With the reform of outpatient reimbursement system, the drug treatment structure is facing great adjustment.

Recently, the State Health Insurance Administration issued "on the establishment and improvement of basic medical insurance outpatient co-insurance mechanism guidance (draft for comments), " caused a huge response in the entire industry.
of medical insurance personal accounts for employees will undoubtedly have a considerable impact on the entire drug use structure, as well as on pharmaceutical companies, pharmacies and medical institutions.
in fact, it is not difficult to find that each policy is basically a continuation of the past policy, the reform of the personal accounts of employees is no exception, there have been signs.
June 4, 2019, the State issued the "Key Tasks for Deepening the Reform of the Medical and Health System 2019", which mentioned the need to "develop a policy document to improve the personal accounts of workers' health insurance."
February 25 this year, the State issued the Opinions on Deepening the Reform of the Health Care System, which also explicitly mentioned the need to improve the basic medical insurance system.
to unify the overall level of basic medical insurance, medical insurance directory, regulate the medical insurance payment policy to determine the method.
to gradually incorporate outpatient medical expenses into the scope of payment of the basic medical insurance co-ordination fund, reform the individual accounts of basic medical insurance for employees, and establish and improve the mechanism for the protection of outpatient assistance.
According to the Draft for Comments, the core initiatives of the employee's medical insurance outpatient co-payment guarantee mechanism (for comments) include three main points: general outpatient expenses can be reimbursed, 50% start, appropriate tilt to retirees;
, 329.25 million people currently participate in health insurance for workers, including 24.224 million active workers and 87 million retired workers.
total balance of individual accounts for basic medical insurance in 2019 has reached 842.6 billion yuan.
addition, by the end of August 2019, we have 1.02 billion people participating in the health insurance of urban and rural residents, according to the National Health Insurance Administration's plan, by the end of this year, urban and rural residents health insurance personal accounts will also be cancelled.
the implementation of outpatient help, the establishment of outpatient reimbursement mechanism, some people in the industry believe that this means that health care funds will usher in a large "expansion."
the proportion of outpatient reimbursement increased, the scope of outpatient reimbursement of diseases expanded, personal account funds decreased, these will cause the adjustment of the entire drug structure, which is also a test of the market layout of pharmaceutical companies.
The proportion of medical insurance reimbursement increased, the retail pharmacy market is facing the impact of the Draft for Comments proposed that the general outpatient co-ordination covers all employees of health insurance participants, the proportion of payment from 50%, with the fund's affordability to gradually improve the level of protection, treatment payment can be appropriately tilted towards retirees.
50 per cent is just the beginning, and some areas with good economic conditions are likely to be higher.
in fact, like Shanghai, the co-ordination of the payment part of the starting section is already 50%.
the proportion of outpatient insurance reimbursement increased, coupled with the unit contribution part is no longer included in the personal account, the personal account of less money, the patient's drug habits will also change.
drugs, which used to be bought in pharmacies, may now be circulating to hospital outpatient clinics, which could be a blow to medicare-targeted retail pharmacies.
addition, the Draft for Comments makes it clear that individual accounts shall not be used for other expenses such as public health expenses, sports fitness or health care consumption that are not covered by basic medical insurance.
limited the use of health insurance personal accounts to medicines and medical supplies, which undoubtedly limits the development of other categories.
, according to official 2018 retail pharmacy data, there will be 341,000 targeted pharmacies in 2018, accounting for nearly 70 percent of the total number of retail pharmacies nationwide.
recent years by the staff medical insurance personal account limit brush non-drugs and fixed-point pharmacies prohibit the sale or placement of non-drugs, the overall sales of fixed-point pharmacies affected.
According to CMH data, the proportion of non-drugs in retail pharmacies nationwide remained basically at 23% in 2019, compared with a further decline in 18 years, the growth of pharmacies is still mainly dependent on drugs, of which chemicals increased by 8.0%, Chinese medicine increased by 6.8%, while health care products growth of only 0.8%, pharmaceutical equipment categories also showed low growth rate, and food / daily necessities, etc.
Outpatient reimbursement of the scope of diseases expanded, inpatient departments and outpatient structure changes, outpatient drug use ushered in a good "draft for comments" proposed from high blood pressure, diabetes and other people's heavy burden of outpatient chronic diseases, and gradually the incidence of frequent, common diseases of general outpatient medical expenses into the scope of co-ordination fund payment.
On May 13, 2019, the State Administration of Medical Security and the Ministry of Finance issued the Notice on Doing a Good Job in Basic Medical Security for Urban and Rural Residents in 2019, which mentioned the need to establish and improve the mechanism for the co-ordination and payment of medical insurance outpatient expenses for urban and rural residents, with emphasis on ensuring that the masses bear a heavy burden of multiple morbid and chronic diseases.
high blood pressure, diabetes and other outpatient medication into the medical insurance reimbursement, the specific plan to be formulated separately.
October 15, 2019, the State Health Security Administration's reply to proposal No. 2374 (Social Management No. 176) of the second meeting of the 13th National Committee of the CPPCC, on "Expanding reimbursement for outpatient medical treatment" Scope" mentioned that, taking into account that some outpatient chronic diseases of special diseases (hereinafter referred to as "slow special diseases") patients mainly in outpatient treatment, medical burden is relatively heavy objective reality, according to national requirements, some long-term, high medical costs of chronic special diseases into the scope of co-ordination fund payment.
Such as chemotherapy for malignant tumors, uremia dialysis, anti-excrete treatment after organ transplantation, insulin treatment for diabetics, drug maintenance therapy for severe mental patients and outpatient day surgery, etc., with reference to hospital management and payment, in order to further reduce the burden.
currently a number of provinces also slow door, mente disease drugs into the scope of the co-ordination fund to explore.
the scope and identification criteria of diseases included in the scope of co-ordination fund payments are also different, with more than 60 species in many places and more than 10 kinds in fewer places.
, and this "draft for comments" will co-ordinate the scope of fund payments once again expanded, not only slow drugs, some common disease drugs will also be included in the scope of reimbursement.
because the general clinic involved a wide variety of drugs, this document is not specifically involved, but in any case, this "expansion" for some pharmaceutical companies is also good news.
, in accordance with the provisions of the draft for comments, some operations carried out in outpatient clinics are also included in the scope of reimbursement of the co-ordination fund, with reference to in-patient reimbursement management.
the proportion of outpatient reimbursement increased, reimbursement of drug varieties expanded, which may also lead to the inpatient department drug diversion to outpatient, medical structure of drug use or face major adjustments.
to promote the hierarchical diagnosis and treatment system this "draft for comments" is also to further promote the graded diagnosis and treatment of an initiative.
The Draft for Comments proposes that primary health care services should be paid per head, actively exploring the combination of head-to-head payment and chronic disease management, the introduction of pay-per-disease and disease-related groups for day surgery and eligible outpatient special diseases, and the payment of outpatient fees that are not suitable for packaging and payment.
, in accordance with the current medical insurance policy, the primary medical institutions to implement the policy of differential reimbursement of medical insurance.
appropriately raise the proportion of medical insurance reimbursement in primary health care institutions, and reasonably guide the flow of medical treatment.
the proportion of medical insurance reimbursement between primary medical institutions and third-level hospitals has been opened by more than 10 percentage points.
the starting line continuously for patients who meet the requirements for referral to hospital.
according to the current 50% starting reimbursement ratio, primary medical institutions can reach 60% or more.
this will inevitably also guide some patients to the primary medical institutions for medical treatment.
, the release of the opinion is a continuation of the reform of the health care system.
is both a challenge and an opportunity for pharmaceutical companies and retail pharmacies.
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