The price of pharmacy services is coming, and the "pharmaceutical service fee" is gone

The Fujian Medical Insurance Bureau carried out the exploration of pharmacy service charges under the guidance of the National Medical Insurance Bureau, which can be understood as another boot after the "14th Five-Year Plan for National Medical Security", specifically: the pharmacy service price policy has come, and the "pharmaceutical service fee" has gone.

The author | Jiang Changsong Director of the Price Recruitment Office of the Medical Insurance Research Institute

The source | Chinese medical insurance

Recently, under the guidance of the National Medical Insurance Bureau, the Fujian Medical Insurance Bureau issued the Notice on the Trial Implementation of the Pharmaceutical Service Charging Policy in Provincial Public Hospitals (Fujian Medical Insurance [2022] No. 49), marking a new level in the price policy of pharmaceutical medical services in the mainland. The author notes that as early as the "14th Five-Year Plan for National Medical Security" issued in September 2021, the reference to "exploring and improving the price of pharmaceutical medical services" rarely appeared in the chapter on reforming and improving the pharmaceutical price formation mechanism, and the industry speculated about whether this new proposal could be equated with "pharmaceutical service fees". The Fujian Medical Insurance Bureau carried out the exploration of pharmacy service charges under the guidance of the National Medical Insurance Bureau, which can be understood as another boot after the "14th Five-Year Plan for National Medical Security", specifically: the pharmacy service price policy has come, and the "pharmaceutical service fee" has gone.

01 Four clear

Pharmacists directly carry out pharmacy services for patients, which is of great significance for promoting rational drug use, improving medical quality, ensuring the safety of patient medication, and improving the level of drug treatment. The "Notice" actively explores the price policy of pharmaceutical medical services, and on the basis of clarifying the price boundaries of pharmaceutical medical services and standardizing the price connotation of pharmaceutical medical services, it is planned to pilot the charging of pharmaceutical services in public hospitals in Fujian Province.

Since then, the price management of pharmaceutical medical services has changed from "drug-centered" to "patient-centered", from "hospital operation-centered" to "patient benefit-centered", from "to ensure drug supply as the center" to "on the basis of ensuring drug supply, to focus on strengthening pharmaceutical professional and technical services and participating in clinical drug use as the center", the core is to make pharmaceutical services close to patients, close to clinics, and close to society. Compared with the "pharmaceutical service fee" that the industry has sought to set in the past, the price policy of the trial pharmacy medical services is significantly different, and it can be summarized into four clear definitions.

Clarify the basic positioning. The pharmacy service charging policy adheres to the basic positioning of "output-oriented, quality and price matching", and the clinical pharmacists of medical institutions who meet the prescribed qualifications apply pharmaceutical professional knowledge and technology for the purpose of promoting rational and economic drug use, and take the clinical pharmacy services for patients, independent content and direct provision as the price items of pharmaceutical medical services, so as to prevent the price items with insufficient service content and the nature of "head fee" and "threshold fee". For the matters that should be fulfilled by hospitals such as traditional prescription review and adjustment, as well as service matters that belong to the internal management of hospital pharmacies, when designing policies, it is clearly considered as the comprehensive operating costs of public hospitals, and medical service price items are not set up separately.

Clarify the scope of the pilot. The "additional fees" for drug treatment outpatient clinics, multidisciplinary comprehensive outpatient clinics and inpatient consultations are limited to the collection of pharmacy services such as clinical drug treatment provided by provincial public hospitals for patients. As the policy of additional fees is still being tried on a trial basis for Chinese medicine tablets, it does not include TCM treatment. Public medical institutions provide pharmacy services such as serum drug concentration determination, screening of various types of drugs of abuse, drug sensitivity tests, intravenous drug dispensing fees, and genetic testing for medication guidance.

Clarify the price items. New drug treatment outpatient projects; sort out and improve the charging items related to pharmaceutical services in the current price projects, standardize and integrate the price items of pharmaceutical medical services, including but not limited to serum drug concentration determination, various types of drug abuse screening, drug sensitivity tests, genetic testing for medication guidance, intravenous drug dispensing fees, etc.; adjust the inpatient consultation fee and multidisciplinary comprehensive outpatient price project, and clinical pharmacists who meet the prescribed qualifications participate in inpatient rounds and multidisciplinary comprehensive outpatient clinics. Provide drug test results interpretation and clinical drug use recommendations, put forward opinions on drug reorganization or drug intervention, and implement the "additional collection" policy on the basis of inpatient consultation fees and multidisciplinary comprehensive outpatient clinics.

Clarify Medicare payments. The outpatient items of drug treatment shall be included in the scope of medical insurance payment, and shall be paid by the basic medical insurance in accordance with regulations; the price items of pharmaceutical medical services such as intravenous drug configuration, serum drug concentration determination, drug sensitivity testing, and genetic testing for medication guidance, as well as the charging standards after the inpatient examination fee is "added" in accordance with regulations, shall be included in the scope of medical insurance payment in accordance with regulations; all kinds of abuse drug screening and multidisciplinary comprehensive outpatient medical insurance shall not be paid.

02 Four transformations

What are the changes, advantages, and innovations in the pricing policy of pharmaceutical services, which can be summarized as four changes.

The project setting is more scientific and the connotation boundary is clearer. In the past, the pharmaceutical service fee with vague connotation boundaries was changed, and the Fujian Medical Insurance Bureau set the pharmaceutical medical services as 15 price items, of which 6 were additional items. Specifically, it includes drug treatment clinics; intravenous drug dispensing fees, intravenous drug dispensing fees (special drugs); serum drug concentration determination; humoral antibiotic concentration determination; various types of drug abuse screening; drug sensitivity tests, drug sensitivity tests (tuberculosis bacteria), drug sensitivity tests (special drugs); genetic testing for medication guidance, genetic testing for medication guidance (more than 1 genetic testing); multidisciplinary comprehensive outpatient clinics, multidisciplinary comprehensive outpatient clinics (including clinical pharmacy); inpatient consultation fees, inpatient consultation fees (clinical pharmacy surcharge). The name of each project is close to the patient, close to the clinic, the project connotation is clear, the project boundary is standardized, and the valuation unit is scientific.

Price items are more optimized and project compatibility is improved. The addition of drug treatment clinics better reflects the clinical service value of pharmacists. At the same time, 8 items such as "conventional drug susceptibility test", "fungal drug susceptibility test" and "tuberculosis bacteria drug susceptibility test" are integrated into the "drug sensitivity test" project, and 2 items such as "vancomycin-resistant gene test" are integrated into "drug-guided genetic testing", which is compatible with various drugs. The "tumor cell chemotherapy drug sensitivity test" is standardized as "drug sensitivity test (special drug)", and the "anti-tumor chemical drug configuration" is standardized as "intravenous drug allocation fee (special drug)", and there is no need to set up a separate item according to each special drug. Expanded compatibility of price items.

The price level is more reasonable, reflecting the quality and price matching orientation. When pharmacy participates in the consultation as an independent discipline, it emphasizes the on-site participation of clinical pharmacists, provides substantive services, and carries out clinical drug intervention, allowing additional fees, avoiding the old road of "head fee" in disguise, and improving the enthusiasm of pharmacists to participate in clinical diagnosis and treatment. Serum drug concentration determination (chromatography), serum drug concentration determination (tumor treatment drug concentration determination), serum drug concentration determination (immunosuppressive drug concentration determination) and other three items are no longer differentiated in pricing, and the price of serum drug concentration determination items is implemented; all kinds of abuse drug screening are no longer differentiated pricing, and various types of abuse drug screening items are implemented; and the value medical orientation is consistent with the quality and price. Serum drug concentration determination of more than 3 drugs is charged according to 3 kinds, various types of drugs of abuse screening more than 2 kinds of drugs are charged according to 2 kinds, and the genetic testing of medication guidance is charged at 680 yuan for each drug test, and other norms are charged to prevent excessive medical treatment.

The management mechanism is more perfect, and the monitoring and evaluation is closed-loop. The "Notice" particularly emphasizes the establishment of a monitoring and evaluation mechanism for pharmacy service charges, carry out the tracking of charges and payments, focus on monitoring the safety, rationality, economy and influence of drug use, and choose the opportunity to evaluate the management of drug treatment, promote rational use of drugs and safe use, and let patients feel the value of pharmaceutical services. The monitoring and evaluation indicators include 4 first-level indicators and 12 second-level indicators, which are related to the clinical pharmacist's allocation, correction of the number of irrational use of drugs, and the rate of drug error reporting, so as to effectively play the value of clinical pharmacists; they are related to the proportion of outpatient drug sub-costs, the proportion of generic drugs, the ratio of diagnosis and examination fees to the average cost of drugs, and encourage the reasonable reduction of drug costs; they are related to the clinical path drug use rate, drug price use structure, and drug delivery route use structure, and evaluate the rationality of drug use; and are related to the reform of payment methods such as DRG, DIP, and single disease , assessment, give play to the role of medical treatment, medical insurance, medicine and medicine.

03 Goodbye "Pharmaceutical Service Fee"

The reference to "pharmaceutical service fees" is found in official documents, starting with the 2009 medical reform opinions, but it has not made waves for a long time, including pharmacists in public hospitals, and the attention is relatively limited. After the drug markup of public medical institutions was completely cancelled in 2017, the pharmaceutical community, especially pharmacy personnel, has a strong call for the establishment of a "pharmaceutical service fee". But for a long time, the voice is very high, but few really land. According to the author's analysis, there is no consensus on the following three aspects:

First of all, what is the relationship between the "pharmaceutical service fee" and the cancellation of the drug markup? The industry's ideal "pharmaceutical service fee" is charged on a prescription or per person-time basis. According to the calculation of 8.53 billion outpatient emergency visits and 240 million discharges in medical and health institutions in 2021, assuming that outpatient clinics are 10 yuan each time and hospitalizations are 30 yuan each time, then the annual charging scale of the country will reach nearly 100 billion yuan. According to the scale of drug sales in public hospitals around 2017, the drug bonus of 15% of the purchase and sales difference rate is about 100 billion yuan. As we all know, the cancellation of drug bonuses is not to reduce the revenue of public hospitals by 100 billion yuan out of thin air, but to replace them by adjusting the price of medical services and increasing financial input. After the replacement is completed, a staggering amount of "pharmaceutical service fees" are added to the backhand, which means that the operation of repeated compensation is extremely heavy, and it is difficult to be accepted by the decision-makers.

Second, is the "pharmaceutical service" suitable for charging patients as a stand-alone project? Pharmaceutical services are complex, one type of service is direct service for specific patients. Among them, some can set up separate services, such as pharmacy clinics, intravenous drug dispensing, blood drug concentration monitoring, etc. Some are internal management matters of the hospital, not direct services for patients, such as warehouse management, drug loss, equipment maintenance, etc., and some are the responsibilities and obligations that the hospital should fulfill when providing services, such as prescription review, medication training, etc. If the pharmaceutical service fee is established independently, it will be difficult to avoid unreasonable and illegal problems such as duplicate compensation, compulsory services, bundled services, and decomposition charges.

Third, can patients feel the "pharmaceutical service" and can they accept the "pharmaceutical service fee"? According to the prescription or the number of people to charge the "drug service fee", the patient is passive, can not choose, then after the fee is charged, the patient can feel from such a service What specific services? A study randomly interviewed hundreds of patients, all of whom said that in addition to the thin service of drug distribution, prescription proofreading, and simple guidance, there was no obvious sense of pharmaceutical services. Whether it is the outpatient "pharmaceutical service fee" charged by head or prescription, or the inpatient "pharmaceutical service fee" charged according to the bed day or the number of hospitalizations, the vast majority of the patients interviewed explicitly stated that they did not accept this charge.

For the hollowing out of the connotation of this service, there is an analysis that the claim that the "pharmaceutical service fee" is not entirely reflected in the value of pharmaceutical services, but has a deeper reason. Specifically, after the cancellation of the drug markup, although the hospital income can be balanced through the adjustment of medical service prices, but specific to the departments in the hospital, the pharmacy has changed from the "profit center" of the bonus era to the "cost center" of the post-bonus era, and the decline in revenue generation capacity has led to a "double decline" in the status and income of the pharmacy department in some hospitals that do not have enough understanding of the necessity of pharmaceutical services, and the treatment of pharmacy personnel has also declined. The "pharmaceutical service fee" has become an effort to strive for new revenue-generating channels from the outside and enhance the right to speak.

In contrast, the pricing policy of pharmaceutical services piloted by the Fujian Medical Insurance Bureau emphasizes specific services directly for patients, services that are needed, and output is paid, and clearly rejects the price items of "head fee" and "threshold fee", and clearly proposes to solve the matters of internal management of hospitals in the pricing cost, which is obviously more pragmatic, and while reflecting the value of pharmaceutical services, it is easier to be recognized and accepted by the demand side. (Original title: The price of pharmacy services is coming, and the "pharmaceutical service fee" is gone)

END

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