Strive to make every penny of the medical insurance fund worth more (policy interpretation) Drugs | Patients | Medical Insurance

The negotiation of the national medical insurance drug catalog has attracted much attention. Every year in the medical insurance negotiation, some new drugs are included in the catalog, and some drugs that have been included in the medical insurance catalog for 8 years are facing renewal. The renewal rules are related to the safety of medical insurance funds and the level of medical security, and are fundamental rules for consolidating negotiation results and ensuring the sustainable and healthy development of negotiation work. Recently, the National Medical Insurance Administration has adjusted and improved the Negotiated Drug Renewal Rules. Our reporter interviewed the relevant person in charge of the National Medical Insurance Administration regarding the relevant situation.

The scientific, standardized, and refined negotiation system for medical insurance has reached a new level

Q: What are the goals of adjusting the Renewal Rules and how can they be achieved?

Answer: The goal of this adjustment to the "Renewal Rules" is to align with the positioning of basic medical insurance as "basic insurance", which is more conducive to safeguarding the vital interests of the majority of insured persons, in line with the direction of strategic purchase and value purchase, and to improve scientificity and fairness. After adjustment and improvement, the scientific, standardized, and refined level of the medical insurance negotiation system has been further elevated.

This adjustment and improvement are mainly reflected in the following aspects:

We have established payment standard adjustment rules that cover the entire lifecycle of drugs. From international experience, it usually takes about 8 to 10 years for a drug to reach its peak from market launch to sales. Thanks to the promotion of dynamic adjustment mechanisms, the process in the Chinese market has accelerated. Based on this, the Renewal Rules propose to include negotiated drugs that have reached 8 years in the regular directory management; For negotiated drugs that have not reached 8 years, and varieties with a continuous agreement period of 4 years or more that trigger price reductions through simple renewal or addition of indications, the reduction will be halved. The above adjustments are conducive to stabilizing enterprise expectations, reducing the pressure of price reduction in the later stage, and reducing the possibility of contract renewal failure.

Further demonstrate support for innovation. In order to further reflect the support for "true innovation", it is added that for Class 1 chemical drugs, Class 1 therapeutic biological agents, Class 1 and Class 3 traditional Chinese patent medicines and simple preparations approved in accordance with the current registration management measures, when the renewal triggers the price reduction mechanism, the application can be renewed in the form of renegotiation. The National Health Insurance Bureau will organize experts to calculate according to the procedures, and the reduction of negotiation renewal may not be higher than the reduction specified in the simple renewal.

Supporting innovation must be based on the premise of "benefiting patients"

Q: In recent years, international and domestic drug research and development have been advancing day by day, and patients are also looking forward to more innovative drugs entering the medical insurance catalog as soon as possible. How can this expectation be realized?

Answer: The medical insurance department has always attached great importance to supporting drug innovation, and has effectively supported pharmaceutical innovation through practical actions such as shortening negotiation cycles, improving evaluation mechanisms, and accelerating drug implementation.

It should be emphasized that supporting innovation must be based on the premise of "ensuring the basics". In all previous adjustments, the National Medical Insurance Administration firmly grasped the positioning of "basic insurance", did its best and acted within its capacity, and established the improvement of drug security level on the basis of economic and financial sustainability, never exceeding the stage and detached from reality.

Supporting innovation must be based on the premise of benefiting patients. The medical insurance fund is the "life-saving money" for insured individuals, and the goal of medical insurance work is to strive to make every penny spent more valuable. In recent years, the National Medical Insurance Administration has adhered to the principle of "value purchase" and closely determined the price level based on the benefits that drugs bring to patients, significantly improving the cost-effectiveness of newly admitted drugs.

Supporting innovation must also be based on scientific, objective, and standardized evaluation. With the progress of negotiation work, the National Medical Insurance Administration has established a set of indicator systems that are in line with China's actual situation, achieving a leap from subjective to objective and from qualitative to quantitative drug evaluation. The measurement of innovation is more accurate and scientific, and has received universal support and approval from all aspects.

Strive to achieve a win-win situation for patients, medical insurance funds, and enterprises

Question: How to balance the interests of all parties and various situations when adjusting the Renewal Rules?

Answer: Improving the "Renewal Rules" is more conducive to safeguarding the vital interests of the majority of insured persons. This adjustment is generally beneficial for maintaining the safety of the fund and stabilizing and reasonably improving the level of patient protection.

By improving the "Renewal Rules", the expectations of enterprises have been stabilized, and the enthusiasm of enterprises to apply for entry into the catalog and add indications for the varieties in the catalog can be further mobilized. The level of medication guarantee for patients will be maintained and improved.

At the same time, according to the new rules, the risk of successfully negotiated varieties being excluded from the catalog solely due to fund expenditure exceeding the budget is reduced, and more cost-effective negotiation drugs can continue to be retained in the catalog, which is conducive to reducing fund expenditure risk and individual patient burden.

The "Renewal Rules" should be adjusted and improved, taking into account the impact on the medical insurance fund, patients, and drugs comprehensively, covering the life cycle of drugs, providing stable expectations for enterprises and society, while also taking into account different situations such as initial and multiple renewals, striving to achieve a win-win situation for patients, medical insurance funds, and pharmaceutical enterprises.