For the 94 medicines successfully negotiated this year, the scope of payment is all consistent with the drug inserts
Why can't the negotiation of medical insurance drugs directly "bright the reserve price"?
Our reporter Li Danqing
"I hope that companies will offer more sincere quotations. We don't want to have routines." Not long ago, "the soaring price of 700,000 yuan per injection into medical insurance" was on the hot search and became a hot spot of social concern.
The video of "soul bargaining" with representatives of pharmaceutical companies, a negotiation expert sent by the National Medical Insurance Bureau and Director of the Medical Equipment Procurement Supervision Division of Fujian Provincial Medical Insurance Bureau Zhang Jinni, was praised on the Internet.
Someone also raised questions: Wouldn't it be more straightforward to see whether the company can accept the reserve price directly by the experts?
In this regard, the relevant person in charge of the Medical Management Department of the National Medical Insurance Administration recently accepted an interview with reporters to interpret the story behind the negotiations.
On-site negotiation is only part of the catalogue adjustment
The 2021 national medical insurance drug catalog adjustment started in May this year and ended at the end of November. After more than half a year, it is divided into five stages: preparation, declaration, expert review, negotiation, and announcement of results.
Among them, in the preparation stage, it is necessary to study and draft adjustment plans, extensively solicit opinions, improve related mechanisms, and establish an expert team; in the application stage, guide companies to submit drug information, organize experts to review and publicize the information, and form a list of successful drug applications; in the expert review stage, organize experts from safety Evaluate the successfully declared drugs in terms of sex, effectiveness, and economy, and determine the list of drugs for negotiation and negotiation.
The negotiation phase includes two links: one is to organize experts to use pharmacoeconomics methods, taking into account factors such as the affordability of the fund, and scientifically determine the negotiated base price of each drug, that is, the highest price that the medical insurance fund can afford; the second is to organize experts and enterprises On-site consultation and confirmation of the results on the spot.
"The successfully negotiated drugs are included in the catalog, and the negotiation result is determined to be the unified national medical insurance payment standard." The person in charge introduced that on-site negotiation is only one link in the catalog adjustment process. Before the "soul bargaining", medical insurance parties and enterprises A lot of preparatory work must be carried out, repeated demonstration, review, calculation, and communication.
According to the "Interim Measures for the Administration of Medications for Basic Medical Insurance," exclusive drugs determine the payment standard through access negotiations.
According to this person in charge, the purpose of conducting drug negotiations is to negotiate and negotiate prices with companies on the basis of "national medical insurance usage" for drugs included in the negotiation, so as to coordinate the realization of the goal of improving the efficiency of fund use and reducing the burden on patients, so that the limited Medical insurance funds have the greatest protection effectiveness.
The intersection of the bottom lines of both sides
In the live video of the negotiation, many people noticed that the negotiating expert already has a reserve price in advance.
"The negotiation base price is calculated by experts organized by the medical insurance department." The relevant person in charge of the medical management department disclosed that for the drugs that have obtained the qualifications for negotiation, the medical insurance department organizes pharmaceutical companies to submit calculation data, organizes experts in pharmacoeconomics, medical insurance management, etc., from the cost effect of drugs Develop scientific calculations from the perspectives of budgetary impact, medical insurance fund burden, etc., to form the highest price that the medical insurance fund can bear, that is, the negotiation base price, as the bottom line of the negotiation.
During the calculation process, the experts communicated face-to-face with pharmaceutical companies one by one, and tried their best to improve the scientificity, rationality, and standardization of the calculation.
According to the current negotiation rules, on-site negotiations are jointly participated by the business side and the medical insurance party, the enterprise side is negotiated by the authorized negotiating representative, and the medical insurance side is led by the negotiation team leader, and the negotiation result is determined on the spot.
First, the company will make a quotation, and the company will have two opportunities to make a quotation and confirm it.
If the price after the second confirmation of the company is higher than 115% (excluding) of the negotiated base price of the medical insurance party, the negotiation fails and it will be automatically terminated.
If the price after the second confirmation of the company is not higher than 115% of the base price negotiated by the medical insurer, it will enter the negotiation link between the two parties.
During the negotiation process, the authorized representative of the enterprise can ask for instructions by telephone, etc., but should give clear opinions on the spot.
The price agreed by both parties must not be higher than the negotiated base price of the medical insurance party.
"The ultimate success of the negotiation depends on whether there is an intersection between the bottom line of the medical insurance party and the enterprise side." The person in charge revealed that the responsibility of the medical insurance side negotiation expert is to use the negotiation mechanism to guide the enterprise to quote the lowest price it can accept.
In other words, negotiating experts strive to obtain more favorable prices for the masses within the range that the fund can bear and the enterprise can accept. This is the charm of "soul bargaining".
Return medication options to doctors
In 2004, the former Ministry of Labor issued the "National Basic Medical Insurance and Work Injury Insurance Drug Catalog", which began to limit the scope of medical insurance drug payment, and it has been used today.
The reporter combed and found that these restrictions include restrictions on the use of patients, medical institutions, etc., and drugs must be used within the restricted scope before reimbursement can be made.
For example, some drugs are limited to the rescue of clinically critically ill patients, and some injections are limited to medical institutions above the second level.
"Objectively speaking, limiting the scope of payment for medical insurance drugs has played a certain role in maintaining fund safety and preventing drug abuse under specific historical conditions. At the same time, the fairness and rationality of the limited payment range have also been repeatedly questioned." According to introduction, more and more medical staff and patients report that the limitation of medical insurance drug payment has gradually become an important factor that affects clinical rational use of drugs and even triggers doctor-patient disputes.
He believes that from the perspective of maintaining fairness in patient medication, improving the relationship between doctors and patients, and facilitating reasonable clinical treatment, it is necessary to gradually restore the scope of drug payment in the catalog to the scope of the drug insert approved by the drug regulatory authority, and the right to choose medication and decision-making power Really return it to the clinician.
"For the 94 drugs successfully negotiated in this year's adjustment, the payment scope has all been consistent with the instructions." The person in charge revealed that the original payment limit for other drugs in the catalogue is complicated and sensitive, which involves fund safety, patient benefit, and For corporate interests, in order to be stable, orderly, fair and just, the National Medical Insurance Bureau has decided to launch a pilot program of medical insurance payment standards.
In the next step, the National Medical Insurance Bureau will gradually restore the payment scope of more drugs in the catalog to the drug instructions on the premise of ensuring the safety of the fund and the fairness of patients' medications, and in accordance with the principle of reducing increments and digesting stocks, based on the progress of the pilot.