Medical insurance payment reform accelerates the promotion |

According to a person familiar with the situation on April 25, according to informed sources, recently, Zhan Jifu, director of the Fujian Provincial Health Insurance Office, proposed in a recent meeting that the reform of medical insurance payment is the next major task of Fujian's medical reform, and at the same time, it clearly and severely cracks down on all kinds of fraudulent medical insurance funds. behavior.

As early as June 28, 2017, the State Council promulgated the Guiding Opinions on Further Deepening the Reform of Basic Medical Insurance Payment Methods, emphasizing its importance and urgency, and referring the reform of the medical insurance payment method to a new height.

On March 13 this year, the reform of the departmental system was finalized, and the National Bureau of Medical Protection turned out. Professor Gu Wei of the School of Government of Peking University previously told Cypress that the establishment of the Medical Insurance Bureau will greatly promote the above-mentioned documents. Implement the promotion and accelerate the reform of medical insurance payment.

As the medical reform star of Fujian province, the reform of the medical insurance payment method in the past two years is also worthy of attention.

On March 8th last year, Fujian Province issued "About Announcement drug The joint limit sunshine purchase medical insurance maximum sales limit and medical insurance payment settlement price related issues Notice, started the medical insurance payment reform 'first shot'.

Two new prices have been added to this latest provincial drug plan. The first one is the maximum price for Medicare and the second is the payment price for Medicare. According to the plan, the portion with the highest price limit will be borne by the hospital in the future. , And the price between the price paid by Medicare and the maximum price will be borne by the patient.

In addition, in December last year, the People’s Government of Fujian Province issued “About the Issuance of the 'Thirteenth Five-Year' Deepening of Fujian Province. medicine The notification of the health system reform plan will clearly demonstrate the leveraging of the basics of medical insurance and squeeze the circulation and use of pharmaceutical consumables and hospital 'Control fees' block the space created by waste.

The notice requires reforming the pricing method of medical services, gradually reducing the pricing according to the project, and implementing the price management mode of medical services coexisting with multiple types of fee collection based on the type of disease. The implementation is based on the implementation of 100 diseases in public hospitals in the province, and further 2. Expand the scope of disease-based fees and payment reforms, and strive to add 500 new diseases.

Some experts said that under the general tightness of the national health insurance funds, the Fujian Province's pioneering exploration has changed the previous role of the medical insurance department as a pure cost payer, and began to exert its influence on the overall cost of medical care. Medical insurance management will inevitably be implemented in the future.

In fact, the current situation is like this. For medicines purchase The question of who is responsible for the regulation of the work, and the reform plan of the state agency that was introduced before, gives the answer - it will be taken over by the Medical Insurance Bureau.

The Medical Insurance Bureau took over the drug procurement work, on the one hand, it reflected the 'who paid for it, who handled the transaction' and tried to realize the 30-day payment as much as possible; on the other hand, under the actual medical insurance funds, the drug bid price and Medicare payment will be adopted. standard Closely bound, further reduce the high drug prices, in order to maximize the interests of all parties.

According to reports, at the above meeting, Zhan Jifu also clearly pointed out that it is necessary to severely crack down on all kinds of acts of defrauding medical insurance funds.

So what is fraudulent health insurance fund? For example, if the bottom price of the pharmaceutical company's big bag is only 3 yuan, but the bid price is 60 yuan, which is to defraud the Medicare fund.

The “big bag” is a specific term in pharmaceutical marketing. In the past, many pharmaceutical representatives embarked on the career development of medical marketing. They simply turned into 'professional managers' or 'big bags' and 'small bags'.

The big package model refers to linking marketing performance to sales, including salary of marketing personnel (including pharmaceutical representatives), daily expenses, promotion costs, etc. Simply put, it is to put all the expenses of the marketing value chain into one package. Give marketing participants the ability to complete their own value-added process. Small bags are responsible for one of the links, such as sales promotion.

The reform of the medical insurance payment method we mentioned above is the pattern of co-existence of multi-payment methods, mainly consisting of prepaid packages such as package payment, from the post-payment system based on project-based payment. The core of this is to implement the system. Disease pays.

Payment by case type is based on the calculation of the total cost package system, which means that consumables and medicines will become the hospital's cost, rather than revenue. Hospitals, doctors will be subject to the past in the pursuit of rebates under the constraints of the health insurance payment reform. In order to pursue the cost-effectiveness of medicines, in this case, the medication structure of the hospital will take place, and the medicines with inflated prices will be gradually replaced by cheap and cost-effective medicines.

In addition, under the two-vote system policy, pharmaceutical companies also need to carry out marketing model transformation and upgrades. Under the new environment of 'two-vote system + battalion reform + gold tax three', the bottom price model is completely finished, and the high-opening, high-return model is approaching. At the same time, what comes with this is how to increase taxation, how to redeem large amounts of commissions, and how large amounts of bills are legally compliant. For these problems, many pharmaceutical companies do not have a solution. The ones most affected are the package mode. Operating pharmaceutical companies.

It can be seen that in today's competitive environment, the competition rules among pharmaceutical companies will fundamentally change. The 'high pricing, dark rebate' marketing model will also be completely impassable.

The two-vote system of the past two years has caused the previous package price of medicines to shrink, and the current reform of Medicare payments will be supplemented. It can be said that the reserve price is completely exhausted.