福建三明成中国医改先锋

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.

中国一个城市为了抗击医疗费用膨胀而拿制药公司和当地医生开刀，该市现在被宣传为全国医改楷模。

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，中国的医疗支出增加了两倍，超出收入增长速度。逐渐老龄化的人口更容易患上慢性病，同时医院通过以高额加价销售品牌药物来弥补公共资金短缺。

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.

由于国家出资的医保覆盖范围有限，患者须自行支付三分之一以上的医疗费用。同期中国人的平均预期寿命延长了三年，达到76岁。

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.

三明是中国福建省一个拥有约250万人口的城市，该市展示了一条摆脱困境的途径：从跨国公司生产的高价药物转向比较便宜的国产仿制药，并打击医生从经销商获得回扣的行为。

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.

在赢得中国最高卫生官员和世界银行(World Bank)的赞誉后，三明的许多政策正在全国推广。多数省份已禁止医院加价，并从跨国公司争取到大幅降价，影响了这些公司的增长。

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.

十几个省正在试行打击药品经销商的严厉政策。“卫生部正试图在全国推广(三明的改革)，”咨询公司罗兰贝格(Roland Berger)分析师金毅表示。

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.

如今困扰全国的人口结构挑战早就影响到了三明。该市出了名地交通不便，在毛泽东时代被指定为工业基地，但随着中国经济从上世纪80年代起开放，工业迁移至沿海地区，该市的许多年轻人也随之迁居。

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，三明的劳动者与被抚养人(子女、退休人员和失业人员)之比为全国平均水平的一半。当年该市医保计划的赤字达到3000万美元，相当于该市财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.

为了解决这个问题，当地官员詹积富将负责医院管理、药品采购和医保的各部门合并为一个机构，通过将医院领导的薪酬与他们降低多少成本挂钩来控制医院。他制止了对药品大幅加价的做法，并减少了从整个体制获利的中间商。

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.

詹积富没有理睬由省有关部门设定药品价格的指示，而是开始直接与药企谈判，同时政府医保基金接到了根据仿制药价格设定报销标准的命令。价格大幅下降。例如，用于治疗乳腺癌的依西美坦(exemestane)的价格2012年至2014年间从每盒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.

三明市的官员们表示，这些改革使医疗费用增速低于GDP增长率，而该市医保计划截至去年9月录得2300万美元盈余。医院提高了住院治疗费用，但自付费用占该市总医疗支出的比例仍接近全国平均水平。

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

詹积富在2016年晋升为福建省的高级卫生官员。

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.

这些改革并不是一帆风顺的。一些制药商放弃在该市进行销售后，三明遭遇了药品短缺。根据中国财政部2014年的一份报告，打击贿赂导致许多医生离开。

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.

改革还疏远了大型制药公司。“跨国企业不那么高兴……因为降价力度非常激进，”中国欧盟商会(European Chamber of Commerce in China)制药工作组负责人崔宣(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，医生林小青(音)表示，对国产仿制药的不信任开始蔓延，导致药店开始向无法从医院获得高价药物的患者销售这类药物。

“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. “有时我会问一个病人：‘这种药很便宜，但你真敢服用吗?如果不敢，你可以去另找一家药店。这里的一瓶氨基酸售价比矿泉水还要低——你敢用吗?”林小青说道。

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.

尽管三明市的药品价格下跌了，但曾经担任药品公司代表的周先生表示，“高质量的药品不再供应，所以很多药品代表改行开了药店”。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.

三明的一些市民称赞降低成本方面的成功，但多数人指出，改革举措减轻了国家的负担，但代价是医疗服务质量受到影响。

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岁的当地店主Lucy Chen抱怨诊疗费用增加。“诊疗费需要48元人民币，而保险只负担18元人民币，”她说。“越改革越贵。”

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.

正要陪同达到了两周住院治疗上限的母亲出院的Amanda Li说，在三明市，治疗“费用低廉，但效果不佳”。与此同时，政府宣传标语“切实减轻患者医疗负担”在她身后飘扬。

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.

市卫生官员于修芹坚称，药品质量问题与该市药品价格谈判过程无关。与此同时，北京将从今年底开始推出一套测试制度，称这将确保劣质仿制药被挡在市场门外。

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.”

但香港教育大学(Education University of Hong Kong)医疗保健专家和经纬(Alex Jingwei He)表示，当地市民的不满预示了将改革推广到中国更富裕城市的潜在隐患。“中上阶层不会真的希望自己获得的医疗质量打折扣，”他表示。“没有一种模式是适合全国的。”

Twitter: @hancocktom 译者/和风