On November 11, beijing Yinbao Jianguo Hotel, the three-day negotiation of 2021 national medical insurance drugs entered the final day. A screen is blocked at the entrance, and from time to time, representatives of enterprises "snoop" inward through the gap between the screens. The four conference rooms inside are the main battlefield of this year's "national talks", and Zhang Jinni, a negotiator and director of the Pharmaceutical and Equipment Procurement Supervision Department of the Fujian Provincial Medical Insurance Bureau, is in one of the rooms.
It wasn't until December 3 that people learned about the real scene of "soul bargaining" through a video. After 8 rounds of competition, which lasted for one and a half hours, the market price of 697,000 yuan per shot of rare disease drug Nocinasin sodium injection was finally cut to less than 33,000 yuan per injection by the negotiation expert group led by Zhang Jinni. A parent of a child left a message in the group of patients, "After watching the video, a person hid in a corner and cried a lot. ”
Which medicines require a "soul bargain"? What to prepare for the "soul bargain"? What will happen on the spot? Around the topic of public concern, the reporter interviewed relevant experts to understand the doorway behind the drug negotiations.
Focus 1
What kind of medicine is entering the "soul bargaining"?
Most of the negotiated drugs are good and expensive
Whether a drug can be reimbursed is determined by the national medical insurance drug list. After the establishment of the National Medical Insurance Bureau in 2018, the adjustment period of the national medical insurance drug list was shortened from a maximum of 7 years to 1 year. At the same time, it is stipulated that for exclusive drugs with high clinical value, breakthrough efficacy but expensive prices, they must be negotiated to be included in the medical insurance directory, which is the so-called "every advance must be discussed".
Since 2018, the national medical insurance drug catalogue has been adjusted for four consecutive years, and a total of 507 drugs have been transferred to the catalogue, of which exclusive drugs account for two-thirds. This means that more than 300 "soul bargains" are staged in reality.
Which medicines can come to the negotiating table? Judging from the successful drugs negotiated in the past, it mainly involves cancer, chronic diseases (diabetes, hepatitis B, rheumatoid arthritis), cardiovascular and cerebrovascular diseases, digestive diseases, rare diseases and other clinical treatment areas. The medicine is good, but the price is expensive, which is the characteristic of most negotiated drugs.
How expensive is it? The Nocinasin sodium injection negotiated by Zhang Jinni is a typical example. The public price of the injection is 697,000 yuan a shot, and the patient needs 6 injections in the first year, followed by 3 injections per year. The indications for the drug are rare spinal muscular atrophy (SMA), muscle weakness and muscular atrophy are the main symptoms, and many children leave with long-term breathing difficulties and eating difficulties.
It is estimated that there are 1,200 new neonatal SMA patients in China every year, and the stock of patients is about 30,000. Northinalsan sodium injection is a gene-targeted drug that can rapidly improve the quality of life of patients. But the millions of medical expenses are completely unaffordable for ordinary people.
Drug negotiations are the last "life-saving straw" for children with these rare diseases. Through drug negotiations, we can give full play to the role of the "strategic purchaser" of the medical insurance department and negotiate with enterprises with "national medical insurance usage". "With China's population base and the Chinese government's determination to serve patients, it is actually difficult to find such a market." In the negotiation, Zhang Jinni said. It can be said that China's huge market size is the biggest chip in the hands of medical insurance experts.
In the first round of drug negotiations of the National Medical Insurance Bureau in 2018, 17 drugs were successfully negotiated, involving more than 10 kinds of cancer treatment drugs, with an average reduction of 56.7%; in 2019, 70 drugs were successfully negotiated, including 22 high-priced anti-cancer drugs including PD-1, with an average reduction of 65%; the third round of drug negotiations in 2020 included 96 exclusive drugs, and the average price of drugs fell by more than half; this year's new version of the national medical insurance drug list added 7 rare disease drugs in one go. Through negotiations, the world's well-known chronic disease drugs, oncology drugs and rare disease drugs have been prescribed "civilian prices", and imported drugs have basically given the lowest prices in the world.
Focus 2
How is the negotiated reserve price determined?
Find out the "civilian price" through calculation
Patients urgently need drugs, pharmaceutical companies urgently need to open the market, the National Medical Insurance Bureau acts as a "super buyer" on behalf of the insured, and drug negotiations begin.
However, the "soul bargaining" is only one stage of drug negotiation, and the entire drug negotiation process often lasts for half a year, which is divided into five stages: preparation, declaration, expert review, negotiation, and announcement of results. "The workload is extremely huge, and there are many departments that need to communicate, but everyone is holding their hearts, that is, they want the people to use medicines and afford medicines as soon as possible." An expert who has been involved in the negotiations for a long time said.
The adjustment of the national medical insurance drug list in 2021 will be launched from May, and the preparatory stage will mainly study and draft the adjustment plan, improve relevant norms and mechanisms, and establish an expert team. At the declaration stage, the main organization guides enterprises to make declarations and submit drug-related information in accordance with procedures, organizes a team of experts to review the declaration information and publicizes it, and feedbacks the review results to the corresponding enterprises to form a list of drugs that have been successfully declared.
After the list of drugs was formed, the "battle" began. In the expert review stage, a key task is to measure the negotiated drug by experts and determine the negotiated reserve price.
How is the negotiated reserve price formed? Xu Wei, director of the Pharmaceutical Service Management Division of the Zhejiang Provincial Medical Security Bureau, who has long participated in drug negotiations, revealed that the calculation team often has two groups of people, one group of experts is basically based on pharmacoeconomics experts, according to the efficacy and the price of similar products at home and abroad to measure the real price of drugs; the other group of experts is the medical insurance department personnel, according to the medical insurance fund for comprehensive stress testing. The two working groups calculated in parallel, independently gave reference prices in complete secrecy, and finally determined the negotiated reserve price of each drug.
"During the review period, all experts gathered in the Great Hall of the People Hotel closed, all participants signed confidentiality agreements and letters of responsibility, and it was strictly forbidden to exchange the content of the review with each other. At the same time, interest-related avoidance is carried out, and immediate family members cannot work in pharmaceutical companies, nor can they review the companies or drugs they have been exposed to. Liu Guoen, dean of the Institute of Global Health Development of Peking University, who served as the leader of the measurement expert group, said.
Isn't the lower the bargaining floor price, the better? "The fund's calculation is not to pursue the lowest price of drugs, but to give a reasonable payment standard. It is meaningful to find a price that is affordable to most patients and benefits the people to the greatest extent. Zheng Jie, director of the Beijing Medical Insurance Affairs Management Center, said.
After repeated argumentation, review, measurement, communication, and traces throughout the process, a top-secret negotiated reserve price is sealed in an envelope. This reserve price will also become the basis and bottom line for the experts of the negotiation team to carry out negotiations.
Focus 3
Who talks? What's so hard about negotiating?
The baht will be more suspenseful
"Zhang Jinni has always been very good, and her negotiation style has always been soft on the outside and strong on the inside." Zhan Jifu, a Sanming medical reform operator and director of the Standing Committee of the Sanming Municipal People's Congress, told reporters. Zhan Jifu is Zhang Jinni's "old boss". In 2016, Zhan Jifu prepared to build the office of the Fujian Provincial Medical Security Management Committee, becoming the first provincial-level specialized medical insurance institution in the country. The Fujian Provincial Medical Security Fund Management Center was also established at the same time, and Zhang Jinni served as the deputy director of the center. "You have now become an Internet celebrity, and you have talked very well, so that the people of the whole country can see the determination of the reform of the medical and health system." After seeing the "soul bargaining" video, Zhan Jifu called Zhang Jinni and liked her.
"Soul bargaining" is a psychological game around the price, medical insurance experts can not disclose the "bottom card" in their hands, but also as far as possible to guide the enterprise to quote a price that meets expectations, which requires a very high professional level and psychological quality. Xu Wei revealed in an interview with the media that the experts involved in the negotiation are often selected from the experienced medical insurance experts in various provinces, and the provinces recommend 2 to 3 experts, requiring long-term medical insurance work, preferably participating in medical insurance negotiations. As a person in charge of the regulatory department of pharmaceutical equipment procurement, Zhang Jinni is the most suitable candidate for drug negotiators.
The "soul bargaining" in the video, the hammer must be compared, the suspense is repeated, is the real scene like this? An expert who has watched the "soul bargain" many times gave a positive answer, "There are all kinds of emotional reactions, and there are many people who shed tears."
The negotiation team is generally composed of 1 negotiation team leader and 4 staff members, and on the day of the negotiation, the negotiators draw lots on the spot to determine the negotiation venue for the day. Before the negotiation begins, the negotiator will receive an envelope containing the name of the drug under negotiation and the negotiated reserve price, and after reading out the negotiation rules, the negotiation officially begins. Business representatives are only allowed to bring paper, pens and calculators into the market. Whenever a business representative needs to apply for a new offer from headquarters, he needs to retrieve his mobile phone at the door and make a call in the corridor.
According to the current negotiation rules, the first quotation is made by the enterprise side, and the enterprise side has two opportunities to quote and confirm. If the price after the second confirmation of the enterprise is still higher than 115% (exclusive) of the negotiated reserve price of the medical insurance party, the negotiation fails and is automatically terminated. "If the first round of quotation is far from the negotiated reserve price, the negotiator will give some tips, and then the representative of the pharmaceutical company will make the second round of quotation, which is often the most tense time." If the requirements are not met, the enterprise will be directly eliminated. The insider said.
53680, 48000, 45800, 42800, 37800, 34020..." In Zhang Jinni's "soul bargaining", after eight rounds of negotiation, the drug for the treatment of the rare disease spinal muscular atrophy finally reached the negotiation goal.
Some people also questioned why the negotiation site did not let the experts directly show the base price, and see if the company could accept it more directly. "The ultimate success of the negotiation depends on whether there is an intersection between the bottom line of the health insurance side and the corporate side." From a practical point of view, the responsibility of the negotiator of the medical insurance party is to use the negotiation mechanism to guide the enterprise to quote the lowest price it can accept. That is to say, negotiators strive to obtain more favorable prices for the people within the scope that the fund can afford and the enterprise can accept, which is the charm and value of 'soul bargaining'. The National Health Insurance Agency responded to this.
For Zhang Jinni's negotiation performance, Zhan Jifu bluntly said that she was "very excellent and professional.". In 2012, Sanming City launched medical reform, the "first fire" burned to the inflated prices of drugs and consumables, Zhan Jifu can be described as the "inventor" of "soul bargaining". Some experts joked that representatives from Fujian can generally bargain. Are there any skills in drug negotiation? "In my opinion, as a national drug negotiator, we must have the people in our hearts and consider issues from the people's interests and positions." Without the feelings of the people, this work is difficult to do well. Zhan Jifu said.
Source: Beijing Evening News reporter Yang Xujun cartography Feng Chenqing
Process Editor: Dan Guo
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