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    Home > Active Ingredient News > Immunology News > What are the outpatient insurance policies for medicines negotiated by the national medical insurance outside the "dual channel"?

    What are the outpatient insurance policies for medicines negotiated by the national medical insurance outside the "dual channel"?

    • Last Update: 2021-06-06
    • Source: Internet
    • Author: User
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    Wen | Jiang Bin, Deputy Director, Public Policy Research Center, Peking University

    Since 2017, the national medical insurance department has routinely carried out negotiations on the admission of medical insurance catalogues every year, and more and more innovative drugs with high clinical value have been included in the national medical insurance catalogue, which greatly reduces the burden of patients' medication and guarantees the needs of patients for medication.


    Today, I hope that by summarizing the typical models and characteristics of negotiated medicines in outpatient clinics in various regions, it can provide reference for the better implementation of the national medical insurance negotiated drugs in various regions, and the benefits and patients.


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    In 2020, a total of 119 negotiated drugs were included in the national medical insurance catalog, which is the largest number of inclusions.


    The state attaches great importance to the implementation of medical insurance negotiations.


    In order to solve the problem of the last mile, the National Medical Insurance Bureau issued a document on April 1, 2021, requiring all provinces to report monthly documents and implementation plans for implementing the new version of the medical insurance drug catalog and promoting the implementation of the national talks.


    On May 10, 2021, the National Medical Insurance Administration, in conjunction with the Health Commission, issued the "Guiding Opinions on Establishing and Improving the "Dual Channel" Management Mechanism for Drugs in National Medical Insurance Negotiations", which covers classified management, pharmacy selection procedures, standardized use, and improved payment policies.


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    General Outpatient Coordination Policy

    General Outpatient Coordination Policy

    Ordinary outpatient co-planning refers to the payment of common and frequently-occurring medical expenses in outpatient visits by the co-ordinating fund, with a wide range of reimbursements, and it belongs to inclusive outpatient care.


    For example, for outpatient co-ordination in Shanghai, the minimum payment line for urban employees’ on-the-job medical insurance is 1,500 yuan, and the reimbursement ratio is divided by age group.


    For outpatient clinics in Beijing, the minimum payment line for in-service medical insurance for urban employees is 1,800 yuan, and the reimbursement ratio is determined by the hospital level, the type of insured person, and the age.


    For outpatient clinics in Fujian, the minimum payment line for urban employees at the provincial level is 1,300 yuan, the reimbursement rate for on-the-job insured personnel is 70%, and the ceiling for outpatient expenses is 10,000 yuan per person per year.


    The level of coordination of outpatient clinics in my country varies greatly, and most of the areas where the coordination of general outpatient services have a low level of protection have limited outpatient protection for negotiated drugs.

    Outpatient chronic disease (in some areas referred to as outpatient special disease, etc.
    , hereinafter collectively referred to as outpatient chronic disease) policy

    Outpatient chronic disease (in some areas referred to as outpatient special disease, etc.
    , hereinafter collectively referred to as outpatient chronic disease) policy

    Outpatient chronic disease policy refers to the separate reimbursement policy for some chronic diseases and special diseases that are treated in outpatient clinics for long-term and high cost in the coordinated area, which can solve the cost burden of these chronic disease outpatient clinics to a certain extent.
    This policy guarantees the use and payment of drugs that have been included in the national talks for treatment or are suitable to be added to the outpatient chronic disease list.

    At present, most coordinating areas have established outpatient chronic disease policies, mainly selecting outpatient diseases that have long treatment cycles, high costs, relatively stable conditions and incurable short-term.
    From the perspective of specific diseases, it can be roughly divided into two categories: one is chronic diseases in the traditional sense, including cardiovascular and cerebrovascular diseases, metabolic diseases, mental diseases and respiratory diseases; the other is the major outpatient treatment.
    Diseases, including malignant tumors, blood system diseases, immune diseases, etc.
    The scope of chronic and special diseases in outpatient clinics and the diagnosis and identification standards are clarified in all regions.
    Patients can be included in reimbursement after approval and confirmation by medical insurance institutions, and patients are required to review regularly.
    In the same overall planning area, the types of diseases covered by the medical insurance of employees and residents in the outpatient chronic disease management are generally similar, but in terms of the reimbursement amount and ratio, the medical insurance benefits of employees are generally better than residents' medical insurance.
    Some cities also divide diseases into different categories according to the severity and cost of the disease, and set different reimbursement limits for each category.
    Outpatients for major and serious diseases are generally managed as hospitalizations, and their annual reimbursement limits are the same as the annual ceiling for hospitalization.

    Hypertension, diabetes, malignant tumors and other drugs in the national talks are suitable for outpatient chronic disease management.
    For example, Sichuan Province divides outpatient special diseases into four major categories, and has introduced corresponding supporting measures to restrict medication, inspection items, and disease types to effectively control medical insurance costs while ensuring that patients can use state-of-the-art new drugs in a timely manner.
    Starting from the medical insurance side, Fujian Province has set a capping line for special diseases in outpatient clinics.
    The capping line for hypertension and diabetes is 6,000 yuan.
    Other diseases are implemented according to the hospitalization standard, 140,000 yuan per person per year; outpatient clinics for urban and rural residents insured The capping line for special diseases is 2,000 yuan-8,000 yuan depending on the type of disease, and the capping line for malignant tumor radiotherapy and chemotherapy is 120,000 yuan.

    In short, the level of policy guarantee for chronic diseases in outpatient clinics is significantly higher than that in general outpatient clinics, which can guarantee the use and payment of negotiated drugs to a certain extent.

    Special medicine management policy

    Special medicine management policy

    Special drug management policy refers to a separate medical insurance management policy for high-value drugs that are not included in the outpatient chronic and special disease management, but are specific to the user population, have clear medication indications, are suitable for outpatient use or pharmacy supply, also called single line payment, single line payment , Payment in a fixed proportion, national drug outpatient guarantee policy, etc.
    , are collectively referred to as special drug policy hereinafter.
    This management model is an innovative and important policy path that guarantees the smooth progress of national drug talks.

    As of the end of April 2021, 21 provinces and cities including Beijing, Fujian, Sichuan, Chongqing, Jilin, Liaoning, and Xinjiang have issued special drug management policies.
    There are two main types of drugs included in the management of special drugs: one is drugs for major diseases, such as tumor drugs and rare diseases; the other is drugs with higher treatment costs for other diseases.
    Special drug management generally does not have a deductible payment line, and the annual maximum payment limit is generally the same as inpatient or outpatient special disease treatment, which effectively alleviates the burden of patients' medication and reduces the waste of medical insurance funds such as hanging beds.

    In the provinces and cities that implement special drug management, most of them have opened a "dual channel" drug supply model in pharmacies and hospitals.
    Doctors prescribe external prescriptions, and patients purchase medicines through designated pharmacies and conduct medical insurance settlements.
    The pharmacies play an active role in guaranteeing the supply of nationally negotiated varieties and further improve the availability of medications for patients.
    The "dual channel" can solve the problem of the difficulty in entering the hospital for the National Talks drug to a certain extent, and provide patients with double guarantees that they can use and can afford to use the National Talks good medicine.
    Therefore, on May 10, 2021, the National Medical Insurance Administration and the Health Commission jointly issued a document "Guiding Opinions on Establishing and Improving the "Dual Channel" Management Mechanism for Negotiated Drugs in National Medical Insurance", which standardizes the "dual-channel" management requirements for negotiated drugs, which is equivalent to Added out-of-hospital pharmacies for the launch of national talks.
    "Dual-channel" pharmacies as a new drug supply channel, when the reform of the hospital supervision model cannot keep up with the reform of the medical insurance, the indicators such as the total control, the proportion of medicines, and the performance appraisal in the hospital management and the national talks product landing policy have not been straightened out.
    , May well be a more pragmatic solution.

    Summary: The above three models are based on the overall planning model of cost, disease and drugs.
    Local practice is often based on three conventional policies, combined with local characteristics, combined and optimized, and introduced different negotiated drug outpatient clinics.
    policy.
    For areas where medical insurance funds are under pressure, the outpatient management policies for chronic diseases and special drugs have a significant effect on improving the national medical insurance benefits.
    They are the main focus of optimizing outpatient benefits in various places and are worthy of further study.

    summary:
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