Depth . . . What should I do with high-value supplies health insurance access?

Wen . . . Yang Jianlong high-value consumables are high-tech products, product replacement fast, in recent years, the annual market growth rate of related enterprises in China more than 26%, far higher than China's GDP growth rate of about 6% and the national total medical costs of 12% annual growth rate.
The market scale of high-value consumables was formed much later than the establishment time of the current national medical insurance system, which led to China's failure to establish a clear medical insurance payment policy on high-value consumables, coupled with China's high-value consumables field has not been launched suitable for medical insurance payment product generic name and consistency evaluation, resulting in many difficulties in medical insurance payment work, urgent need to be resolved and standardized.
June 8, 2020, the website of the State Health Insurance Administration published the Interim Measures for the Administration of Medical Supplies for Basic Medical Insurance (Draft for Comments), which is the first time that China has explicitly proposed from the national level to establish medical supplies-related medical insurance access and payment policies.
policies, once issued, will greatly assist the supervision of health insurance funds, but also guide the rational use of medical supplies in clinical areas, and indirectly promote industrial development.
The medical insurance characteristics of high-value consumables China's high-value consumables market formed later than the current medical insurance system molding, with cardiac intervention as the representative of the implant interventional medical materials after 2004 gradually began clinical scale applications, other types of high-value supplies after 2008 more than a large number of medical institutions.
although the development time is not long, but the market development of high-value consumables is very fast, the impact on the health insurance fund is also growing.
Take coronary intervention stents as an example, in 2000 China completed a total of 11750 cases of coronary artery interventional therapy (PCI) surgery, coronary stent market size of about 300 million yuan, because many places have not yet included it in health insurance, the impact on health insurance funds is small; Volume has been more than 910,000 cases, the market size of about 14 billion yuan, because all provinces of the country have been crown stent into health insurance, the total cost of related medical services conservatively estimated at about 50 billion yuan, according to the average payment of 75% of the local medical treatment projects, the annual payment of the crown bracket health insurance is about 37.5 billion yuan.
the entire consumables market, the annual payment of medical insurance for high-value consumables should be more than 100 billion yuan.
from the two main factors of price cost and technical performance, high-value consumables show two characteristics in health insurance payment.
first, the unit price is high, and the cost of medical treatment items accounts for a high proportion.
to a coronary drug stent as an example, the average unit price of domestic mainstream products is 7000 yuan / each, imported products are 10000 yuan / each.
data from a well-known cardiovascular hospital in Beijing show that the cost of implanting a single domestic stent-type consumables accounted for 72%, while the proportion of imported products was 76%.
reason, in addition to the relatively high unit price of consumables, the low price of medical technical services is also an important reason for the high proportion of consumption.
take catheter aortic valve implantation as an example, the cost of medical surgery is up to 9800 yuan, the unit price of interventional valve products is 250,000 yuan, the cost of the entire surgical supplies accounted for nearly 90%.
can be said that the cost of supplies determines the cost of the entire operation.
from the point of view of medical insurance cost control, the medical service items involving high-value consumables should formulate the medical insurance payment policy with supplies as the main body.
second, advanced technology, rapid market growth.
high-value consumables often represent the latest technologies in their therapeutic field and are irreplaceable.
technology, the higher the price.
without the relevant payment policies, both doctors and patients are willing to use the latest products and treatments, which also exacerbates the market growth of high-value consumables, resulting in rapid cost of health care.
The current policy of access to medical insurance for high-value consumables In June 1999, the former Ministry of Labor and Social Security, the former National Development Planning Commission, the Ministry of Finance, the former Ministry of Health and the State Administration of Traditional Chinese Medicine jointly formulated the Opinions on the Project Management of Basic Medical Insurance for Urban Workers (No. 22 of the Ministry of Labor and Social Security), making it clear that basic medical insurance treatment projects should be managed through the formulation of the scope and catalogue of basic medical insurance treatment projects, and that medical materials should be included in the medical treatment items.
The document uses exclusions to define the scope of medical treatment items that are not paid and partially paid for by the Basic Health Insurance Fund, as well as the medical equipment and medical materials that are not paid and partially paid under the relevant scope.
thus, China's medical insurance work field has formed a "drug catalog in accordance with the access law" and "diagnosis and treatment projects in accordance with the exclusion law" these two major principles of medical insurance payment management, and continue to use to this day.
use of access methods to include high-value consumables in health insurance payments is subject to one condition: the consumables can be charged separately.
the author found in the research, most parts of the country will be high-value supplies into the management of medical services, only a small number of regions (such as Shanghai) according to the type of supplies developed a separate health insurance access directory.
addition, because the supplies access catalogue is a regional policy, the contents of the catalog vary greatly from place to place, and the access situation and payment standards of the same high-value consumables vary from region to region.
Take pacemakers with defibrillator function as an example, because the product function is more advanced, relatively expensive, some areas to take the limit of the name of supplies, some areas do not pay, some economically developed areas according to the use of supplies occurred in the medical services to pay.
At present, China's high-value supplies-related medical insurance payment methods are: (1) pay by quota: according to the price of supplies set the starting line, payment limit or maximum payment limit, the product categories and origin do not make a distinction.
(2) pay in a fixed proportion: according to the price of supplies design a fixed proportion of payment, domestic and imported products pay the proportion of difference.
(3) according to different price points set different proportions of payment.
(4) shall be paid in proportion to the medical program.
, the entry and payment criteria are set according to the price of consumables, ignoring the technical performance and functional differences of consumables.
the policy of high-value supplies medical insurance access policy is not enough fairness of medical insurance treatment first of all, the same high-value supplies in different medical treatment projects of different medical treatment treatment treatment is different.
for example, a non-vascular stent produced in China can be used for both chest surgery and abdominal surgery, and some provinces and cities have chest surgery-related treatment items within the scope of medical insurance payments, while abdominal surgery is not paid for.
, the same supplies are treated differently in different regions.
Such as the market price of 15,000 yuan - 22,000 yuan or so of bile braces, mostly used in developed areas of medical institutions, Beijing and Guangzhou to its medical insurance reimbursement ratio of about 50%-80%, but Shanghai does not pay.
2 health insurance fund is inefficient in the high-value supplies according to medical service project access reimbursement, the vast majority of regions are directly proportional payment, do not distinguish between the price and performance of products.
Take the crown vein bracket as an example, a domestic mainstream bracket selling price of about 6000 yuan, the same use of imported products sold for nearly 12,000 yuan, the clinical efficacy of the two products is similar;
of course, high-value consumables are different from pharmaceuticals, not only in terms of single-use costs, but also in terms of their performance on the cost and efficacy of the entire treatment process.
Such as a company's production of cavity mirror ligation device, although the price is more than 2 times higher than ordinary products, but it can be used for early digestive tract cancer minimally invasive surgery, and even can achieve root treatment;
but the new product has not been able to get into health insurance in many places, and there is a problem of inefficient use of health insurance funds.
3 Health insurance access adjustment mechanism missing high-value supplies high-tech content, product updates fast, the vast majority of regions do not have a clear medical insurance access adjustment mechanism, even if the establishment of supplies access directory areas, there are many years of catalog no adjustment, resulting in new products, new projects can not enter health insurance, not only affect the improvement of medical technology level, but also patients can not enjoy better treatment opportunities.
4 strategic purchase of health insurance does not reflect that because there is no clear health insurance access policy, the health insurance sector as the largest funder of medical services and high-value supplies, it is difficult to play the role of strategic purchase of health insurance.
high-value consumables are mostly sensitive to the treatment of medical insurance, and medical insurance access is of great value to them.
the state's access negotiations on health insurance drugs to save a lot of health care funds, this move, if used in the field of high-value supplies, I believe that can also achieve better industry governance results.
5 lack of national health insurance catalog support author found in the research, the local health insurance departments generally call on the state should be issued as soon as possible high-value supplies of health insurance directory guidance.
lack of guidance from the national directory, many difficulties have been encountered in carrying out practical work.
high-value consumables technology is complex, a wide variety of categories, local health insurance departments can not rely on their own technical strength to its scientific classification.
Once the national version of high-value supplies medical insurance access directory issued, all places can be in accordance with the directory combined with the status of the local medical insurance fund to formulate the corresponding payment provisions, but also to achieve the catalog of supplies products to implement key monitoring and classification management, to achieve the rational use of medical insurance funds and medical technology services reasonable protection.
recommendation 1 to develop a particle-appropriate access catalog medical supplies catalog is not only the basis for the reimbursement of insured patients, but also the business tools of the management department.
suggested that the national medical insurance department to organize professional strength, according to the clinical function and technical characteristics of high-value consumables, the classification of suitable particle size of the national version of the supplies access directory.
Because of the special background of the industry, medical supplies do not have a common name, companies can independently name the product, resulting in "different names of the same name, different names of the same thing, a multi-species" phenomenon, to the same function, used to treat coronary blockage of the Repamycin drug stent as an example, the companies have six or seven similar products of different names.
name confusion led the relevant departments can not according to the name of the product approval to market to form a health insurance supplies catalog, according to the actual clinical use of re-sorting and the development of the catalog.
Need to emphasize that the name design of the supplies catalog should not be too broad, to almost all vascular intervention surgery to use the stent as an example, for nerve intervention stent price or can be as high as 100,000 yuan, for the heart intervention stent minimum pricing in about 3000 yuan, in the development of the catalog only "bracket" as the catalog name, it is difficult to carry out effective health insurance payment and fund management, fairness is not reflected.
the category and name formulation of the catalogue is the basic guarantee to ensure the smooth development of the medical insurance payment business and the rational use of the fund, and the category granularity should not only facilitate the operation of medical insurance payment, but also not design too many items to increase the difficulty of the work.
2 The use of health economics to set payment standards in addition to the development of health insurance payment principles, can reflect the special value of supplies access directory, the relevant departments should also establish a database of enterprise products corresponding to the catalog, to ensure that the overall area according to the use of local funds and clinical practice to determine the catalog of various types of products payment methods and specific payment standards.
Notably, the choice of consumables can affect the cost of treatment as a whole and the long-term cost of treatment for patients, so the health insurance department should consider the total cost of health care for patients when determining the criteria for payment, not just the price of supplies."
experience has proved that the standard of medical insurance payment for high-value consumables should be determined on the basis of market mechanism, and the system of health economics evaluation index of high-value consumables should be gradually established in the light of the access catalogue.
In addition, in order to do a good job in the fine management of medical insurance treatment, to achieve a comprehensive national high-value supplies of medical insurance payment data for comprehensive statistics, analysis and key monitoring, it is recommended that the National Health Insurance Administration is responsible for the formulation of a unified national high-value supplies medical insurance access directory and dynamic adjustment.
3 To play the strategic purchasing role of medical insurance suggested that according to the characteristics of high-value consumables industry, the National Health Insurance Administration led by some key products to take a centralized volume procurement or access negotiations to guide their prices back to reasonable, and form a reasonable payment standard, in order to give full play to the strategic purchase role of health insurance, with limited medical insurance funds for patients to strive for the best medical technology security effect, to maximize the efficiency of the use of health insurance funds.
4 as soon as possible to achieve clear responsibilities of the graded management recommendations in the introduction of the relevant access directory at the same time, as soon as possible the introduction of "high-value supplies medical insurance access management measures", so that all levels of health insurance departments to achieve law-based, rule-based, clear management.
At the national level, it is mainly responsible for the development of access catalogues, while ensuring the unification of the names and catalogues of supplies in the national health insurance system, to achieve statistical analysis and treatment comparison of medical insurance-related data, and the provincial health insurance departments are mainly responsible for determining the payment methods and payment standards for various local products, and should also implement the transfer and transfer of high-value supplies medical insurance access catalogues.
Only by achieving a truly clear grading management of authority and responsibility, it is possible to make the high-value consumables catalog update speed and product upgrade speed to match, in the protection of patient rights and interests, improve the efficiency of the use of funds at the same time, promote the healthy development of the industry.
the original title: China's high-value medical supplies medical insurance access management inquiry.