Why do some high-priced drugs enter the medical insurance but not the hospital?

The answer to this question is also very simple. There is no conspiracy theory behind it, but there are many helplessness and entanglements from doctors, hospitals and local medical insurance bureaus. One sentence is interpreted as "because rare and high-priced drugs will affect the assessment of the proportion of drugs in hospitals, and it may also make the annual medical insurance quota of hospitals exceed the standard-departments and doctors are worried about' posting money backwards' for this.

So some people may not understand the meaning. For example, the medical insurance bureau has an agreement with the hospital. For example, the cost of a patient's single visit is 1 10,000 yuan, the medical insurance bureau is responsible for 8,000 yuan, and the hospital bears 2,000 yuan. Moreover, the medical insurance bureau also has requirements for the total amount of drugs used in hospitals. For example, the total expenses reimbursed by the medical insurance bureau to this hospital in that year was 50 million, and the hospital depends on the use of this money. After the medical insurance reimbursement amount reaches 50 million, the hospital has to bear it itself. Because the hospital can allocate so much money to medical insurance every year, patients can only be adjusted according to the total amount issued by the medical insurance bureau! This also includes serious humanitarian money for saving lives, and every hospital has to be careful.

Now hospitals are independent enterprise entities, and of course, annual income should also be considered. In order not to lose money, the hospital should decompose the amount of medical insurance into various departments and doctors. Therefore, the words "drug proportion" and "second average cost" have appeared, that is, once high-priced drugs are used, the annual cost may exceed the limit; Drug proportion = drug income/(drug income+medical income+other income), high drug price and no royalty income will affect the assessment indicators such as drug proportion in departments and hospitals. This is also the reason why hospitals and doctors are reluctant to introduce drugs.

A real case reported by the media some time ago, the specific drug "Ruipujia" for patients with rare diseases entered the national medical insurance drug list through the national medical insurance negotiation (referred to as Sinopharm) at the end of 20021.000, and the price of a single needle was reduced from1.2000 yuan to 3 1.000 yuan. Originally, this was a good news for patients, but in practice, the landing of this drug in primary hospitals was not smooth. For the hospital, even if Repajia enters the medical insurance drug list through negotiation, its price is still higher than that of conventional drugs. Because of the reasons mentioned above, many grass-roots hospitals in China are reluctant to let Ripjia enter. Although many patients run around appealing, they still can't really enjoy this medicine after they enter the medical insurance in primary hospitals.

But in fact, in order to get through the "last mile" between the national drug negotiation and patients, in April of 20021,the National Medical Insurance Bureau and the Health and Health Commission issued guidance on establishing and improving the "dual-channel" management mechanism of drugs in national medical insurance negotiation. "Dual channels" refers to two channels, namely designated medical institutions and designated retail pharmacies, to meet the needs of negotiating drug supply security and clinical use. The opinion also mentioned that a separate drug guarantee mechanism can be explored for negotiated drugs with long use cycle and high treatment cost.

In other words, at the national level, "Ruipujia" further landed in primary hospitals in time after entering medical insurance, and there was no institutional problem. You can separate the use of drugs from the settlement of medical insurance. Don't add extra burden to the hospital. But up to now, there are still many primary hospitals that have the problem that drugs such as "Ripujia" are difficult to enter. To sum up, there are several reasons:

First, the coordination between departments is poor.

The seemingly sky-high medical insurance drugs entering the hospital also involve the coordination of medical insurance, drug supervision, health and health commission and other departments, which can be completed by establishing specific mechanisms such as procurement, reimbursement and assessment at the grassroots level. This process is actually not smooth.

Second, it involves the interests of all parties.

The entry of high-priced drugs into hospitals may not only affect the interests of hospitals, departments and doctors, but may even involve deep-seated problems such as the overall balance of local medical insurance funds. Therefore, for many grass-roots hospitals and local functional departments, it is better to do more than one thing. If you can't touch it, try not to. If you can touch it later, try to touch it later.

Third, the policy is not clear enough.

The national high-level officials did not explicitly require rare drugs such as "Ruipujia" to enter primary hospitals in more detail. The original intention is to let primary hospitals formulate more local measures in light of the actual situation. However, due to the shortage of local medical insurance funds, it has become a gray excuse for some grassroots hospitals to be lazy to perform their duties.

In the final analysis, the fundamental reason is that some primary medical institutions or regulatory departments lack enough enthusiasm for active work and the ideology of truly serving patients on the issue of medical care for the people and medicine for the people. This is undoubtedly the hope of those rare patients with heavy economic burden to see the national policy, but it is blocked everywhere in the actual medical process, thus causing secondary harm to their body and mind.