蔡江南:医改核心问题不在药而在医

2017-04-20 蔡江南 搜狐健康

围绕着药品有关的各方包括:病人、医院和医生、药企、医保、政府政策制定方、媒体,他们追求着各自的目标和利益,从自己的角度发出不同的呼声和诉求。


过去一年多来,围绕药品发生了一系列的热点事件和话题,引起了与药品有关各方的心潮起伏、七上八下,欢呼叫好、悲愤交加。仿制药的一致性评价,将会推动国内仿制药企业的洗牌兼并重组,一些企业的微博利润都支付不了评价费用。公立医院取消药品加成,许多医院的经济状况面临重大挑战,迫使他们寻找各种新的出路。随着药品流通两票制的推进,一大批药品流通企业同样面临着新的洗牌兼并重组。药品经销领域的反腐,使得大批药品代表面临着转型、甚至失业。新的医保药品目录的公布,一些地方推出医保的药品支付标准,给跨国药企带来巨大降价压力。

围绕着药品有关的各方包括:病人、医院和医生、药企、医保、政府政策制定方、媒体,他们追求着各自的目标和利益,从自己的角度发出不同的呼声和诉求。局外人弄不明白,为什么我们对药品充满如此的爱恨情仇,这一切到底为什么?我们是否还能找到一条妥协前进的出路?

老百姓为什么对药品如此爱不释手?

我国老百姓对于药品的热爱,不知在世界上是否数一数二,或者东亚国家都具有相似的传统。传统中药主要依靠天然物质,相对西药来说,其作用强度、副作用都较小。食药同源使得药品与食品的界限常常不是那么清楚。许多中药即使治不好病,也不至于带来太大的不利影响。因此,中医看病后往往给病人配上一些中药,或者是调理药和补药。久而久之,老百姓习惯了看病和配药成为两件密不可分的事情。如果医生看病后不给药,这样的医生往往得不到病人好评,甚至会受到病人的指责和抱怨。在医生咨询和药品这两件事情中,病人往往更看重看得见、摸得着的药品,这也与我们重物轻人的传统有关。

抗菌素和打点滴在我国的滥用,在相当程度上与老百姓对药品的这种溺爱密不可分。我的孩子在美国出生长大,二十多年来我不记得他使用过抗菌素和打过点滴。美国的诊所和医院看不到打点滴的病人。孩子发烧几乎不去看医生,一般会给家庭医生或护士打个电话咨询一下,自己买点退烧药用。而我们的许多家长,如果医生不给自己孩子使用抗菌素或打点滴,就会要求医生。老百姓对药品的热爱,与医院、医生和药企的诉求相配合,便形成了一种火上浇油的互动,彼此打得热火朝天。所以,以药养医还需要老百姓的热情配合。

医院医生为何在使用药品上饮鸩止渴?

我国医生对于药品的依赖,除了长期以来的习惯传统、与配合老百姓的药品热爱有关外,更重要的在于对以药养医的需要。在1949年解放后,国民经济处于一个非常低级的阶段,老百姓的温饱问题在1978年改革开放前的30年间并没有得到很好解决。为了使得广大人民看得起病,医疗服务价格长期维持在很低水平,主要依靠计划经济的手段,通过控制医疗服务价格、政府补贴、公立医院的药品加成、赤脚医生等多种手段来维持一种医疗服务低水平的运转。这对于解决那个历史时期老百姓的看病需要发挥了积极作用。

改革开放后,国民经济有了飞跃发展,医疗健康领域的技术水平也得到了很大提高,大量国外先进的医疗技术、药品、医疗器械、检验设备等引进国内。随着老百姓生活水平提高、人均寿命增长,大家对于医疗的需求已经发生了很大变化。然而,随着我国医疗服务的硬件条件的极大改善,医疗服务的价格却长期没有变化。许多地方医生门诊收费只有几元,远远低于一张电影票的价格,也低于其他服务行业的价格,例如理发费、洗脚费、保姆的费用等。

既然提供医疗服务本身如此亏损,既然病人如此喜爱药品,医院医生当然只能、并且容易通过药品收入来弥补。这种习惯一旦养成,便成为了一种自我循环和加强的过程,也会慢慢上瘾。这也使得许多医院和医生认为这就是医疗服务的正常工作过程和环境,便不在提高服务质量、管理和环境上下大功夫了。因此,医患之间形成了一种互相依存、互相强化的恶性循环。

药企为什么在药品营销上使出十八般武艺?

我国是一个仿制药大国,药品市场的90%份额是仿制药。我们的药企具有多、小、散的特点,5千多家药企,其中一半企业的年收入低于5千万。大量药企重复生产同样的品种,绝大多数药企不具备创新药的研发能力和财力。地方保护主义、药企对地方财政收入的贡献,都使得这些不具备市场竞争力的药企得以苟延残喘。既然药品本身不具备竞争力,那就只能在营销上使出十八般武艺来,依靠与医院和政府的关系,通过回扣等经济利益输送来获得市场份额。

跨国药企在本国的市场营销主要依靠各种学术手段,例如赞助学术会议临床研究、对医生用药辅导等。而跨国药企进入中国市场后,由于得到专利保护的创新药进入国内的速度缓慢,只好依靠仿制药。为了与大量的国产仿制药竞争,跨国药企在营销上慢慢也本地化了。在一个缺乏有效治理的市场上,通常出现的结果不是劣币驱逐良币,就是良币被劣币同化。在原来由发改委主导的药品定价体制下,跨国企业的原研药还享有独立定价的优惠待遇。而当这个体制消失后,跨国药企与国内药企在营销上的竞争就更加白热化。药企与医院和病人的互动,便形成了一个药品营销和使用的怪圈。

医改为什么持续将药品作为发力点?

爱与恨往往只是一箭之遥。老百姓对药品爱不释手,往往也很容易对药价非常敏感,对药品的可及性非常关注。一旦媒体爆料药价中的猫腻、药品交易中的腐败,便会轻易激起民愤。政府为了迎合老百姓的呼声,在药价上发力便成为大快人心的便捷方式。

医改的核心问题不在药,而在医,在于公立医院长期以来的垄断地位,在于政府缺乏对医疗健康领域的全行业有效监管。2009年的新一轮医改取得的主要成就是在增量的改革上,即扩大政府投入、扩大医保覆盖面,而在存量上的改革,在调整既得利益结构上的改革却始终举步艰难。改革从易到难的路径可以理解,但如果始终在相对比较容易的环节上发力,而在核心难点上无法突破的话,药品领域的问题便无法真正得到解决。

对于老百姓的用药习惯和态度,需要医疗服务方、媒体、政府的宣传教育引导,也需要大家自己的反省。对于医疗服务方的问题,反腐必要,建立一个公平合理的医疗服务定价制度,使得医疗服务得到合理补偿就更加重要。建立一个公平市场竞争的医药生产和流通体系,提高我国药品的研发创新能力,消除大量营销领域的浪费和腐败现象,所有这一切都离不开医改的实质推进,离不开政府职能的转化和监管能力的提升。

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    2017-04-23 jacob9231

    受教了,谢谢分享!

    0

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    2017-04-21 tidiq
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    2017-04-20 lyh994

    加快改革步伐,早见成效

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=189740, encodeId=b243189e4082, content=受教了,谢谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=51, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/Q3auHgzwzM66WRRAmeqIVSnDN88DpaJfEWzRZxg4yBbiaBmMRwcvViaA2C0sE0Ts3Lic24JSSI4YffujDtpnm0GTHpuiao9TytmNArrcYESnSXY/0, createdBy=7938104912, createdName=jacob9231, createdTime=Sun Apr 23 00:11:58 CST 2017, time=2017-04-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1286692, encodeId=9fbb12866928c, content=<a href='/topic/show?id=ebac3442063' target=_blank style='color:#2F92EE;'>#医改#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=34420, encryptionId=ebac3442063, topicName=医改)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b3e9205, createdName=tidiq, createdTime=Fri Apr 21 23:53:00 CST 2017, time=2017-04-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=189048, encodeId=1760189048e6, content=加快改革步伐,早见成效, beContent=null, objectType=article, channel=null, level=null, likeNumber=66, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/04/24/1c2dbd6706e64df33befd6663f1d6b37.jpg, createdBy=94f61661779, createdName=lyh994, createdTime=Thu Apr 20 10:57:21 CST 2017, time=2017-04-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=189039, encodeId=96ea18903945, content=学习了,不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=55, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/icyLhIGqru6gIknBJqfuPhQkEvDREF6S2vZq3ZIpUYjdqicKVoAWaJSGoe8xNvS6o6QpmOlh2AQ7xuUpj8NiaDjJJgjbc7Xj3T6/0, createdBy=1c242047915, createdName=daiyaozu, createdTime=Thu Apr 20 10:14:11 CST 2017, time=2017-04-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=189023, encodeId=63d7189023b8, content=医改不良,最后医生和患者会成为牺牲品的!, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/03/23/e29fc1c9854bd501e11f0bf32d1fcb88.jpg, createdBy=a9561996204, createdName=1e1b80f0m19(暂无匿称), createdTime=Thu Apr 20 09:31:40 CST 2017, time=2017-04-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=189022, encodeId=1ba118902284, content=学习下,了解情况!, beContent=null, objectType=article, channel=null, level=null, likeNumber=50, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/aLGWoFXAyMbIu3qymFOyhb9xDeHojCicsdRdyC3XXdGk2ib9yLypZuHN06WeW4HO8WN0GGrgEfvnTX8gsckof05GHOU5OM4Mvx/0, createdBy=9cee1982656, createdName=执着追梦, createdTime=Thu Apr 20 09:10:26 CST 2017, time=2017-04-20, status=1, ipAttribution=)]
    2017-04-20 daiyaozu

    学习了,不错

    0

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    2017-04-20 1e1b80f0m19(暂无匿称)

    医改不良,最后医生和患者会成为牺牲品的!

    0

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    2017-04-20 执着追梦

    学习下,了解情况!

    0

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