公共视角下基本药物制度定量评估模型研究
摘要
[目的]梳理构建我国基本药物制度的概念框架模型,并从公共视角设计基本药物制度定量评价模型,评价我国医药卫生体制改革近期(2009-2011年)的基本药物制度,比较各省份实施基本药物制度效益的差异并分析原因,为进一步完善和改进当前的基本药物政策提供依据。
[方法]通过文献研究法、专家咨询法等方法深入分析我国基层医疗卫生机构实施基本药物制度的现状、主要问题,以及投入、产出、效果、环境等方面指标,构建基本药物制度概念框架模型,以及成本和效益测算模型。并利用医药卫生体制改革重点实施方案(2009-2011年)中期评估的数据,测算我国整体和各省基层医疗卫生机构实施基本药物制度的总成本、总效益、成本效益。采用两变量相关分析,分析各省基层医疗卫生机构实施基本药物制度成本、效益、成本效益值的相关因素。
[结果]1、基本药物概念框架模型包括投入、产出、效果、环境四个部分。投入分为有形投入和无形投入。有形投入包括人力资源投入、资金投入、基础设施投入等三个部分；无形投入包括政策投入、教育投入、管理投入、政治投入、宣传投入等五个部分。产出包括制度产出和实体产出两个部分。制度产出包括基本药物目录和其他相关配套政策的出台。实体产出包括基本药物生产、采购、配送、使用、监管等部分。效果包括经济效果、健康效果、新机制效果三个部分。环境部分分为自然条件和政策条件。自然条件指地方基础条件,政策条件指相关卫生政策以及财政政策等。
2、基本药物制度定量评价模型构建。(1)可计算的总成本=基层医疗卫生机构实施基本药物制度经常性收支缺口补助支出(含绩效工资政策和各地自行出台的在职人员工资补助政策)+用于招标、采购等基本药物保障体系支出+基本药物制度培训经费；(2)校正的可计算总成本=可计算的总成本*(1+该年度贷款利率)；(3)总效益=可获得性增加节省上级医院门诊费用+可负担性增加节省基层门诊费用+可负担性增加节省的基层住院费用+合理用药程度增加减少生产力损失效益。
3、实施基本药物制度总成本较高省份有江苏、山东、安徽,较低的是西藏、青海。实施基本药物制度的总效益较高的省份有浙江、广东、江苏、山东,较低的省份有陕西、青海、内蒙古。成本效益较高的省份是浙江、广东,最低的两个省份是陕西、甘肃。全国有20个省份成本效益为负值,仅9个省份为正值。
4、2010年我国实施基本药物制度校正可计算的总成本1436688万元,总效益1501328万元,成本效益64640万元。
5、各省实施基本药物制度总效益的相关因素包括地区经济发展状况(GDP总量)、人口状况、基层医疗卫生机构补偿情况(财政支出占基层医疗卫生机构总收入比例)、基层医疗卫生机构建设情况(乡镇卫生院达标率、社区卫生服务中心达标率)、居民电子健康档案建档率,以及总成本。各省实施基本药物制度投入的总成本与地区经济情况和人口数量相关。而各省实施基本药物制度的成本效益只与地区经济情况有关。
[建议]1、对完善当前基本药物制度政策建议：(1)取消基本药物省级增补政策；(2)采取措施激励医生处方基本药物,改变当前强制使用政策；(3)完善基本药物招标采购政策,体现质量优先,价格合理；(4)给予配送企业合理利润,鼓励流通企业做强做大。
2、当前构建的定量评估模型还需要进一步完善,但本研究给制度评价带来了新的思路和尝试。建议在分析公共政策效果时,不仅要客观分析取得的效益,还要注重成本。
3、地区经济状况对基本药物制度效益产生了较大影响。建议我国各地区在发展民生工程的同时,也要继续加强经济建设。在制度设计时,要考虑经不同地区经济条件特点,制定差异化的基本药物政策。基本药物制度投入对效益的影响有限,还要考虑经济、人口、财政补偿、硬件建设,以及居民健康档案等因素。
4、公立医院实施基本药物制度,还需在制度定位、目录遴选、招标采购、价格管理、使用政策等方面加强研究。
[创新与不足]1、创新：(1)本研究创新性的对一项公共制度的整体进行了经济学的定量评价,为今后的制度评价打开了一个新的思路,在考虑效果的同时,也考虑了实施制度的成本。(2)本研究构不仅针对制度现状、问题、投入、产出、效果、效益、环境进行了全面计算和分析,并根据结果,提出了下一步完善基本药物制度的政策建议。
2、不足：(1)由于本研究首次尝试对制度进行定量的经济学评价,所以在建立经济学评价模型时,难免有不尽合理的地方。(2)由于一项制度从建立到其效果发挥通常有一个时间过程。由于受到数据限制,所以本研究只对实施基本药物制度一年来的成本效益进行了定量评价,可能存在有些制度建立的效益还没有充分发挥。
[Objective]To combing the conceptual framework that built the essential medicine system and design the quantitative evaluation model of essential medicine system from the public perspective, evaluate the essential medicine policy in recently medical and health system reform (2009-2011), compare the difference of essential medicine system in different provinces and analyze the causes and provide a basis for further perfection and improvement of the current essential medicine system policy.
[Methods]Understanding and analysis of the status, main problem and indicators of investment, operation, output, effect, environment of the essential medicine system analysis of primary care health institutions through documentary research, expert advice and other methods, and build a conceptual framework of essential medicine system, as well as the costs and benefits estimation model. And the use of drugs and health system focus on the implementation of the program (2009-2011), of the data, estimates the total cost, total benefit, cost-effectiveness of the implementation of essential medicine system in our country as a whole, and primary health institutions in provinces, using the data of a mid-term evaluation of program of the focus on the implementation of the health system reform. Analyzing the relevant factors of the total cost, total benefit, cost-effectiveness of the implementation of essential medicine system in primary health institutions in provinces through univariate analysis.
[Results]1. Essential medicines concept model includes four sections:inputs, outputs, effects, environment. Inputs includes physical inputs and intangible inputs. The physical inputs include investment in human resources, capital investment and infrastructure investment in three parts; the intangible inputs include five sections:the policy investment, investment in education, investment in management, political involvement, and investment in promotion. Outputs include system outputs and entities outputs. The system outputs include the introduction of the Essential Drugs List and other relevant supporting policies. Entity outputs include production, procurement, distribution, use and supervision of essential medicines. Effects comprise economic effects, health effects, and new mechanism effects. The environment section is divided into the natural conditions and policy conditions. Natural conditions refer to the local infrastructure conditions, and policy conditions refer to the relevant health policy and fiscal policy.
2. Building quantitative evaluation model of essential medicine system.(1) Computable total cost=subsidies of the gaps of recurrent balance of payments of primary medical institutions implementing essential medicine system (including pay for performance policy and local self-serving service personnel wage subsidy policy)+expenses for tender, procurement of essential medicine+training funds of essential medicine system;(2) Adjusted computable total cost=Computable total cost*(1+the annual lending rate);(3) Total benefits=primary care outpatient cost savings due to increased affordability+secondary hospital outpatient costs savings due to increased availability+primary care inpatient cost savings due to increased affordability+benefits of reduced loss of productivity due to increased degree of rational use of drugs
3. Jiangsu, Shangdong and Anhui province have higher cost in implementing essential medicine system, while Tibet and have lower cost. Provinces that have higher total benefit in implementing essential medicine system include Zhejiang, Guangdong, Jiangsu and Shandong, while the lower ones include Shaanxi, Qinghai and Inner Mongolia. Zhejiang, Guangdong have higher cost-effective provinces, the lowest two provinces are Shaanxi and Gansu.20provinces have negative cost-effectiveness, only nine positive
4. The total computable cost of essential medicine implementation is￥14,366,880,000, the total benefits is￥15,013,280,000, and cost-effectiveness is￥646.4million
5. Relevant factors of the total benefit of the implementation of essential medicine system in different provinces include Regional economic development status(GDP/per capita GDP), population status, the compensation situation of primary health care institutions (the proportion of fiscal spending accounting for total revenue of primary health care institutions), construction of primary health care institutions (compliance rate of township hospitals, community health service center compliance rate), archiving rate of residents electronic health records, and total cost. The total cost is associated with the regional economic situation and population. The cost-effectiveness is only associated with the regional economic situation.
[Advice]1. Policy recommendations on improving the current essential medicine system:(1) Adjust the addition policy of essential medicine system;(2) Take measures to motivate a doctor's prescription of essential medicines, and change the current policy of mandatory use;(3) Improve the bidding policy of essential medicine, reflecting the priority of quality and reasonable price;(4) Give a reasonable profit to distribution enterprises to encourage circulation enterprises bigger and stronger.
2. The current quantitative evaluation model still needs further improvement, but it brings new ideas and overture to the system. It is proposed that not only the effectiveness but also the cost needs to be evaluated when analyzing the effect of the system
3. Local economic conditions had a significant impact on the essential medicine system effectiveness. It is recommended that the local governments should continue to strengthen the economic construction. While developing livelihood projects In the design of the system, economic characteristic of different regions must be considered to develop differentiated essential medicine policies. The input of essential medicine system has limited effect on the effectiveness, other factors such as economy and population, financial compensation and hardware construction, as well as the residents health record need to be considered.
4. Further research on system positioning, directory selection, bidding, price management, use policy is needed to implement essential medicine system in public hospitals
[Innovation and Limitation]1. Innovation:(1) There is a quantitative evaluation of economics on a whole public system innovatively in this study. It opens up a new way of thinking for future evaluation system. Evaluation need not only consider the effect, but also consider the implementation of the system costs.(2) This study conducted a comprehensive calculation and analysis in inputs, status, output, problems, effects, benefits, environmental of the system, and based on the results presented next perfect system of essential medicine policy recommendations.
2. Limitation:(1) Since the study is the first attempt to quantify the economic evaluation of the system, it is inevitable that there is not quite reasonable in the establishment of economic evaluation model.(2)There is a time course from establishing the system to getting the effect. Due to data limitations, this study only evaluated quantitatively implementation of the essential medicine system of one year to the cost-effectiveness, there may be some benefits of established system that have not fully realized.
[方法]通过文献研究法、专家咨询法等方法深入分析我国基层医疗卫生机构实施基本药物制度的现状、主要问题,以及投入、产出、效果、环境等方面指标,构建基本药物制度概念框架模型,以及成本和效益测算模型。并利用医药卫生体制改革重点实施方案(2009-2011年)中期评估的数据,测算我国整体和各省基层医疗卫生机构实施基本药物制度的总成本、总效益、成本效益。采用两变量相关分析,分析各省基层医疗卫生机构实施基本药物制度成本、效益、成本效益值的相关因素。
[结果]1、基本药物概念框架模型包括投入、产出、效果、环境四个部分。投入分为有形投入和无形投入。有形投入包括人力资源投入、资金投入、基础设施投入等三个部分；无形投入包括政策投入、教育投入、管理投入、政治投入、宣传投入等五个部分。产出包括制度产出和实体产出两个部分。制度产出包括基本药物目录和其他相关配套政策的出台。实体产出包括基本药物生产、采购、配送、使用、监管等部分。效果包括经济效果、健康效果、新机制效果三个部分。环境部分分为自然条件和政策条件。自然条件指地方基础条件,政策条件指相关卫生政策以及财政政策等。
2、基本药物制度定量评价模型构建。(1)可计算的总成本=基层医疗卫生机构实施基本药物制度经常性收支缺口补助支出(含绩效工资政策和各地自行出台的在职人员工资补助政策)+用于招标、采购等基本药物保障体系支出+基本药物制度培训经费；(2)校正的可计算总成本=可计算的总成本*(1+该年度贷款利率)；(3)总效益=可获得性增加节省上级医院门诊费用+可负担性增加节省基层门诊费用+可负担性增加节省的基层住院费用+合理用药程度增加减少生产力损失效益。
3、实施基本药物制度总成本较高省份有江苏、山东、安徽,较低的是西藏、青海。实施基本药物制度的总效益较高的省份有浙江、广东、江苏、山东,较低的省份有陕西、青海、内蒙古。成本效益较高的省份是浙江、广东,最低的两个省份是陕西、甘肃。全国有20个省份成本效益为负值,仅9个省份为正值。
4、2010年我国实施基本药物制度校正可计算的总成本1436688万元,总效益1501328万元,成本效益64640万元。
5、各省实施基本药物制度总效益的相关因素包括地区经济发展状况(GDP总量)、人口状况、基层医疗卫生机构补偿情况(财政支出占基层医疗卫生机构总收入比例)、基层医疗卫生机构建设情况(乡镇卫生院达标率、社区卫生服务中心达标率)、居民电子健康档案建档率,以及总成本。各省实施基本药物制度投入的总成本与地区经济情况和人口数量相关。而各省实施基本药物制度的成本效益只与地区经济情况有关。
[建议]1、对完善当前基本药物制度政策建议：(1)取消基本药物省级增补政策；(2)采取措施激励医生处方基本药物,改变当前强制使用政策；(3)完善基本药物招标采购政策,体现质量优先,价格合理；(4)给予配送企业合理利润,鼓励流通企业做强做大。
2、当前构建的定量评估模型还需要进一步完善,但本研究给制度评价带来了新的思路和尝试。建议在分析公共政策效果时,不仅要客观分析取得的效益,还要注重成本。
3、地区经济状况对基本药物制度效益产生了较大影响。建议我国各地区在发展民生工程的同时,也要继续加强经济建设。在制度设计时,要考虑经不同地区经济条件特点,制定差异化的基本药物政策。基本药物制度投入对效益的影响有限,还要考虑经济、人口、财政补偿、硬件建设,以及居民健康档案等因素。
4、公立医院实施基本药物制度,还需在制度定位、目录遴选、招标采购、价格管理、使用政策等方面加强研究。
[创新与不足]1、创新：(1)本研究创新性的对一项公共制度的整体进行了经济学的定量评价,为今后的制度评价打开了一个新的思路,在考虑效果的同时,也考虑了实施制度的成本。(2)本研究构不仅针对制度现状、问题、投入、产出、效果、效益、环境进行了全面计算和分析,并根据结果,提出了下一步完善基本药物制度的政策建议。
2、不足：(1)由于本研究首次尝试对制度进行定量的经济学评价,所以在建立经济学评价模型时,难免有不尽合理的地方。(2)由于一项制度从建立到其效果发挥通常有一个时间过程。由于受到数据限制,所以本研究只对实施基本药物制度一年来的成本效益进行了定量评价,可能存在有些制度建立的效益还没有充分发挥。
[Objective]To combing the conceptual framework that built the essential medicine system and design the quantitative evaluation model of essential medicine system from the public perspective, evaluate the essential medicine policy in recently medical and health system reform (2009-2011), compare the difference of essential medicine system in different provinces and analyze the causes and provide a basis for further perfection and improvement of the current essential medicine system policy.
[Methods]Understanding and analysis of the status, main problem and indicators of investment, operation, output, effect, environment of the essential medicine system analysis of primary care health institutions through documentary research, expert advice and other methods, and build a conceptual framework of essential medicine system, as well as the costs and benefits estimation model. And the use of drugs and health system focus on the implementation of the program (2009-2011), of the data, estimates the total cost, total benefit, cost-effectiveness of the implementation of essential medicine system in our country as a whole, and primary health institutions in provinces, using the data of a mid-term evaluation of program of the focus on the implementation of the health system reform. Analyzing the relevant factors of the total cost, total benefit, cost-effectiveness of the implementation of essential medicine system in primary health institutions in provinces through univariate analysis.
[Results]1. Essential medicines concept model includes four sections:inputs, outputs, effects, environment. Inputs includes physical inputs and intangible inputs. The physical inputs include investment in human resources, capital investment and infrastructure investment in three parts; the intangible inputs include five sections:the policy investment, investment in education, investment in management, political involvement, and investment in promotion. Outputs include system outputs and entities outputs. The system outputs include the introduction of the Essential Drugs List and other relevant supporting policies. Entity outputs include production, procurement, distribution, use and supervision of essential medicines. Effects comprise economic effects, health effects, and new mechanism effects. The environment section is divided into the natural conditions and policy conditions. Natural conditions refer to the local infrastructure conditions, and policy conditions refer to the relevant health policy and fiscal policy.
2. Building quantitative evaluation model of essential medicine system.(1) Computable total cost=subsidies of the gaps of recurrent balance of payments of primary medical institutions implementing essential medicine system (including pay for performance policy and local self-serving service personnel wage subsidy policy)+expenses for tender, procurement of essential medicine+training funds of essential medicine system;(2) Adjusted computable total cost=Computable total cost*(1+the annual lending rate);(3) Total benefits=primary care outpatient cost savings due to increased affordability+secondary hospital outpatient costs savings due to increased availability+primary care inpatient cost savings due to increased affordability+benefits of reduced loss of productivity due to increased degree of rational use of drugs
3. Jiangsu, Shangdong and Anhui province have higher cost in implementing essential medicine system, while Tibet and have lower cost. Provinces that have higher total benefit in implementing essential medicine system include Zhejiang, Guangdong, Jiangsu and Shandong, while the lower ones include Shaanxi, Qinghai and Inner Mongolia. Zhejiang, Guangdong have higher cost-effective provinces, the lowest two provinces are Shaanxi and Gansu.20provinces have negative cost-effectiveness, only nine positive
4. The total computable cost of essential medicine implementation is￥14,366,880,000, the total benefits is￥15,013,280,000, and cost-effectiveness is￥646.4million
5. Relevant factors of the total benefit of the implementation of essential medicine system in different provinces include Regional economic development status(GDP/per capita GDP), population status, the compensation situation of primary health care institutions (the proportion of fiscal spending accounting for total revenue of primary health care institutions), construction of primary health care institutions (compliance rate of township hospitals, community health service center compliance rate), archiving rate of residents electronic health records, and total cost. The total cost is associated with the regional economic situation and population. The cost-effectiveness is only associated with the regional economic situation.
[Advice]1. Policy recommendations on improving the current essential medicine system:(1) Adjust the addition policy of essential medicine system;(2) Take measures to motivate a doctor's prescription of essential medicines, and change the current policy of mandatory use;(3) Improve the bidding policy of essential medicine, reflecting the priority of quality and reasonable price;(4) Give a reasonable profit to distribution enterprises to encourage circulation enterprises bigger and stronger.
2. The current quantitative evaluation model still needs further improvement, but it brings new ideas and overture to the system. It is proposed that not only the effectiveness but also the cost needs to be evaluated when analyzing the effect of the system
3. Local economic conditions had a significant impact on the essential medicine system effectiveness. It is recommended that the local governments should continue to strengthen the economic construction. While developing livelihood projects In the design of the system, economic characteristic of different regions must be considered to develop differentiated essential medicine policies. The input of essential medicine system has limited effect on the effectiveness, other factors such as economy and population, financial compensation and hardware construction, as well as the residents health record need to be considered.
4. Further research on system positioning, directory selection, bidding, price management, use policy is needed to implement essential medicine system in public hospitals
[Innovation and Limitation]1. Innovation:(1) There is a quantitative evaluation of economics on a whole public system innovatively in this study. It opens up a new way of thinking for future evaluation system. Evaluation need not only consider the effect, but also consider the implementation of the system costs.(2) This study conducted a comprehensive calculation and analysis in inputs, status, output, problems, effects, benefits, environmental of the system, and based on the results presented next perfect system of essential medicine policy recommendations.
2. Limitation:(1) Since the study is the first attempt to quantify the economic evaluation of the system, it is inevitable that there is not quite reasonable in the establishment of economic evaluation model.(2)There is a time course from establishing the system to getting the effect. Due to data limitations, this study only evaluated quantitatively implementation of the essential medicine system of one year to the cost-effectiveness, there may be some benefits of established system that have not fully realized.
引文
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