The broad masses, especially the insured patients, are the final tester and the highest judge of the medical insurance reform. The biggest experience of medical insurance drug management reform in the past three years lies in resolutely safeguarding the legitimate rights and interests of all basic medical insurance participants.
Wen Jialin Liang
Recently, the science and technology development center of China Pharmaceutical Association released the blue book on the progress and effectiveness of China’s medical insurance drug management reform. According to the preliminary estimate of the blue book, since the establishment of the National Medical Insurance Bureau in 2018, the burden of patients has been reduced by nearly 170 billion yuan through negotiation on price reduction and medical insurance reimbursement; In addition, since the reform of national centralized procurement with volume, the accumulated cost has been saved by about 250 billion yuan.
In view of the long-term stability of the participation rate of China’s basic medical insurance at more than 95%, according to the above data, the author estimates that each insured person can benefit about 300 yuan from this round of medical insurance reform. This indicates that the great wish made by the national medical insurance bureau at the beginning of its establishment in 2018 – to relieve all people’s worries about disease and medical treatment – has achieved remarkable phased results.
The broad masses, especially the insured patients, are the final tester and the highest judge of the medical insurance reform. The biggest experience of medical insurance drug management in the past three years is to resolutely safeguard the legitimate rights and interests of all basic medical insurance participants. In the past period, the policy of “basic medical insurance and basic insurance” was misjudged, misread and misoperated as only low-cost drugs, not high-value drugs; Only inpatient medical treatment, not outpatient medical treatment; Only offline medical care is guaranteed, not internet medical care. Once the medical insurance system shrinks from a “health supporter” to a “financial manager”, it runs counter to the implementation of the “healthy China” strategy.
One month after the establishment of the National Medical Insurance Bureau, it coincided with the release of the film “I’m not a god of medicine” reflecting the disease burden of leukemia patients in the 2000s. The national medical insurance administration attaches great importance to the economic affordability of innovative drugs. First, innovative anti-cancer drugs and other “life-saving drugs” have been included in the scope. In recent three years, anti-tumor and immune modulators have continuously ranked first in the amount used by medical insurance; The second is to issue the guiding opinions on establishing and improving the outpatient mutual aid guarantee mechanism of employees’ basic medical insurance, so that the medical insurance overall planning fund can reimburse more and more ordinary outpatient expenses of frequently occurring and common diseases; Third, during the “Hubei defense war”, online follow-up services and electronic prescriptions for mild and severe chronic diseases were included in the scope of medical insurance reimbursement.
In the past three years, from carrying out the special negotiation on the medical insurance access of anticancer drugs to publishing the “drug purchase map” (equipped with the reference list of institutions) for medical insurance drugs that are urgently needed and have weak substitutability; From hospitalization and out-patient care, we gradually achieve direct cross provincial settlement, and relax the compliance prescription dose to 3 months (long prescriptions) for patients with chronic diseases such as hypertension and diabetes. The reform of medical insurance is all aimed at the people’s livelihood.
Medical insurance policy not only belongs to the livelihood security policy guided by “common prosperity”, but also belongs to the pharmaceutical economic policy guided by “innovative China”. In order to give further play to the imagination, execution and guarantee of medical insurance reform, especially medical insurance drug reform, the author suggests:
In terms of objectives, we should base ourselves on “inclusive reform”. Next, based on the national and provincial conditions, we should gradually realize the “no dead corner guarantee” for special medical food, psychological services and long-term care services urgently needed in clinic, and implement the “zero expense guarantee” of the medical expense exemption system for special diseases (such as public health-related diseases) and special groups (the poor under the new standard and the urban “sandwich layer”), For high-value drugs with significant curative effect and irreplaceable, we should realize the “multi-level guarantee” led by medical insurance, commercial insurance and charitable donation.
On the path, we should promote “closed-loop reform”. The next step is to realize the dynamic monitoring and policy optimization of “whole life cycle” of all pharmaceutical products through unified product coding, information platform and data standards; Through the reform of various medical insurance payment methods (such as disease diagnosis related grouping DRG and big data disease point method dip), promote the “all designated institutions” of public hospitals, private hospitals and chain pharmacies to independently carry out cost and service monitoring; Medical insurance departments at all levels should strengthen the “whole subject coordination” with the “three medical” reform departments such as health care and drug supervision, as well as the competent departments of development and reform, industry and information technology, strictly prohibit the fight of regulatory policies and strictly prevent the transfer of administrative costs.
In the end, we should pursue “sustainable reform”. At the pharmaceutical end, drug bargaining should avoid “killing the chicken to get the egg” and try to avoid the complete withdrawal of some pharmaceutical enterprises from the market, resulting in a continuous shortage of clinical essential drugs; Attach great importance to the incentive effect of price signals and reasonable profits on R & D investment, and try to avoid the low incentive drug price, resulting in the sluggish R & D of “life-saving drugs” for rare diseases and Alzheimer’s disease. On the medical insurance side, we should balance the relationship between the “throttling” of drug control fees and the “open source” of fund income increase, the relationship between “short-term” fund safety and “long-term” health benefits, and pay more attention to the saving of comprehensive costs such as repeated treatment and bedside care by high-value drugs with clinical curative effect.
(the author is the Secretary General of the value medical advisory expert committee and the chief editor of the academic platform of “national health policy 2050”)
(China xiaokang.com)
