People's Daily health client reporter Wang Aibing
Recently, the Office of the National Medical Insurance Bureau and the General Office of the National Health Commission jointly issued the "Opinions on the Centralized Procurement and Use of Supporting Measures for High-value Medical Consumables (Artificial Joints) organized by the State" (hereinafter referred to as the "Opinions"), combined with the characteristics of artificial joint procurement, distribution, use and accompanying services, to ensure the timely supply of selected products, promote medical institutions to standardize the use of collection varieties, and standardize the provision of relevant medical services. In September 2021, the National Medical Insurance Bureau organized the centralized procurement of artificial joints, and the average price of the hip joint to be selected was reduced from 35,000 yuan to about 7,000 yuan, and the average price of the knee joint was reduced from 32,000 yuan to about 5,000 yuan, with an average price reduction of 82%, and the selected varieties of the collection were successively landed in various provinces.
Photo by Cao Zihao.
First, the general requirements
Closely combined with the characteristics of artificial joint procurement, distribution, use and accompanying services, give play to the strategic purchase role of medical insurance funds, strengthen policy coordination, make full use of measures such as the collection platform hanging network, medical insurance fund prepayment, medical insurance payment policy, medical service price adjustment, and medical institution incentives and constraints, promote the smooth implementation of the results of artificial joint collection and procurement, and achieve the goals of affordable people, incentives for medical institutions and medical personnel, and high-quality development of the pharmaceutical industry.
Second, standardize the work and price of product hanging nets
The selected products for artificial joint collection and collection are listed on the provincial pharmaceutical centralized procurement platform according to the selected prices of "including accompanying service fees" and "excluding accompanying service fees", and the relevant costs such as distribution and surgical special tools are included in the selected prices. Accompanying services include providing compliant "follow-up" services, assisting with assembly tools, guidance on the use of necessary tools, training in surgical procedures, etc., and non-surgical personnel should be strictly restricted from entering the operating room. Medical institutions choose whether they need enterprises to provide accompanying services according to the actual situation, and pay according to the corresponding price. Public medical institutions (including military medical institutions, the same below) are uniformly charged according to the zero difference rate of the selected price including accompanying service fees, and the cleaning and disinfection of non-dedicated power tools and related tools is borne by medical institutions, and the relevant costs are included in the cost of medical services. Medical institutions and third-party institutions shall not charge additional fees to the selected enterprises in the process of admission to the hospital, inventory, etc.
If the non-selected artificial joint products contain the selected product components, the net is hung according to the selected price of the part, and other components can be combined with the actual transaction price to set the high line of the hanging net price, and for the products that exceed the high price line, a certain restriction is imposed when hanging the net, guiding the relevant enterprises to gradually adjust the price to a reasonable level. If the components of the non-selected artificial joint products are composed of different parts of the selected products, the total price is not higher than the price of the selected products in the same category of the enterprise. Semi-hip prosthesis and monocondylar prosthesis products, can refer to the selected price of a full set of hip and a full set of knee joint products, and hang the net according to the principle of matching performance and price.
Third, implement the prepayment policy of medical insurance funds
Local medical insurance departments should promptly organize medical institutions to sign procurement agreements with the selected enterprises. Each co-ordinating region shall timely calculate the purchase amount of the agreement according to the selected price of the selected products, the purchased products and quantities agreed upon in the agreement between each medical institution and the enterprise. On the basis of the total budget management of the medical insurance fund, a prepayment mechanism is established, and after the medical institution signs a procurement agreement with the selected enterprise, the medical insurance fund is prepaid to the medical institution at a rate of not less than 30% of the annual agreement procurement amount. Medical institutions should settle the payment with the enterprise in a timely manner, and the settlement time should not exceed the end of the next month after the use of consumables. Medical insurance agencies should settle accounts with medical institutions in a timely manner and allocate medical insurance funds in a timely manner. Under the premise of implementing the main responsibility of medical institutions to pay for goods, medical insurance funds are encouraged to settle directly with pharmaceutical enterprises.
Fourth, do a good job of linking medical insurance payment policies
The selected products for artificial joint collection shall be paid at the selected price including the accompanying service fee, which shall be included in the scope of medical insurance payment, and the medical insurance fund shall be paid in accordance with the prescribed proportion. If the non-selected artificial joints belong to the scope of payment of the medical insurance fund, all localities should take measures to gradually adjust the payment standards within two years to no more than the highest selected price of the selected products in the same group. Insured patients use products whose prices exceed the Medicare payment standard, and the part that exceeds the payment standard is paid by the patient. All localities should consider the setting of the price of the hanging net, the out-of-pocket payment ratio of patients and the payment standard of medical insurance, so as to avoid an increase in the burden of patient costs.
V. Implement the balance retention policy and coordinate the adjustment of medical service prices
All provincial-level medical insurance departments should follow the requirements of the Guiding Opinions on The Centralized Procurement and Use of High-value Medical Consumables organized by the State (Medical Insurance Fa [2021] No. 31), refer to the relevant practices of the state-organized centralized procurement of medical insurance funds, and guide the coordinating regions to improve the rules for retaining the balance of medical insurance funds. In areas where DRG/DIP payment is carried out, the weight score of the corresponding DRG/DIP group is not adjusted in the first year, and the subsequent adjustment should consider changes in labor costs and consumable costs, and scientifically and reasonably adjust or lower. All incentives should be well connected to avoid duplication, and all localities should guide medical institutions to improve the implementation of internal assessment methods for balance retention, transmit incentive policies to medical personnel, and encourage the rational, standardized and priority use of selected products.
According to the dynamic adjustment mechanism of medical service prices, in 2022, the total price adjustment can be tilted to the surgical items related to artificial joint replacement in areas that have been assessed to meet the conditions to trigger price adjustments. In areas where the proportion of inter-provincial patients with joint replacement is large, and the price of core items such as "artificial joint replacement" is significantly lower than the national median price and the price of neighboring provinces, the price of related projects can be specially adjusted. Where public medical institutions use intelligent systems such as "surgical robots" to assist surgical operations, they adhere to the principle of balancing labor value and equipment contribution, and matching fees with functions, and in accordance with the actual functions of the intelligent system, the price of the "artificial joint replacement" project is added on the basis of a certain proportion, and no separate charging items are set up.
Sixth, to ensure the stable supply of selected products
All localities should consolidate the supply and distribution responsibilities of the selected enterprises and distribution enterprises, strengthen the docking between the supply and demand sides, strictly implement the distribution of the selected products independently selected by the selected enterprises, and coordinate the selected enterprises, distribution enterprises and medical institutions to establish distribution relations. The selected enterprises and distribution enterprises should timely distribute the selected products according to the needs of medical institutions, provide special tools and accompanying services for surgery, and ensure clinical use.
7. Standardize the procurement and use behavior of medical institutions
Medical institutions should smooth the channels for selected products to enter the hospital, complete the agreed procurement volume on time, and after the agreement procurement volume is completed, they should start from the rational use of clinical practice and give priority to the procurement of selected products with high quality and good price. Medical institutions should adapt to the new mechanism of post-collection distribution, strengthen procurement and inventory management capacity building, improve the efficiency of information transmission and procurement operation, and realize the refined management of medical consumables in hospitals such as stockpiling, use, inventory, and replenishment, so as to provide good services for clinical use. National medical centers and national and provincial regional medical centers should strengthen the guidance on the standardization of joint replacement surgery operations in the coverage areas, improve the medical capacity of joint replacement surgery at all levels of medical institutions, increase retraining efforts, and provide patients with quality services.
All localities should focus on the clinical use of collected consumables, incorporate them into the medical service management system to strengthen supervision, strengthen medical institutions to strictly implement relevant diagnosis and treatment guidelines, technical operation specifications, etc., adhere to the principles of safety, effectiveness, economy and appropriateness, reasonably select treatment methods, and reasonably determine the variety and quantity of consumables.
VIII. Supervise implementation
All localities should closely monitor the performance of the selected enterprises, including product supply, distribution, special tools, and the provision of accompanying services, and include the selected enterprises that fail to perform well and are punished for illegal acts such as commercial bribery into the medical price and procurement credit evaluation records, and punish them accordingly according to the severity. In accordance with the requirements of "monthly monitoring and annual assessment", it is necessary to monitor and supervise the timeliness of the allocation of medical insurance funds and the progress and collection of payments by medical institutions in implementing the agreement. The implementation of the procurement agreement by medical institutions will be included in the assessment of public medical institutions and the performance appraisal of medical insurance designated medical institutions, and the assessment results will be linked to the collection of surplus retained funds and the amount of medical insurance costs in the next year.
All localities should deeply understand the importance of the centralized procurement and use of artificial joints organized by the state, enhance the sense of responsibility and mission, effectively strengthen organizational leadership, implement relevant supporting measures, and smoothly promote the implementation of the results of collection and procurement. It is necessary to strengthen the interconnection and interoperability of procurement and use data and share it in real time. If there are major problems encountered in the implementation of various localities, they should report to the National Medical Insurance Bureau and the National Health Commission in a timely manner.
