医生眼中的“医改” The doctor's eye“medical”

　　8月19日晚8时起，北京协和医院24小时开放挂号窗口，每晚8时开始挂第二天的号。从19日凌晨就有人开始排队，到晚8时前，挂号队伍已经在医院里排了四五百米。

On August 19, the 8 p.m，Beijing union medical college hospital registered window open 24 hours，At 8 every night began to hang the second day number。From 19 morning they began to queue，Till night before 8，Registered team is already in the hospital row of the - meters。

　　医院表示，此举不仅方便患者，而且在一定程度上也可以打击号贩子。

Hospital said，This is not only convenient patients，And in a certain extent can also strike number dealers。

　　

百姓眼中“看病贵”，医生认为贵在哪儿 People eyes“The doctor your”，The doctor think that is

　　

讲述者：北京同仁医院泌尿外科主任医师 杨建林 narrator：Beijing tongren hospital uropoiesis surgical department chief physician YangJianLin

　　医改正在积跬步。其中，“看病贵”是当前百姓印象中的医疗沉疴之一。有媒体统计，2011年中国住院人均花费6632元，相当于农民一年的收入。

Cure is product of yongxing。the，“The doctor your”Is the current people impression of care is one of the severe and lingering illness。Media statistics，In 2011, the Chinese hospital cost 6632 yuan per capita，Is equivalent to a year's income for farmers。

　　但在抱怨背后，你是否了解“看病贵”究竟贵在哪里？

But behind the complain，Whether you realize it“The doctor your”Exactly where in the？

　　在北京同仁医院泌尿外科主任医师杨建林眼中，“看病贵”主要不是贵在挂号和诊疗上，而是贵在手术耗材和进口药品上。

In the Beijing tongren hospital uropoiesis surgical department chief physician YangJianLin eyes，“The doctor your”In the main not registered and the diagnosis and treatment，But in the operation consumables and imported drugs on。

　　“普通病人的看病流程都差不多，基本上是挂号-诊疗-手术-买药等步骤。在这个过程中，挂号费不应该是导致看病贵的主要原因。”他告诉中国青年报记者，“挂号费再高，也不会高到让患者承担不起的程度。”

“Ordinary the patient's doctor process is about the same，Basically is registered - - - to buy medicine diagnosis and operation steps。In this process，The registration fee should not be lead to the main reason for the high cost。”He told the China youth daily reporter，“Registration fee and high，Also not high to let patients can't afford to degree。”

　　既然如此，为何有医院的专家号卖出“天价”？杨建林主任认为，有需求才有“黄牛”市场，而一部分患者没必要非得找专家看病。另外，一些医院试图以调高专家号，来避免医疗资源被浪费，在他看来也不是治本之策，反而抬升了“看病贵”。

so，Why is there a hospital ZhuanGuHao sell“Day price”？YangJianLin director think，Demand have“cattle”market，And part of the patients don't have to have to find experts see a doctor。In addition，Some hospitals trying to raise ZhuanGuHao，To avoid medical resources are wasted，In his view is not the essential strategy，Instead given“The doctor your”。

　　杨建林主任告诉记者，医护人力成本也不高，手术耗材的成本却高，好一点的进口耗材价格更高。“我国的医疗设备和耗材使用不统一，各地医院采用的耗材都不一样。医保不能报销医疗设备和耗材费用，患者若自费负担，很容易导致一部分人无法承受。”

YangJianLin director told reporters，Medical human cost is not high also，The operation cost of consumables is high，Better import consumables prices higher。“Our country's medical equipment and consumables use not unified，All the hospital material is different。Medical insurance cannot submit an expense account medical equipment and consumables cost，If patients burden at one's own expenses，Very easy to lead to some people cannot afford。”

　　某三甲医院一位不愿透露姓名的心血管科医生，给中国青年报记者算了一笔账：一次心血管手术过程中，植入一个支架的费用是3万多一点，住院费一天是700元左右，检查化验费3000多元，药品约2000多元，医生诊疗费和手术费加起来不到2000元。基本上，整个医疗费用4万多元，其中，检查化验费、药品费占在5%以上，耗材费用占80%以上，医疗人力成本仅占不到整个医疗费用的4%。

A 3 armour hospital one does not wish to disclose the name of the cardiovascular department doctor，China youth daily reporter to calculate a bill：A cardiovascular surgery process，A stent implantation is the cost of a little more than 30000，Hospitalization expenses a day is 700 yuan，Check test 3000 multivariate，Drug about 2000 multivariate，The doctor fee and operation added up to no more than 2000 yuan。basically，The whole medical treatment charge 40000 yuan，the，Check test、For drug in more than 5%，Consumable cost accounting for more than 80%，Medical human cost only accounts for less than 4% of the whole medical expenses。

　　“但这也分情况，不同的病，成本比例不一。做不做手术，成本构成也不一样。”这位心血管医生说。

“But it also points situation，Different disease，Cost ratio differ。Do surgery，Cost structure is different also。”The cardiovascular doctors say。

　　在杨建林主任看来，药品也是造成“看病贵”的一方面，尤其在不需要做手术的诊疗中，它占了一个大头。“一些常用药、普通药——比如吡哌酸等是很经济实惠的，但在很多医院已经买不到了。”杨建林主任感觉，从2000年开始，药品开始越来越重包装、轻质量，过度包装背后是价格的翻番。

In YangJianLin director looks，Drugs is also causes the“The doctor your”Aspect of，Especially in do not need to become an operation in the diagnosis and treatment，It accounts for a big head。“Some five、General medicine -- such as pipemidic acid is very economical，But in many hospitals have to buy。”YangJianLin director feel，Begin from 2000，Drugs are becoming more and more heavy packing、Light quality，Excessive packing is behind the double the price。

　　他认为，医院在对药商进行招标的时候，不能光看哪家药商的实力雄厚，规模宏大，利润丰厚，而应该让临床的医生参与招标。“因为他们知道患者需要用什么药，着重找那些既经济又实惠的药品。”他说，“这能大大降低高价格药品的购入，百姓用药的费用也就降低了。”

He thinks，The hospital in the druggist to tender time，Can't see a druggist's strength，large-scale，lucrative，And should make clinical doctor to participate in bidding。“Because they know patients need with what medicine，Mainly to find those who both economical and affordable medicines。”He said，“This can greatly reduce the high price of drugs purchased，People use cost is also reduced。”

　　在杨建林看来，看病贵不贵，还在于医患间的认识与沟通。

In YangJianLin seems，The doctor is expensive or not，It is the understanding and communication between patient and physician。

　　“在我所接触的病人当中，抱怨‘看病贵’的人其实并不多。”他说，“因为在我们诊疗之前或是诊疗过程中，会对治疗的流程作一个基本介绍。看什么病，花什么钱，建议病人哪些检查必须做，哪些检查没有必要做……这些如果事先都能与病人讲清楚，给他们更充分的知情权、选择权，绝大多数人是能接受的。”

“In what I contact the patients in，complain‘The doctor your’People actually not much。”He said，“Because in our before diagnosis or in the process of diagnosis and treatment，Will the treatment process for a basic introduction。See what disease，Spend any money，Recommended that the patient which check must do，What examination did not need to do...These if prior to patient with a clear，Give them the right to know more fully、option，The vast majority of people are acceptable。”

　　

药品“零差价”是破解“看病贵”的良方吗 drugs“Zero spread”Is cracked“The doctor your”Prescription?

　　

讲述者：北京同仁医院泌尿外科主任医师 杨建林 narrator：Beijing tongren hospital uropoiesis surgical department chief physician YangJianLin

　　某中药换包装后身价翻一番，一些常用药从出厂到医院售价猛涨20倍……频现的药品提成丑闻，在令老百姓慨叹“看病贵”的同时，也将现行公立医院实施的以药养医制度，推向改革的前台。

A traditional Chinese medicine in packaging value after double，Some common medicine from the factory to the hospital price jumps 20 times...Frequency is drug commission scandal，In make people sigh with regret“The doctor your”At the same time，Will also present the implementation of public hospital in medicine to raise the medical system，To the reform of the front desk。

　　而新一轮医改的一大亮点，就是在公立医院中推行基本药物“零差价”制度。即不再让被医院加价的这15%，助推老百姓的看病负担。

And a new round of reform, a big luminescent spot，Even in public hospital implementation of essential drugs“Zero spread”system。That is no longer to be the 15% increase hospital，Boosting common people to see a doctor of the burden。

　　目前，该制度已在山东、陕西、安徽等全国多个县(市、区)的基层医院试点，效果不错。据媒体公开报道，在一些基层医院，百姓拿药价普遍比大医院便宜了30%。

At present，This system has set up a file in the shandong province、shaanxi、Anhui province and the national multiple county(city、area)The pilot of the basic-level hospitals，Effect good。According to media public reports，In some basic-level hospitals，People generally take prices than the big hospital was 30% cheaper。

　　杨建林主任所在的北京同仁医院，也是试点医院之一。在他看来，药品“零差价”可以解决一部分“看病贵”问题，但无法从根本上解决问题。“因为医药费用高的主要因素，不在于末端的这15%，而在于药企和中间环节。”

YangJianLin director in the Beijing tongren hospital，The pilot is also one of the hospital。In his view，drugs“Zero spread”Part can be solved“The doctor your”problems，But can't resolve the problem ultimately。“Because of the high cost of medicine of the main factors，This is not the end of the 15%，But in the medicine qi and intermediate links。”

　　据他介绍，药企的逐利特性和臃肿的中间环节，正在“逆向淘汰”一些经济实惠的药品，药品“零差价”与它相比是小头。“同一种药，牌子越来越多、包装越来越精，效果不一定好，几元一瓶的药已经很难找到了。”

According to he introduced，Medicine to study the characteristics and bloated intermediate links，are“Reverse selection”Some economical drug，drugs“Zero spread”Compared with it is capitulum。“The same kind of medicine，Brand more and more、Packaging more and more essence of life，Effect not necessarily good，A few yuan a bottle of medicine have been hard to find。”

　　据披露，之所以如此，是因为每种药品从研发、生产到上市，都要经历生产商、采购商和经销商等环节。在定价部门、招标部门、医院药事委员会面前，一家药企要在“同伴竞争”中脱颖而出，经常要以高额投入来“打通”这些环节。有的投入，甚至能占到药品出厂价的十几倍。而最终这些中间花销，肯定要由患者埋单。

According to the disclosure，so，Because each drug from research and development、Production to listed，Have to undergo producers、Buyers and dealers, and other links。In the pricing department、Bidding department、Hospital pharmacy before a committee，A medicine enterprises in“Peer competition”Come to the fore，Often with high input to“through”These links。Some input，Even can account for drugs ex-factory price more than ten times。And the final among these costs，Patients must be the bill。

　　在日益膨胀的投入面前，几元的“薄利药”自然难抵成本，“金贵药”甚嚣尘上。

In an increasingly expansion in front，A few yuan“Small profits medicine”Natural difficult to cost，“Jin-gui medicine”rumbles。

　　“另外一个关键问题是，医生收入总体偏低，目前，其待遇很大程度上要靠这15%加价来补。你取消了医院加价，国家就要给予资金支持。”杨建林主任认为，否则，其他变相的加价还会涌现。

“Another key problem is，The doctor low overall income，At present，Its treatment to a great extent by the 15% increase to fill。You cancel the hospital tariffs，Nation will give financial support。”YangJianLin director think，otherwise，Other disguised markup3 will emerge。

　　“据我所知，为了弥补收入不足，一些医院已经出现了挂号费上涨的问题。这说明单方面强调药品‘零差价’是不行的，没有财政扶持，难免‘按下葫芦浮起瓢’。”他说。

“As far as I know，In order to make up for lack of income，Some hospitals have appeared in the registration fee。This shows that unilateral emphasize drugs‘Zero spread’Is not，No financial support，unavoidably‘Press the bottle gourd float gourd ladle’。”He said。

　　

“按病种付费”破了大处方，能保证“疗效好”吗 “Press disease to pay”Broke DaChuFang，Can guarantee“Has good curative effect”?

　　

讲述者：首都医科大学附属北京友谊医院核医学科主任医师 李春林 narrator：The capital university of medical sciences, Beijing friendship hospital affiliated to nuclear medicine chief physician LiChunLin

　　去年8月1日起，“按病种付费”已悄然取代“按项目付费”，在北京6家医院开始了试点。这个旨在控制“大处方”、“过度医疗”的医保支付方式，被卫生部部长陈竺形象地比喻为给病人“吃套餐”。

Last August 1，“Press disease to pay”Has quietly replaced“According to the program pay”，Six hospitals in Beijing began pilot。To control the“DaChuFang”、“Excessive medical”The medical insurance payment，By the ministry of health minister Outlines image to compare to give patients“Eat meal”。

　　“套餐”怎么吃？

“package”How to eat？

　　通俗地讲，就是把108个常见病种“打包”，根据病人的年龄、疾病诊断、合并症并发症、治疗方式、病症严重程度以及疗效等多种因素，分成若干组，每组确定一个报销“上限”。同组的病人从入院到治好出院，治疗费用不能超过这个“上限”，否则由医院“埋单”。

Generally speaking，The 108 is a common kind of“packing”，According to the patient's age、Disease diagnosis、Complication complications、treatment、Disease severity and curative effect and so on the many kinds of factors，Into groups，Each group will be a submit an expense account“cap”。In the same group the patient from admission to hospital cure，Treatment costs no more than this“cap”，Otherwise by the hospital“Buried single”。

　　“以前按项目收费，医生容易多做检查，从而助推了‘看病贵’。现在试点按单病种限价收费，在我们医院，对抑制‘大处方’是有效的。”李春林医生所在的友谊医院，正是试点医院之一。他告诉中国青年报记者，“但我国现在的医疗合理性比较差，这种情况下，若单一地搞单病种收费，有点超前。”

“According to the project before charging，The doctor examined easier，So as to boost the‘The doctor your’。Now pilot according to single disease price charge，In our hospital，To control the‘DaChuFang’Is effective。”LiChunLin doctor in the friendship hospital，It is one of the pilot hospital。He told the China youth daily reporter，“But our country and now medical rationality is poorer，This case，If a single charge with single disease，A little advance。”

　　比如，既然定“上限”了，是否会牺牲患者的治疗效果？李春林医生所在的医院，为了“扬长避短”，采用的是DRG诊疗规范化路径管理，即把治疗一种病的标准化诊疗规范全部列出来，按标准化流程走，不能更改或省略，以保证每位病人“该做的检查、治疗项目，一个都不少”。但此举在他看来，又过于机械。

For example，Since set“cap”the，Whether you will sacrifice the therapeutic effect of patients？LiChunLin doctor in the hospital，In order to“Foster strengths and circumvent weaknesses”，The diagnosis and treatment of DRG is standardized path management，The treatment of a disease diagnosis and treatment standard the standardization of all listed，According to the standardization process go，Cannot change or omission，To ensure that each patient“The inspection、Treatment project，A lot”。But the move in his view，Too mechanical。

　　“像做汉堡包一样，两片面包中间，是先夹肉还是先夹生菜？顺序不能变。一旦变了，要在电脑上一一填写变了什么，为什么变，很繁琐，加重了医生的负担。”他的一位在北大人民医院的同行也表示，“更重要的是，看病不是这么机械化的，流程上写着第3天换药，但病人吸收很快，第2天就需要换药；流程上写着用1个注射器，结果用了两个注射器；再加上很多并发症是难以预测的，这样试图用一个框子来‘框住’花费，能适应千差万别的病人和千变万化的突发情况吗？”

“Like do hamburger，Two pieces of bread intermediate，Is first clip meat or first half cooked food？Order cannot be changed。Once changed，In the computer to fill in one changed??????，Why change，A lot，Increase the burden of the doctor。”One of his colleagues at Peking University people's hospital also said，“More important is，The doctor is not so mechanized，Process writing on the third day dressing，But the patient absorption soon，The second day need dressing；The process of writing with a syringe，The results for two syringe；Plus a lot of complications are hard to predict，So try to use a frame to‘Box live’cost，Can adapt to differ in thousands ways of patients and protean burst？”

　　此外，李春林认为，限价也不利于先进医疗技术的使用。“合理的医疗流程和机制，要用技术来承担，但设置上限后，费用不足以使用先进技术，这时医生就会采取保守治疗方案，对患者不利。”

In addition，LiChunLin think，Price also go against the use of advanced medical technology。“Reasonable medical process and mechanism，Want to use technology to bear，But after set limit，Cost is not enough to use advanced technology，Then the doctor will take the conservative treatment，Adverse to patients。”

　　他举例说，比如，肿瘤病人来了，医生首先要作科学判断，“搞清楚了再治”，但这需要一个检查过程。“如果按病种付费，医保只拨给医院1万元，在化验的过程中就花完了，那就只能直接手术。在没搞明白病情的前提下手术，是非常严重的问题。”

He said one example，For example，Tumor patient come，The doctor first will be scientific judgment，“Make sure to cure”，But this requires a check process。“If press disease to pay，Goes to the hospital medical insurance only 10000 yuan，In the process of analysis is spent，It can direct the operation。In didn't understand the illness under the premise of surgery，Is a very serious problem。”

　　李春林认为，如果从解决“看病贵”的角度评价，按病种付费的确是一个办法，但“基本医疗只解决基本问题”。“就像在餐馆里吃饭，如果说目的就是吃饱，那么，服务、营养、环境等条件是保证不了的。”

LiChunLin think，If the solution“The doctor your”Angle evaluation，Press disease to pay is really a way，but“Basic medical only solve basic problems”。“Just like in the restaurant for dinner，If the goal is to eat satisfied，so，service、nutrition、Environmental conditions is the guarantee of the。”

　　权衡以上利弊，他认为目前按病种付费还不足以完全代替按项目付费。“如果要实施这一方案并根治‘看病贵’，第一步就是全面、高水平地落实医保。”

Weigh the advantages and disadvantages above，He argues that the current press disease to pay enough to completely replace item pay。“If you want to implement the plan and effect a radical cure‘The doctor your’，The first step is comprehensive、High level to carry out medical insurance。”