Drug dual-channel policy

First, the background of the formulation and promulgation of the Guiding Opinions

Since the establishment of the National Medical Insurance Bureau, the reform of drug list management has been vigorously promoted, and the dynamic adjustment mechanism of the list has been established and improved. The adjustment cycle of medical insurance drug list has been greatly shortened from the original 8 years to 1 time per year, and even some new drugs have been included in the medical insurance drug list in the same year. The frequency of medical insurance catalogue access has been greatly accelerated, but the drug access mode of medical institutions has not changed significantly. Before the reform, most drugs were "advanced hospitals and backward medical insurance" after listing, and drugs had enough time to go through the process of listing, clinical experience accumulation, clinical experts' approval and wide use. After the reform, it has become "advanced medical insurance, then entering the hospital", which puts forward higher requirements for the rapid access of medical institutions and the wide use of clinicians in a short time. Objectively speaking, it is difficult for some negotiated drugs to enter hospitals, which is to some extent the result of deepening the reform of medical insurance drug list management.

In order to solve the problem of "difficulty in entering the hospital", it is planned to include designated retail pharmacies in the scope of negotiating drug supply guarantee, and jointly form a "dual channel" for negotiating drug reimbursement with designated medical institutions, and strive to improve drug accessibility.

Two. Main contents of "Guiding Opinions"

According to the ideas of strict management, supply guarantee, moderate treatment, standardized use and strengthened supervision, the Guiding Opinions contain seven aspects: First, classified management to improve the level of supply guarantee. Classified management of negotiated drugs, focusing on bringing drugs with high clinical value, urgent demand and high cost into the "dual-channel" management. The second is to clarify the pharmacy selection procedure and dynamically adjust it. Clarify the principles and procedures for the selection, moderate competition and access of designated retail pharmacies. The third is to standardize the use and ensure safety. Mainly from the perspective of ensuring the quality and safety of drugs and rational clinical use. The fourth is to improve the payment policy and ensure an appropriate level of protection. Ensure the reasonable payment of drugs and reduce the burden on patients. The fifth is to optimize management services and enhance people's sense of gain. Promote policies and measures such as "dual-channel" drug direct settlement to provide convenient services for patients. Sixth, strengthen supervision and guard against risks. Strengthen the supervision of the whole process of drug use, guard against fund risks and ensure the safety of the fund. Seventh, strengthen leadership and make solid progress. "Dual Channel" is a brand-new policy arrangement, which involves the adjustment of reimbursement channels and policies. It is necessary to strengthen organizational leadership and do a good job in linking relevant policies.

Three, the main factors to consider when determining the scope of drug "dual channel" management

Drugs included in the "dual-channel" management shall, in principle, be determined by the provincial medical insurance administrative department according to the procedures. It is necessary to comprehensively consider factors such as the level of regional economic development, the affordability of medical insurance funds and patients' drug demand, and implement classified management of negotiated drugs. Varieties with high clinical value, urgent need of patients and low substitution should be included in the scope of "dual-channel" drug management in time. "Dual-channel" drugs can be adjusted regularly according to the situation.

Four, the establishment of a "dual channel" management mechanism, put forward new requirements for designated retail pharmacies.

Compared with ordinary designated retail pharmacies, it puts forward higher requirements for designated retail pharmacies that meet the management requirements of "dual channels". The first is information technology. Designated retail pharmacies should be connected with the medical insurance information platform and the electronic prescription circulation platform to ensure that the communication between drugs and medical insurance payment information is comprehensive, accurate and timely. The second is drug management. Some negotiated drugs have special requirements for storage, and designated retail pharmacies need to establish a storage and distribution system that meets the requirements to ensure the quality and safety of drugs. At the same time, it is equipped with professionals to guide patients to use drugs rationally to ensure the safety of clinical medication. The third is the supervision of medical insurance funds. Designated retail pharmacies should take stricter measures to verify the identity of patients, ensure that "prescription patients" and "actual drug users" are consistent, plug the loopholes of "fraudulent insurance fraud" and ensure the safety of funds.

Fifth, after the establishment of a dual-channel management mechanism, the management of medical insurance payment for negotiated drugs was adjusted.

Unified payment policy

For drugs managed by dual channels, a unified payment policy will be implemented in designated medical institutions and retail pharmacies to ensure the reasonable treatment of patients. For negotiated drugs with long use cycle and high treatment cost, we can explore the establishment of a separate drug guarantee mechanism. Local medical insurance departments will determine the appropriate level of protection according to the affordability of the fund and the level of hospitalization compensation.

(2) Strengthen the establishment of a "dual-channel" mechanism for fund supervision, transfer some functions of drug management in the original hospital to the outside of the hospital, and obviously increase the management links, posing new challenges to fund safety risk management and control. Taking the prescription circulation center as the core, connecting medical insurance agencies, designated medical institutions and designated retail pharmacies, implementing the requirements of "fixed institutions, fixed doctors and traceability" and realizing the whole process supervision of patients' medication behavior. Improve and refine the rules of medical insurance drug audit, introduce intelligent monitoring, and severely crack down on the fraud of medical insurance funds in the "dual channel" field. Strengthen the routine analysis and monitoring of "dual-channel" drug expenses and fund expenditures, timely adjust and improve regulatory policies and measures to ensure the safety of the fund.

(3) Optimize the management service of "making information run more and patients run less errands", integrate basic medical insurance, serious illness insurance and medical assistance services, and vigorously promote the "two-channel" one-stop settlement. On the basis of effective risk control, explore and promote the inclusion of "dual-channel" negotiated drugs in the direct settlement scope of medical treatment in different places.

Six, in solving the negotiation of drugs "into the hospital", in addition to the establishment of a "dual channel" management mechanism, the main work is carried out by the National Medical Insurance Bureau.

(a) to establish and improve the negotiation of drug monitoring mechanism, timely grasp the progress of landing.

Since 2020, the National Medical Insurance Bureau has established a monitoring mechanism for the landing of negotiated drugs, organized all provinces to regularly submit data on the dosage, expenses and reimbursement of negotiated drugs, regularly analyzed the progress of various localities and the main problems found during the landing process, and timely notified all localities to promote the landing.

(2) Strengthen supervision and guidance to promote the negotiation of drugs.

Led by the leaders of the bureau in charge or department heads, they went to seven provinces including Beijing to supervise, investigate and discuss the progress and practice of drug landing, deeply understand the difficulties and problems existing in "entering the hospital" and strengthen supervision and guidance to all localities. Dispatch to understand the practices and effects of 32 provincial medical insurance bureaus (including the Corps) in promoting drug negotiation, sort out and summarize the experience and practices in Sichuan, and play a typical demonstration and radiation-driven role.

(three) to collect and publish a list of some institutions that have been equipped with negotiating drugs for public inquiry.

Recently, the National Medical Insurance Bureau organized forces to select the first batch of 19 drugs that are urgently needed in clinic and have weak substitutability from the newly negotiated drugs in 2020, arranged relevant enterprises to submit information of designated medical institutions and retail pharmacies, opened public inquiry channels in the National Medical Insurance Service Platform (APP), and held a media conference to publicly release them to the public, so as to facilitate the insured in need to seek medical treatment and purchase drugs. Next, the National Medical Insurance Bureau will continue to organize enterprises to submit and update relevant information.