Under the realistic background of universal health insurance, the medical insurance department, which has huge purchasing power and represents the interests of medical service demanders, will inevitably have a considerable impact on the supply of medical services and even the development of the entire pharmaceutical industry.
Medical insurance payment affects the industry pattern.
The impact of medical insurance on the development of the pharmaceutical industry is mainly reflected in the following three aspects:
First, it provides important financial support for the development of the pharmaceutical industry. Generally speaking, the income of medical institutions mainly consists of three parts: medical insurance payment, patient payment and financial subsidy. Because financial subsidies have always been low in the proportion of income of medical institutions, medical insurance and patient payment actually constitute the main sources of income of designated medical institutions.
Because medical insurance agreements usually limit the self-payment and self-payment ratio of insured patients, in a sense, under the realistic background of universal medical insurance, the payment method of medical insurance directly determines the annual income of designated medical institutions, among which medical insurance fund occupies a considerable share and is an important source of funds for the development of medical institutions.
At the same time, with the full implementation of centralized procurement of drugs and medical consumables and the continuous expansion of procurement scope, the medical insurance department also plays an increasingly important leading role in centralized procurement of drugs and medical consumables, which not only ensures the orderly promotion of procurement, but also ensures the timely withdrawal of enterprise payment. In particular, the state vigorously promotes the direct settlement between medical insurance funds and pharmaceutical enterprises, providing direct financial support for the development of pharmaceutical and medical consumables manufacturing enterprises.
The second is to promote designated medical institutions to improve the level of refined management. At the beginning of the implementation of China's social medical insurance system, most medical insurance departments at all levels adopted the payment method of project payment, which led to the uncontrolled and rapid growth of medical expenses, and the medical insurance fund quickly made ends meet, which seriously challenged the sustainability of the system. After years of exploration and practice, at present, a multi-component compound medical insurance payment method based on the total budget and focusing on payment by disease type has been gradually formed.
Its main feature is "package payment", that is, according to different medical scenarios, different medical insurance payment units are formulated, specifically according to single disease, DRGs, DIP, per head, per bed day and per time, and the medical insurance settlement amount is determined according to the average medical resource consumption of each payment unit.
As the payment method of medical insurance directly determines the annual income of each designated medical institution, in order to strive for as much medical insurance fund settlement as possible, each designated medical institution will inevitably adjust the medical service behavior around the baton of medical insurance payment method and optimize the allocation of medical resources, thus promoting the continuous improvement of the fine management level of each designated medical institution. This is the essence that medical insurance payment can guide and regulate medical service behavior.
The third is to improve the quality and efficiency of pharmaceutical and medical consumables manufacturers. With the continuous expansion of centralized mining scope and standardization of centralized mining, it will be a foreseeable development trend to implement "all drugs and medical consumables should be mined". There are strict quality regulations to be included in the national centralized procurement catalogue, such as: either the original drug or the generic drug that has passed the consistency evaluation of quality and efficacy. Although it is said that based on the current reality in China, non-over-rated drugs are allowed to be concentrated by local organizations, this is only a phased measure, not a long-term strategy, and it will inevitably develop in the direction of exhaustion in the future.
Therefore, under the general trend of comprehensive centralized procurement of drugs and medical consumables, the survival and development of drug and medical consumables manufacturers are still based on product quality. For pharmaceutical manufacturers, their products must at least pass the consistency evaluation of quality and efficacy. On the other hand, because the procurement with quantity organized by the state has strict quantitative restrictions on the winning bidders, once the manufacturers of generic drugs and medical consumables fail to win the bid, it means the loss of market share, and they will inevitably face great survival risks and development crises during the bidding period. From the micro level, the pattern of comprehensive utilization of various materials will promote the production enterprises to continuously improve the production management level, thus improving product quality and enhancing product market competitiveness; From a macro point of view, it will promote the differentiation, combination, transformation and upgrading of production enterprises, and gradually build a number of intensive, large-scale and highly competitive pharmaceutical and medical consumables production enterprises in the international market.
The exploration of medical insurance reform continued to deepen.
The importance of medical insurance for the development of pharmaceutical industry has been made clear. However, in order to really help the development of the pharmaceutical industry, medical insurance should also do the following work at present.
First, constantly improve the medical insurance payment policy. On the basis of improving the scientificity, accuracy and rationality of the medical insurance fund budget, the medical insurance fund pre-allocation system is generally implemented, and medical expenses are settled with designated medical institutions in time to support the smooth operation of designated medical institutions.
We will comprehensively carry out the reform of multiple compound medical insurance payment methods based on the total budget of the medical insurance fund and focusing on payment by disease, so as to help medical institutions continuously improve the quality and level of refined management services. Explore medical insurance payment methods that meet the characteristics of Chinese medicine, encourage the implementation of the same disease, the same effect and the same price, and guide primary medical institutions to provide appropriate Chinese medicine services.
The second is to steadily carry out the "Internet plus medical insurance" service. We will continue to improve the fixed-point agreement management of "Internet+medical health" medical insurance services, improve the price of Internet plus medical services and medical insurance payment policies, support the orderly development of new medical and health service models and formats such as telemedicine services, Internet diagnosis and treatment services, Internet drug distribution, and home-based care services, and promote the rational application of new technologies such as artificial intelligence.
Support the chain, specialization and digital development of pharmacies, and give full play to the unique advantages of Shantang sushi pharmacy. Relying on the national unified medical security information platform, support the circulation of electronic prescriptions.
The third is to standardize the agreement management of designated institutions. Continue to optimize the designated management process, and establish a scientific, reasonable, fair and open performance evaluation mechanism and access and exit mechanism for designated medical institutions.
On the premise of ensuring that the access standards are not lowered, we will continuously expand the number of designated medical institutions, include more qualified medical institutions into the designated scope of medical insurance, expand the coverage of designated medical institutions, and promote the development of medical institutions. At the same time, strengthen the supervision of medical service behavior included in the scope of medical insurance payment, and promote the continuous standardization of medical service supply behavior and the continuous improvement of medical service quality.
The fourth is to strengthen and optimize the management of medical insurance services. Reform and improve the medical insurance access, payment and supervision policies of medical services, gradually establish a scientific, fair and transparent medical service access and dynamic adjustment mechanism on the basis of standardizing the details and unifying the connotation, simplify the price declaration process of new medical services, speed up the acceptance and review, promote the innovative development and clinical application of medical technologies, and promote the orderly development of new medical service technologies.
At the same time, strengthen the macro-management of medical service prices, improve pricing rules, reform and optimize pricing procedures, and explore a medical service price formation mechanism that adapts to economic and social development, gives full play to the role of the government, fully participates in medical institutions, and reflects the value of technical services. Explore and improve the price items of medical services. Support the inclusion of qualified Chinese medicine medical services in the scope of medical insurance payment according to regulations. Improve the price policy of on-site medical services.
The fifth is to dynamically adjust the catalogue of medical insurance drugs and medical consumables. Drugs and medical consumables with high clinical value, obvious benefits to patients and excellent economic evaluation shall be included in the scope of medical insurance payment in time according to procedures, and dynamic adjustment shall be implemented. Will meet the requirements of traditional Chinese medicine (including traditional Chinese medicine decoction pieces and traditional Chinese medicine formula granules) in accordance with the provisions into the scope of medical insurance payment.
From the aspects of drug negotiation, centralized drug procurement and medical insurance payment standard for patients with "two diseases", the connection between medical insurance drug list management and medical insurance payment standard will be gradually realized. Establish a medical insurance medical consumables access system, and expand the application of unique identification of medical devices in the field of health and medical security. Explore the formulation of medical consumables medical insurance payment standards, guide and standardize medical service behavior, and promote the rational use of medical consumables.
The sixth is to continuously optimize the collection and procurement of medical insurance drugs and medical consumables. Establish and improve a provincial centralized procurement platform based on medical insurance payment, which integrates bidding, procurement, transaction, settlement and supervision. We will promote and standardize the direct settlement between medical insurance funds and pharmaceutical and medical consumables manufacturers, and improve the coordination mechanism between medical insurance payment standards and centralized purchase prices.
Improve the incentive and restraint mechanism that matches the centralized procurement with quantity, implement the policy of retaining the balance of medical insurance fund, promote the centralized procurement with quantity to become the leading mode of purchasing drugs and medical consumables in public medical institutions, and encourage social medical institutions and designated retail pharmacies to participate in the centralized procurement with quantity. While curbing the inflated prices of drugs and medical consumables, we should give consideration to the reasonable profits of enterprises and promote the high-quality development of the pharmaceutical industry.