On the morning of April 11, the National Health Insurance Administration held a regular press conference for the first half of 2024, at which the meeting replied to hot issues of social concern such as the national insurance situation, the medical insurance catalog, the reform of payment methods, remote medical treatment, and centralized procurement. China Medical Insurance (ID: zgylbxzzs) combines social concerns and takes you to review the key points of the press conference:
First, the operation of the medical insurance fund is stable, and a reasonable balance is achieved, not without money, but also not extravagantly
From January to December, the total income of the basic medical insurance pooling fund (including maternity insurance) was 2.7 trillion yuan, the total expenditure was 2.2 trillion yuan, the current balance of the pooled fund was 500 billion yuan, and the cumulative balance of the pooled fund was 3.4 trillion yuan.
Zhu Yongfeng, deputy director of the Department of Regulation, Finance and Regulations of the National Health Insurance Administration, pointed out that these data are more mutually beneficial pooled funds, and they are funds that can really be used by all insured, and the official website of the National Health Insurance Administration will continue to publish the relevant data of the pooled funds in the future. This means that the medical insurance fund available for the use of the national insured is running smoothly and can meet the basic medical security needs of the masses.
The cumulative balance of the employee medical insurance pooling fund is 2.6 trillion yuan, and the cumulative balance of the residents' medical insurance pooling fund is more than 760 billion yuan. Although the amount of funds in the overall fund of employee medical insurance seems to be a lot, it needs to maintain a reasonable scale because it is used to ensure the treatment of retired employees who do not need to pay after retirement, and the resident medical insurance is still in a tight balance, not as some people say, "too much medical insurance balance should not be paid", but still to maintain a reasonable insurance payment fee.
2. The drugs in the medical insurance catalogue can meet clinical needs, and the vast majority of the drugs purchased by hospitals are in the medical insurance catalogue
In the current version of the National Medical Insurance Catalogue, there are a total of 3,088 kinds of Western medicines and proprietary Chinese medicines, as well as 892 kinds of Chinese medicine decoction pieces. On this basis, the provinces have also included eligible ethnic medicines, traditional Chinese medicine decoction pieces, and preparations of medical institutions into the medical insurance catalogue of their regions. After the establishment of the National Health Insurance Administration, a dynamic adjustment mechanism has been established, and some newly listed new drugs and good drugs have been added to the catalogue every year, with a total of 744 kinds of drugs included in the catalogue in 6 years, and the number of Western medicines and Chinese patent medicines in the catalogue has increased from 2,535 in 2017 to 3,088 at present, and the level of protection has been significantly improved. In particular, in the therapeutic fields such as tumors, hypertension, diabetes, rare diseases, and autoimmune diseases, the number of varieties in the catalogue and the efficacy of drugs have been greatly improved, achieving a higher degree of matching between the scope of protection and the epidemic of diseases and the demand for clinical drugs. Statistics show that at present, the purchase amount of the varieties in the catalogue has accounted for more than 90% of the drugs purchased by public hospitals across the country.
Third, the catalogue has been implemented, and the prices of included drugs have returned to reasonableness, greatly reducing the burden on patients, and reducing the average daily treatment cost of some patients by nearly 93%
Huang Xinyu, director of the Department of Pharmaceutical Administration of the National Health Insurance Administration, introduced that the new version of the drug catalogue will be implemented from January 1, 2024, and from January to February 2024, the medical insurance fund has paid 15.45 billion yuan for 397 negotiated drugs during the agreement period, benefiting 39.5 million insured patients. Taking sacubitril-valsartan sodium tablets, a drug used for the treatment of chronic heart failure and essential hypertension, as an example, before entering the medical insurance catalog, the average daily treatment cost of the drug was nearly 70 yuan, and after the access negotiation and two renewals in 2019, the average daily treatment cost of individuals is less than 5 yuan after being reimbursed by basic medical insurance, and the average daily treatment cost has been reduced by nearly 93%, and preliminary statistics show that more than 5 million people have benefited from January to February alone. The inclusion of good drugs and new drugs in the medical insurance catalogue effectively reduces the burden of medication on patients.
Fourth, the cost of treatment has been greatly reduced by centralized procurement, and the cost of the same surgery for some patients has been reduced from 80,000 yuan to 30,000 yuan
Centralized procurement has reduced the economic burden of drugs and consumables for the people, and the benefits are visible: on the one hand, the price of pharmaceutical consumables with seriously inflated prices has decreased. For example, a patient in Hunan Province used 60,000 yuan of all-ceramic joint prosthesis for left hip replacement before centralized collection, and the total cost of the operation was 80,000 yuan, and after the centralized collection of artificial joints, he did left hip replacement surgery, and the same ceramic joint only cost more than 8,000 yuan, and the total cost was only 30,000 yuan. On the other hand, high-quality and affordable products have opened the market, the original price difference between different manufacturers of some drug consumables is very large, some are particularly high, and some although the price is appropriate, but under the existing purchase and sales system due to various factors can not open the market, the price discovery mechanism of centralized procurement will push low-price products to the user end in a "volume" way. For example, the price of metformin, an antihypertensive drug, is less than 1 cent per tablet, and the annual dosage of the selected product is more than 11 billion tablets, accounting for 84% of the total dosage of the drug. The saved medical expenses are not only a reduction in medical insurance funds, but also a reduction in the personal burden of the insured.
Fifth, centralized procurement allows the insured to enjoy newer pharmaceutical and medical equipment products with less money, and the quality of life is improved
Centralized procurement has promoted the accessibility of a new generation of drug consumables, promoted the replacement of old drugs and new drugs, and accelerated the upgrading of the structure of clinical medical devices. Ding Yilei, director of the Price Procurement Department of the National Health Insurance Administration, gave two examples: First, after the centralized procurement of insulin, the ratio of second-generation and third-generation insulin was adjusted from 4:6 to 3:7. The centralized procurement of cardiac stents has promoted the use of chromium alloy stents with better material performance from 60% to more than 95%. Second, in the past, most cataract patients used low-cost monofocal lenses for surgery, which could only see clearly in the distance and solve the problem of "seeing"; after the centralized collection of intraocular lenses was implemented, the bifocal lenses that can see both far and near clearly, as well as the trifocal lenses that can be seen clearly in the distance, will be more beneficial to the people, and more cataract patients will be able to "see clearly" and "see comfortably", which will greatly improve the visual quality of patients.
These two examples provide a new perspective when the society is still focusing on the discussion of "whether the quality of centralized procurement of drugs is credible": centralized procurement is not only to ensure quality, but also to allow the insured to enjoy higher quality medical services than the original, so that the quality of life of the insured is not only the same as the original, but also can live a better life.
6. The "surrender wave" is fake, and the actual number of insured people will increase by about 4 million in 2023
In recent years, news about the "surrender" of resident medical insurance participants has been reported from time to time. However, according to the latest statistics of the National Health Insurance Administration, the number of people enrolled in basic medical insurance will reach 1.334 billion by the end of 2023, and the participation rate will remain above 95% according to the number of participants, and the total scale has been consolidated. At the same time, on the basis of excluding nearly 40 million people with duplicate insurance and invalid data in provinces (autonomous regions and municipalities directly under the central government) in 2022, the National Health Insurance Administration will continue to exclude 16 million people from inter-provincial duplicate insurance in 2023, and after considering the impact of "deduplication", the actual net increase in the number of insured people in 2023 will be about 4 million, and the quality of insurance will be further improved.
7. The purpose of the DRG/DIP payment method reform is by no means a simple "fee control", and the payment standard is not set in stone but raised in a timely manner
By the end of 2023, more than ninety percent of the country's overall planning areas have carried out DRG/DIP payment method reform, and the proportion of hospitalization medical insurance funds paid by project in the reform areas has dropped to about a quarter. Through the reform, the payment and settlement of medical insurance has become more scientific and reasonable, and positive results have been achieved in reducing the burden on the masses, the efficient use of funds, and the norms of behavior of medical institutions.
It should be noted that the purpose of the reform of DRG/DIP payment methods implemented by the medical insurance department is by no means a simple "fee control", but to guide medical institutions to focus on clinical needs, adopt appropriate technology for treatment and reasonable diagnosis and treatment, avoid large prescriptions and indiscriminate examinations, and better protect the rights and interests of insured persons through the medical insurance payment lever. The payment standards for DRG/DIP are based on historical cost data, scientifically calculated using big data methods, and increased in a timely manner with social and economic development, price level changes, etc., to ensure that patients receive reasonable and necessary treatment. In fact, the annual expenditure of medical insurance funds has maintained a relatively reasonable growth trend, which is higher than the growth rate of GDP and prices.
8. Not afraid of spending too much money on new technologies, new drugs and severe diseases, medical institutions can make good use of the rules of "exclusion payment" and "special case single discussion" in the DRG/DIP reform
In order to support the application of new clinical technologies and ensure the adequate treatment of seriously ill patients, the reform of payment methods has introduced the "except payment" rule that eligible new drugs and new technologies can not be included in the payment standard of the disease, and the "special case single discussion" rule for severe cases that are significantly higher than the average cost of the disease, which can be settled according to the actual expenses incurred, please rest assured that the medical insurance will pay the reasonable diagnosis and treatment expenses correctly.
9. There is no rule that "hospitalization cannot exceed 15 days", if you encounter it, please call the hotline to report
At this press conference, the National Health Insurance Administration once again publicly emphasized that the medical insurance department has never issued restrictive regulations such as "a single hospitalization does not exceed 15 days", and a small number of medical institutions have changed the "average" of medical insurance payment standards to "limits", and forcibly required patients to be discharged on the grounds that "the medical insurance quota has arrived". In the case of transfer to hospital or self-funded hospitalization, the National Health Insurance Bureau firmly opposes and welcomes the public to report to the local medical insurance department, or directly to the National Health Insurance Bureau (Tel: 010-89061397), and the medical insurance department will seriously deal with the corresponding medical institutions.
10. Centralized procurement has brought a stage of fair competition, and the speed of industry innovation and research and development is accelerating
On the question of whether centralized procurement has affected the enthusiasm for innovation and R&D, Ding Yilei, director of the Price Procurement Department of the National Health Insurance Administration, made a vivid response, with three views:
1. When there is a lack of fair competition, high prices do not mean real innovation. 2. Centralized procurement essentially promotes fair competition. 3. Fair competition drives real R&D innovation.
First, in an environment where there is no level playing field, high prices do not necessarily lead to real innovation. In the past, when drug prices were high, about 30%-40% of drug prices were sales and promotion expenses, and the income obtained from high prices was not used for innovation, quality improvement, or even corporate profits, but became the "moisture" of circulation. For example, in the case of polymyxin B sulfate for injection, which was jointly investigated and dealt with by multiple departments, relevant enterprises and individuals conspired to increase the price of drugs with a production cost of several tens of yuan to more than 2,000 yuan, and the inflated price was suspected of being used for commercial bribery. The drug dropped from more than 2,000 yuan to more than 100 yuan after an interview, and if this background is not discussed, some people may worry that the reduction will not cover the cost, whether it will affect the profits of the enterprise, and whether it will affect innovation.
Second, centralized procurement promotes fair competition and makes the price of "old drugs" that have expired their patent expires reasonable again. Innovative drugs generally enjoy a patent protection period of more than 10 years, during which they can enjoy the benefits of eliminating competition and monopolizing the market, which is also an encouragement and compensation for the hard work and huge investment of enterprises. After the patent period of innovative drugs, more consideration should be given to social benefits, and fair market competition should be faced, and the research and development of 20 years ago should not be talked about forever. Other companies can imitate it and bring it to the market after strict review and approval to benefit the majority of patients. Due to the savings in the "trial and error" cost of R&D and the process of clinician approval, the hidden cost of generic drugs is significantly lower than that of innovative drugs. However, in the domestic drug market, due to the lack of open and transparent competition in the past, a large number of "old drugs" still maintained high prices after the expiration of patents, and they have long been "dominant" in the drug sales ranking of medical institutions. Centralized drug procurement allows original drugs to compete with generic drugs that have passed the consistency evaluation on the same stage, so that the drug market can return to efficiency and quality competition. More than 1,600 products have been selected in the 9 batches of state-organized drug centralized procurement, of which 96% are Chinese-made generic drugs.
Third, centralized procurement reshapes the industry ecology and creates a good environment for innovation and R&D. Before centralized procurement, the core competitiveness generally recognized by pharmaceutical companies is not innovation, quality and efficiency, but seeking high pricing, high rebates and high sales models. In various drug fairs, the introduction of "good drugs" by enterprises is often large price space, wide indications, and high development potential. This environment not only leads to a lack of enthusiasm for innovation in the industry, but also increases the burden on patients, and is easy to deteriorate the industry ecology. The selected products in the centralized procurement do not need to be marketed, there is no need to redevelop the hospital, and there is no need for the so-called "cost" to directly "bring volume" into the hospital, skipping the so-called "customer maintenance" and "market development" in the industry from the mechanism, and no longer need sales agents to a certain extent, creating a clean and upright industry environment. The majority of enterprises also realize that the "old method" of focusing on marketing in the past is no longer effective, and they need to truly base themselves on the market with innovation, quality and efficiency. In the past few years, the R&D and innovation momentum of the pharmaceutical industry has been strong, the R&D investment of the whole pharmaceutical industry has increased by 23% annually, the number of new drugs under development in China has jumped to the second place in the world, and 40 varieties of innovative drugs will be approved for marketing by the State Food and Drug Administration in 2023. These all show that the pharmaceutical industry has not only not slowed down the pace of innovation after centralized procurement, but has more clearly defined its development strategy and trend positioning, and accelerated its transformation to innovation.
11. The cross-provincial direct settlement of outpatient chronic diseases will be expanded, and 3-5 types of outpatient chronic diseases will be added
Long Xuewen, deputy director of the Medical Insurance Center of the National Health Insurance Administration, brought good news to the insureds who have medical needs in other places at the press conference: the scope of cross-provincial direct settlement of outpatient chronic diseases will be expanded this year. At present, 5 kinds of outpatient chronic diseases have covered most of the patient groups and costs, and this year will further expand the scope of cross-provincial network designated hospitals, and promote the designated hospitals that have the ability to carry out outpatient chronic disease diagnosis and treatment, so that it is more convenient for outpatient patients to seek medical treatment in other places. On this basis, the scope of outpatient chronic diseases should be further expanded, and 3-5 outpatient chronic diseases with a large number of covered populations, drug treatment, and small treatment differences should be added, so that more outpatient chronic disease patients can enjoy direct settlement in other places.
12. Establish and complete long-term mechanisms for preventing and resolving the return to poverty due to illness, with nearly half of the needy people bearing less than 1,000 yuan in annual inpatient medical expenses in 2023
The National Health Insurance Administration has been making continuous efforts to help rural revitalization and ensure basic medical care for people in difficulty. Fan Weidong, director of the Department of Treatment and Security of the National Health Insurance Administration, said that since 2021, the medical insurance department has resolutely implemented the decision-making and deployment of the Party Central Committee and the State Council on consolidating and expanding the achievements of poverty alleviation and effectively connecting rural revitalization, focusing on consolidating and improving "basic medical care" Results, coordinate and improve the transitional medical insurance assistance policy, gradually realize the transition from concentrating resources to support poverty alleviation to the normalization of the three-tier system, and simultaneously establish and improve a long-term mechanism to prevent and resolve poverty due to illness, and give full play to the positive role of the medical insurance system in helping the comprehensive revitalization of rural areas. The main initiatives are:
First, we need to implement the policy of categorical funding and consolidate the results that should be guaranteed. At the same time, the central government will subsidize the individual contributions of the needy people according to the degree of difficulty, including full subsidies for the extremely poor, fixed subsidies for the recipients of the subsistence allowance and eligible targets for poverty prevention monitoring. In specific work, we have also established an inter-departmental information sharing mechanism, strengthened the mobilization of suspected uninsured persons and floating populations to participate in insurance by increasing the verification and comparison of insurance information, and made every effort to ensure that the people in difficulty "have a system guarantee for medical treatment". On the whole, in 2023, a total of about 80 million people in need will be subsidized to participate in medical assistance, and the participation rate of low-income rural population monitored will be stable at more than 99%; individually, taking the subsistence allowance recipients as an example, in 2023, the individual payment will be 380 yuan, the average medical assistance subsidy will be more than 200 yuan, and the individual payment will be less than 180 yuan, and the burden will be significantly reduced.
Second, strengthen the three-fold system guarantee and reduce the burden on the masses in stages. The "triple system" is often referred to as basic medical insurance, serious illness insurance and medical assistance. The first is to give full play to the main guarantee function of basic medical insurance, stabilize the level of hospitalization treatment, and improve the outpatient mutual aid security mechanism. The second is to enhance the burden reduction function of critical illness insurance, increase the reimbursement level of residents with serious illness in an inclusive manner, and accurately implement inclined payment for people with special difficulties. The third is to consolidate the basic guarantee of medical assistance and resolve the burden of high medical expenses on the needy. According to monitoring, in 2023, the triple system will benefit more than 180 million low-income people in rural areas to seek medical treatment, helping to reduce the burden of expenses by 188.3 billion yuan. After reimbursement under the triple system, nearly half of the people in difficulty bear less than 1,000 yuan in annual inpatient medical expenses.
Third, establish and improve long-term mechanisms to prevent and resolve the risk of disease and poverty. Guide all localities to do a solid job of monitoring and early warning of patients with high medical expense burdens, promptly include eligible people in difficulty in the scope of medical assistance, coordinate with relevant departments to implement comprehensive assistance, and at the same time promote the participation of social forces such as charity in aid and assistance, and accelerate the construction of a diversified assistance pattern. In 2023, 333,000 people will be rescued in a timely manner through the early warning push of local medical insurance departments and the verification and confirmation of relevant departments, with medical assistance expenditures of 2.23 billion yuan and per capita assistance reaching 6,700 yuan, keeping the bottom line of not returning to poverty on a large scale due to illness.
13. The medical insurance fund is not only a payment but also an empowerment, and qualified designated medical institutions may be able to obtain medical insurance settlement advances
Medical insurance convenience service is one of the key points of medical insurance reform in recent years, Fu Chaoqi, deputy director of the Office of the National Health Insurance Administration, introduced that this year's 12 key matters in the field of medical insurance and medical insurance "do one thing efficiently" mainly involve three aspects:
The first is form optimization. The masses can not only use their social security cards to seek medical treatment and purchase medicines, but also scan the medical insurance code or brush their faces more conveniently to achieve medical insurance reimbursement; the personal accounts of employees' medical insurance and family mutual aid can be handled directly online without going to the window; and the masses can inquire about medical insurance related information more conveniently.
The second is to streamline the process. Through the joint office of information sharing, the reimbursement of medical expenses for newborns and maternity, the retirement of employee medical insurance participants, and the verification of information when enterprises go bankrupt no longer need to be handled by multiple departments;
The third is to speed up services. After the masses give birth and submit the application, they can get the maternity allowance payment within 10 working days, and after the pharmaceutical company submits the application, the drug code can be reviewed within 10 working days, and the compliant medical expenses can be settled with the designated medical institutions in a timely manner, further shortening the service processing time.
Author | Yang Zi
Source | China Medical Insurance
Edit | Fu Meiru Zhang Wenqing
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