Health insurance payment price formation mechanism clear medical supplies market adjustment speed will be accelerated
Last Update: 2020-06-16
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Following the april 28 release of the Interim Measures for the Administration of Drug Use in Basic Medical Insurance (Draft for Comments), on June 8, 2020, the State Medical Insurance Administration issued the Interim Measures for the Administration of Medical Supplies for Basic Medical Insurance (the "Measures")"Measures" on the medical insurance medical supplies catalog and medical supplies medical insurance payment standardadjustment path gives detailed guidance, clear and similar to several principles: the establishment of a unified national "basic medical insurance medical supplies catalog", to negotiate and collect for the standard of medical insurance payment mechanism, the same category, similar functions of the medical supplies of the lowest selection price to determine the price of medical insurance paymentThe Measures clarify the implementation of access management of medical supplies, regular updates and dynamic adjustment, "comprehensive consideration of medical supplies functional role, clinical value, cost level, medical insurance fund affordability and other factors." This means that in catalog management, the four factors will be the core of the trade-off, of which clinical value and health insurance fund affordability as the key to the trade-off, ideally the two will get a dynamic balanceOn the basic principles, it emphasizes that "based on the full life cycle cost of medical supplies, highlighting clinical value, on the basis of strengthening safety, effectiveness and economic assessment, in accordance with the functional positioning of basic medical insurance, gradually clarify the standard of medical insurance payment." In the establishment of medical insurance payment price is also adhering to the clinical value of the premise to do a comprehensive assessment, according to the functional positioning of health insurance to determineThe affordability of health insurance remains key to the assessment, but the full life cycle cost is also emphasized, meaning it will be tilted towards exclusive varietiesIn the determination of the catalog, in addition to the specific section is not currently included in the medical supplies catalog, but also stressed the scope of direct transfer out of the catalog, which is worth noting: "considering safety, clinical value, economic and other factors, assessed risk is greater than the benefits." This means that if the clinical value of medical supplies is not prominent, safety problems, or too expensive, there is a possibility of being includedUnder the health insurance treatment list system, introduced in 2019, not only will the drug catalog be unified across the country, but medical supplies will follow suitIn the medical supplies catalog after the national unification, supplies coding and use will also be unified throughout the countryBased on the three uniform ities of cataloguing, coding and use, recruitment and the use of medical institutions will also be easier to regulate, changing the regulatory dilemmas caused by the lack of uniformity in the pastIn the standard of medical insurance payment, the Measures give a clear principle: exclusive access through negotiation, non-exclusive access through collectionArticle 21 The determination and adjustment of the standard of payment for medical insurance shall, in principle, determine the first medical insurance payment standard through negotiation for the exclusive productIf the negotiation is successful, the health insurance department shall pay according to the payment standards established by the negotiation agreementUnsuccessful negotiations, not included in the scope of health insurance payments, have been included in the list to be transferred outNegotiating rules for medical supplies will be developed separatelyFor non-exclusive products, payment criteria are determined and adjusted in principle through centralized procurementThe provincial medical security administrative departments shall, in accordance with the results of the purchase of the provinces, alliances and provinces (autonomous regions and municipalities directly under the Central Government), determine the standard of medical insurance payment for the province (autonomous regions and municipalities directly under the Central Government) at the lowest winning price for medical supplies with the same category and similar functionsFor medical supplies that are not included in the scope of the volume purchase, the payment standards shall be determined by the provinces (autonomous regions and municipalities directly under the Central Government) according to the calculation method of the payment standard in the catalogue The rules for determining the standard of payment for medical supplies medical insurance shall be formulated separately It is worth noting that for exclusive varieties, if the negotiations are not successful, it is directly transferred out of the catalog, even if the original in the catalog to be transferred out, which will be very important pressure on consumables manufacturers Unlike non-exclusive varieties, even if not in the collection of winning bid, you can also accept the cost of medical insurance under the premise of medical insurance compensation, exclusive varieties negotiations are not successful can only be out As the price of medical insurance will also be determined by collection price, but because consumables are different from generic drugs, there is no consistency evaluation, the Measures emphasize the same category and similar functions, but ultimately how to determine how to wait for medical supplies to pay the standard of the rules In addition, the Measures "support all areas of the catalog of medical supplies into the scope of packaged payment by disease, according to disease diagnosis-related group payment." With the introduction of DRG reform, supplies is one of the main expenses of hospitalization, through collection and negotiation into the consumables catalog of medical supplies price is lower, in the packaging and payment, if the hospital choose collection and negotiation supplies easier to meet the demand for compensation, but also help to pay the implementation of the reform If combined with Article 16, "targeted medical institutions should be given priority with the use of "basic medical insurance medical supplies catalog" medical supplies and medical insurance department organizations in the centralized volume of procurement of medical supplies", medical supplies reform and drug reform is more similar, compact hospital use is the key Finally, the regulation of medical institutions, doctors and businesses will be strengthened Among them, the supervision of medical institutions will not only strengthen the use and payment of consumables, but also extend to the front end, requiring hospitals to regularly submit data on the purchase and sale, hospitals will face a comprehensive data review, to circumvent the difficulty of supervision And enterprises will establish and pharmaceutical companies similar to the integrity system, the breach of trust enterprises will be punished It is worth emphasizing here that the Measures mention that "the right to informed consent of insured persons shall be guaranteed by the use of medical supplies or medical supplies in the non-medical insurance catalogue at a price higher than the standard of payment" With the reform of DRG and the decline in the price of medical supplies, hospitals and doctors have the incentive to induce patients to use higher-yielding self-funded supplies, how to regulate the use of self-funded supplies will be the future between health care and medical institutions between the continuous game of one of the main areas Overall, the payment reform of medical supplies is about to start, the basic path is consistent with the drug, but due to the lack of consistency evaluation of consumables, the development and push of standards will take up a certain amount of time, push away the speed is relatively slow However, with some provinces of the collection of pilot and national supplies collection is about to start, supplies payment system reform will bring a greater impact on the relevant enterprises, how to establish an effective coping strategy and promote their own transformation will be the key to enterprise development.
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