The impact of health insurance on the profits of pharmaceutical companies

The responsibility of the health insurance department is to form a group purchasing power of pharmaceutical services through the financing of the health insurance fund as a bargaining chip with pharmaceutical institutions, supplemented by the health insurance payment and the organization of centralized purchasing of medicines and medical consumables as a means of realizing the strategic purchasing of the health insurance fund and obtaining high-quality pharmaceutical services for the insured people.

In the context of the reality of universal health insurance, as a huge group of purchasing power, representing the interests of the demand side of the medical services of the medical insurance sector, will inevitably have a considerable impact on the supply of pharmaceutical services and even the development of the entire pharmaceutical industry.

Medicare Payment Ties Industry Patterns

The impact of medicare on the development of the pharmaceutical industry is mainly reflected in the following three aspects:

One of them is to provide an 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 subsidies. Since the financial subsidies in the medical institutions of the proportion of income has been low, medical insurance and patient fees in fact constitute the main source of income of the designated medical institutions.

As the medical insurance agreement usually will be insured patients personal out-of-pocket and out-of-pocket expenses to make restrictive provisions, in the context of the reality of universal health care, in a sense, the medical insurance payment method directly determines the annual income of the designated medical institutions, which the medical insurance fund occupies a high share, is an important source of funds for the development of medical institutions.

At the same time, with the full implementation of the centralized purchasing of drugs and medical consumables and the continuous expansion of the scope of procurement, the health insurance sector in the centralized purchasing of drugs and medical consumables is also playing an increasingly important leading role in ensuring that the procurement of work in an orderly manner at the same time, but also to ensure that the enterprise payment of money back in a timely manner. In particular, the state's efforts to promote the medical insurance fund and pharmaceutical enterprises to carry out direct settlement, but also to help the development of drugs and medical supplies production enterprises to provide direct financial support.

The second is to promote the fixed-point medical institutions to improve the level of fine management. In the early stages of the implementation of the social health insurance system in China, most of the health insurance departments at all levels have adopted the payment method of itemized payment, resulting in rapid and uncontrolled growth of medical costs, and the health insurance fund will soon be unable to make ends meet, and the sustainability of the system has been seriously challenged. After years of exploration and practice, the current gradually formed in the total budget based on the main payment by type of disease, multi-compound medical insurance payment method.

Its main feature is "packaged payment", that is: according to different medical scenarios, the development of different health insurance payment unit, specifically, according to a single disease, according to the DRGs, according to DIP, per capita, per bed day, according to the average payment unit, according to the average consumption of medical resources per payment unit. The amount of medical insurance settlement is determined according to the average consumption of medical resources of each payment unit.

As the health insurance payment method directly determines the annual income of the designated medical institutions, the designated medical institutions in order to fight for the largest possible amount of health insurance fund settlement, will inevitably be around the health insurance payment method of this baton to regulate the behavior of medical services, optimize the allocation of health care resources, so as to promote the designated health care institutions continue to enhance the level of fine-tuned management. This is the health insurance payment method can guide and adjust the essence of medical service behavior.

Thirdly, it is to boost the quality and efficiency of drugs and medical consumables manufacturers.
With the expanding scope of the collection and the collection of the continuous standardization of the work, the implementation of drugs and medical supplies "should be collected as much as possible" will be the future of the foreseeable development of the general trend. To be included in the scope of the national procurement catalog has strict quality requirements, such as: either the original drug, or through the quality and efficacy consistency evaluation of generic drugs. Although, based on the current realities of our country, allowing non-evaluated drugs by local organizations to implement the alliance procurement, but this is only a staged initiative, rather than a long-term strategy, the future will certainly be to the direction of should pick up all pick up.

Therefore, in the drugs and medical supplies to implement a comprehensive collection trend, drugs and medical supplies production enterprises to survive and develop the fundamental product quality, for drug manufacturers, their products at least through the quality and efficacy consistency assessment. On the other hand, due to the national organization of band purchasing bidding enterprise has a more stringent number of restrictions, in the procurement volume allocation of highly centralized situation, generic drugs and medical consumables manufacturers once the bidding loss, which means the loss of market share, bidding cycle must face a huge risk of survival and development crisis. Should pick all the pattern, from the micro level, will prompt the production enterprises to continuously improve the production management level, so as to improve product quality, enhance product competitiveness in the market; from the macro level, will prompt the production enterprises to differentiate the combination and transformation and upgrading, and gradually create a number of intensive, on the scale of the international market has a strong competitiveness of the drugs and medical consumables production enterprises.

Medicare reform exploration continues to deepen

The importance of health insurance for the development of the pharmaceutical industry has been clear. However, the medical insurance to really play a role in the development of the pharmaceutical industry, but also to do the following aspects of work.

One is to continuously improve the health insurance payment policy. On the basis of improving the scientific, accurate and reasonable budget of the medical insurance fund, the general implementation of the medical insurance fund advance allocation system, timely settlement of medical expenses with the designated medical institutions, to support the stable operation of the designated medical institutions.

Comprehensively carry out the total budget of the medical insurance fund as the basis to pay by the type of disease, mainly multi-compound medical insurance payment method reform, and promote the medical institutions to continuously improve the quality and level of fine management services. Explore the medical insurance payment method in line with the characteristics of Chinese medicine, encourage the implementation of Chinese and Western medicine with the same disease, the same effect, the same price, and guide the primary medical institutions to provide appropriate Chinese medicine services.

The second is the steady development of "Internet + medical insurance" services. Continuously improve the "Internet + medical health" medical insurance service fixed-point agreement management, improve the "Internet +" medical service price and medical insurance payment policy, support telemedicine services, Internet diagnostic and treatment services, Internet drug delivery, The new mode of medical and health services such as door-to-door nursing services and other new modes of business development in an orderly manner, and promote the rational use of artificial intelligence and other new technologies.

Support the development of pharmacy chain, specialization and digitalization, and give better play to the unique advantages of pharmacies and the role of pharmacists. Relying on the national unified medical insurance information platform, to support the flow of electronic prescriptions.

Third, the unified standardization of fixed-point institutions agreement management. Continuously optimize the fixed-point management process, and establish a scientific, reasonable, fair and open performance evaluation mechanism for fixed-point medical institutions and an entry and exit mechanism.

Under the premise of ensuring that access standards are not lowered, the number of designated medical institutions will continue to expand, and more qualified medical institutions will be included in the scope of the medical insurance designated to extend the coverage of the designated medical institutions, and promote the development of medical institutions. At the same time, strengthening the supervision of medical services included in the scope of payment of medical insurance, and promoting the continuous standardization of the supply of medical services and the continuous improvement of the quality of medical services.

Fourth, strengthen the optimization of medical insurance medical service project management. Reform and improve the medical service project medical insurance access, payment, supervision policy, in the standardization of detailed, unified content based on the gradual establishment of scientific, fair and transparent medical service project access and dynamic adjustment mechanism, simplify the process of new medical service price declaration, accelerate the acceptance of the audit, promote the development of medical technology innovation and clinical application, promote the development of new technologies in medical services in an orderly manner.

At the same time, to strengthen the macro management of medical service prices, improve the pricing rules, reform and optimize the pricing procedures, and explore to adapt to economic and social development, better play the role of the government, the full participation of medical institutions, reflecting the value of technical services of medical service price formation mechanism. Explore and improve the price of pharmacy medical services. Support the eligible medical services of traditional Chinese medicine into the scope of medical insurance payments in accordance with the regulations. Improve the pricing policy for medical services provided at home.

Fifth, dynamically adjusting the catalog of medicare drugs and medical consumables. The medicines and medical consumables with high clinical value, obvious benefits to patients, and excellent economic evaluations will be incorporated into the scope of payment of medical insurance in a timely manner according to the procedures, and will be dynamically adjusted. The eligible Chinese medicines (including Chinese medicinal tablets and Chinese medicinal granules) are included in the scope of payment of medical insurance in accordance with the provisions of the law.

Starting from the negotiation of drugs, centralized volume purchasing drugs and "two diseases" patients with medication payment standards, and gradually converge with the management of the Medicare drug catalog and Medicare payment standards. Establish a medical insurance access system for medical consumables, and expand the application of unique identification of medical devices in the fields of health care and medical insurance. Explore the development of medical supplies medical insurance payment standards, guide the standardization of medical service behavior, and promote the rational use of medical supplies.

Sixth, continue to optimize the medical insurance drugs and medical supplies procurement work. Establishing and improving the provincial centralized purchasing platform based on medical insurance payment and integrating bidding, purchasing, trading, settlement and supervision. Promote and standardize the direct settlement between the health insurance fund and pharmaceutical and medical consumables manufacturers, and improve the health insurance payment standard and centralized purchasing price synergy mechanism.

Improve the incentive and constraint mechanism in line with centralized purchasing with quantity, implement the policy of retaining the balance of health insurance funds, promote centralized purchasing with quantity as the leading mode of purchasing medicines and medical consumables for public medical institutions, and encourage the participation of socially-run medical institutions and designated retail pharmacies in centralized purchasing with quantity. While curbing the inflated prices of medicines and medical consumables, it also takes into account the reasonable profits of enterprises and promotes the high-quality development of the pharmaceutical industry.