Text/ Sun Aimin
Editor / Wang Xiao
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China provides free of charge for some examinations of tuberculosis patients and first-line anti-tuberculosis drugs, but patients still have to pay for CT and other examinations, second-line drugs, and hepatoprotective and kidney-protecting drugs.
The vast majority of TB patients are cured, but treatment requires a longer course of treatment, with the average TB patient taking six to eight months and drug-resistant TB lasting up to 18 to 24 months. The long treatment process and economic burden have dragged down the patient's compliance, and many patients have stopped taking the drug halfway.
The World Health Organization (WHO) report shows that the number of newly diagnosed TB patients in China will drop by 8% in 2020.
Despite this, China is still one of the 30 countries with a high burden of tuberculosis in the world, with about 900,000 new cases of tuberculosis patients every year, and the situation of tuberculosis prevention and control in the central and western regions and rural areas is grim. The WHO estimates that there are 65,000 MDR-TB patients in China each year, of which about two-thirds are not diagnosed.
The 2022 Government Work Report will include improving the level of tuberculosis prevention and treatment services. How to make health insurance play a greater role in the settlement of tuberculosis diagnosis and treatment? On March 21, 2022, a number of experts suggested at the thematic seminar on tuberculosis prevention and control that the incentive and guidance role of medical insurance should be used to strengthen the management of patients in designated hospitals.
Fee gap
Medicare reimbursement for tuberculosis has been tilted. In 2021, Shandong, Guizhou and other provinces will include tuberculosis in the management of outpatient chronic diseases, and the reimbursement rate will reach 60%-70%, close to the proportion of hospitalization reimbursement; multi-drug resistance/extensive drug resistance will be included in outpatient serious diseases, and the reimbursement rate will be the same as that of hospitalization.
In addition to Medicare reimbursement, patients still have 20%-30% of the payment costs, and do not include out-of-pocket project costs. "These two parts of the cost are not 'burdens' for middle- and high-income families, and may be 'catastrophic' expenses for families with tuberculosis patients suffering from 'poor people's diseases'." Mao Zongfu, a professor at the School of Public Health of Wuhan University and director of the Global Health Research Center of Wuhan University, said that there is a large gap between medical insurance standards and actual costs.
In fact, the elderly in economically underdeveloped areas, migrant workers in cities, etc., belong to the specific susceptible groups with a high incidence of tuberculosis. Globally, countries with a high burden of TB are concentrated in developing countries with large population bases.
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China has implemented a number of policies, including the inclusion of a number of anti-tuberculosis drugs in the national essential drug list and the national medical insurance directory, the inclusion of tuberculosis patient health management in the national basic public health service project, and the inclusion of tuberculosis outpatient treatment in outpatient special chronic diseases.
However, drug-resistant TB has a greater burden because of its longer treatment cycle, more complex treatment and higher cost.
Drug-resistant TB currently requires treatment with second-line anti-TB drugs and is more expensive. For example, second-line anti-tuberculosis new drugs such as bedaquinoline and drumani, a course of treatment every six months, the drug cost is about 60,000 yuan. The treatment of drug-resistant tuberculosis generally takes about 18 months, and according to the who recommended drug regimen, it will take about 200,000-300,000 yuan.
Bedaquinoline and Drumani have been included in the national class B medical insurance directory, unlike the class A directory can be fully reimbursed, the proportion of drugs reimbursed in the class B directory varies from place to place, and patients still need to bear a considerable part of the medical expenses.
Some out-of-pocket examinations and self-paid drugs, especially some drugs used by drug-resistant patients, have not been included in the scope of medical insurance reimbursement, often resulting in the actual reimbursement rate generally less than 60%, and the out-of-pocket medical expenses are still high.
In addition, According to Professor Tang Shenglan, executive deputy director of the Global Health Research Institute of Duke University in the United States, the setting of the hospitalization reimbursement threshold for tuberculosis patients, especially drug-resistant tuberculosis patients, also needs to be adjusted.
The hospitalization rate of tuberculosis patients is relatively high, and the hospitalization rate of ordinary tuberculosis patients is as high as 50%; patients with MDR-TB need to be hospitalized for the first few weeks. Patients are hospitalized in second- and third-level hospitals, and the general reimbursement rate is only 60% to 70%, but the threshold is generally 600 to 800 yuan, or even thousands of yuan. The higher the hospital level, the higher the Medicare threshold.
"In the reform of the payment method, medical insurance hopes to also consider some special policies for infectious diseases, such as whether it is possible to consider canceling the hospitalization threshold for MDR-TB and further reducing or canceling the out-of-pocket payment of patients." Tang Shenglan suggested.
Payment exploration
Standardizing the behavior of medical services is one of the goals of several rounds of medical reform. In the field of tuberculosis diagnosis and treatment, irregular diagnosis and treatment, or even excessive medical treatment, is one of the reasons for the decline in patient compliance. The current payment pilot in China is intended to further standardize the diagnosis and treatment behavior and efficiently use medical insurance funds.
DIP and DRG are both medicare payment methods that are based on inpatient services. Unlike other diseases, TB lasts long and is mostly outpatient, with MDR-TB patients requiring hospitalization for the first two months and nearly 20 months thereafter; about half of patients with general TB do not require hospitalization.
When Medicare settles TB costs, outpatient and inpatient settlements are still separate. Outpatient fees are paid according to the outpatient chronic disease for one year or one course of treatment, and the hospitalization is settled according to the hospitalization compensation. "This method of payment and settlement is limited in the constraints on hospitals over-providing inpatient services and providing too many other services." Chen Jiaying, director of the Faculty of Humanities and Management of Kangda College of Nanjing Medical University, said.
For TB, there is still a need for more targeted, personalized payment methods.
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In 2020, the National Medical Insurance Bureau said in response to the proposal of the National Committee of the Chinese People's Political Consultative Conference: "Regarding the implementation of single-disease payment for tuberculosis patients, it will combine the reform of payment methods, encourage local governments to explore single-disease payment, and timely summarize the pilot experience, and continuously improve the medical insurance payment policy." ”
According to Mao Zongfu, many places have actively explored the management model of multi-sectoral participation in the co-construction, sharing and co-governance of tuberculosis prevention and control, and have formed some good practical experience.
Ningxia implements the method of medical insurance first, the government bottom, and the hierarchical burden financing method, so that the proportion of out-of-pocket (fee) for the total medical expenses of ordinary tuberculosis patients is less than 30%, and the out-of-pocket (fee) of multi-drug-resistant and poor patients is less than 10%.
Zhejiang Province implements medical insurance first, financial support, civil affairs supplement multi-channel financing methods, the provincial government will include tuberculosis in chronic diseases / special diseases included in the 2019 provincial government "ten people's livelihood facts" out-of-pocket (fee) ratio of less than 30%, multi-drug resistance and poor patients out-of-pocket (fee) less than 10%.
Jiangsu Province's special fund for the prevention and treatment of drug-resistant tuberculosis in 2020 is about 40 million yuan, of which 20 million subsidized drugs. The finance has successively purchased second-line drugs such as linezolid, moxifloxacin, levofloxacin, propylthionicotinamide and bedaquinoline, which are provided to patients free of charge; some high-value special drugs are included in the "dual channel" management, and paid for alone to improve the accessibility of out-of-hospital drugs for patients.
"Medical insurance can disperse the economic burden of diseases for patients, adjust and standardize the behavior of suppliers for suppliers, and more importantly, hope to strengthen the management of patients in designated hospitals through the guidance and incentive of medical insurance." Chen Jiaying said.