福建三明成中國醫(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.

中國一個城市為了抗擊醫(yī)療費用膨脹而拿制藥公司和當?shù)蒯t(yī)生開刀，該市現(xiàn)在被宣傳為全國醫(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，中國的醫(yī)療支出增加了兩倍，超出收入增長速度。逐漸老齡化的人口更容易患上慢性病，同時醫(yī)院通過以高額加價銷售品牌藥物來彌補公共資金短缺。

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)療費用。同期中國人的平均預期壽命延長了三年，達到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.

三明是中國福建省一個擁有約250萬人口的城市，該市展示了一條擺脫困境的途徑：從跨國公司生產(chǎn)的高價藥物轉向比較便宜的國產(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.

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

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.

十幾個省正在試行打擊藥品經(jīng)銷商的嚴厲政策。“衛(wèi)生部正試圖在全國推廣(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.

如今困擾全國的人口結構挑戰(zhàn)早就影響到了三明。該市出了名地交通不便，在毛澤東時代被指定為工業(yè)基地，但隨著中國經(jīng)濟從上世紀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，三明的勞動者與被撫養(yǎng)人(子女、退休人員和失業(yè)人員)之比為全國平均水平的一半。當年該市醫(yī)保計劃的赤字達到3000萬美元，相當于該市財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.

為了解決這個問題，當?shù)毓賳T詹積富將負責醫(yī)院管理、藥品采購和醫(yī)保的各部門合并為一個機構，通過將醫(yī)院領導的薪酬與他們降低多少成本掛鉤來控制醫(yī)院。他制止了對藥品大幅加價的做法，并減少了從整個體制獲利的中間商。

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部門設定藥品價格的指示，而是開始直接與藥企談判，同時政府醫(yī)保基金接到了根據(jù)仿制藥價格設定報銷標準的命令。價格大幅下降。例如，用于治療乳腺癌的依西美坦(exemestane)的價格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)療費用增速低于GDP增長率，而該市醫(yī)保計劃截至去年9月錄得2300萬美元盈余。醫(yī)院提高了住院治療費用，但自付費用占該市總醫(yī)療支出的比例仍接近全國平均水平。

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順的。一些制藥商放棄在該市進行銷售后，三明遭遇了藥品短缺。根據(jù)中國財政部2014年的一份報告，打擊賄賂導致許多醫(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.

改革還疏遠了大型制藥公司。“跨國企業(yè)不那么高興……因為降價力度非常激進，”中國歐盟商會(European Chamber of Commerce in China)制藥工作組負責人崔宣(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，對國產(chǎn)仿制藥的不信任開始蔓延，導致藥店開始向無法從醫(yī)院獲得高價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. “有時我會問一個病人：‘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格下跌了，但曾經(jīng)擔任藥品公司代表的周先生表示，“高質量的藥品不再供應，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，改革舉措減輕了國家的負擔，但代價是醫(yī)療服務質量受到影響。

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?shù)氐曛鱈ucy Chen抱怨診療費用增加。“診療費需要48元人民幣，而保險只負擔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“費用低廉，但效果不佳”。與此同時，政府宣傳標語“切實減輕患者醫(yī)療負擔”在她身后飄揚。

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)生官員于修芹堅稱，藥品質量問題與該市藥品價格談判過程無關。與此同時，北京將從今年底開始推出一套測試制度，稱這將確保劣質仿制藥被擋在市場門外。

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

Twitter: @hancocktom 譯者/和風