1. What is the medical insurance payment standard?

The medical insurance payment standard refers to the basis for payment by the basic medical insurance fund when basic medical insurance participants use medical insurance items. The part within the payment standard shall be shared proportionally by the insured and the medical insurance fund, and the part beyond the payment standard shall be paid by the insured himself. As shown in the example below, when a patient buys this box of medicine, the 8 yuan is shared by the insured and the medical insurance fund according to the reimbursement ratio. The 2 yuan that exceeds the medical insurance payment standard is not covered by medical insurance and must be paid by the patient. In addition to medicines having medical insurance payment standards, medical consumables and medical services also have corresponding medical insurance payment standards. At present, only national medical insurance negotiated drugs and national centralized procurement drugs have clear medical insurance payment standards. Among them, the payment standard for negotiated drugs is the price determined through negotiation for exclusive varieties, and "one product, one price" is implemented, and a unified standard is implemented nationwide; the payment standard for centralized procurement drugs is the selected price, and all varieties with the same generic name are paid according to this standard, but Under the current rule design that allows multiple companies to be selected at the same time, the payment standards for the same product in different provinces are different. As for medical consumables and medical services, due to my country's vast territory, large differences in economic development and fund financing levels between regions, and the low level of medical insurance co-ordination, there is no unified standard for medical insurance payment at the national level. , generally formulated by provincial medical insurance administrative departments based on local conditions.

2. How to determine the drug and medical insurance payment standards? In 2020, the National Medical Insurance Administration clarified the method for determining the drug and medical insurance payment standards in the "Interim Measures for the Administration of Basic Medical Insurance Drug Use": 1. Exclusive drugs must be admitted The payment standards are determined through negotiation; 2. Among non-exclusive drugs, the payment standards for drugs selected by the national centralized procurement shall be determined in accordance with the relevant provisions of the centralized procurement; 3. The payment standards for other non-exclusive drugs shall be determined according to access bidding and other methods; 4. Implementing government For priced narcotic drugs and Class I psychotropic drugs, the payment standards are determined according to government pricing. According to the above rules, except for narcotic drugs and first-category psychotropic drugs that are priced by the government, other categories of drugs can determine payment standards through adjustments to the national medical insurance catalog and national centralized procurement. So, how is it implemented specifically?

1. Negotiating drugs in the medical insurance catalog. When the national medical insurance catalog is adjusted every year, drug negotiations will be carried out for exclusive varieties reviewed by experts. The medical insurance party and the enterprise representatives conducted on-site negotiations, and finally included the drug in the medical insurance drug catalog at a price acceptable to both parties, and determined that the negotiated price would be the national unified medical insurance payment standard. In this year's catalog adjustment work, the National Medical Insurance Administration issued the "Rules for Negotiating Drug Contract Renewal", which for the first time clarified the three negotiation rules for drug renewal including regular catalog management, simple renewal and renegotiation, and clarified them accordingly. Methods for determining respective medical insurance payment standards: For "inclusion in regular catalog management", the previous condition was "the original negotiated drug becomes a non-exclusive variety", this year it added "exclusive drugs that have not adjusted the payment standard and payment scope for two consecutive agreement cycles" The new condition of "drugs" also clarifies that the exclusive drugs included in the regular catalog will temporarily be subject to the current payment standards, that is, the prices negotiated that year.

"Simple renewal" means that for "exclusive drugs that have been successfully included in the medical insurance drug catalog through negotiation, the fund expenditure does not exceed 200% of the budget, the increase in fund expenditure in the next two years is reasonable, and the market environment has not changed significantly. "For varieties, the medical insurance payment standards will be recalculated in accordance with the corresponding rules based on the actual fund expenditures and the fund expenditure budget and the changes in the added value of the fund expenditure budget due to adjustments to the payment scope, and the validity period will be renewed for 2 years.

2. National centralized procurement of drugs Since the establishment of the National Medical Insurance Administration, seven batches of nationally organized centralized procurement of drugs have been carried out, with a total of 294 types of drugs successfully purchased. In addition, various regions have simultaneously carried out different forms of provincial and inter-provincial alliance centralized procurement, and the procurement varieties cover the three major fields of chemical drugs, Chinese patent medicines and biological preparations. Table: The situation of centralized and volume-based procurement of drugs organized by the state In March 2019, the National Medical Insurance Administration issued the "Opinions on Supporting Measures for the Centralized Procurement and Use of Pilot Medical Insurance for Nationally Organized Drugs", clarifying the need to coordinate medical insurance payment standards and purchase prices. In September of the same year, this measure was once again clarified in the "Implementation Opinions on Expanding the Regional Scope of the National Organized Drug Centralized Procurement and Use Pilot" issued by nine ministries and commissions including the National Medical Insurance Administration. Specifically, the method for determining the medical insurance payment standard for national centralized procurement of drugs is as follows: for selected drugs, the price selected for centralized procurement is used as the medical insurance payment standard for the generic name; for drugs with a price higher than the payment standard, the portion exceeding the payment standard will be borne by the patient. At the same time, non-selected companies are encouraged to take the initiative to reduce prices and converge to the payment standards; drugs whose prices are lower than the payment standards shall be paid according to the actual price. However, it should be noted that since the selection rules of the national centralized procurement allow multiple manufacturers to select a single product, the winning prices can also be different. Therefore, in actual implementation, each province uses the price of the selected product from the supplier company in that province as the local medical insurance payment standard. This also leads to the situation that the same type of national centralized procurement of drugs has different medical insurance payment standards in different provinces.

3. Non-exclusive varieties to be included in the medical insurance catalog. Non-exclusive varieties in the medical insurance catalog were not within the scope of management of the medical insurance payment standards in the past.

After the release of the "Interim Measures for the Administration of Drug Use in Basic Medical Insurance", this year's adjustment of the medical insurance catalog also proposed bidding rules for non-exclusive varieties for the first time. At the same time, it was clarified that varieties successfully bid to be included in the medical insurance catalog will simultaneously determine their medical insurance payment standards. According to the "Non-exclusive Drug Bidding Rules" announced in this catalog adjustment, for non-exclusive drugs that have been included in the regular catalog after expert review, medical insurance will calculate and determine the willingness to pay, that is, the expected price of medical insurance. When at least one company's quotation is not higher than the expected price of medical insurance, the drug can be included in the regular medical insurance catalog. Medical insurance will take the higher of the enterprise's lowest quote and 70% of the expected medical insurance price as the medical insurance payment standard for the drug. This standard is valid for 2 years. At the same time, the quotation companies are required to promise to supply medical insurance designated medical institutions across the country at a price not higher than the company's quotation within two years, so as to reduce patients' out-of-pocket payments due to exceeding payment standards. In the past, because drug prices were set independently by enterprises, not only were there large price differences between different manufacturers of the same drug, but there were also price differences between drugs from the same manufacturer in different provinces, which to a certain extent resulted in the medical insurance department being unable to include the drug in medical insurance. Make accurate predictions about the impact of fund expenditures. This catalog adjustment will change this status quo. By forming a national unified medical insurance payment standard for non-exclusive drugs, these drugs will be included in the scope of payment management, and further promote the return of more drug prices to a reasonable range.

4. Other drugs in the medical insurance catalog. There are 2,860 drugs in the current 2021 version of the drug catalog. Except for 275 drugs negotiated during the agreement period, the remaining 2,585 drugs have not determined unified national medical insurance payment. standard. These drugs have also become the targets of pilot reform of medical insurance payment standards in various places. According to incomplete statistics, as of now, more than 20 provinces have carried out pilot work on medical insurance drug payment standards, mainly determining medical insurance payment standards for the 30 categories in the catalog pointed out by the National Medical Insurance Administration, and formulating provincial payment standard pilot varieties based on the actual conditions of each province. Directory, to achieve unified payment standards within the province, and the pilot period is generally 2 years. Overall, although the number of pilot varieties in each province is not large, and they mainly start from minor diseases and small market volume varieties, and there are relatively few clinically necessary varieties involving major diseases, chronic diseases, etc., they are also an important step in establishing a drug and medical insurance payment standard system. A great start. In the next step, the national level can summarize the experience of pilot projects in various places, which can lay a solid foundation for exploring and establishing a national unified medical insurance drug payment standard.