福建三明成中國(guó)醫(yī)改先鋒

A Chinese city has taken on pharmaceutical companies and local doctors in the battle against healthcare cost inflation — and is now being touted as a nationwide model.

中國(guó)一個(gè)城市為了抗擊醫(yī)療費(fèi)用膨脹而拿制藥公司和當(dāng)?shù)蒯t(yī)生開刀，該市現(xiàn)在被宣傳為全國(guó)醫(yī)改楷模。

Health spending in China tripled in the decade to 2014, outpacing income growth, as an ageing population became more susceptible to chronic diseases and hospitals have made up for shortfalls in public funding by selling branded drugs at steep mark-ups.

在截至2014年的10年里，中國(guó)的醫(yī)療支出增加了兩倍，超出收入增長(zhǎng)速度。逐漸老齡化的人口更容易患上慢性病，同時(shí)醫(yī)院通過以高額加價(jià)銷售品牌藥物來彌補(bǔ)公共資金短缺。

As state-funded healthcare insurance is limited, patients pay more than a third of medical costs from their own money. China’s average life expectancy rose by three years to 76 over the same period.

由于國(guó)家出資的醫(yī)保覆蓋范圍有限，患者須自行支付三分之一以上的醫(yī)療費(fèi)用。同期中國(guó)人的平均預(yù)期壽命延長(zhǎng)了三年，達(dá)到76歲。

Sanming, a city of about 2.5m people in eastern China’s Fujian province, has shown one way out of the conundrum — switching from premium drugs made by multinationals to cheaper local generics and cracking down on physicians taking kickbacks from distributors.

三明是中國(guó)福建省一個(gè)擁有約250萬人口的城市，該市展示了一條擺脫困境的途徑：從跨國(guó)公司生產(chǎn)的高價(jià)藥物轉(zhuǎn)向比較便宜的國(guó)產(chǎn)仿制藥，并打擊醫(yī)生從經(jīng)銷商獲得回扣的行為。

After winning praise from China’s top health official and the World Bank, many of Sanming’s policies are being enacted nationally. Most provinces have banned hospital mark-ups and secured aggressive price cuts from multinationals, hitting growth for those companies.

在贏得中國(guó)最高衛(wèi)生官員和世界銀行(World Bank)的贊譽(yù)后，三明的許多政策正在全國(guó)推廣。多數(shù)省份已禁止醫(yī)院加價(jià)，并從跨國(guó)公司爭(zhēng)取到大幅降價(jià)，影響了這些公司的增長(zhǎng)。

A dozen provinces are testing tough policies to curtail drug distributors. “The health ministry is trying to promote [Sanming’s reforms] nationwide,” says Jin Yi, an analyst at consultancy Roland Berger.

十幾個(gè)省正在試行打擊藥品經(jīng)銷商的嚴(yán)厲政策。“衛(wèi)生部正試圖在全國(guó)推廣(三明的改革)，”咨詢公司羅蘭貝格(Roland Berger)分析師金毅表示。

The demographic challenges that are now afflicting China hit Sanming early. The city’s reputation for inaccessibility meant it was designated an industrial base under Mao Zedong, but as the Chinese economy opened from the 1980s, industry migrated to coastal areas and many of the city’s young people followed.

如今困擾全國(guó)的人口結(jié)構(gòu)挑戰(zhàn)早就影響到了三明。該市出了名地交通不便，在毛澤東時(shí)代被指定為工業(yè)基地，但隨著中國(guó)經(jīng)濟(jì)從上世紀(jì)80年代起開放，工業(yè)遷移至沿海地區(qū)，該市的許多年輕人也隨之遷居。

Sanming’s ratio of workers to dependants — children, retirees and the unemployed — was half the national average by 2011. The municipal health insurance scheme’s $30m deficit that year was equivalent to about a quarter of the city’s revenues.

到2011年，三明的勞動(dòng)者與被撫養(yǎng)人(子女、退休人員和失業(yè)人員)之比為全國(guó)平均水平的一半。當(dāng)年該市醫(yī)保計(jì)劃的赤字達(dá)到3000萬美元，相當(dāng)于該市財(cái)政收入的四分之一左右。

In an attempt to tackle the problem, local bureaucrat Zhan Jifu combined the offices for hospital management, drug procurement and health insurance into a single agency, wresting control of hospitals by linking bosses’ salaries to how much they cut costs. He stopped big mark-ups on drugs and cut down on middlemen profiting from the system.

為了解決這個(gè)問題，當(dāng)?shù)毓賳T詹積富將負(fù)責(zé)醫(yī)院管理、藥品采購(gòu)和醫(yī)保的各部門合并為一個(gè)機(jī)構(gòu)，通過將醫(yī)院領(lǐng)導(dǎo)的薪酬與他們降低多少成本掛鉤來控制醫(yī)院。他制止了對(duì)藥品大幅加價(jià)的做法，并減少了從整個(gè)體制獲利的中間商。

Ignoring instructions that provinces set drug prices, Mr Zhan began direct negotiations with drug companies, while the government insurance fund was ordered to set reimbursement rates by the price of generics. Prices plummeted. For example, the cost of exemestane, a drug used to treat breast cancer, fell from $108 to $22 per box between 2012-2014.

詹積富沒有理睬由省有關(guān)部門設(shè)定藥品價(jià)格的指示，而是開始直接與藥企談判，同時(shí)政府醫(yī)保基金接到了根據(jù)仿制藥價(jià)格設(shè)定報(bào)銷標(biāo)準(zhǔn)的命令。價(jià)格大幅下降。例如，用于治療乳腺癌的依西美坦(exemestane)的價(jià)格2012年至2014年間從每盒108美元降至22美元。

Sanming officials say the reforms have held medical expenditure inflation below GDP growth, while the city’s insurance scheme recorded a $23m surplus as of September. Hospitals have raised fees for inpatient treatment, but out-of-pocket payments as a proportion of health spending in the city remain close to the national rate.

三明市的官員們表示，這些改革使醫(yī)療費(fèi)用增速低于GDP增長(zhǎng)率，而該市醫(yī)保計(jì)劃截至去年9月錄得2300萬美元盈余。醫(yī)院提高了住院治療費(fèi)用，但自付費(fèi)用占該市總醫(yī)療支出的比例仍接近全國(guó)平均水平。

Mr Zhan was promoted to top provincial health official in 2016.

詹積富在2016年晉升為福建省的高級(jí)衛(wèi)生官員。

It was not all plain sailing. Sanming suffered from medicine shortages after some drugmakers gave up on sales there. Many doctors left because of the crackdown on bribery, according to a 2014 finance ministry report.

這些改革并不是一帆風(fēng)順的。一些制藥商放棄在該市進(jìn)行銷售后，三明遭遇了藥品短缺。根據(jù)中國(guó)財(cái)政部2014年的一份報(bào)告，打擊賄賂導(dǎo)致許多醫(yī)生離開。

The reforms also alienated large pharmaceutical companies. “Multinationals are not so pleased . . . because of the very aggressive price cuts,” says Xuan Cui, head of the pharma working group of the European Chamber of Commerce in China.

改革還疏遠(yuǎn)了大型制藥公司。“跨國(guó)企業(yè)不那么高興……因?yàn)榻祪r(jià)力度非常激進(jìn)，”中國(guó)歐盟商會(huì)(European Chamber of Commerce in China)制藥工作組負(fù)責(zé)人崔宣(音)表示。

Mistrust of local generic drugs began to spread, leading pharmacies to begin selling pricey drugs to patients who can no longer obtain them at hospitals, according to Lin Xiaoqing, a physician from Fuzhou, a city in Fujian province that followed Sanming’s model.

在效仿三明模式的福建省福州市，醫(yī)生林小青(音)表示，對(duì)國(guó)產(chǎn)仿制藥的不信任開始蔓延，導(dǎo)致藥店開始向無法從醫(yī)院獲得高價(jià)藥物的患者銷售這類藥物。

“Sometimes I'll ask a patient: ‘This drug is so cheap, do you really dare take it? If not you can go to a pharmacy elsewhere. A bottle of amino acid here sells for less than mineral water — would you dare use it?” says Mr Lin. “有時(shí)我會(huì)問一個(gè)病人：‘這種藥很便宜，但你真敢服用嗎?如果不敢，你可以去另找一家藥店。這里的一瓶氨基酸售價(jià)比礦泉水還要低——你敢用嗎?”林小青說道。

While drug prices have fallen in Sanming, “high-quality drugs are no longer supplied so a lot of drug representatives have changed professions and opened pharmacies,” said a former drug company representative who gave his name only as Zhou.

盡管三明市的藥品價(jià)格下跌了，但曾經(jīng)擔(dān)任藥品公司代表的周先生表示，“高質(zhì)量的藥品不再供應(yīng)，所以很多藥品代表改行開了藥店”。他只愿透露自己的姓氏。

Some Sanming residents praise the success in reducing costs, but most say the drive has reduced state burdens at the expense of quality care.

三明的一些市民稱贊降低成本方面的成功，但多數(shù)人指出，改革舉措減輕了國(guó)家的負(fù)擔(dān)，但代價(jià)是醫(yī)療服務(wù)質(zhì)量受到影響。

Local shopkeeper Lucy Chen, 47, complains about increased service fees. “It costs Rmb48 to make an appointment, and only Rmb18 is covered by insurance,” she says. “The more they reform, the more expensive it gets.”

47歲的當(dāng)?shù)氐曛鱈ucy Chen抱怨診療費(fèi)用增加。“診療費(fèi)需要48元人民幣，而保險(xiǎn)只負(fù)擔(dān)18元人民幣，”她說。“越改革越貴。”

Treatment in Sanming “is cheap but not effective”, says Amanda Li, who was leaving a hospital with her mother, who had reached a two-week limit on inpatient treatment. A government banner reading “earnestly lighten the burden of medical care on patients” fluttered behind her.

正要陪同達(dá)到了兩周住院治療上限的母親出院的Amanda Li說，在三明市，治療“費(fèi)用低廉，但效果不佳”。與此同時(shí)，政府宣傳標(biāo)語“切實(shí)減輕患者醫(yī)療負(fù)擔(dān)”在她身后飄揚(yáng)。

Yu Xiuqin, a city healthcare official, insists drug quality issues are unrelated to the city’s drug price negotiation process. Beijing, meanwhile, is rolling out a testing system from the end of this year that it says will ensure inferior-quality generics are taken off the market.

市衛(wèi)生官員于修芹堅(jiān)稱，藥品質(zhì)量問題與該市藥品價(jià)格談判過程無關(guān)。與此同時(shí)，北京將從今年底開始推出一套測(cè)試制度，稱這將確保劣質(zhì)仿制藥被擋在市場(chǎng)門外。

But the pushback from locals points to potential pitfalls in expanding the reforms to wealthier cities in China, says Alex Jingwei He, a healthcare expert at the Education University of Hong Kong. “The middle class and upper classes wouldn’t really want to compromise the quality of their care,” he says. “There is no one-size-fits-all model for the entire country.”

但香港教育大學(xué)(Education University of Hong Kong)醫(yī)療保健專家和經(jīng)緯(Alex Jingwei He)表示，當(dāng)?shù)厥忻竦牟粷M預(yù)示了將改革推廣到中國(guó)更富裕城市的潛在隱患。“中上階層不會(huì)真的希望自己獲得的醫(yī)療質(zhì)量打折扣，”他表示。“沒有一種模式是適合全國(guó)的。”

Twitter: @hancocktom 譯者/和風(fēng)