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HomeNewsIs innovative medicine listed as medical insurance? It's very difficult for the medical insurance bureau to collect the payment in circulation!

Is innovative medicine listed as medical insurance? It's very difficult for the medical insurance bureau to collect the payment in circulation!

2021-01-04
On December 23, the National Health Insurance Bureau publicly responded to 19 proposals and suggestions made by CPPCC members and NPC and CPPCC representatives at the third session of the 13th National People's Congress, including rare diseases, early screening of tumors, development of traditional Chinese medicine, support for innovative medicine, and difficulty in collecting money from medical circulation, among which the topics most involved are rare diseases.

How to improve the accessibility and affordability of drugs for patients with rare diseases and set up special funds?

The main issues raised by CPPCC members or representatives of the two sessions of the Chinese people's Political Consultative Conference on rare diseases are to strengthen and accelerate the medical security for rare diseases, and further improve the accessibility and affordability of medication for patients with rare diseases.

The National Medical Insurance Bureau replied that since the establishment of the basic medical insurance system, the medical insurance department has attached great importance to the medical security work of rare diseases. At the national level, five versions of the medical insurance drug catalog have been released, and the number of drugs in the catalog has increased from 1535 to 2709. By adjusting the medical insurance catalog, the scope of drug security has been expanded and the catalog structure has been optimized. The catalog includes drugs for rare diseases such as recombinant human coagulation factor, riluzole, and most drugs for symptomatic treatment. In the process of national medical insurance drug catalog adjustment in 2019, levocarnitine oral solution for primary carnitine deficiency in children patients will be added, and more than 10 drugs such as terfluramide tablets for multiple sclerosis, megestat capsules for C-type Niemann Pick disease, and silepag tablets, bosentan tablets, maxitengtan tablets and lioxigua tablets for pulmonary hypertension will be added through admittance negotiation Drugs for rare diseases have been included in the national medical insurance drug catalog, and the price has decreased significantly, and the protection level for patients with rare diseases has improved significantly. At the same time, for some very expensive drugs for special rare diseases, they can not be included in the payment scope of basic medical insurance because they are far beyond the fund and the patient's affordability.

In general, the qualified drugs for rare diseases have been basically included in the payment scope of basic medical insurance, and provide a solution channel for poor patients with rare diseases. However, from the perspective of the affordability of basic medical insurance fund, the per capita financing of medical insurance for urban and rural residents in 2019 is only about 800 yuan, which makes it difficult for basic medical insurance to bear the extremely expensive drug costs for some rare diseases.

In addition, in 2018 and 2019, our bureau, together with the Ministry of human resources and social security and the health and Health Commission, issued a document clearly requiring medical institutions not to affect the supply guarantee of negotiated drugs on the grounds of total cost control, "drug proportion" and drug variety and quantity restrictions.

At the same time, the State encourages commercial insurance institutions to develop insurance products related to rare diseases, improve the health insurance level of patients with rare diseases, and improve the medical insurance system for rare diseases. At present, more than 160 insurance companies have carried out health insurance business, and developed more than 5000 products covering five categories of disease insurance, medical insurance, nursing insurance, disability income loss and medical accident insurance. In terms of disease insurance, more than 200 major disease insurance products have included some rare diseases in the coverage; in terms of medical insurance, most commercial medical insurance products have included the medical expenses of patients with rare diseases in the coverage, providing medical expenses protection for patients with rare diseases.


In response to the proposal of "establishing a special fund for rare diseases" put forward by several members, the National Health Insurance Bureau will strengthen its research, actively explore drug security measures for rare diseases together with relevant departments, and do its best to gradually improve the security level of patients with rare diseases. It is understood that some social organizations have carried out special charity activities for certain rare diseases. For example, the Red Cross has set up the first special fund for poor children with severe aplastic anemia aged 0-14 in China, the Oriental Angel Fund. So far, nearly 300 children have been rescued, with a total amount of more than 7 million yuan.


In the next step, the National Health Insurance Bureau will be based on the basic medical insurance "basic" positioning, combined with the insured drug demand, medical insurance financing ability and other factors, through strict expert review, and gradually bring the rare disease drugs with exact curative effect and affordable by the medical insurance fund into the scope of medical insurance payment. On this basis, we should further improve the multi-level medical insurance system, give full play to the role of social forces of charitable organizations in the field of medical security for rare diseases, vigorously promote the development of commercial health insurance, strengthen the connection between various security systems, give full play to the security forces, effectively reduce the drug burden of patients with rare diseases, and improve the medical security level of insured patients at multiple levels.


Innovative medicine is approved to enter medical insurance seamlessly?

Wu Depei, member of the National Committee of the Chinese people's Political Consultative Conference and director of the Department of Hematology of the First Affiliated Hospital of Soochow University, submitted the proposal on strengthening the support for China's "independent intellectual property rights" innovative drugs. It is worth mentioning that Wu Depei suggested in the proposal that the national medical insurance bureau should establish a policy pilot mechanism of "seamless connection between drug approval and medical insurance admission, and market access" to optimize the medical insurance access mechanism, To promote the rapid access of innovative drugs and other innovative drugs into the medical insurance.

The National Medical Insurance Bureau replied that the medical insurance department has always attached great importance to the medical insurance access of innovative drugs. "Opinions of the CPC Central Committee and the State Council on deepening the reform of the medical security system" proposed that we should base on the positioning of "basic medical security", adapt to the basic medical needs of the masses and the progress of clinical technology, adjust and optimize the medical insurance catalogue, and include drugs with high clinical value and excellent economic evaluation into the scope of medical insurance payment. In order to adapt to the progress of clinical medicine science and technology and the change of drug demand of insured personnel, in July 2020, the National Medical Insurance Bureau issued the "Interim Measures for drug administration of basic medical insurance", which clearly stipulated the formulation, adjustment, use and payment of drug catalogue of basic medical insurance. In principle, the drug catalogue of national medical insurance is adjusted once a year. At the national level, five versions of medical insurance drug catalog have been released successively, and the number of drugs in the catalog has increased from 1535 to 2709, and some clinically necessary drugs listed in recent years have been included in the catalog through negotiation. At present, the vast majority of drugs supported by the major science and technology projects of "major new drug creation" have been included in the national drug catalogue.

According to the decision-making and deployment of the Party Central Committee and the State Council, the State Medical Insurance Bureau recently launched a new round of adjustment of medical insurance catalogue. According to the "2020 national medical insurance drug catalog adjustment work plan" (hereinafter referred to as the work plan), the scope of this year's drug catalog adjustment is the drugs approved to be listed before August 17, 2020 (inclusive), which significantly shortens the waiting period for innovative drugs to enter the medical insurance catalog, and also allows the insured to use innovative drugs with better clinical value as soon as possible and benefit as soon as possible.

In addition, the State supports the insurance industry to vigorously develop commercial health insurance. At present, most groups' supplementary medical insurance, million medical insurance and anti-cancer insurance products have included part of the expenses of innovative drugs out of the basic medical insurance catalog into the scope of protection. Some insurance companies are researching and developing insurance products for specific innovative drugs, which provides convenience for the people to use innovative drugs.

In the next step, the National Health Insurance Bureau will take into account the insured's drug demand, affordability, medical insurance financing ability and other factors, and gradually bring the innovative drugs with exact curative effect and affordable by medical insurance fund into the scope of medical insurance payment through strict expert evaluation. On this basis, we should further improve the multi-level medical insurance system, vigorously promote the development of commercial health insurance, give full play to the role of risk management and security function of commercial insurance, and improve the medical security level of insured patients.

Promote and protect the technological innovation and development of traditional Chinese Medicine

The development of traditional Chinese medicine has been the focus of discussion in recent years, especially in the new epidemic period this year, traditional Chinese medicine has played an important role in the anti epidemic effect.


The National Medical Insurance Bureau replied that in the process of formulating and improving various basic medical insurance policies, the National Medical Insurance Bureau attaches great importance to supporting and protecting traditional Chinese medicine. The medical insurance department always adheres to the basic principle of "paying equal attention to both Chinese and Western medicine" when formulating the drug catalogue of basic medical insurance. According to the common name, the current national medical insurance drug catalog contains 2709 drugs, including 1370 kinds of Western medicine and 1339 kinds of Chinese patent medicine (including 93 ethnic medicines). The proportion of Chinese patent medicine has increased from 40.52% in 2000 to 49.43% in 2019, and the number of Chinese and Western Drugs is basically the same. In 2019, when the national basic medical insurance drug catalog was adjusted, the Chinese herbal pieces were changed from the exclusion method to the access method, and a total of 892 Chinese herbal pieces with national standards were included in the payment scope of the medical insurance fund. In addition, it can be added according to the national or local standards.

In terms of reimbursement proportion of medical insurance, according to the relevant data of health statistics in 2008, 58% of the number of patients in TCM clinical departments (excluding TCM hospitals) occurred in primary medical and health institutions, and most TCM services have enjoyed the preferential policy of reimbursement proportion. In some areas, the reimbursement starting line of TCM hospitals was reduced and the reimbursement proportion of TCM services was increased; in some areas, the dominant diseases of TCM were selected to carry out the pilot reform of collection and payment methods, and the treatment of the same disease and the same fee with traditional Chinese and Western medicine was explored.

As for the proposal of "gradually expanding the medical insurance coverage of TCM formula granules" put forward by some representatives, the medical insurance bureau said that considering that TCM formula granules are currently in the pilot stage, there are still some disputes in academic circles and clinical practice in terms of management attribute and clinical effect, so it will recognize the research opinions and suggestions and scientifically and steadily determine the relevant payment policy.

Next, the National Health Insurance Bureau will implement the opinions of the CPC Central Committee and the State Council on deepening the reform of the medical security system and the opinions of the CPC Central Committee and the State Council on promoting the inheritance and innovation of traditional Chinese medicine, and work with relevant departments to further study and improve the support and promotion policies for traditional Chinese medicine, so as to jointly create a good environment to support the healthy development of traditional Chinese medicine.

To solve the long-standing problem of payment collection in pharmaceutical circulation enterprises

In response to the proposal on solving the long-standing problem of payment collection of pharmaceutical circulation enterprises put forward by Zhang Feng and other three members, the National Health Insurance Bureau replied to continue to promote the national negotiation price reduction and GPO mode with the goal of reducing the comprehensive procurement cost of drugs and medical devices; "ensuring timely payment" is an important factor to reduce the cost of enterprises and thus reduce the drug price, and all departments attach great importance to it and formulate practical measures A series of policy measures have been taken. Each province has also introduced the relevant detailed provisions to implement the policy, and constantly increased the supervision on the payment settlement of medical institutions, so as to effectively ensure the speed of payment collection.

On the one hand, it is clear that the medical insurance department should advance the drug payment to medical institutions. The opinions of Qi State Medical Security Bureau on the supporting measures for the pilot medical insurance of centralized drug procurement and use organized by the state (Medicare Fa [2019] No. 18) clearly requires "implementing the prepayment policy of medical insurance fund". Before the pilot work is officially launched, the medical insurance agencies should prepay the medical institutions in advance according to not less than 30% of the special procurement budget, and require the medical institutions to settle accounts with the enterprises in time according to the contract, so as to reduce the financial costs of the enterprises.

On the other hand, medical insurance agencies or purchasing agencies are encouraged to settle accounts or prepay drug payments directly with enterprises. From the actual operation of the "4 + 7" pilot, the 30 day settlement rate of the selected products in the "4 + 7" pilot has reached more than 90%, and the problem of medical institutions' Arrears of drug payment has been effectively alleviated. In Shanghai, Shenyang, Dalian and Chengdu, the medical insurance department pays in advance to the production or distribution enterprises; in Xiamen, the medical insurance department settles directly with the distribution enterprises; in the other six pilot cities, the medical insurance fund pays in advance to the medical institutions. The proportion of prepayment in most pilot cities reached 50%, and in some cases 60%.

In the next step, according to the suggestions of the members, the National Health Insurance Bureau will further attach great importance to the payment collection of pharmaceutical circulation enterprises, continuously improve the supporting policies and measures for drug procurement management, and effectively reduce the financial pressure of enterprises.

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