The payment standard of medical insurance refers to the expenses paid by the basic medical insurance fund when the insured uses the medical insurance project. The part within the payment standard is shared by the insured and the medical insurance fund in proportion, and the part outside the payment standard is paid by the insured. For example, as shown in the figure below, the patient buys this box of medicine, and the 8 yuan is shared by the insured and the medical insurance fund according to the reimbursement ratio, and the 2 yuan medical insurance that exceeds the medical insurance payment standard is not borne by the patient.
In addition to the medical insurance payment standard for drugs, medical consumables and medical services also have their corresponding medical insurance payment standards. At present, only the national medical insurance negotiated drugs and the national centralized drugs have clear medical insurance payment standards. Among them, the negotiated drug payment standard is the negotiated price of exclusive varieties, and the "one product and one price" is implemented, and the unified standard is implemented nationwide; The payment standard for centralized drug use is the selected price, which is the standard for all varieties with the same generic name. However, under the current rules that allow multiple enterprises to choose drugs at the same time, the payment standards of the same variety in different provinces are not the same.
For medical consumables and medical service projects, due to China's vast territory, the regional economic development and financing levels are quite different, and the overall level of medical insurance is low. There is no unified standard for medical insurance payment standards at the national level, which is generally formulated by the provincial medical insurance administrative department according to local conditions.
Second, how to determine the payment standard of drug medical insurance?
In 2020, the National Medical Insurance Bureau defined the method of determining the medical insurance payment standard in the Interim Measures for the Administration of Medication in Basic Medical Insurance: 1, and the exclusive drug payment standard was determined through access negotiation; 2. For non-exclusive drugs, the payment standard shall be determined in accordance with the relevant provisions of the national centralized procurement of selected drugs; 3. The payment standard for other non-exclusive drugs shall be determined according to the access bidding. 4, the implementation of government pricing of narcotic drugs and psychotropic drugs of category I, the payment standard is determined according to government pricing.
According to the above rules, except for narcotic drugs and psychotropic drugs of category I priced by the government, the payment standards of other drugs can be determined through the adjustment of the national medical insurance catalogue and centralized national procurement. So, how exactly is it achieved?
1. Medical Insurance Catalogue Negotiating Drugs
Every year, when the national medical insurance adjusts the catalogue, the exclusive varieties reviewed by experts will be negotiated. On-site negotiations between medical insurance providers and business representatives were finally included in the medical insurance drug list at a price acceptable to both parties, and the negotiated price was determined as the national unified medical insurance payment standard. In this year's catalogue adjustment work, the National Medical Insurance Bureau issued the contract renewal rules for negotiated drugs, which defined three contract renewal rules for the first time, namely, regular catalogue management of negotiated drugs, simple contract renewal and renegotiation, and correspondingly defined their respective methods for determining medical insurance payment standards:
For "inclusion in the routine catalogue management", the previous condition was that "the original negotiated drugs became non-exclusive varieties", but this year, the new condition of "exclusive drugs whose payment standards and payment scope have not been adjusted for two consecutive agreement cycles" was added. At the same time, it is clear that the current payment standard, that is, the price negotiated in that year, is temporarily implemented for this part of exclusive drugs included in the regular catalogue.
"Simple renewal" refers to the varieties whose exclusive drugs have been successfully included in the medical insurance drug list through negotiation. If the fund expenditure does not exceed 200% of the budget, the fund expenditure will increase reasonably in the next two years, and the market environment has not changed significantly, the medical insurance payment standard will be recalculated according to the actual fund expenditure and the changes in the added value of the fund expenditure budget caused by the adjustment of the payment scope, and the validity period will be renewed for two years.
2. National centralized drug collection
Since the establishment of the National Medical Insurance Bureau, the centralized procurement of drugs organized by the state has been carried out in 7 batches, and 294 kinds of drugs have been successfully purchased. In addition, different forms of intra-provincial and inter-provincial alliances are carried out simultaneously in various places, and the procurement varieties cover three major fields: chemical drugs, Chinese patent medicines and biological agents.
Table Number of centralized drug purchases organized by the state
From March 2065438 to March 2009, the National Medical Insurance Bureau issued the Opinions on the Supporting Measures for the National Organization of Centralized Drug Purchase and Pilot Medical Insurance, which made it clear that the payment standard of medical insurance should be coordinated with the purchase price. In September of the same year, nine ministries and commissions, including the National Medical Insurance Bureau, issued the "Implementation Opinions on the National Organization of Centralized Drug Purchase and Use Pilots to Expand Regional Scope", which once again clarified this measure. Specifically, the methods to determine the national medical insurance payment standard for centralized drugs are: selecting drugs, and taking the selected centralized drug price as the medical insurance payment standard for generic names; For drugs whose price is higher than the payment standard, the patient will pay the part that exceeds the payment standard, and encourage non-selected enterprises to take the initiative to reduce prices and converge to the payment standard; Drugs whose price is lower than the payment standard shall be paid at the actual price.
However, it should be noted that the national centralized procurement rules allow multiple manufacturers to win the bid for a single product, so the winning price can be different. Therefore, in the actual implementation, all provinces take the product price selected by the suppliers in the province as the local medical insurance payment standard, which also leads to different medical insurance payment standards for the same variety of drugs in different provinces.
3. Non-exclusive varieties included in the medical insurance catalogue
Non-exclusive varieties in the medical insurance catalogue were not within the management scope of medical insurance payment standards in the past. After the promulgation of the Interim Measures for the Administration of Medication in Basic Medical Insurance, this year's medical insurance catalogue adjustment also put forward the bidding rules for non-exclusive varieties for the first time, and made it clear that the varieties that won the bid for inclusion in the medical insurance catalogue will simultaneously determine their medical insurance payment standards.
According to the bidding rules for non-exclusive drugs published in this catalogue adjustment, medical insurance will calculate and determine the willingness to pay for non-exclusive drugs that have been included in the regular catalogue after expert review, that is, the expected price of medical insurance. When there are at least 1 companies whose quotation is not higher than the expected price of medical insurance, the drug can be included in the regular catalogue of medical insurance. The medical insurance will take the higher of the lowest quotation of the enterprise and 70% of the expected medical insurance price as the medical insurance payment standard of the drug, and the validity period is 2 years. At the same time, the quotation enterprise is required to promise that the supply price of the designated medical institutions of national medical insurance within two years will not be higher than the enterprise quotation, so as to reduce the out-of-pocket expenses caused by patients exceeding the payment standard.
In the past, due to the independent pricing of drugs by enterprises, not only the price difference between different manufacturers of the same drug was large, but also the price difference between different provinces of the same manufacturer was large, which led to the inability of medical insurance departments to accurately predict the impact of drugs on fund expenditures after they were included in medical insurance. This catalogue adjustment will change this situation. Through the formation of a unified national non-exclusive drug medical insurance payment standard, this part of the drug 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 catalogue
There are 2860 kinds of drugs in the current 202 1 version of the drug list. Except for 275 drugs negotiated during the agreement period, the national unified medical insurance payment standard has not been determined for the remaining 2,585 drugs. These drugs have also become the targets of the pilot reform of medical insurance payment standards in various places.
According to incomplete statistics, up to now, more than 20 provinces have carried out the pilot work of payment standards for medical insurance drugs, mainly determining the payment standards for 30 varieties in the catalogue pointed out by the National Medical Insurance Bureau, and formulating the catalogue of pilot varieties of payment standards in the province according to the actual situation of each province, so as to realize the unification of payment standards in the province. The pilot period is generally 2 years.
On the whole, although the number of pilot varieties in each province is small, and mainly from minor diseases and small market varieties, there are relatively few clinically necessary varieties involving major diseases and chronic diseases, but it is also a good start for establishing the payment standard system for drug medical insurance. In the next step, the national level can sum up the experience of pilot projects in various places and lay a solid foundation for exploring the establishment of a unified national payment standard for medical insurance drugs.