The implementation of new medical insurance reimbursement restrictions faces great challenges

Original: Scarecrow in the wind On January 10, the national medical security working conference was held in Beijing Leaders continued to emphasize "two not worry, three security", continued to emphasize the implementation of "no worry about food, no worry about clothing, compulsory education, basic medical care and housing safety" In 2019, great progress has been made in the realization of basic medical insurance, especially in the formulation of new medical insurance catalogue and medical insurance negotiation catalogue Price reduction and restriction, highlighting the Chinese characteristics of new medical insurance As one of the breakthrough signs of medical reform, 2019 medical insurance catalog bears many responsibilities The new medical insurance catalog has been implemented for 14 days, and doctors are facing many problems The proportion of restrictions on new medical insurance products has increased significantly The restrictions are more specific than the previous version of the catalog, especially the restrictions on negotiated products To promote the balance of medical insurance funds from the policy level, there will be greater challenges in the implementation level, and it is difficult to benefit patients According to the doctor's feedback, there are many kinds of medical insurance restrictions, some of which are not clear In case of restricted varieties, they dare not to prescribe, but will be punished by the hospital for exceeding the medical insurance restrictions For example, "compound amino acid 18aa-v-sf, medical insurance payment standard of 30 yuan / bottle, medical insurance limit, nutritional risk screening, clear patients with nutritional risk Patients with functional digestive tract will not be paid "It refers to the patients at risk of nutritional screening and those with digestive tract function These two parts of patients are relatively vague How to determine the risk value of screening first? Patients with digestive tract function will not be paid Is there any specific indicator of digestive tract function? There is no specific standard, so it is more difficult for doctors to prescribe Another part of doctors said that products with limited indications are easy to understand and disease diagnosis is clear in the hospital system The doctors of this part of the patients have a foundation in mind and will not worry about punishment However, doctors are very concerned about some products that are not limited by indications, especially the products with many conjunctions, such as "and", "or", which have different understanding and interpretation For example, "eprazole, the medical insurance payment standard is 10 mg / 156 yuan / piece, and the medical insurance limit is limited to the patients with disease diagnosis indicated in the instructions and with fasting doctor's order or dysphagia." In which "and" and "and" or "appear at the same time, it is difficult to identify without careful consideration Moreover, there is no diagnosis of dysphagia in the hospital system Doctors say that they refuse to prescribe any ambiguous or vague information for self-protection All kinds of medical insurance restrictions are published, but there are no relevant rules at the implementation level and audit level, which brings challenges and increases workload for audit Some hospitals with better implementation will issue a notice, for example, it is necessary to indicate the content of the medical insurance limit in the doctor's order or case It is relatively easy for doctors to implement, but it will increase the workload of auditors The medical insurance department needs special personnel to query the words in the case In addition, some hospitals carry out spot check of prescriptions The results of spot check punish the doctors and departments who violate the regulations In fact, the punishment is not the purpose It is better to implement the norms and actively guide the doctors at the implementation level After all, only doctors working without emotion can provide better treatment for customers (patients) The original intention of the policy benefits patients, but if the implementation level is not well implemented, it will also affect the previously set goals In August 2019, the global innovative drug losartan obtained new indications for anemia treatment of non dialysis dependent chronic kidney disease (NDD CKD) This is the first expansion of its indication range after losartan was approved for anemia treatment of dialysis patients with chronic kidney disease on December 17, 2018 As a global first new drug, losartan is the first to realize the comprehensive application of dialysis and non dialysis chronic kidney disease anemia patients in China, bringing a new treatment breakthrough for the majority of Chinese chronic kidney disease groups This medical insurance reimbursement limits anemia patients caused by chronic kidney disease These patients are clear and easy to diagnose Some products are limited by the hospital, and the prescription should be prescribed by the hospital above the second level The particularity of these varieties lies in the fact that the secondary and lower hospitals are not conducive to treatment or do not have treatment conditions If the limitation is from the hospital level, the advantage is easy to manage, and the disadvantage is that some primary patients cannot be reimbursed in the secondary hospital It is beneficial for the prescription of special medicine and the rational use of drugs Isazolam medical insurance is limited by the prescription of blood specialty or blood specialty hospital of the third level hospital It's a good exploration to limit the use of specialty drugs Based on the complexity of the treatment of this kind of disease, we should avoid excessive reimbursement caused by unreasonable use The compound amino acid injection (18AA) is limited to the patients with nutritional risk through nutritional risk screening Patients with functional digestive tract will not be paid for it This kind of patient portrait is not particularly clear, especially with nutritional risks This part is understood differently in different hospitals, and doctors have concerns about prescription, so they may not be able to prescribe At present, nutrition risk screening mainly includes SGA, pg-sga evaluation form and nrs2002 risk screening form, which are generally divided into good nutrition, light to moderate malnutrition and severe malnutrition It is not known which type can get medical insurance payment Generally speaking, there is an approval process for drugs When drugs are approved, they are generally used as second-line drugs at the beginning of marketing Second-line drugs are drugs with no first-line clinical use frequency or no first-line obvious effect and many adverse reactions The main indication of norfloxacin is community acquired pneumonia As a new type of broad-spectrum fluoroquinolones free antibacterial, it has an effect on Gram-positive bacteria, negative bacteria and atypical pathogens, especially on Streptococcus and Staphylococcus In addition to the characteristics of these fluoroquinolones, they have strong effect on MRSA (Staphylococcus aureus) and weak effect on Mycobacterium tuberculosis As a second-line treatment, it can avoid the drug resistance caused by the widespread use of fluoroquinolones, and has a certain protective effect on innovative drugs Ginkgolide injection is limited to the patients with cerebral infarction in the convalescent stage of secondary and above medical institutions, and the maximum payment for a single hospitalization is 14 days According to the expert's argument, some varieties will be limited in both indications and payment days If the payment days are limited, it may be based on the consideration that the disease can be cured within 14 days, or the treatment over 14 days may not have obvious effect on the disease, or 14 days Angel cost is too high, which needs to be paid by patients themselves The interpretation of different parties is different, but it will be very convenient at the level of hospital implementation The most difficult to understand are those who are unable to take oral preparations such as Diammonium Glycyrrhizinate, those who are limited to liver failure, or those who are unable to use oral preparations of glycyrrhizinate This kind of patients are generally not understood by doctors It is different from esoprazole patients with fasting orders or dysphagia This kind of patients is very clear and can be confirmed by fasting orders There are two possibilities for patients who are unable to use oral glycyrrhizic acid preparation The first is that the treatment of oral glycyrrhizic acid preparation does not meet the treatment needs of patients, and diammonium glycyrrhizinate needs to be used intravenously This is based on the clinical treatment needs, and doctors can make medical decisions The second is that the basic conditions of patients are not available, such as fasting period, so diammonium glycyrrhizinate may be used orally, or it may be diammonium glycyrrhizinate They have both The two possible subjects are different The former takes doctors as the main body, the doctor's judgment belongs to the professional category, and the latter takes patients as the main body and formulates according to the patients' disease performance Finally, there are also objections on how to embody the prescription or diagnosis at the executive level From the perspective of clinical treatment, indication limitation is the most scientific At present, the diagnosis of clinical diseases is clear, in line with the doctor's diagnosis and treatment thinking, the implementation level is easy to understand and promote the realization of the goal China has a vast territory and a large population It is difficult to manage the reasonable prescription of 4.5 million doctors It is reasonable to standardize it from the hospital level Some acute and severe cases are not treated in the second level or below hospitals, which is manifested in the difficulty of doctors or hospital system to carry out treatment Hospital restrictions are simplified from the perspective of management and easy to implement The medical insurance payment price of negotiation products shows the medical insurance reimbursement system with Chinese characteristics Although the global innovative drugs are much lower than the global minimum price during the patent period, the replacement of negotiation products for existing products will further save the medical insurance fund, promote the rational use of drugs, and benefit patients If the negotiation products are further strictly restricted, it will be difficult to share the policy dividend with patients, the implementation will be more difficult, and the effect will be reduced.