How to coordinate the reform of medical insurance payment methods and payment standards?

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The medical insurance payment standard is the settlement standard for the compensation paid by the medical insurance fund when the insured uses the drugs or medical consumables in the medical insurance catalog, and it is also the bargaining standard for the purchase of drugs and medical consumables by hospital pharmacies or social pharmacies.

Beginning with the introduction of medical insurance payment standards in the first medical insurance access negotiations in 2017, my country’s medical insurance management departments have successively introduced medical insurance payment standard policies for negotiated drugs, centralized procurement of drugs, and "two diseases" (diabetes, hypertension) drugs.

This shows that after nearly five years of exploration and development, the payment standards for medicines and medical consumables in my country are no longer just at the theoretical level, but gradually incorporated into the medical insurance management practice system, and are inseparable from the public's daily medical medication behavior.

At the same time, the national level issued the "Guiding Opinions on Further Deepening the Reform of Basic Medical Insurance Payment Methods", "The Opinions of the Central Committee of the Communist Party of China and the State Council on Deepening the Reform of the Medical Security System" (hereinafter referred to as "Deepening Medical Insurance Reform") and other documents to vigorously promote the A payment-based medical insurance payment method reform.

Under the background of the country's comprehensive promotion of the DRG/DIP payment method reform, what is the institutional value of the medical insurance payment standard? How to coordinate the advancement of medical insurance payment standards and DRG/DIP payment to achieve orderly control of medical insurance costs? This article discusses for reference.

The medical insurance payment standard is the settlement standard for the compensation paid by the medical insurance fund when the insured uses the drugs or medical consumables in the medical insurance catalog, and it is also the bargaining standard for the purchase of drugs and medical consumables by hospital pharmacies or social pharmacies.

At the same time, the national level issued the "Guiding Opinions on Further Deepening the Reform of Basic Medical Insurance Payment Methods", "The Opinions of the Central Committee of the Communist Party of China and the State Council on Deepening the Reform of the Medical Security System" (hereinafter referred to as "Deepening Medical Insurance Reform") and other documents to vigorously promote the A payment-based medical insurance payment method reform.

Under the background of the country's comprehensive promotion of the DRG/DIP payment method reform, what is the institutional value of the medical insurance payment standard? How to coordinate the advancement of medical insurance payment standards and DRG/DIP payment to achieve orderly control of medical insurance costs? This article discusses for reference.

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Payment level: Classified settlement

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Payment level: Classified settlement

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Payment level: Classified settlement

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Payment level: Classified settlement

Payment level: Classified settlement

Payment level: Classified settlementus" style="margin:0px;padding:0px;max-width:100%;box-sizing:border-box;overflow-wrap:break-word ;">7) 30%, rgba(224, 224, 224, 0) 100%);height:1px;">7) 30%, rgba(224, 224, 224, 0) 100%);height:1px;">us" style='margin:0px;padding:0px;max-width:100%;box-sizing:border-box;color:#333333;font-family:-apple-system, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif;font-size:16px;letter-spacing:0.
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Figure 1 Schematic diagram of classified settlement

In essence, DRG/DIP payment and medical insurance payment standards are all budget-based payment methods, that is, medical insurance compensation settlement standards are established based on past medical practice data.
However, the two are applicable to different treatment types and product types, and the efficiency of cost control is improved through classification and settlement (see Figure 1).

Figure 1 Schematic diagram of classified settlement

Figure 1 Schematic diagram of classified settlement

In essence, DRG/DIP payment and medical insurance payment standards are all budget-based payment methods, that is, medical insurance compensation settlement standards are established based on past medical practice data.
However, the two are applicable to different treatment types and product types, and the efficiency of cost control is improved through classification and settlement (see Figure 1).

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Different types of treatment: outpatient services are settled according to the payment standard, and hospitalizations are settled according to the type of disease.

Different types of treatment: outpatient services are settled according to the payment standard, and hospitalizations are settled according to the type of disease.

Different types of treatment: outpatient services are settled according to the payment standard, and hospitalizations are settled according to the type of disease.

Different types of treatment: outpatient services are settled according to the payment standard, and hospitalizations are settled according to the type of disease.

Different types of treatment: outpatient services are settled according to the payment standard, and hospitalizations are settled according to the type of disease.
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Judging from the experience of global medical insurance compensation settlement, the medical insurance payment standard is mainly used for the settlement of outpatient expenses.
The DRG/DIP payment is mainly applicable to the package settlement of hospitalization expenses including drug costs, thus forming a classification settlement pattern of "payment for hospitalization according to disease type and settlement for outpatient service according to payment standards".

The reason for this is that the cost of medicines for outpatients and inpatients is settled by classification, because different types of treatment have different levels of complexity and require different settlement mechanisms for targeted control of fees.

1.
Outpatient medication is settled according to the medical insurance payment standard, which exceeds the burden of some patients.
For outpatient medication, the cause and the generic name of the therapeutic drug have been clarified through the doctor’s diagnosis and prescription in advance.
Therefore, patients have a certain degree of independent judgment and choice in the choice and use of drug brand names.
At this time, the settlement through the medical insurance payment standard can guide the rational use of drugs and realize cost control through the substitution of generic drugs.

Figure 2 Schematic diagram of the standard settlement method of medical insurance payment

As shown in Figure 2, the global mainstream settlement model for the medical insurance payment standard is: when a patient chooses an original drug with a price higher than the medical insurance payment standard, the medical insurance is settled according to the payment standard, and the higher part is borne by the patient, thereby guiding the patient to use the drug rationally.
When a patient chooses a generic drug whose price is lower than the medical insurance payment standard, the patient will be settled at the retail (purchase) price of the generic drug, but medical insurance will still be settled with the pharmacy according to the payment standard.
The balance between the retail price (purchase price) and the payment standard belongs to the pharmacy.
This incentivizes pharmacies to actively control fees.

The policy basis for achieving the above-mentioned system objectives is: first, formulate payment standards based on common names, that is, "one common name, one payment standard"; second, promote generic drug substitution policies, such as encouraging generic name prescriptions and priority dispensing order for generic drugs Wait.

In 2019, the proportion of outpatient and inpatient drug costs in public hospitals in my country was about 44.
3% and 55.
7% (source: "China Health Statistics Yearbook 2020").
Outpatient services are lower than hospitalizations, and a large amount of drug billing occurs at the outpatient end, which can be seen in medical insurance.
Payment standards play an important role in medical insurance settlement.
Article 26 of Order No.
1 stipulates that “the payment standard is the basis for the basic medical insurance fund to pay for the drugs when the basic medical insurance participants use the drugs in the "Drug List".
" It can be seen that the settlement system has basically been in line with international rules.
However, in order to achieve the policy goal of guiding the rational use of drugs through medical insurance payment standards, it is necessary to gradually advance the process of formulating payment standards based on generic names in accordance with the progress of my country's generic drug consistency evaluation, and increase the pace of reform of generic drug substitution policies.

2.
The types of hospitalization are packaged and settled according to the type of disease, which exceeds the burden of some hospitals.
Inpatient diagnosis and treatment are usually complicated, involving various inspections, treatments, medicines, and medical consumables.
The degree of medical specialization is high.
There is a serious information asymmetry between doctors and patients, and patients cannot judge their condition, decide on treatment mode, and choose treatment by themselves.
Types of medicines and consumables in the process.
Therefore, it is necessary to start with guiding the diagnosis and treatment behavior of medical institutions, and to encourage medical institutions to actively control medical costs through the packaged payment according to the type of disease, so as to achieve the goal of cost control.

As shown in Figure 3, under the payment method of disease-based payment, the medical insurance fund settles with the medical institution in accordance with the established payment standard.
The actual medical expenses exceeding the payment standard are borne by the medical institution, and the lower part is retained as the balance of the medical institution.
This can effectively encourage medical institutions to actively control expenditures, rationally use medical resources, and optimize clinical pathways.

As for the insured patients, the actual expenses and payment policies (deductible line, reimbursement ratio, cap line, etc.
) are determined in accordance with the actual expenses incurred for medicines, medical consumables, and diagnosis and treatment services, and they are settled on a project basis.
For example, for 18 public medical institutions in Anhui Province, the payment standard for cataract surgical treatment (unilateral) is 6,500 yuan, and the medical insurance reimbursement ratio for urban and rural residents is 40%, and the medical insurance payment quota is 2,600 yuan; urban and rural residents are based on the self-pay ratio 60 % And the actual expenses incurred to calculate the personal borne expenses.

Therefore, under the packaged payment by disease type, the cost control effect mainly depends on the medical institution, and medicines and medical consumables no longer become the source of profit for the medical institution, but the cost part.

Judging from the experience of global medical insurance compensation settlement, the medical insurance payment standard is mainly used for the settlement of outpatient expenses.
The DRG/DIP payment is mainly applicable to the package settlement of hospitalization expenses including drug costs, thus forming a classification settlement pattern of "payment for hospitalization according to disease type and settlement for outpatient service according to payment standards".

The reason for this is that the cost of medicines for outpatients and inpatients is settled by classification, because different types of treatment have different levels of complexity and require different settlement mechanisms for targeted control of fees.

1.
Outpatient medication is settled according to the medical insurance payment standard, which exceeds the burden of some patients.
For outpatient medication, the cause and the generic name of the therapeutic drug have been clarified through the doctor’s diagnosis and prescription in advance.
Therefore, patients have a certain degree of independent judgment and choice in the choice and use of drug brand names.
At this time, the settlement through the medical insurance payment standard can guide the rational use of drugs and realize cost control through the substitution of generic drugs.

1.
Outpatient medication is settled according to the medical insurance payment standard, which exceeds the burden of some patients.
1.
Outpatient medication is settled according to the medical insurance payment standard, which exceeds the burden of some patients.

Figure 2 Schematic diagram of the standard settlement method of medical insurance payment

Figure 2 Schematic diagram of the standard settlement method of medical insurance payment

As shown in Figure 2, the global mainstream settlement model for the medical insurance payment standard is: when a patient chooses an original drug with a price higher than the medical insurance payment standard, the medical insurance is settled according to the payment standard, and the higher part is borne by the patient, thereby guiding the patient to use the drug rationally.
When a patient chooses a generic drug whose price is lower than the medical insurance payment standard, the patient will be settled at the retail (purchase) price of the generic drug, but medical insurance will still be settled with the pharmacy according to the payment standard.
The balance between the retail price (purchase price) and the payment standard belongs to the pharmacy.
This incentivizes pharmacies to actively control fees.

The policy basis for achieving the above-mentioned system objectives is: first, formulate payment standards based on common names, that is, "one common name, one payment standard"; second, promote generic drug substitution policies, such as encouraging generic name prescriptions and priority dispensing order for generic drugs Wait.

In 2019, the proportion of outpatient and inpatient drug costs in public hospitals in my country was about 44.
3% and 55.
7% (source: "China Health Statistics Yearbook 2020").
Outpatient services are lower than hospitalizations, and a large amount of drug billing occurs at the outpatient end, which can be seen in medical insurance.
Payment standards play an important role in medical insurance settlement.
Article 26 of Order No.
1 stipulates that “the payment standard is the basis for the basic medical insurance fund to pay for the drugs when the basic medical insurance participants use the drugs in the "Drug List".
" It can be seen that the settlement system has basically been in line with international rules.
However, in order to achieve the policy goal of guiding the rational use of drugs through medical insurance payment standards, it is necessary to gradually advance the process of formulating payment standards based on generic names in accordance with the progress of my country's generic drug consistency evaluation, and increase the pace of reform of generic drug substitution policies.

2.
The types of hospitalization are packaged and settled according to the type of disease, which exceeds the burden of some hospitals.
Inpatient diagnosis and treatment are usually complicated, involving various inspections, treatments, medicines, and medical consumables.
The degree of medical specialization is high.
There is a serious information asymmetry between doctors and patients, and patients cannot judge their condition, decide on treatment mode, and choose treatment by themselves.
Types of medicines and consumables in the process.
Therefore, it is necessary to start with guiding the diagnosis and treatment behavior of medical institutions, and to encourage medical institutions to actively control medical costs through the packaged payment according to the type of disease, so as to achieve the goal of cost control.

2.
The types of hospitalization are packaged and settled according to the type of disease, which exceeds the burden of some hospitals.
2.
The types of hospitalization are packaged and settled according to the type of disease, which exceeds the burden of some hospitals.

As shown in Figure 3, under the payment method of disease-based payment, the medical insurance fund settles with the medical institution in accordance with the established payment standard.
The actual medical expenses exceeding the payment standard are borne by the medical institution, and the lower part is retained as the balance of the medical institution.
This can effectively encourage medical institutions to actively control expenditures, rationally use medical resources, and optimize clinical pathways.

As for the insured patients, the actual expenses and payment policies (deductible line, reimbursement ratio, cap line, etc.
) are determined in accordance with the actual expenses incurred for medicines, medical consumables, and diagnosis and treatment services, and they are settled on a project basis.
For example, for 18 public medical institutions in Anhui Province, the payment standard for cataract surgical treatment (unilateral) is 6,500 yuan, and the medical insurance reimbursement ratio for urban and rural residents is 40%, and the medical insurance payment quota is 2,600 yuan; urban and rural residents are based on the self-pay ratio 60 % And the actual expenses incurred to calculate the personal borne expenses.

Therefore, under the packaged payment by disease type, the cost control effect mainly depends on the medical institution, and medicines and medical consumables no longer become the source of profit for the medical institution, but the cost part.

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Different product types: conventional varieties are packaged and settled according to disease types, and high-value innovative varieties are settled according to payment standards

Different product types: conventional varieties are packaged and settled according to disease types, and high-value innovative varieties are settled according to payment standards

Different product types: conventional varieties are packaged and settled according to disease types, and high-value innovative varieties are settled according to payment standards

Different product types: conventional varieties are packaged and settled according to disease types, and high-value innovative varieties are settled according to payment standards

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From the foregoing analysis, it can be seen that DRG/DIP payment is mainly applicable to the settlement of hospitalization expenses, but not all hospitalization items can be included in its payment scope.
For some special high-value innovative products, medical insurance payment standards still need to be adopted as the settlement basis.
The reasons are as follows:

1.
The high cost of high-value innovative products affects the grouping.
Since the DRG/DIP payment method is mainly based on historical costs or clinical pathways to estimate payment benchmarks, some drugs and medical consumables that have a short time to market, high treatment costs, and immature clinical use, especially those in clinical use or among the same varieties For varieties with large price differences, there may be a large gap in the final diagnosis and treatment costs, which makes it difficult to be included in the scope of disease payment or increase disease groupings.

The "National Medical Security Disease Diagnosis Related Grouping (CHS-DRG) Grouping and Payment Technical Specifications" clarified that the grouping is mainly based on the resource consumption of cases, and hospitalization expenses or length of stay are usually used as measurement indicators.
Each pilot area formulates the final DRG grouping plan according to the actual situation.
When grouping, the difference in hospitalization expenses within the same disease group is required to be small (the coefficient of variation CV is less than 1).
If the difference is large (CV is greater than or equal to 1), it should be affected according to the cost.
The factors continue to be broken down.
Therefore, for high-value innovative products, the cost of diagnosis and treatment may affect the coefficient of difference of the same disease group, which in turn affects the scientific nature of disease grouping.

For example, in Beijing’s DRG disease, the payment basis for "bronchitis and asthma with comorbidities and concomitant diseases" is 8714 yuan, while the annual treatment cost of omalizumab, a negotiated drug for the treatment of asthma, is 28,120 yuan (the price of the drug is determined by Beijing Pharmaceuticals).
According to the inquiry from Sunshine Purchasing Network, it is calculated based on the treatment course of 2.
5 per capita/month for 8 months).
There is a big gap between the cost of medicine and the payment standard of the disease, which is difficult to be directly included in the scope of payment.

2.
Affect the enthusiasm of medical institutions to use.
On the one hand, the payment standard of disease-based payment is based on past data, and the cost of high-value innovative products is not taken into account; Actively controlling the cost of treatment in order to obtain profits below the payment standard has caused doctors to be reluctant to use high-value drugs or consumables, thereby inhibiting the use of innovative products.

Therefore, in order to solve the problem of the use of this part of high-value innovative products and increase the enthusiasm of medical institutions to use them, separate settlements can be adopted by formulating separate payment standards.
Taking Germany as an example, in order to reduce unnecessary groupings in DRG, Germany has set up an additional fee ZE (Zusatzentgelt) as a supplementary payment method, and separately established payment standards for the included drugs and medical consumables as the reimbursement basis.

In addition, some places in my country (such as Sanming City) also adopt separate payment methods for high-value innovative products and exclude them from the scope of disease-based payment (see Table 1).

From the foregoing analysis, it can be seen that DRG/DIP payment is mainly applicable to the settlement of hospitalization expenses, but not all hospitalization items can be included in its payment scope.
For some special high-value innovative products, medical insurance payment standards still need to be adopted as the settlement basis.
The reasons are as follows:

1.
The high cost of high-value innovative products affects the grouping.
Since the DRG/DIP payment method is mainly based on historical costs or clinical pathways to estimate payment benchmarks, some drugs and medical consumables that have a short time to market, high treatment costs, and immature clinical use, especially those in clinical use or among the same varieties For varieties with large price differences, there may be a large gap in the final diagnosis and treatment costs, which makes it difficult to be included in the scope of disease payment or increase disease groupings.

1.
The high cost of high-value innovative products affects the grouping.
1.
The high cost of high-value innovative products affects the grouping.

The "National Medical Security Disease Diagnosis Related Grouping (CHS-DRG) Grouping and Payment Technical Specifications" clarified that the grouping is mainly based on the resource consumption of cases, and hospitalization expenses or length of stay are usually used as measurement indicators.
Each pilot area formulates the final DRG grouping plan according to the actual situation.
When grouping, the difference in hospitalization expenses within the same disease group is required to be small (the coefficient of variation CV is less than 1).
If the difference is large (CV is greater than or equal to 1), it should be affected according to the cost.
The factors continue to be broken down.
Therefore, for high-value innovative products, the cost of diagnosis and treatment may affect the coefficient of difference of the same disease group, which in turn affects the scientific nature of disease grouping.

For example, in Beijing’s DRG disease, the payment basis for "bronchitis and asthma with comorbidities and concomitant diseases" is 8714 yuan, while the annual treatment cost of omalizumab, a negotiated drug for the treatment of asthma, is 28,120 yuan (the price of the drug is determined by Beijing Pharmaceuticals).
According to the inquiry from Sunshine Purchasing Network, it is calculated based on the treatment course of 2.
5 per capita/month for 8 months).
There is a big gap between the cost of medicine and the payment standard of the disease, which is difficult to be directly included in the scope of payment.

2.
Affect the enthusiasm of medical institutions to use.
On the one hand, the payment standard of disease-based payment is based on past data, and the cost of high-value innovative products is not taken into account; Actively controlling the cost of treatment in order to obtain profits below the payment standard has caused doctors to be reluctant to use high-value drugs or consumables, thereby inhibiting the use of innovative products.

2.
Affect the enthusiasm of medical institutions to use.
2.
Affect the enthusiasm of medical institutions to use.

Therefore, in order to solve the problem of the use of this part of high-value innovative products and increase the enthusiasm of medical institutions to use them, separate settlements can be adopted by formulating separate payment standards.
Taking Germany as an example, in order to reduce unnecessary groupings in DRG, Germany has set up an additional fee ZE (Zusatzentgelt) as a supplementary payment method, and separately established payment standards for the included drugs and medical consumables as the reimbursement basis.

In addition, some places in my country (such as Sanming City) also adopt separate payment methods for high-value innovative products and exclude them from the scope of disease-based payment (see Table 1).

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Procurement level: coordinated cost control

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Procurement level: coordinated cost control

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Procurement level: coordinated cost control

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Procurement level: coordinated cost control

Procurement level: coordinated cost control

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Fully implement DRG/DIP payment, and strengthen the effect of centralized procurement policies through the demand-side active fee control model

Fully implement DRG/DIP payment, and strengthen the effect of centralized procurement policies through the demand-side active fee control model

Fully implement DRG/DIP payment, and strengthen the effect of centralized procurement policies through the demand-side active fee control model

Fully implement DRG/DIP payment, and strengthen the effect of centralized procurement policies through the demand-side active fee control model

Fully implement DRG/DIP payment, and strengthen the effect of centralized procurement policies through the demand-side active fee control modelus" style='margin:0px;padding:0px;max-width:100%;box-sizing:border-box;color:#333333;font-family:-apple-system, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif;font-size:16px;letter-spacing:0.
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Centralized procurement is linked to volume and price, and supply companies bid in the same group, thereby controlling the price of pharmaceutical procurement and medical consumables in public hospitals, and realizing medical insurance control costs, which is a typical supplier control mode.
In 2018, after the establishment of the National Medical Insurance Administration, four rounds of national centralized procurement of drugs and one round of coronary stents were successively carried out.
As of 2020, the overall cost savings have exceeded 100 billion yuan, and significant results have been achieved in squeezing the falsely high prices of medicines and medical consumables and reducing the burden on patients.

International experience shows that in centralized procurement, only a single supplier passively controls costs, and there may be certain market risks.
First, the demand side is passive, which affects the cost control effect.
Due to the implementation of "quantity-for-price, volume-price linkage" in centralized procurement, the demander (public medical institution) loses the right to choose the product brand, which will easily lead to weaker initiative to use the selected product in the later period, and it needs to pass the quantity supervision and medical insurance.
The mandatory advancement of administrative intervention measures such as interviews and performance appraisal will not only cause high administrative costs, but also easily lead to the "double price increase" of drugs with the same indication and different generic names that are not included in the centralized procurement, thereby weakening the cost control effect of centralized procurement .
The second is that the supplier is passive and there is a supply risk.
In the existing centralized procurement bidding model, there is no market game behavior of multiple rounds of bargaining between the supplier and the demander.
The supplier (supplier) has only one opportunity to quote, but faces two choices of winning or losing the entire centralized procurement market.
It is easy to report The non-economic rational low price close to the cost price results in less room for the supplier to cope with cost changes, which in turn leads to problems such as supply shortages.

In January 2021, the General Office of the State Council issued the "Opinions on Promoting the Normalized and Institutionalized Development of Centralized and Volume Procurement of Drugs" (hereinafter referred to as the "Regularized Opinions on Centralized Procurement"), and centralized procurement will enter the normalized implementation stage.
In order to adhere to the two basic principles of the "Opinions on the Normalization of Centralized Procurement", namely "adhere to demand-oriented" and "adhere to market-oriented" and solve the passive control mode of a single supplier, the following two measures are recommended:

Figure 4 Two-way collaborative fee control mode of supply and demand

One is to achieve two-way fee control.
Judging from international experience, most countries such as the United States, Canada, and Japan adopt a demand-side fee control model, that is, starting from the payment side, stimulate the endogenous motivation of medical institutions through payment methods, guide medical institutions to actively negotiate prices, and promote products The price drops.
Therefore, the pace of reform of payment methods should be accelerated.
Through the overall advancement of DRG/DIP payment, hospitals’ active cost control will become the dominant mode, and centralized procurement and other procurement policies should be used as optional measures for hospitals to control the cost of medicines and consumables to achieve a two-way supply and demand.
Control fees (see Figure 4).

Figure 5 Schematic diagram of classified procurement

The second is to promote classified procurement.
In order to improve the efficiency of centralized procurement and maximize the effect of cost control, a small part of the products with large demand and unreasonable prices are purchased through centralized procurement, thereby greatly reducing the reasonable level; and most of the products with small demand and relatively reasonable prices Products are mainly purchased through online bargaining, relying on hospitals to actively negotiate prices, and have played many games with enterprises under the market competition mechanism to guide the formation of reasonable prices (see Figure 5).

Centralized procurement is linked to volume and price, and supply companies bid in the same group, thereby controlling the price of pharmaceutical procurement and medical consumables in public hospitals, and realizing medical insurance control costs, which is a typical supplier control mode.
In 2018, after the establishment of the National Medical Insurance Administration, four rounds of national centralized procurement of drugs and one round of coronary stents were successively carried out.
As of 2020, the overall cost savings have exceeded 100 billion yuan, and significant results have been achieved in squeezing the falsely high prices of medicines and medical consumables and reducing the burden on patients.

International experience shows that in centralized procurement, only a single supplier passively controls costs, and there may be certain market risks.
First, the demand side is passive, which affects the cost control effect.
Due to the implementation of "quantity-for-price, volume-price linkage" in centralized procurement, the demander (public medical institution) loses the right to choose the product brand, which will easily lead to weaker initiative to use the selected product in the later period, and it needs to pass the quantity supervision and medical insurance.
The mandatory advancement of administrative intervention measures such as interviews and performance appraisal will not only cause high administrative costs, but also easily lead to the "double price increase" of drugs with the same indication and different generic names that are not included in the centralized procurement, thereby weakening the cost control effect of centralized procurement .
The second is that the supplier is passive and there is a supply risk.
In the existing centralized procurement bidding model, there is no market game behavior of multiple rounds of bargaining between the supplier and the demander.
The supplier (supplier) has only one opportunity to quote, but faces two choices of winning or losing the entire centralized procurement market.
It is easy to report The non-economic rational low price close to the cost price results in less room for the supplier to cope with cost changes, which in turn leads to problems such as supply shortages.

In January 2021, the General Office of the State Council issued the "Opinions on Promoting the Normalized and Institutionalized Development of Centralized and Volume Procurement of Drugs" (hereinafter referred to as the "Regularized Opinions on Centralized Procurement"), and centralized procurement will enter the normalized implementation stage.
In order to adhere to the two basic principles of the "Opinions on the Normalization of Centralized Procurement", namely "adhere to demand-oriented" and "adhere to market-oriented" and solve the passive control mode of a single supplier, the following two measures are recommended:

Figure 4 Two-way collaborative fee control mode of supply and demand

Figure 4 Two-way collaborative fee control mode of supply and demand

One is to achieve two-way fee control.
Judging from international experience, most countries such as the United States, Canada, and Japan adopt a demand-side fee control model, that is, starting from the payment side, stimulate the endogenous motivation of medical institutions through payment methods, guide medical institutions to actively negotiate prices, and promote products The price drops.
Therefore, the pace of reform of payment methods should be accelerated.
Through the overall advancement of DRG/DIP payment, hospitals’ active cost control will become the dominant mode, and centralized procurement and other procurement policies should be used as optional measures for hospitals to control the cost of medicines and consumables to achieve a two-way supply and demand.
Control fees (see Figure 4).

Figure 5 Schematic diagram of classified procurement

Figure 5 Schematic diagram of classified procurement

The second is to promote classified procurement.
In order to improve the efficiency of centralized procurement and maximize the effect of cost control, a small part of the products with large demand and unreasonable prices are purchased through centralized procurement, thereby greatly reducing the reasonable level; and most of the products with small demand and relatively reasonable prices Products are mainly purchased through online bargaining, relying on hospitals to actively negotiate prices, and have played many games with enterprises under the market competition mechanism to guide the formation of reasonable prices (see Figure 5).

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Give full play to the key role of medical insurance payment standards in coordinated cost control

Give full play to the key role of medical insurance payment standards in coordinated cost control

Give full play to the key role of medical insurance payment standards in coordinated cost control

Give full play to the key role of medical insurance payment standards in coordinated cost control

Give full play to the key role of medical insurance payment standards in coordinated cost controlus" style='margin:0px;padding:0px;max-width:100%;box-sizing:border-box;color:#333333;font-family:-apple-system, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif;font-size:16px;letter-spacing:0.
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First of all, through the classification settlement of outpatients and hospitalizations, the medical insurance payment standard and DRG/DIP payment together realize the full coverage of treatment types and treatment products, and through the reform of payment methods, promote medical institutions as the endogenous driving force of the demand side to control expenses, and take the initiative to adopt a centralized belt.
To control the cost of medicines and consumables through bargaining purchases on the Internet, and to achieve medical insurance control fees.

Secondly, medical insurance payment standards also play an important role in promoting classified procurement.
In February 2020, the "Deepening Medical Insurance Reform Opinions" pointed out that "improving the coordination mechanism of medical insurance payment standards and centralized procurement prices" and forming a market-led drug price formation mechanism.

One is to serve as a reference benchmark for purchase bargaining.
In bargaining procurement, medical institutions form reasonable procurement prices through repeated bargaining with enterprises, and scientific and reasonable bargaining benchmarks need to be established in the process.
Combined with the procurement experience inside and outside the region, a unified payment standard should usually be formed based on the measurement and calculation of the purchase quantity and price data, as a basis for bargaining to guide the purchasers to negotiate prices.
The "Opinions on the Normalization of Centralized Procurement" stipulates that "the same medical insurance payment standard shall be implemented for the original research drugs, reference preparations, and generic drugs that have passed the consistency evaluation under the same generic name.
" This is to promote classified procurement and set bargaining prices for online procurement.
The benchmark laid the institutional foundation.

The second is to serve as a criterion for judging the transformation of the procurement model.
Establish a mechanism for the transformation of drug procurement models.
For products with high clinical demand and unreasonable price levels, they will be purchased through centralized and volume purchases.
When their prices fall to a reasonable level, they will switch to a bargaining procurement model and return to market regulation.
The standard for judging whether the price is reasonable is the payment standard.
In this regard, Article 14 of the "Opinions on Normalization of Centralized Procurement" clearly stipulates that "the selected price and the medical insurance payment standard shall be coordinated.
For the centralized and large-volume purchase of drugs in the medical insurance catalog, the medical insurance payment standard shall be determined based on the selected price.
"

First of all, through the classification settlement of outpatients and hospitalizations, the medical insurance payment standard and DRG/DIP payment together realize the full coverage of treatment types and treatment products, and through the reform of payment methods, promote medical institutions as the endogenous driving force of the demand side to control expenses, and take the initiative to adopt a centralized belt.
To control the cost of medicines and consumables through bargaining purchases on the Internet, and to achieve medical insurance control fees.

Secondly, medical insurance payment standards also play an important role in promoting classified procurement.
In February 2020, the "Deepening Medical Insurance Reform Opinions" pointed out that "improving the coordination mechanism of medical insurance payment standards and centralized procurement prices" and forming a market-led drug price formation mechanism.

One is to serve as a reference benchmark for purchase bargaining.
In bargaining procurement, medical institutions form reasonable procurement prices through repeated bargaining with enterprises, and scientific and reasonable bargaining benchmarks need to be established in the process.
Combined with the procurement experience inside and outside the region, a unified payment standard should usually be formed based on the measurement and calculation of the purchase quantity and price data, as a basis for bargaining to guide the purchasers to negotiate prices.
The "Opinions on the Normalization of Centralized Procurement" stipulates that "the same medical insurance payment standard shall be implemented for the original research drugs, reference preparations, and generic drugs that have passed the consistency evaluation under the same generic name.
" This is to promote classified procurement and set bargaining prices for online procurement.
The benchmark laid the institutional foundation.

The second is to serve as a criterion for judging the transformation of the procurement model.
Establish a mechanism for the transformation of drug procurement models.
For products with high clinical demand and unreasonable price levels, they will be purchased through centralized and volume purchases.
When their prices fall to a reasonable level, they will switch to a bargaining procurement model and return to market regulation.
The standard for judging whether the price is reasonable is the payment standard.
In this regard, Article 14 of the "Opinions on Normalization of Centralized Procurement" clearly stipulates that "the selected price and the medical insurance payment standard shall be coordinated.
For the centralized and large-volume purchase of drugs in the medical insurance catalog, the medical insurance payment standard shall be determined based on the selected price.
"

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Conclusion

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Conclusion

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Conclusion

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Conclusion

Conclusion

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The "Opinions on Deepening the Reform of Medical Insurance" pointed out that it is necessary to "enhance the overall, systematic, and synergistic nature of the joint reform of medical insurance, medical care, and medicine.
" The coordinated advancement of the medical insurance payment standard and the DRG/DIP payment method reform fully reflects this point.

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