The Overall Situation Of "Medical Insurance Cost Control" Has Been Decided: The Normalized Compound Payment Of Drug Centralized Purchase Is On The Way

Innovation of medical insurance payment

With the aging of the population and the improvement of the level of medical technology, China's medical expenses continue to increase. In order to reduce unnecessary medical expenditure and effectively meet the medical needs of more people, medical insurance cost control has become one of the important goals and directions of the new medical reform. In order to cope with the payment pressure and challenges, the government, enterprises and society are stepping up the linkage, and through the innovation of system and mechanism, promote the integrated development of compound payment reform, medical insurance and commercial insurance, so as to benefit more patients.

The impact of medical insurance fee control is continuing to deepen.

On October 19, the State Medical Security Bureau officially issued the notice of the office of the State Medical Security Bureau on printing and distributing the total budget of the regional point method and the pilot program of payment according to the score of diseases (hereinafter referred to as the notice).

"Notice" put forward the goal of the pilot: 1-2 years, the overall regional medical insurance budget and the number of points method, to achieve the multiple compound payment method of hospitalization based on the score of disease type.

Among them, the settlement and payment method of compound medical insurance is the common concern of patients and hospitals. The notice pointed out that the corresponding medical insurance handling procedures and agreement management process will be improved according to the characteristics of payment according to the score of diseases.

The pilot cities will carry out disease cost calculation, classify and summarize disease types and cost data, and calculate the score according to the average cost of each disease. The score floating mechanism was tried out, and the grade coefficient of medical institutions was introduced to distinguish the scores of different levels of medical institutions and adjust them dynamically. For the diseases that are suitable for diagnosis and treatment in primary medical institutions and have the ability of diagnosis and treatment, the disease score standards formulated in different levels of medical institutions are consistent.

In this regard, Lin Zihong, founder and CEO of the United doctors group of Guangdong Weill hospital, told the reporter of the 21st century economic report that the change of medical insurance payment mode is a good thing, because charging according to disease means spending money on "cutting edge". Secondly, it is helpful to put an end to the problem of insurance fraud, and it is helpful to increase the attention of medical technology and reduce the dependence on medical devices.

Increase medical insurance charge

Medical insurance cost control has been a long-term national policy.

In order to reduce unnecessary expenditure in medical expenses, effectively meet medical needs and reduce unreasonable waste of resources, medical insurance cost control is one of the means.

Some people in the industry pointed out that due to the impact of the new crown pneumonia epidemic this year, the shortage of medical expenses in China has been aggravated, and the medical insurance cost control will undoubtedly continue to advance.

According to the statistics of the State Medical Insurance Bureau, the total income of the basic medical insurance fund in 2019 was 2333.487 billion yuan, an increase of 9.12% over the previous year, and the total expenditure was 1994.573 billion yuan, an increase of 11.9% over the previous year, which was generally in a relatively balanced situation.

However, with the aging of the population and the continuous improvement of medical technology, the growth rate of medical expenses is also rising. Some central and western provinces and cities had no current balance for many years, and even the accumulated balance in some places was very tight, and the medical insurance fund was on the edge of "bottoming out".

In the long run, there are still many controversies about the health care reform.

The important means of medical insurance payment system reform is disease diagnosis related grouping (DRG). Specifically, DRG payment is divided into different groups according to different factors, such as gender and age of patients, disease type, clinical diagnosis, length of stay, disease severity and treatment methods, and then pay according to different groups.

In recent years, China has begun to promote DRG as a medical insurance payment method. One of the reasons is that in order to achieve the ultimate direction and goal of medical insurance cost control. From purchase with quantity to multiple payment, all of them point to the direction of medical insurance cost control. The multiple and compound payment method is also established under the background of the new policy of medical insurance cost control and purchase with quantity, and all parties are involved in each other.

On the other hand, purchasing with quantity has a positive effect on medical insurance cost control.

The so-called procurement with quantity means that the required purchase quantity will be announced in the bidding announcement. In the bidding process, in addition to the price, it is also necessary to consider whether the enterprise can bear the corresponding production energy.

On December 10, 2019, the State Medical Insurance Bureau issued the opinions on how to do a good job in the current drug price management, clearly deepening the reform of centralized drug procurement system, adhering to the direction of "purchasing with quantity, linking quantity with price, and integrating bidding and purchasing", so as to promote the drug price to return to a reasonable level.

In the past, patients who went to the hospital for medical treatment generally reflected that the price of hospital drugs was too high, and the purchase with quantity had a certain effect on the price reduction of drugs.

According to statistics, 57 selected drugs were involved in the first two batches of national bulk purchase. The drug cost was reduced from 42.7 billion yuan to 8.3 billion yuan, saving 34.4 billion yuan, including 18 billion yuan of price reduction effect and 16.4 billion yuan of substitution effect.

Hospitals and pharmaceutical enterprises are under pressure

Under the background of medical insurance cost control, it is undeniable that public hospitals and pharmaceutical enterprises are facing challenges that can not be ignored.

As far as DRG payment method is concerned, it has great influence on hospital management. The hospital can locate the development status of the hospital and departments by the composition ratio of DRG group and the profit and loss situation of DRG group. By comparing the ranking of similar hospitals and departments of our hospital by benchmarking value, we can find the DRG group with large difference in cost or length of stay, analyze the cost composition of high cost DRG group, and find compressible space, so as to select the optimal clinical pathway according to cost-benefit analysis.

However, DRG payment also puts forward requirements on cost control and manual allocation of hospitals.

First of all, after the implementation of DRG payment method, clinical laboratory staff will be reduced. Take blood routine examination as an example, in order to control the total consumption amount, such test items will be cancelled because the amount of medication for patients should be reserved. If you can judge the medication by experience, you must not do physical examination. As a result, the volume of business including physical examination and emergency laboratory tests will be reduced, and the relevant inspection personnel will also be reduced.

Secondly, there will be fewer clinicians. In DRG mode, the drugs needed for a disease are basically fixed, and the gold content of outpatient doctors becomes disease judgment.

At the same time, pharmaceutical enterprises that provide drugs for public hospitals are facing more severe impact.

From the aspect of purchasing with quantity, if the drug does not win the bid, the survival of the enterprise will be a problem. But even if the pharmaceutical enterprises win the bid, they may also face the huge pressure of cost optimization. How to reduce the cost and complete the production of prescribed quantity of drugs is a big problem. Therefore, it is a logical cost optimization method for enterprises to lay off staff and reduce their burden.

In a word, no matter whether winning the bid or not, pharmaceutical enterprises are facing a lot of difficulties. After the pilot project of "4 + 7" procurement with quantity, it can be intuitively found that the benefits and profits of many pharmaceutical enterprises have shrunk. According to a data of national public sample hospitals of Ameda, taking atorvastatin and clopidogrel as examples, the sales volume of atorvastatin and clopidogrel has shown an obvious downward trend in 2019.

Lin Zihong told the 21st century economic reporter: "purchasing with volume has a great impact on public hospitals. First of all, with volume procurement makes the price of drugs open, which to a certain extent reduces the long-standing gray income of public hospitals in the past drug trade. The most direct reflection of the decrease in income is that the income of hospital management and doctors will also decrease. Second, the profits of pharmaceutical companies will also decline. Moreover, as far as hospital operation is concerned, some pharmaceutical companies may no longer be willing to supply drugs to the hospital, or the variety of drugs supplied is limited, so the variety of drugs will be much worse than before. Finally, problems may arise in clinical work due to these factors. Although these problems can be solved, they will still have certain impact. "

The staff of the purchasing department of a Grade-A hospital in Guangzhou told the reporter of the 21st century economic report that the impact of purchasing with quantity on the funds of public hospitals in the short term is obvious. The trend of medical development in the future should be to return to the medical service itself and remove the development mode of "relying on medicine to support medicine".

Talking about the future development trend of medical insurance payment method, Lin Zihong believes that the main direction should be more work, more high-tech content. And the payment will be classified, so that hierarchical management can play a greater role. In addition, at the level of Medical Union and medical community, the unified settlement of medical insurance is also the future development direction.