药品领域无序发展的现状分析及政策效果论证
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摘要
一、研究目的和意义
“看病贵”已经成为社会普遍关注的问题,如何实现“人人享受基本医疗卫生服务”,使百姓不再“看病贵”,是建设社会主义和谐社会的基础。药品市场混乱导致的“药价贵”成为“看病贵”的首要原因,因此药品领域改革成败关系到能否有效降低百姓的药费负担,解决“看病贵”问题。分析药品市场混乱的根源及作用机制,制定出“标本兼治”的政策方案,成为药品领域迫切需要解决的问题。
然而,目前国内解决药品市场混乱的策略及研究,大都是针对药品市场中某一个或者某几个问题进行现状分析,据此提出解决问题的策略。由于缺乏对问题系统全面的认识,没有系统分析问题涉及的相关利益团体、各自的利益倾以及问题的根源和作用机制,同时在研究或者制定政策时还忽略了对各方利益的协调,最终出现“上有政策,下有对策”,很难达到政策效果。
研究集成政策制定科学程序、市场分析理论、利益相关者分析等多种理论与方法,通过聚焦当前我国药品市场的相关利益团体及其指责的诸多问题,明确药品市场乱象,及其产生的根源与作用机制,研制理顺药品市场混乱现象、促进医药领域健康和谐发展的策略思路,为我国医药体系的深入改革提供科学的依据。
二、材料与方法
本研究选用“政策制定科学程序”可行性论证中的方法和步骤指导本次研究。
运用零售商买方势力原理,确定医疗机构是形成扭曲药品市场导向的主要原因；运用利益相关者理论分析利益相关者的利益倾向及与药品领域问题的相互关系,明确药品市场混乱的根源和作用机制；运用定性定量多重论证法论证药品市场存在的问题、问题的表现形式以及关键策略对药品市场的影响。
资料收集方法包括文献归纳分析、居民意向调查和基本情况调查、二级资料提取等。同时还采用多阶段分层整群随机抽样的方法,对山东、江苏常州、上海嘉定三地居民进行调查,收集居民对药价贵问题的看法。
三、主要研究结果
(一)药品领域及其相关利益团体的界定
1、药品领域的界定：根据药品从研发到生产的全流程,确定本研究中涉及的药品领域包括药品研发机构、药品生产企业、各级药品批发机构、药品招标公司、医院、患者、以及药品监管部门。
2、药品领域利益相关者的收集：通过文献归纳分析法、焦点访谈法以及多维细分法,明确药品领域利益相关者包括政府部门、卫生部门、物价部门、医保部门、药品监管部门、医疗机构、药品供应商、消费者等。
(二)文献论证药品领域存在的问题
收集2004-2008年专业期刊中药品相关文献共290篇,通过文献边界分析法确定我国医药领域大致包括以下26类大问题。
药品研发
问题1：研发药品品种重复多
问题2：国有药企新药研发积极性不高、国家新药研发支持政策不到位
问题3:儿童专用药品,罕用药品研发不足,满足不了临床需要
药品生产
问题4：药品生产厂家设备落后,低水平重复建设,入行门槛低,呈现百业经营药品
问题5:药品生产过程操作不规范、药企生产项目文档不完备、药物说明书制作不规范
问题6:药品生产中劣药、假药猖獗
药品销售
问题7：药品销售中不正当促销手段和方式多样,回扣、财物等商业贿赂现象盛行,尤其在新、特药经营中
问题8:药品流通中劣药、假药严重
问题9:以非法途径宣传广告,假药广告盛行
问题10:药品零售药店经营操作不规范
问题11：销售领域药价虚高
问题12:医疗机构消极应对药品招标采购
药品使用(医院中)
问题13：基层医疗机构普遍缺乏药学技术人员,给患者的用药安全造成极大隐患
问题14:医疗机构设备陈旧,药品储存条件差
问题15:特殊疾病的药品和价格低廉的普药存在缺货现象
问题16:政府补偿机制不到位,药品收入仍是主要补偿途径,“以药养医”没有改变药品使用(患者)
问题17:缺乏基本用药知识,患者盲目用药
问题18:百姓药物经济可及性差药品监管
问题19:药品监管部门协作不力,如在药价调控、药品招标监管过程中缺乏通力协作
问题20:药品定价机制不合理,政府对药价监管不力
问题21：我国药品质量管理制度不健全,尤以农村地区为甚
问题22:国家对药品流通领域缺乏合理监管
问题23：药品集中招标采购制度存在许多弊端
问题24:药品相关法律法规不健全
问题25:国家对药品不良反应的监测与管理存在问题,鉴定结果难以达成共识
问题26:基本药物供应及使用不足,基本药物制度尚不完善
(三)利用相关利益团体利益倾向与问题产生之间的关系探讨,分析药品市场混乱的根源及作用机制
1、药品领域相关利益团体相互指责问题分析
针对药品领域,社会主要指责“基本药物供应及使用不足,基本药物制度尚不完善”,“销售领域中药价虚高”；物价部门主要指责“销售领域中药价虚高”；药监部门主要指责“药品监管部门协作不力”,“药品生产厂家设备落后,低水平重复建设严重,入行门槛低,呈现百业经营药品”,“基层医疗机构普遍缺乏药学技术人员,给患者的用药安全造成极大隐患”等问题；药品供应商主要指责“国有药企新药研发积极性不高、国家新药研发支持政策不到位”,“医药品相关法律法规不健全”等问题；医疗机构主要指责“政府补偿机制不到位”,“以药养医”没有改变等问题。
2、问题的产生与相关利益团体利益倾向之间的关系探讨
社会团体关注的是基本药物质优价廉、新药及专利药品价格合理,去除虚高定价成分,医生用药行为规范,减少不必要的药品资源浪费。因此指责由于“政府部门监管不力”,导致“药价虚高”,“药品销售不正当促销手段和方式多样,回扣、财物等商业贿赂现象盛行”,患者药费负担加重。由2008年居民健康状况调查可以看出,绝大多数居民认为看病贵的主要原因是药价贵(其中嘉定：80.43%,常州：75.81%,山东：80.77%)。
在现行条块分割的管理方式下,政府部门在关注自身利益最大化的同时,还关注维持药品领域各方面关系的协调和平衡。卫生行政部门关注维持稳定的医疗环境,在条件允许的情况下为患者提供高质的医疗服务。面对药品市场现状,卫生行政部门指责“基本药物供应不足”,“药价虚高”,致使百姓药费负担加重,医患关系紧张。物价部门关注如何建立和完善价格监测和调控体系,指责“药价虚高”。药监部门关注增强自身的资源配置以及管辖权,以便更好的履行药品市场秩序监督的职责,指责“药品监管相关部门协作不力”,“基层医疗机构普遍缺乏药学技术人员”,难以有效实施药品监管职责,导致“劣药、假药猖獗”,“给患者的用药安全造成极大隐患”。
药品供应商主要关注利益最大化以及自身竞争力的提高。指责国家缺乏对药品生产销售的总体规划,“药品生产厂家设备落后,低水平重复建设严重,入行门槛低,呈现百业经营药品”,“国家新药研发支持政策不到位、国有药企新药研发积极性不高”,使大多数企业的产品都为仿制品种,缺乏国际竞争力。
医疗机构关注在正常运营机制下,能够得到合理补偿。认为社会反响强烈的问题,是政府主导的医疗机构补偿机制扭曲造成的,责任在政府。面对政府财政行为的变迁,医疗机构只能将谋求补偿的重点放在高新检查和药品收益上,客观上形成了“以药养医”的局面。
3、药品市场混乱根源和作用机制分析
我国的药品市场是典型的买方市场,而医疗机构又是药品的主要购买方和销售市场,占药品零售市场销售量的80%以上。因此医疗机构具有药品零售买方势力的特征,对药品购买拥有绝对主导权。这种情况下,药品供应商必须按照医疗机构这一巨大买方市场的需求进行调整。消费者在医疗机构进行药品消费时,只能买到由医疗机构筛选出来的药品种类和剂型(即高价药品),买方市场的需求偏好直接决定了药品市场供应的产品种类和结构,进而引发药品市场一系列混乱问题的产生。因此药品市场混乱的起点和主要诱因在医疗机构。
由于政府对医疗机构投入不足,为了自身发展,医疗机构将补偿重点放在服务收费上。受服务收费价格制约,医疗机构无法从基本的卫生服务上得到补偿,转而通过15%的药品差价和能增加收益的项目获得补偿,于是高价药、大处方、滥用检查等成为医疗机构的普遍行为,医院通过尽量多处方药,处方贵药获得更多的政府额定的差价净收入,药品销售方在此方面与医院利益趋同。政府为了控制药价虚高,不断出台政策降低药价,企业为了规避降价政策,避免经济损失,同时迎合医疗机构喜用贵药的倾向,将降价药品通过改换剂型及规格的方式以新药重新上市,价格迅速翻倍。医疗机构和药企双方默契对药品市场的混乱起了推波助澜的作用,进一步导致药价虚高,产品结构失调,低水平重复的畸形发展趋势。
(四)解决药品市场混乱的政策思路
根据药品市场混乱的根源和影响因素,形成了增加财政投入,改变支付方式、理顺收费标准这三项“治本”的政策思路。
前期研究显示,要解决药品市场混乱问题,必须设法切断补偿机制恶性循环环路,阻断医疗机构与药品之间的经济关联。经过对以上三项政策思路的进一步分析发现,解决药品市场混乱现状现实可操作的政策思路是“总额预算,按服务量支付”。该政策促使医疗机构减少不必要的诊疗项目、使用价廉质优药品,“主动控费”,增加医疗机构收益,从根本上切断医院和药品之间的经济关联,促使药品市场恢复薄利多销的秩序。
(五)支付方式改革对药品市场的影响效果论证
2006年如果采取药品平进平出以及高低价替换,医疗机构至少能够增加药品净收益1465.5亿元,增加的净收益为原药品收益的2.5倍数；即使药品高低价替换的比例仅为30%,药品收益也能达到772.5亿元,其中增加的收益为434.9亿元,支付方式改革为医疗机构增加了70%的药品收益。
药品生产领域预计至少损失109.7亿元-171.0亿元,企业的倒闭率将达到69%-74%,涉及3230-3464家药品生产企业,在职职工62-67万人；药品流通领域毛利损失至少达到53.6-129.4亿元,药品流通企业的倒闭率将达到41-44%,涉及13292家药品流通企业。支付方式改革有助于整合资源,提高药品生产、流通企业的核心竞争力和管理水平。
因此,如果实施“总额预算”基础上“按服务量收费”的组合型支付方式,医疗机构药品方面的收益将会有很大程度的提高,同时促进了药品上游企业整体素质的提高。
二、研究创新之处
(一)方法创新
将利益相关者理论和买方势力理论运用于药品领域,分析药品市场混乱的根源和作用机制。
研制了“总额预算+按服务量支付”对医疗机构药品收益、药品生产领域、流通领域影响的测算思路、测算步骤、测算公式,使用全国卫生决算资料数据进行支付方式改革对药品领域影响的模拟测算。
(二)结果创新
1、运用利益相关者理论,通过分析药品市场存在的问题,各利益相关者利益倾向及其关注的问题,利益相关者关注问题与市场存在问题之间的关系,明确药品市场混乱的根源和作用机制,为今后医疗卫生领域的政策研究提供新的切入点。
2、从医疗机构药品购买特征分析药品市场存在的问题,明确药品市场问题的特征和表现形式,为药品市场的混乱现状和根源分析提供了有力的佐证。
3、利用买方势力理论分析医疗机构的市场优势地位和对药品市场产品供应和产品结构的引导作用,明确医疗机构为药品市场混乱的起点,为进行其他课题的研究提供了思路。
4、运用定量的方法详细论证了“总额预算+按服务量支付”对医疗机构药品收益、医疗行为、药品生产流通领域收益的影响,定量论证了支付方式的改变引发的社会震荡,为策略思路的实施和改进提供了科学的依据。
Objectives
"Everyone has access to basic medical and health services" is the basis of harmonious society. "Costly access to health care services" is a major focus in China. The key cause is considered to be the over high-priced drug mainly caused by chaos in the medicine market. Therefore, whether government can solve the "costly access to health care services" is closely related to the effects of the prospective pharmaceutical market reform. The urgent mission now is to seek out available and feasible policy or policies by dissecting what causes a disorder pharmaceutical market and why.
However, current policy makers or researchers who majoring in drug market development, merely revolve around one or a few issues in pharmaceutical field, rather than over systematic or comprehensive analysis. More importantly, they ignore pharmaceutical stakeholders, the holders'interest preferences and relationship between these holders. Thus, current policies and researches achieve few results.
Therefore, this research aims to focus on stakeholders and their mutual rebuke in current pharmaceutical market, figure out the disorders in pharmaceutical market and why such a disorder market coming into being, provide scientific evidence and suggestion for further health care system reform. Methods and theories in our research include integrated policy-making procedures, health macroscopic models, market analysis theory and stakeholder analysis.
Materials and Methods
Scientific Policy-making procedures, one way of feasibility demonstration, were selected in this study.
By buyer power principle, the pivotal cause of chaos in Chinese medicine market is medical agencies. By the theory of stakeholder, we state stakeholders'interest preference and problems in pharmaceutical field and find out the reason and mechanism of disorder in drug market. By multiple qualitative and quantitative methods, we investigate the issues in market and evaluate the effect of key strategies on pharmaceutical market.
Several data-collection methods, such as literature's review, resident opinion survey, the second-handed data collection, are applied in this study. Meanwhile, the cluster stratification sampling method is also used to collect people's (including residents in Shandong, Changzhou in Jiangsu, Jiading in Shanghai.) opinions on current drug prices.
Main results
1. Definition of pharmaceutical field and it's stakeholders
(1) Pharmaceutical field:according to the process of pharmaceutical research and the development to production, we dissect the pharmaceutical field as pharmaceutical research and development agencies(R&D), pharmaceutical manufacturers, pharmaceutical wholesale sectors, drug bidding companies, hospitals, patients, and food and drug administration departments.
(2)Collection of stakeholders in pharmaceutical field: the literatures induction and analysis, focus group discussion, multi-dimensional subdivision were applied in this article. Stakeholders in pharmaceutical field include government departments, health departments, the price department, health care sectors, food and drug administration departments, hospital, pharmaceutical suppliers, and patients.
2. Problems in pharmaceutical field through literature induction and analysis
We collect 290 literatures openly published in 5 years from 2004 to 2008 within Chinese pharmaceutical field. Through literature induction and analysis, we finally extract 26 major problems in pharmaceutical field.
Pharmaceutical R & D
Problem 1:Low and backwardly medical species have been repeatedly done in pharmaceutical R & D
Problem 2:Seriously scarcity of specific and/or new medicine research in pharmaceutical R & D in state-founded plants, for lack of state policy support.
Problem 3:Both a small number of child-specific drugs and seldom-used drugs can not meet the clinical needs
Pharmaceutical production
Problem 4:Such drug plant with informal GMP (do not have the technical, financial, or human resources required for the application of such standards), major products been produced by thousands of other plants, has been constructed repeatedly and been less strict when the product being manufactured is destined for sale.
Problem 5:Operation process of pharmaceutical manufacturing is not standardized, the document of producing is not complete and drugs description is informal.
Problem 6:Recent years have seen an increase in the prevalence of fake and substandard drugs on the market.
Pharmaceutical sales
Problem 7:Improper promotions, various kickbacks, flagrant bribery are prevalent in drug sales, especially new and/or special drugs
Problem 8:There are many inferior and fake medicines in pharmaceutical distribution
Problem 9:There are many illegal drugs and fake drugs advertisement
Problem 10:The GSP(Good Supply Practice) in retail drug stores are not properly fulfilled
Problem 11:Drugs are too expensive in retail compared with in wholesale
Problem 12:Many medical agencies are bumbling in the drug bidding
Pharmaceutical use (in hospital)
Problem 13:Less pharmaceutical technicians work in primary healthcare agencies, the risks of adverse reactions and dangerousness of medical treatment of patients are much higher than normal.
Problem 14:Outdated medical equipments and poor drug storage conditions
Problem 15:Lacking specific drugs for specific diseases and low-priced yet useful drugs
Problem 16:Governmental investment in health is insufficient, made the drug income as the main revenue of the medical institutions, such phenomenon that medical institution maintained by drug has never transformed
Pharmaceutical use (by patients)
Problem 17:Due to lacking of medical knowledge, patients can not properly use of drugs independently
Problem 18:Most people can not afford too expensive drugs.
Pharmaceutical administrations
Problem 19:The inferior FDAs’poor cooperation with each other in the process of drug price controlling and drug bidding in local and regional areas.
Problem 20:Government fails to control drug prices
Problem 21:Drug quality management system has not yet overwhelmed in the whole country, particularly in rural areas
Problem 22:Government does not effectively and efficiently monitor pharmaceutical distribution field
Problem 23:The drug bidding system as a whole is still immature
Problem 24:Many drug-related laws and regulations are still far away from perfection
Problem 25:Many problems such as technical issues in adverse drug reaction monitoring and management, so it is difficult to reach consensus with the identifications
Problem 26:Unsound essential drugs system make shortage of essential drugs supply often happening
3. Analyze the origin and mechanism of pharmaceutical market confusion by discussing the relationship between pharmaceutical stakeholders’interest preference and the existing problem of expensive medical charges
(1)Analyze pharmaceutical stakeholders’mutual rebuke
In pharmaceutical field, society mainly criticize of "Scarcity of essential drugs supply, imperfection of essential drugs system". Price-control agency criticize of "Drug prices too high". SFDA criticize of "the inferior FDAs weak cooperation with each other", "drug firms with backward facilities, low cultured workers and technicians, having been constructed repeatedly and easily coming into market, major products been produced by thousands of other plants", "less pharmaceutical technicians working in primary healthcare agencies, the risks of adverse reactions and dangerousness of medical treatment of patients are much higher than normal". Drug suppliers complain "serious insufficient R&D for new drugs research in state-founded plants, for lack of state policy support", "many drug-related laws and regulations are still far away from perfection", etc. Medical institutions think "governmental financing insufficiency "made the drug sale as the main income of many medical institutions, the phenomenon that medical institution maintained by drug has never transformed till now, and so on.
(2) Discuss the relationship of pharmaceutical stakeholders’interest preferences and the existing problem of expensive medical charges
Patients pay more attention to the essential drug with lower price and higher quality, the new medicine and patent drug with feasible price to reduce unnecessary drug resources waste through doctors drug-taking behavior standardization.
So public think the drug regulatory authorities lack supervision in the process of drug price control, "drug prices too high" and "improper promotions, kickbacks, bribery are prevalent in drug sales at medical agencies, especially new drugs and medicines in particular", so patients have to pay more. According to the residents healthy condition survey we have done in 2008, the majority believe that the reason of expensive medical charges is basically highly-cost medicine (the results:in Jiading: 80.43% vs. in Changzhou: 75.81% vs. in Shandong: 80.77%).
With the current segmentation of trap and block management mode, the government might concern of maintaining the coordination and balance of various pharmaceutical relationship, as the government maximize their own gains. Health administrative departments focus on keeping stability of internal medical environment, and then improve medical service on permissible condition. Now, the departments blame the expensive medicine and emphasis these "scarcity of essential drugs supply" and "too highly-costly medicine" have increased patients" economical burden, tensed relationship between patients and doctors. Price-controlled departments take on how to establish and perfect the price controlling system, price monitoring and regulation. FDAs concern of strengthening their resource allocation and the jurisdiction, so as to fulfill their responsibility of ordering and supervision for the drug market. They exclaim against "drug regulatory authorities inter-independently work without cooperation with each other", "less pharmaceutical technicians working in primary healthcare agencies", so efficient and effective implementation of responsibility and supervision on the quality of drugs cannot be applied, which lead to "many low quality and fake medicines in pharmaceutical distribution" and "the risks of adverse reactions and dangerousness of medical treatment for patients are much higher than normal".
Drug suppliers also pay close attention to maxim profit and improve competition. So they insist the states lack general planning medical production and sale, "with backward facilities, drug plants have been constructed repeatedly and easily approved to come into market", "Many plants produce many kinds of drugs rather than mainly concentrating on some specific drugs", "One popular clinically used drug may be produced by thousands of companies", Insufficiency of governmental financing support, scarcity of new/specific medicine research force many medicine plants to sharply reduce basic costs in new drug research. In general, medical resources and time have been greatly and repeatedly wasted on such work, therefore lower international competitiveness has been gradually forming.
Under normal operation, medical agencies mind reasonable compensation from government. They think the government should be in charge of the common concerned fact of" costly access to health care services ". When the government's policies have changed these years, medical agencies are primarily and increasingly concentrating the reimbursement on costs of new high-tech examinations and sale drug income, which directly and indirectly leads to medical institutions rely on drugs.
(3)Analyze the cause of drug market disorganization
In our country, medicine market is a typical buying one. And medical institutions are responsible for more than 80% drug buying and sale. So medical institutions have absolute power in drug retailing and buying in Chinese drug market. Under such condition, drug suppliers have to design and supply drugs corresponding with the needs of medical agencies. Patients as consumers, consuming drugs at hospital, have to buy some certain sorts and forms of drug (that is of course high cost drugs) directed by doctors in agencies. So hospitals'demand preferences directly define the production formation and construction of market. Consequently, a series of distorted problems are coming. In this sense, medical agencies initiate and develop drug market disruption.
For insufficient investment from the government, medical institutions rely more on drugs and service charges to compensate which previously governmental invest but none now for further development. Worse one, limited by the control of medical service cost policy, they can not get enough compensation from the revenues of basic health care, except the 15% drug price difference(the percentage of the differential value of cost got from the pharmaceutical plants and brought by patients to the cost got from the pharmaceutical plants) and other items help increase income, such as higher-cost drugs, big prescription, unnecessary medical tests. At this point, drug suppliers and medical agencies are convergence of interest. As government continuously release drug price regulations, the pharmaceutical plants immediately change the form of down-priced drug and resale the new-formed drug yet the same drug in quality to hospital with higher price to minimize the economic profit loss result from the declining prices, which is also according with the tendency of medical agency. Furthermore, tacit understanding between medical agencies and pharmaceutical companies help irritate the drug market more disorder: more expensive drug, more unbalanced structure, lower and more repeated drugs on sale.
(4)Tactics to resolve chaos of the pharmaceutical market
According to the reasons and factors leading to the disordered drug market mentioned above, we conclude three ways that might usefully help solve these problems deeply rooted in Chinese pharmaceutical field:to increase financial investment from government, to change the traditional payment and to rationalize fee.
Former research show that, to change the drug market chaos, it is important to cut off the vicious cycle loop of compensation mechanism, block off economic interests associated between healthcare institutions and the drug's price. Furthermore, we believe the operational police of solving the problems is "total budget and payment for service unit." Such policy urges the medical institutions to reduce unnecessary items, to turn to effective yet cheap drugs, to "actively obey budget". By this way, not only economic association between hospital revenue and medicine price can be cut off but also hospital can also earn more from more available patients'payment. Finally normal order of the pharmaceutical market can be slowly and gradually restored.
(5) Demonstration of the effect of payment reform in pharmaceutical market
If drug would be sold at a normal rather than in a too expensive price, if unreasonably highly-cost prescribed drug could be replaced by cheaper but not inferior alternatives in 2006, we have calculated the net income of medical drugs would increase 146.55 billion RMB in medical agencies at least, which is about 2.5 times of their previously revenue. Even 30% of low-cost drug can replace higher one, drug income in medical agencies as a whole could reach 77.25 billion RMB or so, the increased earning was more than 43.49 billion RMB. We assume the payment reform would provoke more than 170% of the drug revenue per year for Chinese medical institutions.
If the medical institutions could follow above suggestion, pharmaceutical companies are expected to reduce losses at least 109.7 to 171.0 billion RMB. In turn, bankruptcy rate will down to 69 to 74%(involving about between 3230 to 3464 drug manufacturers,62 to 67 million workers). At least 53.6 to 129.4 billion gross losses can be saved in medicine circulation, the bankruptcy rate of the pharmaceutical distribution companies will drop to 41 to 44% (involving about 13292 staff in drug distribution enterprises). In all, the payment reform will help consolidate medical resources, promote pharmaceutical production, enhance core competitiveness and improve d management in both production and distribution enterprises.
Therefore, if the combination of the two-"total budget" and "payment for service unit" could carry out in China, the GDP in medical filed will be largely and greatly increased. Meanwhile, the upstream medicine business will also be promoted.
2. Research Innovations
(1) Methods Innovations
The stakeholder theory and the forces of the buyer theory are used to analyze the causes and mechanism of Chinese drug market chaos.
We define calculation ideas, steps and formulas to measure the effects of "total budget" and "payment for service unit" on medical revenue, pharmaceutical production, and distribution and use national health accounts to estimate effects of payment reform in drug field.
(2) Results innovations
Using the theory of stakeholders and analyzing the problems in Chinese pharmaceutical market, the interests of all stakeholders, relationship between stakeholders, we conclude specific cause and mechanism of our disordered drug market, thus providing a new way for future health policy research.
Analyzing the characteristics of medical institutions purchasing drugs to disintegrate the problems in market, we provide strong evidence for resolving the cause and mechanism in drug market.
Dissecting medical institution's domination on medical market and product structure by the buyer power theory, we find out medical institutions should be responsible for pharmaceutical market disorder. Through our investigation, our research gives a hint for further studies.
Using quantitative methods to proof the effect of "total budget and payment for service unit" on medical revenues, medical practices, revenues of pharmaceutical production and distribution, and quantitatively clarifying social turmoil caused by unmoral payment. Our study provides a scientific view for the policy implementation and improvement.
“看病贵”已经成为社会普遍关注的问题,如何实现“人人享受基本医疗卫生服务”,使百姓不再“看病贵”,是建设社会主义和谐社会的基础。药品市场混乱导致的“药价贵”成为“看病贵”的首要原因,因此药品领域改革成败关系到能否有效降低百姓的药费负担,解决“看病贵”问题。分析药品市场混乱的根源及作用机制,制定出“标本兼治”的政策方案,成为药品领域迫切需要解决的问题。
然而,目前国内解决药品市场混乱的策略及研究,大都是针对药品市场中某一个或者某几个问题进行现状分析,据此提出解决问题的策略。由于缺乏对问题系统全面的认识,没有系统分析问题涉及的相关利益团体、各自的利益倾以及问题的根源和作用机制,同时在研究或者制定政策时还忽略了对各方利益的协调,最终出现“上有政策,下有对策”,很难达到政策效果。
研究集成政策制定科学程序、市场分析理论、利益相关者分析等多种理论与方法,通过聚焦当前我国药品市场的相关利益团体及其指责的诸多问题,明确药品市场乱象,及其产生的根源与作用机制,研制理顺药品市场混乱现象、促进医药领域健康和谐发展的策略思路,为我国医药体系的深入改革提供科学的依据。
二、材料与方法
本研究选用“政策制定科学程序”可行性论证中的方法和步骤指导本次研究。
运用零售商买方势力原理,确定医疗机构是形成扭曲药品市场导向的主要原因；运用利益相关者理论分析利益相关者的利益倾向及与药品领域问题的相互关系,明确药品市场混乱的根源和作用机制；运用定性定量多重论证法论证药品市场存在的问题、问题的表现形式以及关键策略对药品市场的影响。
资料收集方法包括文献归纳分析、居民意向调查和基本情况调查、二级资料提取等。同时还采用多阶段分层整群随机抽样的方法,对山东、江苏常州、上海嘉定三地居民进行调查,收集居民对药价贵问题的看法。
三、主要研究结果
(一)药品领域及其相关利益团体的界定
1、药品领域的界定：根据药品从研发到生产的全流程,确定本研究中涉及的药品领域包括药品研发机构、药品生产企业、各级药品批发机构、药品招标公司、医院、患者、以及药品监管部门。
2、药品领域利益相关者的收集：通过文献归纳分析法、焦点访谈法以及多维细分法,明确药品领域利益相关者包括政府部门、卫生部门、物价部门、医保部门、药品监管部门、医疗机构、药品供应商、消费者等。
(二)文献论证药品领域存在的问题
收集2004-2008年专业期刊中药品相关文献共290篇,通过文献边界分析法确定我国医药领域大致包括以下26类大问题。
药品研发
问题1：研发药品品种重复多
问题2：国有药企新药研发积极性不高、国家新药研发支持政策不到位
问题3:儿童专用药品,罕用药品研发不足,满足不了临床需要
药品生产
问题4：药品生产厂家设备落后,低水平重复建设,入行门槛低,呈现百业经营药品
问题5:药品生产过程操作不规范、药企生产项目文档不完备、药物说明书制作不规范
问题6:药品生产中劣药、假药猖獗
药品销售
问题7：药品销售中不正当促销手段和方式多样,回扣、财物等商业贿赂现象盛行,尤其在新、特药经营中
问题8:药品流通中劣药、假药严重
问题9:以非法途径宣传广告,假药广告盛行
问题10:药品零售药店经营操作不规范
问题11：销售领域药价虚高
问题12:医疗机构消极应对药品招标采购
药品使用(医院中)
问题13：基层医疗机构普遍缺乏药学技术人员,给患者的用药安全造成极大隐患
问题14:医疗机构设备陈旧,药品储存条件差
问题15:特殊疾病的药品和价格低廉的普药存在缺货现象
问题16:政府补偿机制不到位,药品收入仍是主要补偿途径,“以药养医”没有改变药品使用(患者)
问题17:缺乏基本用药知识,患者盲目用药
问题18:百姓药物经济可及性差药品监管
问题19:药品监管部门协作不力,如在药价调控、药品招标监管过程中缺乏通力协作
问题20:药品定价机制不合理,政府对药价监管不力
问题21：我国药品质量管理制度不健全,尤以农村地区为甚
问题22:国家对药品流通领域缺乏合理监管
问题23：药品集中招标采购制度存在许多弊端
问题24:药品相关法律法规不健全
问题25:国家对药品不良反应的监测与管理存在问题,鉴定结果难以达成共识
问题26:基本药物供应及使用不足,基本药物制度尚不完善
(三)利用相关利益团体利益倾向与问题产生之间的关系探讨,分析药品市场混乱的根源及作用机制
1、药品领域相关利益团体相互指责问题分析
针对药品领域,社会主要指责“基本药物供应及使用不足,基本药物制度尚不完善”,“销售领域中药价虚高”；物价部门主要指责“销售领域中药价虚高”；药监部门主要指责“药品监管部门协作不力”,“药品生产厂家设备落后,低水平重复建设严重,入行门槛低,呈现百业经营药品”,“基层医疗机构普遍缺乏药学技术人员,给患者的用药安全造成极大隐患”等问题；药品供应商主要指责“国有药企新药研发积极性不高、国家新药研发支持政策不到位”,“医药品相关法律法规不健全”等问题；医疗机构主要指责“政府补偿机制不到位”,“以药养医”没有改变等问题。
2、问题的产生与相关利益团体利益倾向之间的关系探讨
社会团体关注的是基本药物质优价廉、新药及专利药品价格合理,去除虚高定价成分,医生用药行为规范,减少不必要的药品资源浪费。因此指责由于“政府部门监管不力”,导致“药价虚高”,“药品销售不正当促销手段和方式多样,回扣、财物等商业贿赂现象盛行”,患者药费负担加重。由2008年居民健康状况调查可以看出,绝大多数居民认为看病贵的主要原因是药价贵(其中嘉定：80.43%,常州：75.81%,山东：80.77%)。
在现行条块分割的管理方式下,政府部门在关注自身利益最大化的同时,还关注维持药品领域各方面关系的协调和平衡。卫生行政部门关注维持稳定的医疗环境,在条件允许的情况下为患者提供高质的医疗服务。面对药品市场现状,卫生行政部门指责“基本药物供应不足”,“药价虚高”,致使百姓药费负担加重,医患关系紧张。物价部门关注如何建立和完善价格监测和调控体系,指责“药价虚高”。药监部门关注增强自身的资源配置以及管辖权,以便更好的履行药品市场秩序监督的职责,指责“药品监管相关部门协作不力”,“基层医疗机构普遍缺乏药学技术人员”,难以有效实施药品监管职责,导致“劣药、假药猖獗”,“给患者的用药安全造成极大隐患”。
药品供应商主要关注利益最大化以及自身竞争力的提高。指责国家缺乏对药品生产销售的总体规划,“药品生产厂家设备落后,低水平重复建设严重,入行门槛低,呈现百业经营药品”,“国家新药研发支持政策不到位、国有药企新药研发积极性不高”,使大多数企业的产品都为仿制品种,缺乏国际竞争力。
医疗机构关注在正常运营机制下,能够得到合理补偿。认为社会反响强烈的问题,是政府主导的医疗机构补偿机制扭曲造成的,责任在政府。面对政府财政行为的变迁,医疗机构只能将谋求补偿的重点放在高新检查和药品收益上,客观上形成了“以药养医”的局面。
3、药品市场混乱根源和作用机制分析
我国的药品市场是典型的买方市场,而医疗机构又是药品的主要购买方和销售市场,占药品零售市场销售量的80%以上。因此医疗机构具有药品零售买方势力的特征,对药品购买拥有绝对主导权。这种情况下,药品供应商必须按照医疗机构这一巨大买方市场的需求进行调整。消费者在医疗机构进行药品消费时,只能买到由医疗机构筛选出来的药品种类和剂型(即高价药品),买方市场的需求偏好直接决定了药品市场供应的产品种类和结构,进而引发药品市场一系列混乱问题的产生。因此药品市场混乱的起点和主要诱因在医疗机构。
由于政府对医疗机构投入不足,为了自身发展,医疗机构将补偿重点放在服务收费上。受服务收费价格制约,医疗机构无法从基本的卫生服务上得到补偿,转而通过15%的药品差价和能增加收益的项目获得补偿,于是高价药、大处方、滥用检查等成为医疗机构的普遍行为,医院通过尽量多处方药,处方贵药获得更多的政府额定的差价净收入,药品销售方在此方面与医院利益趋同。政府为了控制药价虚高,不断出台政策降低药价,企业为了规避降价政策,避免经济损失,同时迎合医疗机构喜用贵药的倾向,将降价药品通过改换剂型及规格的方式以新药重新上市,价格迅速翻倍。医疗机构和药企双方默契对药品市场的混乱起了推波助澜的作用,进一步导致药价虚高,产品结构失调,低水平重复的畸形发展趋势。
(四)解决药品市场混乱的政策思路
根据药品市场混乱的根源和影响因素,形成了增加财政投入,改变支付方式、理顺收费标准这三项“治本”的政策思路。
前期研究显示,要解决药品市场混乱问题,必须设法切断补偿机制恶性循环环路,阻断医疗机构与药品之间的经济关联。经过对以上三项政策思路的进一步分析发现,解决药品市场混乱现状现实可操作的政策思路是“总额预算,按服务量支付”。该政策促使医疗机构减少不必要的诊疗项目、使用价廉质优药品,“主动控费”,增加医疗机构收益,从根本上切断医院和药品之间的经济关联,促使药品市场恢复薄利多销的秩序。
(五)支付方式改革对药品市场的影响效果论证
2006年如果采取药品平进平出以及高低价替换,医疗机构至少能够增加药品净收益1465.5亿元,增加的净收益为原药品收益的2.5倍数；即使药品高低价替换的比例仅为30%,药品收益也能达到772.5亿元,其中增加的收益为434.9亿元,支付方式改革为医疗机构增加了70%的药品收益。
药品生产领域预计至少损失109.7亿元-171.0亿元,企业的倒闭率将达到69%-74%,涉及3230-3464家药品生产企业,在职职工62-67万人；药品流通领域毛利损失至少达到53.6-129.4亿元,药品流通企业的倒闭率将达到41-44%,涉及13292家药品流通企业。支付方式改革有助于整合资源,提高药品生产、流通企业的核心竞争力和管理水平。
因此,如果实施“总额预算”基础上“按服务量收费”的组合型支付方式,医疗机构药品方面的收益将会有很大程度的提高,同时促进了药品上游企业整体素质的提高。
二、研究创新之处
(一)方法创新
将利益相关者理论和买方势力理论运用于药品领域,分析药品市场混乱的根源和作用机制。
研制了“总额预算+按服务量支付”对医疗机构药品收益、药品生产领域、流通领域影响的测算思路、测算步骤、测算公式,使用全国卫生决算资料数据进行支付方式改革对药品领域影响的模拟测算。
(二)结果创新
1、运用利益相关者理论,通过分析药品市场存在的问题,各利益相关者利益倾向及其关注的问题,利益相关者关注问题与市场存在问题之间的关系,明确药品市场混乱的根源和作用机制,为今后医疗卫生领域的政策研究提供新的切入点。
2、从医疗机构药品购买特征分析药品市场存在的问题,明确药品市场问题的特征和表现形式,为药品市场的混乱现状和根源分析提供了有力的佐证。
3、利用买方势力理论分析医疗机构的市场优势地位和对药品市场产品供应和产品结构的引导作用,明确医疗机构为药品市场混乱的起点,为进行其他课题的研究提供了思路。
4、运用定量的方法详细论证了“总额预算+按服务量支付”对医疗机构药品收益、医疗行为、药品生产流通领域收益的影响,定量论证了支付方式的改变引发的社会震荡,为策略思路的实施和改进提供了科学的依据。
Objectives
"Everyone has access to basic medical and health services" is the basis of harmonious society. "Costly access to health care services" is a major focus in China. The key cause is considered to be the over high-priced drug mainly caused by chaos in the medicine market. Therefore, whether government can solve the "costly access to health care services" is closely related to the effects of the prospective pharmaceutical market reform. The urgent mission now is to seek out available and feasible policy or policies by dissecting what causes a disorder pharmaceutical market and why.
However, current policy makers or researchers who majoring in drug market development, merely revolve around one or a few issues in pharmaceutical field, rather than over systematic or comprehensive analysis. More importantly, they ignore pharmaceutical stakeholders, the holders'interest preferences and relationship between these holders. Thus, current policies and researches achieve few results.
Therefore, this research aims to focus on stakeholders and their mutual rebuke in current pharmaceutical market, figure out the disorders in pharmaceutical market and why such a disorder market coming into being, provide scientific evidence and suggestion for further health care system reform. Methods and theories in our research include integrated policy-making procedures, health macroscopic models, market analysis theory and stakeholder analysis.
Materials and Methods
Scientific Policy-making procedures, one way of feasibility demonstration, were selected in this study.
By buyer power principle, the pivotal cause of chaos in Chinese medicine market is medical agencies. By the theory of stakeholder, we state stakeholders'interest preference and problems in pharmaceutical field and find out the reason and mechanism of disorder in drug market. By multiple qualitative and quantitative methods, we investigate the issues in market and evaluate the effect of key strategies on pharmaceutical market.
Several data-collection methods, such as literature's review, resident opinion survey, the second-handed data collection, are applied in this study. Meanwhile, the cluster stratification sampling method is also used to collect people's (including residents in Shandong, Changzhou in Jiangsu, Jiading in Shanghai.) opinions on current drug prices.
Main results
1. Definition of pharmaceutical field and it's stakeholders
(1) Pharmaceutical field:according to the process of pharmaceutical research and the development to production, we dissect the pharmaceutical field as pharmaceutical research and development agencies(R&D), pharmaceutical manufacturers, pharmaceutical wholesale sectors, drug bidding companies, hospitals, patients, and food and drug administration departments.
(2)Collection of stakeholders in pharmaceutical field: the literatures induction and analysis, focus group discussion, multi-dimensional subdivision were applied in this article. Stakeholders in pharmaceutical field include government departments, health departments, the price department, health care sectors, food and drug administration departments, hospital, pharmaceutical suppliers, and patients.
2. Problems in pharmaceutical field through literature induction and analysis
We collect 290 literatures openly published in 5 years from 2004 to 2008 within Chinese pharmaceutical field. Through literature induction and analysis, we finally extract 26 major problems in pharmaceutical field.
Pharmaceutical R & D
Problem 1:Low and backwardly medical species have been repeatedly done in pharmaceutical R & D
Problem 2:Seriously scarcity of specific and/or new medicine research in pharmaceutical R & D in state-founded plants, for lack of state policy support.
Problem 3:Both a small number of child-specific drugs and seldom-used drugs can not meet the clinical needs
Pharmaceutical production
Problem 4:Such drug plant with informal GMP (do not have the technical, financial, or human resources required for the application of such standards), major products been produced by thousands of other plants, has been constructed repeatedly and been less strict when the product being manufactured is destined for sale.
Problem 5:Operation process of pharmaceutical manufacturing is not standardized, the document of producing is not complete and drugs description is informal.
Problem 6:Recent years have seen an increase in the prevalence of fake and substandard drugs on the market.
Pharmaceutical sales
Problem 7:Improper promotions, various kickbacks, flagrant bribery are prevalent in drug sales, especially new and/or special drugs
Problem 8:There are many inferior and fake medicines in pharmaceutical distribution
Problem 9:There are many illegal drugs and fake drugs advertisement
Problem 10:The GSP(Good Supply Practice) in retail drug stores are not properly fulfilled
Problem 11:Drugs are too expensive in retail compared with in wholesale
Problem 12:Many medical agencies are bumbling in the drug bidding
Pharmaceutical use (in hospital)
Problem 13:Less pharmaceutical technicians work in primary healthcare agencies, the risks of adverse reactions and dangerousness of medical treatment of patients are much higher than normal.
Problem 14:Outdated medical equipments and poor drug storage conditions
Problem 15:Lacking specific drugs for specific diseases and low-priced yet useful drugs
Problem 16:Governmental investment in health is insufficient, made the drug income as the main revenue of the medical institutions, such phenomenon that medical institution maintained by drug has never transformed
Pharmaceutical use (by patients)
Problem 17:Due to lacking of medical knowledge, patients can not properly use of drugs independently
Problem 18:Most people can not afford too expensive drugs.
Pharmaceutical administrations
Problem 19:The inferior FDAs’poor cooperation with each other in the process of drug price controlling and drug bidding in local and regional areas.
Problem 20:Government fails to control drug prices
Problem 21:Drug quality management system has not yet overwhelmed in the whole country, particularly in rural areas
Problem 22:Government does not effectively and efficiently monitor pharmaceutical distribution field
Problem 23:The drug bidding system as a whole is still immature
Problem 24:Many drug-related laws and regulations are still far away from perfection
Problem 25:Many problems such as technical issues in adverse drug reaction monitoring and management, so it is difficult to reach consensus with the identifications
Problem 26:Unsound essential drugs system make shortage of essential drugs supply often happening
3. Analyze the origin and mechanism of pharmaceutical market confusion by discussing the relationship between pharmaceutical stakeholders’interest preference and the existing problem of expensive medical charges
(1)Analyze pharmaceutical stakeholders’mutual rebuke
In pharmaceutical field, society mainly criticize of "Scarcity of essential drugs supply, imperfection of essential drugs system". Price-control agency criticize of "Drug prices too high". SFDA criticize of "the inferior FDAs weak cooperation with each other", "drug firms with backward facilities, low cultured workers and technicians, having been constructed repeatedly and easily coming into market, major products been produced by thousands of other plants", "less pharmaceutical technicians working in primary healthcare agencies, the risks of adverse reactions and dangerousness of medical treatment of patients are much higher than normal". Drug suppliers complain "serious insufficient R&D for new drugs research in state-founded plants, for lack of state policy support", "many drug-related laws and regulations are still far away from perfection", etc. Medical institutions think "governmental financing insufficiency "made the drug sale as the main income of many medical institutions, the phenomenon that medical institution maintained by drug has never transformed till now, and so on.
(2) Discuss the relationship of pharmaceutical stakeholders’interest preferences and the existing problem of expensive medical charges
Patients pay more attention to the essential drug with lower price and higher quality, the new medicine and patent drug with feasible price to reduce unnecessary drug resources waste through doctors drug-taking behavior standardization.
So public think the drug regulatory authorities lack supervision in the process of drug price control, "drug prices too high" and "improper promotions, kickbacks, bribery are prevalent in drug sales at medical agencies, especially new drugs and medicines in particular", so patients have to pay more. According to the residents healthy condition survey we have done in 2008, the majority believe that the reason of expensive medical charges is basically highly-cost medicine (the results:in Jiading: 80.43% vs. in Changzhou: 75.81% vs. in Shandong: 80.77%).
With the current segmentation of trap and block management mode, the government might concern of maintaining the coordination and balance of various pharmaceutical relationship, as the government maximize their own gains. Health administrative departments focus on keeping stability of internal medical environment, and then improve medical service on permissible condition. Now, the departments blame the expensive medicine and emphasis these "scarcity of essential drugs supply" and "too highly-costly medicine" have increased patients" economical burden, tensed relationship between patients and doctors. Price-controlled departments take on how to establish and perfect the price controlling system, price monitoring and regulation. FDAs concern of strengthening their resource allocation and the jurisdiction, so as to fulfill their responsibility of ordering and supervision for the drug market. They exclaim against "drug regulatory authorities inter-independently work without cooperation with each other", "less pharmaceutical technicians working in primary healthcare agencies", so efficient and effective implementation of responsibility and supervision on the quality of drugs cannot be applied, which lead to "many low quality and fake medicines in pharmaceutical distribution" and "the risks of adverse reactions and dangerousness of medical treatment for patients are much higher than normal".
Drug suppliers also pay close attention to maxim profit and improve competition. So they insist the states lack general planning medical production and sale, "with backward facilities, drug plants have been constructed repeatedly and easily approved to come into market", "Many plants produce many kinds of drugs rather than mainly concentrating on some specific drugs", "One popular clinically used drug may be produced by thousands of companies", Insufficiency of governmental financing support, scarcity of new/specific medicine research force many medicine plants to sharply reduce basic costs in new drug research. In general, medical resources and time have been greatly and repeatedly wasted on such work, therefore lower international competitiveness has been gradually forming.
Under normal operation, medical agencies mind reasonable compensation from government. They think the government should be in charge of the common concerned fact of" costly access to health care services ". When the government's policies have changed these years, medical agencies are primarily and increasingly concentrating the reimbursement on costs of new high-tech examinations and sale drug income, which directly and indirectly leads to medical institutions rely on drugs.
(3)Analyze the cause of drug market disorganization
In our country, medicine market is a typical buying one. And medical institutions are responsible for more than 80% drug buying and sale. So medical institutions have absolute power in drug retailing and buying in Chinese drug market. Under such condition, drug suppliers have to design and supply drugs corresponding with the needs of medical agencies. Patients as consumers, consuming drugs at hospital, have to buy some certain sorts and forms of drug (that is of course high cost drugs) directed by doctors in agencies. So hospitals'demand preferences directly define the production formation and construction of market. Consequently, a series of distorted problems are coming. In this sense, medical agencies initiate and develop drug market disruption.
For insufficient investment from the government, medical institutions rely more on drugs and service charges to compensate which previously governmental invest but none now for further development. Worse one, limited by the control of medical service cost policy, they can not get enough compensation from the revenues of basic health care, except the 15% drug price difference(the percentage of the differential value of cost got from the pharmaceutical plants and brought by patients to the cost got from the pharmaceutical plants) and other items help increase income, such as higher-cost drugs, big prescription, unnecessary medical tests. At this point, drug suppliers and medical agencies are convergence of interest. As government continuously release drug price regulations, the pharmaceutical plants immediately change the form of down-priced drug and resale the new-formed drug yet the same drug in quality to hospital with higher price to minimize the economic profit loss result from the declining prices, which is also according with the tendency of medical agency. Furthermore, tacit understanding between medical agencies and pharmaceutical companies help irritate the drug market more disorder: more expensive drug, more unbalanced structure, lower and more repeated drugs on sale.
(4)Tactics to resolve chaos of the pharmaceutical market
According to the reasons and factors leading to the disordered drug market mentioned above, we conclude three ways that might usefully help solve these problems deeply rooted in Chinese pharmaceutical field:to increase financial investment from government, to change the traditional payment and to rationalize fee.
Former research show that, to change the drug market chaos, it is important to cut off the vicious cycle loop of compensation mechanism, block off economic interests associated between healthcare institutions and the drug's price. Furthermore, we believe the operational police of solving the problems is "total budget and payment for service unit." Such policy urges the medical institutions to reduce unnecessary items, to turn to effective yet cheap drugs, to "actively obey budget". By this way, not only economic association between hospital revenue and medicine price can be cut off but also hospital can also earn more from more available patients'payment. Finally normal order of the pharmaceutical market can be slowly and gradually restored.
(5) Demonstration of the effect of payment reform in pharmaceutical market
If drug would be sold at a normal rather than in a too expensive price, if unreasonably highly-cost prescribed drug could be replaced by cheaper but not inferior alternatives in 2006, we have calculated the net income of medical drugs would increase 146.55 billion RMB in medical agencies at least, which is about 2.5 times of their previously revenue. Even 30% of low-cost drug can replace higher one, drug income in medical agencies as a whole could reach 77.25 billion RMB or so, the increased earning was more than 43.49 billion RMB. We assume the payment reform would provoke more than 170% of the drug revenue per year for Chinese medical institutions.
If the medical institutions could follow above suggestion, pharmaceutical companies are expected to reduce losses at least 109.7 to 171.0 billion RMB. In turn, bankruptcy rate will down to 69 to 74%(involving about between 3230 to 3464 drug manufacturers,62 to 67 million workers). At least 53.6 to 129.4 billion gross losses can be saved in medicine circulation, the bankruptcy rate of the pharmaceutical distribution companies will drop to 41 to 44% (involving about 13292 staff in drug distribution enterprises). In all, the payment reform will help consolidate medical resources, promote pharmaceutical production, enhance core competitiveness and improve d management in both production and distribution enterprises.
Therefore, if the combination of the two-"total budget" and "payment for service unit" could carry out in China, the GDP in medical filed will be largely and greatly increased. Meanwhile, the upstream medicine business will also be promoted.
2. Research Innovations
(1) Methods Innovations
The stakeholder theory and the forces of the buyer theory are used to analyze the causes and mechanism of Chinese drug market chaos.
We define calculation ideas, steps and formulas to measure the effects of "total budget" and "payment for service unit" on medical revenue, pharmaceutical production, and distribution and use national health accounts to estimate effects of payment reform in drug field.
(2) Results innovations
Using the theory of stakeholders and analyzing the problems in Chinese pharmaceutical market, the interests of all stakeholders, relationship between stakeholders, we conclude specific cause and mechanism of our disordered drug market, thus providing a new way for future health policy research.
Analyzing the characteristics of medical institutions purchasing drugs to disintegrate the problems in market, we provide strong evidence for resolving the cause and mechanism in drug market.
Dissecting medical institution's domination on medical market and product structure by the buyer power theory, we find out medical institutions should be responsible for pharmaceutical market disorder. Through our investigation, our research gives a hint for further studies.
Using quantitative methods to proof the effect of "total budget and payment for service unit" on medical revenues, medical practices, revenues of pharmaceutical production and distribution, and quantitatively clarifying social turmoil caused by unmoral payment. Our study provides a scientific view for the policy implementation and improvement.
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