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    Home > Medical News > Medical World News > Negotiation and access: two main mechanisms for determining the standard of payment for medical insurance drugs.

    Negotiation and access: two main mechanisms for determining the standard of payment for medical insurance drugs.

    • Last Update: 2020-08-24
    • Source: Internet
    • Author: User
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    Wen . . . Tao Libo issued a draft for comments on April 29, 2020, which lasted three months, and the Interim Measures for the Administration of Drug Use in Basic Medical Insurance (hereinafter referred to as the Measures for the Administration of Drug Use) were officially issued on July 30, and are scheduled to take effect on September 1.
    is a major event in the field of medicine and health in China and will have a far-reaching impact.
    In many contents of the Measures for the Administration of Drug Use, the confirmation method of the standard of payment of medical insurance drugs is particularly striking, because it is the purchase price paid by medical insurance to pharmaceutical products, which is "real money", which is related to the safety and efficiency of medical insurance funds, and is closely related to the survival and development of pharmaceutical manufacturers.
    in the Measures for the Administration of Drug Use, this is expressed as follows: establish a mechanism for bridging access to the Drug Catalog with the standard payment standards for medical insurance drugs.
    addition to Chinese medicine tablets, in principle, the new drugs included in the "Drug Catalog" to determine the payment standards simultaneously.
    criteria for the payment of exclusive medicines through access negotiations.
    non-exclusive drugs, the central procurement of selected drugs by state organizations shall determine the payment standards in accordance with the relevant provisions of centralized procurement;
    drug and class I psychothesties, which are priced by the Government, are paid according to government pricing.
    the exclusive variety is negotiation, non-exclusive is bidding (the pricing mechanism is also bidding), the government pricing of refined drugs.
    addition to the final government pricing, most Medicare drugs will be based on "exclusive" or not, using negotiations or bidding to set payment standards.
    the formation of prices: it is well known that prices (payment criteria) are at the heart of market transactions.
    access to and payment of medicare drugs is essentially the purchase and transaction of pharmaceutical products, and the price factor is crucial.
    generally speaking, the essence of the price formation mechanism is that both the supply and demand sides determine a value between the "lowest available price" and the "maximum available purchase price".
    the lowest available price reflects the manufacturer's cost, pricing higher than the manufacturer's profit, and the highest available purchase price reflects the consumer's utility, pricing less than its consumer's purchase makes sense.
    Pricing within this range is win-win for both supply and demand, which is the underlying reason for transactions to promote happiness, but the specific location of pricing reflects the difference in the distribution of benefits: prices close to the cost of manufacturers then consumers profit more, prices close to consumer utility manufacturers profit more.
    in the purchase and transaction of drugs, manufacturers certainly want the price to be close to the patient's utility.
    , as a group buyer with a large market share, will try to bring the cost of paying close to the manufacturer's to make health insurance money more efficient.
    the development of payment standards in the Drug Administration Measures reflects the internal logic of this aspect.
    's efforts to find the cost line: in fact, the government, including Medicare, has always wanted to determine the cost levels of manufacturers to price them reasonably.
    A more senior person in the field of Chinese medicine knows that the National Development and Reform Commission's drug price management was based on the idea of "cost plus": the NDRC tried to check, audit and calculate the costs of pharmaceutical manufacturers to control prices.
    because of the huge information asymmetry between government departments and pharmaceutical manufacturers, it is actually very difficult to determine the cost, so the cost-plus management method is not satisfactory.
    in the "Drug Management Measures" we can see that the medical insurance sector has learned from past experience, in the exploration of the cost level of manufacturers, the use of different ideas and methods.
    Since it is very difficult for managers to understand the true cost of manufacturers (in fact, the cost of pharmaceutical products is mostly complex, the real opportunity cost of resources even manufacturers themselves may not be clear), then let manufacturers in the fierce market competition, their own cost level exposed.
    In the current belt collection, which is in full swing, the health care sector brings together a large number of demand for manufacturers to bid on each other, in order to obtain health insurance procurement volume, manufacturers in the fierce competition must be based on their own cost level, as far as possible to report low prices in order to win.
    as long as the "carrot" in the collection is large enough, as long as the competition between manufacturers is fierce enough, the final price level will tend to the manufacturer cost line.
    It is on the basis of such management ideas, "Drug Management Measures" for non-exclusive varieties to develop a bid-based payment standard-setting method, the purpose is to explore the real cost level of manufacturers through bidding, so that the formulation of payment standards close to the manufacturer's cost line, so that health insurance funds in drug access and procurement efficiency significantly improved.
    exclusive variety negotiation mechanism: However, the above-mentioned pricing mechanism based on the vendor's bid, in the face of exclusive varieties, it appears pale and weak, because of the lack of bidding on the home.
    therefore, for exclusive varieties, the "Drug Management Measures" proposed a negotiated pricing strategy.
    The so-called access negotiations, based on past experience and the newly released Work Programme for the Adjustment of the National Health Insurance Drug Catalog 2020 (Draft for Comments), refer to the process by which the manufacturer submits product information, reviews and measures by experts, and finally negotiates with the manufacturer on behalf of the health insurance to determine the payment criteria.
    look closely at the rule design of access negotiations, we can see the health care sector by exploring the consumer utility of pharmaceutical products and manufacturer costs to reasonable pricing management strategies.
    , the information submitted by the manufacturers of medical insurance includes the pharmaceutical research, clinical research, pharmace economics research and so on.
    by the medical insurance experts to review and further estimate these information, can be scientifically and objectively assessed the value of pharmaceutical products.
    value assessment reveals the benefits that pharmaceutical products can generate, i.e. consumer utility.
    value assessment can help determine the price level of pharmaceutical products based on consumer utility, which is the maximum available purchase price described earlier.
    However, pricing for consumer utility alone is not appropriate, so at this point the drugmaker gains, while the patient and health insurance benefit almost nothing (to give a simple example, the cost of the drug is 10, the value to the patient is 100, if the patient and the health insurance pay 100, the need for no income, and the manufacturer gets 90).
    therefore, in the access negotiations, health insurance also needs to further explore the cost line of manufacturers.
    In concrete practice, the foreign sales price of pharmaceutical products, the access price of local medical insurance, the real price of the manufacturer's charitable project, etc., can prompt the manufacturer's real affordable price level, indirectly reflect its cost line, and the management of the pharmaceutical manufacturer's cost verification information, can also help the medical insurance to understand the manufacturer's cost level, and so on.
    , even with the above information, it is difficult for health insurance to accurately understand the real cost of manufacturers.
    Therefore, the system design of health insurance in access negotiations is to set payment standards by allowing manufacturers to quote themselves, using over-quote as a pressure mechanism to negotiate failure, to force manufacturers to quote prices close to the cost line.
    this quoting mechanism, which is intertly consistent with the bidding of non-innovative products, forces vendors to lead the exposure of cost information, thus making payment standards as close as possible to cost management strategies.
    the conclusion of this paper, there can be a more in-depth understanding of the two main mechanisms for formulating payment standards in the Measures for the Administration of Medication: negotiation and bidding.
    the two mechanisms have intert consistency, both based on the cost of manufacturers and consumer utility to explore the reasonable formulation of payment standards.
    In short, for a number of competing non-innovative products, through vendor bidding to explore the payment standards close to the cost line, for the lack of competition for exclusive products, through value assessment to explore consumer utility, through international price, cost accounting and other methods to explore the cost of manufacturers, and through the pressure mechanism of self-quoting manufacturers to explore the payment standards close to the cost line.
    The above analysis can be explained by the following diagram: Based on the analysis of this paper, we can understand the internal logic of the standard-setting method of medical insurance payment in the Measures for the Administration of Drugs, and understand the institutional efforts of medical insurance to squeeze the price moisture of drugs and improve the efficiency of the purchase of medical insurance funds.
    of these systems and rules is based on past reform experience and reflects the great progress of drug price management level in China.
    Of course, it is important to note that the standard of payment is too close to the cost, resulting in low profit levels for manufacturers, weakening their ability to invest in research and development and expand re-production, in the long run is also not worth it.
    Therefore, the standard-setting mechanism of medical insurance payment needs to be flexible, constantly improved, in the value assessment and manufacturer's cost between the determination of the appropriate level of payment standards, so that consumer benefits and manufacturers profit coexistence, so that China's medical insurance industry and pharmaceutical industry have long-term benign development.
    .
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