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药改:以药养医体制需要承担必要的责任
时间:2017-08-11 点击率 : 743

 药价改革难以过河的一个重要标志,是2014年11月底公布的《推进药品价格改革方案(征求意见稿)》未能依时落地。这一改革意见稿由国家发改委推出。不同于国家发改委的方案,国家卫生计生委近来用力的方向,则是在药品价格谈判方面。

药价虚高问题,是中国社会的一个痛点,舆论已经讨论多年。虚高的价格必须降下来,也是除了某些既得利益者之外的整个社会的共识。这个问题不解决,不只是民生之痛,也会在体制层面形成“病变”,最终沉疴难治。

从目前情况来看,发改委系统的改革方案有停滞之感,国家卫生计生委在药品价格谈判方面的一些举措,也遭遇了很多的批评意见,甚至被指“法外设权”。尽管今年两会政府工作报告中提出,2015年将取消绝大部分药品的政府定价,但改革这条路究竟怎么走,很多人心中没底。

药价虚高,一个重要原因是回扣问题,这也是多年来人们似乎习以为常的潜规则。医药界的腐败,似如层层冰山,世人所见的,不过为冰山一角。从治理腐败角度审视药价问题,当然是一个角度,但即便市场环境改善,药价问题也未必能如愿解决。这背后的体制机制之弊,非回扣二字所能诠释。

近来又有声音提及医药分家,或指其为未来药改的重要一环。其实,有关医药分家亦非新话题。医院向来“以药养医”,这是药价一直居高不下的重要原因。前不久,70多万种药品底价在某网站上曝光,部分药品的价差据称高得令人咋舌,这当中,“以药养医”体制需要承担必要的责任。

有识者早就有言,单从药改角度看医药分家,难以真正有结果。这种说法是有道理的。倘若医药强行分开,又会如何?医院方拥有“处方权”,在医疗体制未能深刻变革的背景下,这一权力或会因为医药强行分开而有异化的可能。目前,政府与医院的权利问题未能厘清,一线医生的收入缺少制度性的保障,这些都是“以药养医”长期存在的背景性因素。

看起来,药改当与医改齐头并进才行。医改已进行多年,亦在局部上有成绩,但此方面需要看到更多的改革成果。在医改未有更明显成效之时,单靠药改单兵突进,困难重重自是必然。或者说,在解决药价虚高的问题上,药价改革没法替代医改。

医疗领域的各种改革,注定会是在各种困难中推进。这也正是“深水区”改革的特点。太多的既得利益群体会在各个方面阻击改革,形成拉锯局面。药改、医改如此,其他领域的改革同样也会是如此。整体改革步履艰难,摸着石头过不了河,自然也不足为怪。

药品价格的市场化,以及药价形成机制方面的改革都是必要的,但不是全部。医改仍在半途中,这影响了药价改革的进度。而医改的踟蹰,有各种利益协调之难,更有利益受损者的拼命阻击。

在某种意义上,医改、药改的状况是今天中国整体改革事业的一个缩影。当然,困难虽现实存在,公众却不必垂头丧气。改革的步履虽有点徘徊、不够坚实,但到底在往前走。就方向而言,药价虚高的问题迟早是能解决的,这也正是希望所在。

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