Image source @ Visual China
Text | Cai Jian Dao, author | Yin Lina, Editor | Yang Zhongxu
The instrument arm is the "hand", the optical imaging system is the "eye", behind the console, it is the "brain" of the doctor's command, and under the shadowless lamp, the surgical robot is becoming the "high-end configuration" of more and more large hospitals.
However, such a set of system equipment, the introduction cost of the hospital is as high as tens of millions. Emerging technologies need to evolve, iterate in applications, and then reduce costs and increase efficiency. But a real problem also lies ahead - how to charge patients for the use of surgical robots? Should surgical robots that have not yet become clinical "just needed" be included in medical insurance reimbursement?
The answer is gradually emerging.
The pricing standards for orthopedic surgical robots have not yet been dusted down, but the principle of directionality has become clear.
On the evening of March 30, the National Medical Insurance Bureau and the National Health Commission jointly issued documents related to supporting measures for artificial joint collection.
Among them, the charging principle of artificial joint replacement surgery robots is stipulated - no separate charging items are set up, and the traditional surgical price is increased proportionally.
The kits and consumables used by surgical robots are not mentioned. An executive of a domestic surgical robot research and development company sighed: "Consumables are not included, which is the biggest victory." ”
In addition, the document emphasizes the need to "implement the balance retention policy and coordinate the adjustment of medical service prices", and the price of artificial joint replacement surgery projects is significantly lower than the national median price and the surrounding provinces, and the prices of related projects can be specially adjusted.
Screenshot of the document on the official website of the National Medical Insurance Bureau
In other words, the price of traditional surgery for artificial joint replacement in some provinces and cities may be increased. This is because the collection of artificial joints has reduced the price of prosthetics, providing mature conditions for compensating the price of labor services for medical personnel and introducing innovative technologies.
At the beginning of March, the National Medical Insurance Bureau issued a red-headed letter of "Guidelines on Improving the Price of Auxiliary Operations such as Orthopedic "Surgical Robots" and "3D Printing" and Related Policies (Draft for Comments)", which stirred up thousands of waves and caused a lot of public opinion and capital market reactions in the field of surgical robots (for details, see the previous report "Exclusive | Medical Insurance Pricing Game: Domestic Surgical Robots Stand on the Critical Threshold").
Combining the two documents, Caijian Dao interviewed a number of industry insiders and learned that the national medical insurance department's move revealed a number of important signals.
01 Joint surgery robots into medical insurance, is a major trend
Orthopedic surgery is not only "technical work", but also "hard work".
Photo/ During a simulated artificial joint replacement procedure, the doctor is demonstrating
In the case of more than 900,000 artificial joint replacements in China every year, the core role of the operation is the implanted artificial joint prosthesis. The quality of the prosthesis, the degree of matching, the precision of the doctor's operation, etc., play a major role in the rehabilitation of the patient, and the implanted prosthesis can be used for more than 20 years in the case of good results.
To do this, orthopedic surgeons need to use various tools such as drills, bone hammers, screws and nails to knock and beat, cut off the bone and open the pulp... So as to achieve the best surgical results. The tools and consumables needed in a surgery weigh more than a dozen pounds.
Figure/Partial tool used in artificial joint surgery
The role of surgical robots in it is currently focused on preoperative planning, navigation and positioning, and some robots can participate in surgery, perform osteotomy under the command of doctors, and replace the traditional surgical "slash-and-burn" operation mode, which is more accurate at the same time, and can also reduce the trauma and bleeding of patients on the operating table.
As a result, orthopedic surgical robots have become cutting-edge equipment successively introduced by large general hospitals around the world.
Jiang Feng (pseudonym), an orthopedic professor at a large tertiary hospital in Liaoning Province, told Caijian Dao that his hospital has completed hundreds of robot-assisted orthopedic surgeries in the past few years, which was previously mainly concentrated in the field of spine, and this year also began to try robot assistance in joint replacement surgery. "The hospital has a plan, and the joint surgery robot must be introduced, because that is the inevitable trend of the future development of medical technology." He said.
"In November last year, only Stryker's MAKO was approved in the field of domestic joint surgery robots, and in February this year, we already had domestic robots listed on the market and could compete with them." An orthopedic expert from a well-known third-class hospital in Beijing also believes that it is currently in the cultivation period of the domestic surgical robot industry, and it is also a critical period for industrial development to help, and it is not possible to attack or give up technological innovation and progress because it is not mature enough.
However, if we put aside the development and iteration of supporting important cutting-edge technologies, there are also voices in the industry that point out that at this stage, orthopedic surgical robots cannot be equated with clinical "just need".
The so-called "just need", in layman's terms, is that the patient "can't do without you", whether it is difficult to replace the clinical use for many years, or to fill the clinical needs that have not been met before, all counted.
Many relevant people believe that orthopedic surgical robots = the "luxury" of the niche high-end market should not be paid for by the national medical insurance fund, but the "self-option" of a small number of conditional patients.
Previously, surgical robots were reimbursed by the medical insurance departments of various provinces and municipalities directly under the Central Government, and explored pricing. In May last year, Tianzhihang (688277. SH) performance exchange meeting, its chairman Zhang Shenggen said: "Orthopedic surgical robot treatment, has been in 15 provinces and cities into the charging directory. ”
However, since March this year, the National Medical Insurance Bureau has twice issued opinions/red-headed letters to stipulate the principle of charging orthopedic surgical robots, and also released a clear signal to the outside world - it is the trend of the times to gradually incorporate orthopedic robots into medical insurance, so it is necessary to introduce guidance and norms from the national level.
Tao Libo, a researcher at the Health Policy and Technology Evaluation Center of Peking University Medical College, said that the background of the introduction of this policy may be that the relevant departments are worried that the effect of collecting and reducing fees is "offset".
"Since last year, nationwide centralized procurement has significantly reduced the price of artificial joints, so the medical insurance department does not want to see hospitals push up surgical fees again through surgical robots or 3D printing assistance projects." He said.
An executive of a foreign-funded instrument giant in China told Caijian Dao that in the case of artificial joint collection and landing, the DGR/DIP weight score in the first year is unchanged, it may indeed boost the motivation of the hospital to introduce joint surgery robots.
He explained: "For example, suppose the current implementation of DRG/DIP, according to the previous situation, for artificial joint replacement surgery to give the medical insurance package payment price is 100,000 yuan, artificial joint collection, all at once saved 50,000 yuan, but the total amount of 100,000 yuan has not changed, the hospital in order not to affect the next year's medical insurance payment price adjustment, it tends to through other forms, the cost of saving 50,000 yuan to make up for it." ”
Previously, after the collection of coronary stents, the use of drug balloons and degradable stents with higher prices and not yet widely included in the collection has surged in many places. According to Lepu Medical's first quarter report in 2021, its innovative product portfolio (biodegradable stents, drug balloons, cutting balloons, etc.) achieved sales revenue of 132 million yuan, an increase of 1400% over the same period last year.
02 Under the bonus fee method, the traditional surgery fee is expected to be raised
In other words, the National Medical Insurance Bureau clarified the charging principle of joint surgery robots in the document of supporting measures for artificial joint collection and collection, which is to prevent joint surgery robots from becoming the next "drug balloon".
However, the National Health Insurance Bureau's move seems to be a constraint on surgical robots, but if taken properly, it may also become an important turning point to encourage the development of the industry. The key lies in two words – pricing.
In the letter issued by the National Medical Insurance Bureau in early March to solicit opinions on the pricing scheme of orthopedic surgical robots, according to the functional differences of surgical robots, four different standards of "package prices" were divided:
According to this standard, taking the total knee replacement surgery as an example, the above-mentioned Beijing expert told CaiJian Dao that the current charging standard for the traditional surgical method of the operation in Beijing is that the single price is less than 3000 yuan, and if it is charged according to the highest proportion of 80% of the above plan, that is, 2400 yuan, the total cost of an operation is less than 5400 yuan (the cost of artificial joint prosthesis is not counted).
Shortly after the letter was issued, the China Medical Equipment Association temporarily organized and held a seminar on online medical price policy for surgical robots, and representatives of more than ten imported and domestic orthopedic surgical robot manufacturers such as Zimmer, Medtronic, and Tianzhihang were launched.
Yang Jianlong, director of the technical department and training department of the association, told Caijian Dao: "The National Medical Insurance Bureau regulates the charging principle of surgical robots, which is very necessary and timely, and is also very welcome in the industry. Because surgical robots are a new thing, there were no medical service projects suitable for them in various places before, and they could only be used in the form of temporary projects or other projects. ”
However, "in terms of pricing, the way and the level of fees are charged is critical." He said, "If the price is too low, hospitals and doctors have no motivation to use orthopedic surgical robots, hospitals have no motivation, then enterprises that do technological innovation will also lose the motivation to do research and development, and when the power of innovation is exhausted, the development of this industry will also stagnate and be dangerous." ”
The pricing dispute has become the topic of "fierce debate" in the industry in the past month.
The price is too high, which violates the principle of "basic insurance" of the medical insurance fund and the KPI of "saving and controlling costs"; the price is too low, which will hit the power of industrial research and development, which is not conducive to industrial upgrading, and may even affect product production, distribution and service quality, which in turn may affect patients and clinical use effects.
Tao Libo analyzed that the supply and demand sides of the market are already around the price of the game, the key is to determine how much the price is reasonable. "If you can negotiate a price that can be accepted by both sides (health insurance and manufacturers), expand the application of cutting-edge technology in the clinic, and promote the development of the industry, while doctors and patients do not have to worry about the decline in the quality of products and services, this is a win-win choice."
It can be seen that the expression in the newly introduced artificial joint collection supporting policy document is different from the previous consultation letter, although it is no longer allowed to be a single item for joint surgery robots, it seems to have made certain "concessions" in the pricing process.
First, although they are all proportionally added on the basis of the traditional surgical price, the supporting documents issued later do not package the tool consumables, or can be priced by the market free competition, and the manufacturer charges separately.
Second, the specific proportion of additional revenue is not clearly stipulated, leaving room for local responsible departments to set their own prices.
Third, it is clearly proposed to "implement the balance retention policy and coordinate the adjustment of medical service prices" - the price of artificial joint replacement surgery projects is significantly lower than the national median price and the surrounding provinces, and the prices of related projects can be specially adjusted.
Another industry company executive said, "The policy is currently more directional and qualitative, and it is not good to say how to understand the policy quantitatively." However, it is possible to increase the cost of doctors' surgical services. The goal of national policy, I personally believe, is not to reduce medical and health investment, but to change the payment structure and lean more towards the services of doctors. ”
In August last year, the National Medical Insurance Bureau and eight other departments jointly issued the "Pilot Program for Deepening the Reform of Medical Service Prices", emphasizing "dynamic adjustment", "separation of technical labor services and material consumption" and "mobilization of medical staff enthusiasm", and explored the formation of replicable and generalizable medical service price reform experience through 3-5 years of pilots.
A week ago, a person close to the National Medical Insurance Bureau also revealed to Caijian Dao, "The bureau introduced orthopedic robot pricing rules in accordance with the bonus fee method, perhaps considering that there is room for price increases for traditional surgeries." ”
Jiang Feng and many other interviewers also confirmed to reporters that this year, medical insurance departments in Liaoning Province, Beijing Municipality and other places have relevant adjustment plans. "The previous pricing in Liaoning Province has been in use for many years, and if it goes well, it will land in April and May."
More business people have roughly estimated after many "inquiries" that after gradual adjustment in various places, the price of traditional artificial joint replacement surgery is expected to be close to about 5,000 yuan on average, while for joint robot surgery, the "boot fee" + tool consumables cost will total more than 10,000 yuan.
In the past 10 years, from the State Council, to the Ministry of Science and Technology, the Ministry of Industry and Information Technology and other ministries and commissions, down to the Beijing Municipal Medical Insurance Bureau and other ministries and commissions, there have been at least 15 important policies mentioning the "development and application of surgical robots".
With policy encouragement and capital assistance, according to incomplete statistics, in the past 3 years, it is expected that 18 surgical robots will be approved for listing in China.
Whether there is a bubble in this market, niche or popular, ultimately depends on the clinical value of the product, depending on the degree of technological progress.
A first-level market analyst whose institution has invested in a number of surgical robot companies said, "At present, it is only the first wave of surgical robots, and there are many follow-up companies, and the technology is a quick technology." In the future, who can simplify and optimize the entire structure and materials, and achieve a price acceptable to secondary hospitals, can be regarded as the industry's leading subversive. ”