Medical insurance negotiation drug reimbursement opens "dual channel", and anti-cancer drugs become the focus of protection
In the future, medicines that enter the medical insurance catalog through national negotiations can be bought not only in hospitals, but also in designated retail pharmacies, and enjoy the same medical insurance reimbursement treatment.
The nationwide launch of the "dual-channel" management mechanism for drugs negotiated by the national medical insurance will greatly ease the problem of negotiating drugs that "can get medical insurance but not enter the hospital".
On May 10, the National Medical Insurance Administration and the National Health Commission issued the "Guiding Opinions on Establishing and Improving the "Dual Channel" Management Mechanism for Drugs in National Medical Insurance Negotiations" (hereinafter referred to as the "Guiding Opinions").
China Business News learned from the National Medical Insurance Bureau that this is the first time that designated retail pharmacies have been included in the coverage of medical insurance drugs at the national level, and a unified payment policy with medical institutions has been implemented. Kilometers hinder the efforts made.
Huang Huabo, Director of the Medical Service Management Department of the National Medical Insurance Administration, stated that the negotiated drugs should be classified and managed, and the varieties with high clinical value, urgent needs of patients, and low substitutability should be included in the "dual channel" management in a timely manner, and the provincial medical insurance administrative departments should comprehensively Factors such as the level of economic development in the region, the affordability of medical insurance funds, and the needs of patients for medication should be taken into consideration to determine the scope of the "dual channel" drugs.
From the perspective of local pilot projects, high-value drugs, mainly anti-cancer drugs, are the focus of the “dual-channel” guarantee. The first batch of 19 national medical insurance negotiation drugs announced by the National Medical Insurance Bureau at the end of last month are available in designated medical institutions and designated pharmacies. The provision of anti-cancer drugs also shows that the most institutions are equipped with anti-cancer drugs.
"Dual Channels" Improve Access to Medicines
"Dual Channels" Improve Access to Medicines
"Dual channel" refers to the mechanism that meets reasonable needs for negotiating drug supply guarantees and clinical use through two channels, designated medical institutions and designated retail pharmacies, and simultaneously incorporates them into the medical insurance payment mechanism.
The National Medical Insurance Bureau stated in its policy interpretation that the purpose of issuing the "Guiding Opinions" is to give full play to the characteristics of flexible and widely distributed services of designated retail pharmacies, to include them in the scope of negotiated drug supply guarantees, to increase drug supply channels and patient medication options, and to promote Designated retail pharmacies will improve service quality and increase the availability of negotiated drugs.
The "difficulty in entering the hospital" of negotiating drugs is a persistent problem that my country has been facing since the initiation of medical insurance drug negotiations.
After 119 drugs were included in the latest edition of the National Drug List through negotiations this year, some patients continued to report that some negotiated drugs could not be prescribed in hospitals.
Since its establishment, the National Medical Insurance Administration has vigorously promoted the reform of drug catalog management and established a sound catalog dynamic adjustment mechanism. The adjustment cycle of the medical insurance drug catalog has been greatly shortened from the original maximum of 8 years to once a year, and some new drugs have even been included in the medical insurance drug catalog in the year when they were launched. .
The frequency of access to the medical insurance catalog has been greatly accelerated, and the mode of drug access in medical institutions has not changed significantly.
Before the reform, most of the medicines were “advanced hospitals, and later entered the medical insurance” after the reforms. After the reforms, they became “advanced medical insurance, then enter the hospitals”, which puts forward a higher level of rapid access to medical institutions and widespread use by clinicians in the short term. Requirements.
The National Medical Insurance Administration believes that the "difficulty in hospital admission" of most negotiated drugs is to a certain extent the result of deepening the reform of the medical insurance drug catalog management.
Hu Xin, the chief physician of the Department of Pharmacy of Beijing Hospital, said that there is a process for the admission of drugs in the National Medical Insurance Catalogue. Both clinical medical experts and medical institutions need a process of cognition, and a series of procedures such as the Pharmacy Council must be passed during the process. .
The inclusion of drugs in the hospital catalog, known as drug selection in the industry, is the key task of the Pharmaceutical Affairs Management and Pharmacotherapy Committee.
To successfully enter the hospital catalogue, a drug needs to go through multiple steps and the process is more complicated.
In addition, from the perspective of medical institutions, after the full implementation of the "zero mark-up rate of medicines" policy, the provision, storage, and loss of medicines have become the costs of public hospitals, and medicines will change from a profit factor to a cost factor for medical institutions. Willingness of medical institutions to equip medicines.
The industry generally believes that the "dual channel" is another way to bypass the hospital and solve the difficult problem of negotiating drugs through pharmacies.
Huang Guangzhen, deputy director of the Medical Insurance Bureau of Xuzhou City, Jiangsu Province, told CBN that designated pharmacies will be launched significantly faster than hospitals. After the new medical insurance catalog is launched on March 1, the medical insurance department requires designated pharmacies to add new pharmacies before March 31. All 14 kinds of oncology drugs were put on the market. "As a result, the pharmacies were equipped in only two days. The supply of pharmaceutical companies was extremely fast, and the pharmacies were very motivated."
The "Guiding Opinions" also clarified the principles and procedures for the selection of designated retail pharmacies, with moderate competition and both in and out.
Huang Guangzhen believes that the "dual-channel" policy is also good for medical institutions. The cost of using negotiated drugs is separately included in the fund budget at the beginning of the year, which eliminates the doubt that medical institutions will occupy the total control of their occupation and avoids the loss of the source of disease. Very active in applying for the designation of high-value drugs.
Guo Yanhong, Inspector of the Medical Administration and Medical Administration of the National Health Commission, said that in the next step, the National Health Commission will focus on two aspects: First, it is necessary to urge medical institutions to provide timely and on-demand equipment. Comparing reasons to influence the reasonable use of negotiated drugs; for negotiated drugs that are urgently needed clinically, the admission process should be appropriately simplified on the basis of full evaluation.
The second is to emphasize the rational use of clinical norms.
Which negotiation drugs give priority to "dual channel"
Which negotiation drugs give priority to "dual channel"
The "Guiding Opinions" put forward the principle of "classified management" for drugs included in the "dual channel".
Varieties with high clinical value, urgent need by patients, and low substitutability should be included in the "dual channel" management in a timely manner.
The "dual-channel" supply guarantee of negotiated drugs is included in the scope of the designated medical institution agreement management, the drug supply subject and responsibilities are clarified, and the designated medical institution is urged to be equipped in a timely manner according to functional positioning and clinical needs, and designated retail pharmacies are equipped according to supply capacity and agreement requirements.
Zhang Xifan, Director of the Catalogue Division of the Medical Department of the National Medical Insurance Administration, said that the scope of drugs included in the "dual-channel" management is determined by the provincial medical insurance department in principle, and factors such as the reasonable needs of clinical patients, fund safety, and clinical medication habits should be considered.
In local practice, anti-cancer drugs and other drugs are the key guarantee scope of the "dual channel".
Xuzhou City, according to the drug treatment field, treatment cycle, treatment cost, limited payment scope, etc., manages the national talk drugs in two categories.
The first is high-value medicines, including anti-tumor special guarantee mechanism medicines and outpatients pay-per-disease medicines.
The second is general class B drugs. The 55 new drugs that directly treat chronic diseases in the National Talks will be included in the scope of subsidies for outpatient use of chronic diseases of employee medical insurance and residents’ medical insurance for hypertension and diabetes.
In terms of high-value drugs, Xuzhou City has included 56 anti-tumor targeted drugs under generic names into the scope of the special mechanism. There is no minimum payment standard. First, employees and residents’ funds will reimburse 55% and 50% respectively, and then individual The self-paid part is included in the reimbursement of employee supplementary medical insurance and resident serious illness insurance, and the highest reimbursement rate for individual expensive drugs reaches 82%.
Zhang Xifan believes that the implementation of the "dual channel" has introduced new challenges to the negotiation of drug fund safety.
It turned out that the hospital management of medicines was closed-loop. After the implementation of the "dual channel", the number of management links increased, especially for the matching of funds, medicines, personnel, and information.
The "Guiding Opinions" proposes to deploy a prescription circulation center based on a unified national medical insurance information platform.
With the circulation of prescriptions as the core, implement the requirements of "designated institutions, designated physicians, and traceability" to realize the whole-process supervision of patients' medication behavior.
(Author: Guo Jinhui)