Why is it difficult to enter the hospital after the anticancer drug "soul bargaining" enters the medical insurance?
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In order to reduce the burden of medication for patients, since 2017, the medical insurance department has negotiated to include urgently clinically needed and expensive innovative drugs into the medical insurance catalog.
However, patients continue to report that these innovative drugs negotiated for medical insurance cannot be prescribed in hospitals.
The reporter interviewed many experts and learned that, on the one hand, hospitals are equipped with negotiated drugs and doctors understand innovative drugs. It takes a process from unfamiliar to familiar. On the other hand, it is necessary to implement a "dual-channel" guarantee policy for some negotiated drugs to optimize hospitals. The access process and incentive and restraint mechanisms for innovative drugs will solve the problem of drug use by insured participants.
Since March, the new version of the medical insurance drug catalog has been officially launched, and 119 drugs have been negotiated for an average price reduction of more than half to enter the medical insurance, which has benefited many patients.
However, some patients reported that some medicines could not be prescribed in the hospital.
In fact, since the medical insurance department started drug negotiations in 2017, the problem of anti-cancer drugs "getting medical insurance but not entering the hospital" has occurred from time to time.
According to the statistics of 1420 sample hospitals of the Chinese Pharmaceutical Association, about 25% of the oncology innovative drugs included in the National Medical Insurance List from 2018 to 2019 entered the hospital.
Why is it difficult for innovative oncology drugs to enter the hospital, and how to break through the "last mile" blockage of admission?
The reporter recently interviewed professionals to analyze these hot issues that the insured personnel are concerned about.
Innovative drugs need a process to enter the hospital
At present, hospitals are the main channel to ensure the landing of innovative drugs for negotiation.
Cao Zhuang, an associate researcher of the National Medical Security Research Institute of Capital Medical University, said that whether medical institutions can be equipped with innovative drugs and the rate of such equipment directly affects the implementation of the negotiated drug policy.
There is a certain rule for hospitals to equip innovative drugs, and it also requires a process.
The National Medical Security Research Institute of Capital Medical University has conducted a survey on the deployment of western medicines in some tertiary A general hospitals and tumor specialist hospitals in the 2019 negotiation drugs. The results show that after the implementation of the policy in January 2020, most of the negotiations The provision of medicines showed a substantial increase in the first quarter, and there was a trend of steady growth, and stabilized in the third and fourth quarters.
"From this, we found some laws: First, after the negotiation of drugs enters the medical insurance, the hospital's provision rate will generally increase significantly; second, the rate of drug provision in hospitals has a process and gradually stabilizes; third is the category of drugs It will affect its provision in hospitals.” Cao Zhuang introduced that through negotiations, the provision of newly approved anti-tumor drugs will be higher than other types of drugs, especially in cancer hospitals.
Cao Zhuang believes that the provision of drugs in hospitals for negotiation is mainly affected by multiple factors such as the value of the drugs themselves, the choice of hospitals, and the relationship between supply and demand in the market.
Especially for medical institutions, after implementing the drug zero markup policy, hospital drugs are sold at the purchase price, and the profit part is subsidized by the government, drug equipment, storage, and wear have become the costs of public hospitals, and drugs have changed from a profit factor to a cost. Factors seriously affected the hospital’s willingness to equip medicines.
At the same time, according to requirements, public hospitals with more than 800 beds shall not be equipped with more than 1,500 drugs.
“For some hospitals that have been fully equipped, if they want to add new drugs, they need to bring out the corresponding amount of drugs at the same time, which is more difficult and difficult.” Cao Zhuang said. At the same time, the setting of the review procedure of the hospital pharmacy management committee will also affect Whether the medicine can be admitted to the hospital and when.
Chen Hao, a professor at Tongji Medical College of Huazhong University of Science and Technology, agreed with Cao Zhuang’s views, “From the launch of innovative drugs to hospital admission, both doctors and hospitals have to go through the process from unfamiliar to familiar. At the same time, from the doctor’s understanding of drugs to diagnosis and treatment. The formulation, formation and adjustment of the norms, and then to widespread use, will also take time."
Increase the frequency of meetings of the Pharmaceutical Council to improve the efficiency of drug selection
Drugs entered the hospital catalogue and became drug selection again. Zhao Bin, deputy director of the Pharmacy Department of Peking Union Medical College Hospital, said that this is the responsibility of the internal organization of the hospital, the Pharmaceutical Affairs Management and Therapeutics Committee.
Zhao Bin said that a new drug needs to go through several steps to enter the hospital. First, it takes a long time to accumulate enough information for a drug to be marketed. It will take a long time before the doctor has a detailed understanding of the effectiveness and safety of the drug. evidence.
To apply drugs to patients on a large scale, it is necessary to consider the limitations of the effectiveness evaluation of new drugs, the safety of drugs used in special populations, the limitations of clinical research indicators, and the incidence of rare adverse reactions.
"Serious adverse reactions of many drugs were only discovered after several years of marketing, with the increase in the number of users." Zhao Bin said.
When the doctor confirms to submit the medication application, his clinical department will organize an initial selection of experts, and then submit the selection results to the Drug Administration and Pharmacotherapy Committee for review.
Subsequently, the hospital will regularly hold drug selection meetings.
"The first consideration in the selection of drugs is to meet the needs of treatment, especially the irreplaceability of treatment, safety and comparison with existing drugs." Zhao Bin said that drug price reduction will not become the leading direction of drug selection.
In this way, the frequency of meetings of the Pharmaceutical Affairs Management and Pharmacotherapy Committee determines the time and speed of new drugs entering the hospital.
It is understood that most hospitals convene pharmaceutical committees less frequently. Some large hospitals generally convene once a year or half a year, and some hospitals convene once every few years.
The validity period of negotiated drugs entering the medical insurance catalogue is two years, which means that some negotiated drugs have not yet entered the hospital and the agreement period has passed.
Professionals suggest that the frequency of hospital pharmacy meetings should be increased to improve the efficiency of drug selection.
"Dual channel" may alleviate the problem of drug admission
"It can be predicted that in 2020, the country will have a gradual increase in the provision of drugs in hospitals. However, it is obviously unrealistic to ensure that all negotiated drugs have a high rate of provision in the short term, or are fully equipped." Cao Zhuang said bluntly. .
He revealed that there are still regions that include negotiated drugs into the range of assessment indicators such as the proportion of drugs and the average cost increase per second, which affects the enthusiasm of public hospitals to equip drugs, especially innovative drugs with higher costs.
He suggested further loosening the policy and providing support for the provision of negotiated drugs for medical institutions.
At present, there have been such attempts in some areas. For example, the Yunnan Provincial Medical Insurance Joint Health Department has adopted the cancellation of the proportion of drugs, the increase in the average outpatient cost, the increase in the average drug cost in the outpatient period, the increase in the average cost of hospitalization, the increase in the average drug cost in hospitalization, etc. 5 assessment indicators to solve the problem of negotiating drug admissions.
According to incomplete statistics, more than 20 provincial-level medical insurance departments have issued policies to implement the "dual-channel" guarantee policy for some negotiated drugs, that is, the use and reimbursement of some high-value or special Medicines shall be guaranteed jointly by medical institutions and designated pharmacies.
"This is an active approach of the medical insurance department to'find a new way', and solve the supply problem caused by negotiating drugs that cannot enter the hospital." said Song Ruilin, executive chairman of the China Pharmaceutical Innovation Promotion Association.
In addition, Chen Hao believes that hospitals’ scientific understanding of innovative drugs and service capabilities should be improved, doctors’ understanding and use of drugs, innovative payment methods, and a diversified co-paying cost sharing mechanism for innovative drugs should be established to optimize hospitals’ ability to innovate. The drug access process and incentive and restraint mechanisms promote the rational use of drugs.
Li Danqing