How Outpatient Coordination Changes the Medical Market

With the official implementation of the overall support for outpatient clinics, several important changes will occur in the medical market: medical service institutions, especially urban community medical services, will receive a significant increase in drugs, retail pharmacies will become increasingly differentiated, and outpatient services will accept more hospitalization flows.

In April 2021, the General Office of the State Council "Guiding Opinions on Establishing and Improving the Employee Basic Medical Insurance Outpatient Mutual Aid Guarantee Mechanism" (hereinafter referred to as the "Opinions") was officially released.

The "Opinions" clarified that the overall planning of outpatient clinics starts with chronic diseases and gradually expands to other types of diseases that have a large cost burden.

Although the "Opinions" "include the medication protection services provided by qualified designated retail pharmacies into the scope of outpatient protection, support the settlement and dispensing of external prescriptions in designated retail pharmacies, and give full play to the convenience and accessibility of designated retail pharmacies", it supports After all, it is far from being mandatory.

As for "exploring to include eligible'Internet +'medical services in the scope of coverage", since the medical insurance limit is all offline medical institutions, outpatient coordination only includes hospital-based online services, and patients and services are all centered within the hospital.

However, the overall funds for outpatient clinics need to be obtained from individual accounts, so the scale of individual accounts will be significantly reduced, and the scope of application will also increase or decrease, which will have a greater impact on the market.

"Incumbent employees' personal accounts are included in the basic medical insurance premiums paid by individuals, and the accounting standard is in principle controlled at 2% of the insurance payment base, and all basic medical insurance premiums paid by the unit are included in the overall planning fund; the principle of individual accounts for retirees The above is allocated by the overall planning fund according to the fixed amount, and the allocated amount is gradually adjusted to about 2% of the average level of the basic pension in the year when the reform is implemented in the overall planning area according to this opinion.

It is clear here that the medical insurance funds paid by the unit will no longer be credited to the individual account, which will reduce about half of the individual account fund injection.

"Personal accounts are mainly used to pay for out-of-pocket expenses incurred by insured persons in designated medical institutions or designated retail pharmacies.

Here it is clear that the scope of application of individual accounts has increased or decreased.

From the "Opinions", the core is to strengthen the mutual aid function of medical insurance, which will be launched from two aspects of financing and medical security.

From the perspective of the impact on the market, first of all, the overall planning of outpatient clinics clearly benefits medical institutions.

According to the statistical bulletin of the Health Commission, the proportion of outpatient visits in primary medical institutions continues to shrink.

From 2013 to 2019, the income structure of community health centers (only centers, excluding stations) changed little.

The income of township hospitals is heavily dependent on subsidies.

With the unfolding of outpatient coordination, more users will flow into hospitals and primary medical institutions.

Second, the overall planning of outpatient clinics will have an impact on the pharmaceutical retail market, and the market structure will be further differentiated.

According to the 2019 Statistical Bulletin issued by the National Medical Insurance Administration, personal accounts spent 202.
9 billion yuan in pharmacies.
In 2019, drug sales in retail pharmacies were 400.
8 billion yuan, which means that 50.
6% of drug sales revenue in retail channels comes from medical insurance.
Once the medical insurance account is reduced, the mid- to long-term drug revenue of retail pharmacies will face a decline.

Of course, the drugs coordinated by outpatient clinics are also open to pharmacies, but a prescription circulation and supervision system needs to be established.
More importantly, the economic motivation of doctors must no longer be affected by drugs.
Otherwise, prescription outflow will still be difficult.
Although some pharmacies can obtain the medical insurance coverage for outpatient clinics, it is certain that hospitals with strong interest relationships with the hospital will receive More.
Therefore, the entire pharmaceutical retail market will be divided into hospital-side stores and other retail stores that have a clear interest connection with hospitals.
The hospital side shop mainly undertakes some high-value consumables and medicines.
Although the revenue of the courtyard shop will be higher, the gross profit will be lower because the interests of the courtyard must be guaranteed, and it is difficult to make a profit.
Other retail pharmacies mainly sell high-margin health products and OTC drugs.
Although single-store revenue is not high, they can maintain a net profit of about 5%.

With the acceleration of the chain of pharmacies, in the process of this market transformation, hospital-side stores will continue to grow, but competition will also become fierce, mainly dependent on the relationships and interests of the hospital.
After the growth reaches a certain level, the market will undergo a significant adjustment.
Due to the reduction of medical insurance accounts and the suppression of fraudulent insurance, other retail pharmacies will increasingly reduce their reliance on medical insurance and develop in the direction of general health.
This will test the pharmacy's product selection and sales ability.

Finally, from the perspective of the impact of the implementation of DRG, in order to meet the requirements of packaged payment, hospitals have the need to transfer hospitalization expenses to outpatient clinics.
If outpatient overall planning is not implemented, patients can only use limited individual account funds, and the amount of out-of-pocket expenses will greatly increase.
It is not conducive to the burden of patients.

After the implementation of DRG, due to the packaged payment of a single medical record, stripping non-surgical items from hospitalization is the main operating method of the hospital.
Whether it is the integrated medical care (integration of outpatient and inpatient) launched by Germany, or the increase in outpatient development by hospitals in Taiwan, it is for more convenient transfer of peelable inpatient items to the inpatient clinic.
However, in order to prevent these incomes from being obtained by other medical institutions, all hospitals are increasing the development of outpatient services.
If you look at the U.
S.
market, it is the same trend.
Once the payer increases the supervision of hospitalization, the hospital will expand the scale of acquisition of primary clinics to ensure that its total income does not decline.

Therefore, with the development of medical consortium and medical community, hospitalization expenses will be transferred to outpatient clinics, mainly into the hospital's own outpatient clinics, while after hospital management and services, some outpatient clinics will be transferred to the grassroots under their own control.
Medical institutions will also drive the development of primary medical service institutions to a certain extent.

With the final implementation of outpatient coordination, the market structure will undergo significant adjustments.
First, large hospitals and urban community medical institutions will see a significant increase in volume.
Second, retail pharmacies are facing overall disadvantages, but the growth of hospital-side stores will gradually become fierce, triggering a market reshuffle, while other retail pharmacies are facing the compression of medical insurance and seek to develop into large-scale health products.
Pharmacies are more interested in healthy fast-moving consumer products.
Sales ability will determine its market development prospects.
Third, the increase in transfer from hospitalization to outpatient clinics is mainly obtained from outpatient clinics in large hospitals, and part of it will be allocated to primary medical institutions.