongbo, director of the Department of Pharmaceutical Price and Bidding Procurement of the National Medical Insurance Bureau, believes that this centralized procurement will not only help medical machinery enterprises reduce their circulation costs, but also purify the industry ecology.
From the perspective of supervision, the requirements for product quality will not be relaxed. "The intensity of supervision will only be strengthened than in the past, and will not be weakened." Zhang Tiejun, member of the party group and deputy director of Tianjin Medical Insurance Bureau, said that the products will continue to maintain the original quality standards and levels as in the past.
It is widely used in clinic.
The circulation link has the most moisture.
Why can the price of coronary stents drop like a cliff? According to the analysis of the insiders interviewed by the reporter of the Rule of Law Daily, because the original price was too "moisture". Some people describe the price "moisture" in high-value medical consumables as a towel in a basin. "You can pour water when you pick it up, and you don’t have to squeeze it at all."
The reporter of Rule of Law Daily interviewed the public randomly and found that people’s awareness of the term medical devices is not very high, but they think that medical devices are as indispensable as medicines.
It is precisely because of low awareness that people often have no idea about expensive equipment. In the era when medical reform has not yet set sail and the medical system is not perfect, the asking price of equipment is even higher than that of drugs.
In recent years, some corruption cases in the medical field have been exposed one after another, revealing a "black interest chain" in circulation — — It may be a link in the chain from manufacturers, intermediate distributors to related doctors. For example, a certain department of a hospital illegally accepts kickbacks from suppliers many times outside the account according to the proportion of domestic consumables 30%, imported consumables 25%, joint and spine consumables 20% and trauma consumables 30%. These "moisture" are ultimately paid by patients and medical insurance funds.
Taking coronary stent as an example, the most effective treatment for coronary heart disease is PCI (percutaneous coronary intervention) surgery. Small and delicate coronary stents are the most critical consumables in this operation. The basic principle of PCI operation is to implant the stent into the coronary artery, spread the artery wall and restore the blood flow.
"China Cardiovascular Health and Disease Report 2019" shows that the number of patients with cardiovascular diseases in China has reached 330 million at present; From 2009 to 2019, the number of coronary heart disease (PCI) operations in China increased from 230,000 to over 1 million, with an annual growth rate of 10% to 20%.
Huo Yong, vice chairman of China Cardiovascular Health Alliance, has published a set of data: In 2018, the total number of cases of coronary heart disease in Chinese mainland has reached 915,256, an increase of nearly 160,000 cases compared with 2017, with a compound growth rate of 15.03% in the past five years. With the rapid growth of the number of cases of coronary intervention, people also put forward higher requirements for coronary stents. The price of domestic stents is about 8000 yuan to 12000 yuan; The price of imported stents is about 18,000 yuan to 20,000 yuan.
Although stent surgery can be partially reimbursed in recent years, the cost is still high for rural families.
A number of cardiovascular experts told the reporter of the Rule of Law Daily that the production process of domestic stents is completely comparable to that of imported stents, so most doctors will advise patients to use domestic stents, unless patients need special stent models or patients require them. Only then will doctors use imported stents.
"This time, the centralized procurement of the national medical insurance department chose coronary stents first ‘ Operation ’ The main reason is that coronary stents are widely used in clinic and belong to ‘ Moisture ’ A relatively large class of high-value consumables. " Wang Yue, a professor at Peking University College of Medical Humanities, said in an interview with the reporter of Rule of Law Daily.
It is understood that the cost of coronary stents is not high. In medical institutions, the price of more than 10,000 yuan is mostly concentrated in circulation.
Zhong Dongbo once told the media: "Although the average price of coronary stents is 13,000 yuan, the price actually packaged for agents is more than 2,000 yuan, and the middle part is completely the circulation cost. Now we have a large number of direct mining production enterprises with clear use expectations, so medical machinery companies don’t have to promote them. If this money is saved, there is still a fair and reasonable profit margin for enterprises, and it may be higher than the general industry. "
Liu Xin, director of the Medical Law and Ethics Research Center of China University of Political Science and Law, also explained: "The phenomenon of inflated medical device prices is relatively common, and the consumption of medical devices is small, and it is market pricing, so it is more a problem in the circulation field. The supply and demand of medical devices is one-way, and there is no market choice problem. Because after medical equipment enters the hospital, the hospital needs to use equipment when performing surgery on patients. It is great to have one or two manufacturers’ equipment in general hospitals. "
"Manufacturers produce certain medical devices, which are wholesaled by middlemen and finally enter the hospital. Therefore, in the intermediate link, the hospital’s bonus price can be limited, but other intermediate links can hardly be limited. And now there are many intermediate links, and every link is increasing the price. Many manufacturers may take some improper means to carry out marketing, so the price will go up, thus forming a phenomenon of high price. " Liu Xin said.
Innovating products and narrowing the gap
Domestic substitution squeezes out water
It is worth noting that expensive and high-value consumables are not only coronary stents, but why do coronary stents become the "pioneers" of national consumables collection?
The answer to this question implies a key logic of the medical device industry: domestic substitution.
According to industry insiders, the market share of domestic stents now exceeds 75%, and four head enterprises, Lepu Medical, Minimally Invasive Medical, Jiwei Medical and Sino Medical, occupy most of the market, and the proportion is quite stable.
At the same time, however, most medical devices and consumables are faced with the technology monopoly and patent control of foreign enterprises, and neither the regulatory authorities nor the downstream procurement have the right to choose. The proportion of domestic and imported specialized consumables in high-tech fields such as nerve interventional instruments, surgical robots and artificial joints is almost inverted. In addition to consumables, the field of high-end medical equipment is monopolized by foreign companies. 80% of the CT market, 90% of the ultrasonic instrument market and 90% of the magnetic resonance equipment are occupied by foreign brands.
High-performance MRI systems and high-end CT machines usually cost more than 5 million yuan, while high-performance equipment means clearer images. In the diagnosis of diseases such as tumors, a higher definition means that more detailed human tissue information can be seen. The gap of dozens of pixels can affect the doctor’s diagnosis of the disease.
"At present, most consumables in China can be made in China. Although there is still a certain gap in quality between domestic products and imported products, it is not entirely necessary to rely on foreign products. Perhaps only some consumables need to rely on foreign products. But in recent years, enterprises should really focus more on product innovation than on product promotion. Enterprises should reduce costs through product innovation and narrow the gap between their products and imported products. " Wang Yue said, but it doesn’t affect the pursuit of the lowest price, because drugs and consumables are too special and related to people’s life safety, and now the quality of drugs and consumables in China is uneven.
In recent years, the relevant state departments have launched a series of policies to try to squeeze out the "moisture" of high-value medical consumables.
In Liu Xin’s view, it is still difficult to squeeze out the "moisture" of high-value medical consumables, but it is not too difficult.
"The problem now is to restrict from hospitals, especially from the scope of medical insurance. This time, the behavior of the National Medical Insurance Bureau can effectively crowd out ‘ Moisture ’ , lower the price and form a virtuous circle. " Liu Xin said, "From a certain point of view, in the past, the health administrative department and the drug supervision department may even be a sharer of interests, so they will not promote the process. Now because it involves medical insurance funds, the medical insurance department has to move this cake. "
Liu Xin believes that this centralized procurement with quantity is a good sign, and through some administrative intervention, the "moisture" may be squeezed out.
Standardize the development of medical devices
Balance price and quality.
After the exposure of the bid price of coronary stent, some stent manufacturers immediately told the media that coronary stent is no longer a high-value consumable product, and even bluntly said that "the original in-hospital coronary stent market was about 12 billion yuan, but this time, the market size was reduced to less than 1 billion yuan. In the next five years, there may not be any innovative products in this market, and purchasing with quantity will crowd out the industry ‘ Moisture ’ , and now ‘ Floor price ’ There is also no room for innovation. "
In this regard, Liu Xin expressed disapproval. "The price of medical devices is set at such a high level, and it is not the right holder of medical devices who enjoys the price. From the perspective of rights protection, stents are the same as other patented products, and anyone can produce them after the patent protection period. From this perspective, it has little to do with invention and creation. As long as there is a patent protection mechanism, some people will invent and create. "
Wang Yue put forward another view: "The reduction of prices brought by centralized purchasing may lead to the failure to guarantee the reasonable profits of enterprises’ innovative research and development. The government collects a large number of purchase orders to exchange prices for quantity, and enterprises often have no way to deal with this horizontal group purchase, either out or promising low prices."
Wang Yue further analyzed that the current chaos in the industry is mainly commercial bribery, and the purpose of centralized procurement is to reduce unreasonable costs. But objectively speaking, the price reduction brought by centralized purchasing may lead to the failure to guarantee the reasonable profit of enterprise innovation and R&D, so centralized purchasing may not be the best purchasing method, but now there is no better solution, so it is a second best choice.
"Perhaps with the popularity of Internet drugs and consumables sales, it may gradually change from centralized procurement to decentralized procurement. When the inflated price of drugs or equipment is suppressed in a short period of time, it may be possible to find the best and reasonable balance point of prices through the transition from centralized procurement to decentralized procurement." Wang Yue said.
Wang Yue believes that there is indeed a problem with domestic drugs and consumables, that is, if the government’s centralized purchase price is not set, the price will be artificially high; If the centralized purchasing price is too low, there may be quality problems and innovation stagnation. Therefore, we should think about how to find a balance between the two.
Liu Xin believes that there are two aspects worthy of attention for the road to breaking the sky-high medical devices in the future:
First, hospitals should return to public welfare. The medical institutions sponsored by the government are non-profit medical institutions, but now these medical institutions are making profits under the banner of non-profit, because without government investment, if hospitals are not profitable, there is no way to pay employees, so the government should provide subsidies to the medical industry.
Second, we can restrict the circulation and production links through some other participation mechanisms, such as purchasing with quantity by drug supervision departments.
Wang Yue’s suggestion is that in addition to taking care of bribers, it is also necessary to take care of bribers. "The new law on medical practitioners has established a lifelong ban system for doctors. If commercial bribery is punished by administrative punishment and criminal responsibility is investigated, you can no longer register as a doctor in the future. Once the license is revoked, it will be revoked forever and you can no longer engage in this industry. "
Wang Yue also mentioned that at present, the income and treatment of medical staff are polarized, with the high being very high and the low being very low. The income gap of medical staff should be greatly reduced, especially between general practitioners and specialists.
"We should also encourage enterprises to sell directly, and even require production enterprises to sell directly. We are not allowed to engage in agency system, turn the current drug and consumables dealers into distributors, and transfer the moral hazard and legal responsibility of all circulation links to production enterprises through direct sales mode. Production enterprises generally dare not commit commercial bribery." Wang Yue said.
In addition, Wang Yue also suggested establishing a blacklist system for enterprises, blacklisting production and operation enterprises involved in bribery, and prohibiting sales within a few years.
