药品福利管理（Pharmacy Benefit Management,PBM）在我国医疗保险和商业健康保险中的运用

发布时间：2018-05-14 12:40

本文选题：药品福利管理 + 医疗保险　；参考：《西南财经大学》2014年硕士论文

【摘要】：美国是早期推行医疗保险市场化的代表性国家之一,为了控制飞涨的医药费用支出,解决参保人因选择过多而难以抉择,无法合理使用保险政策的难题,改善保险市场在运作、管理和监控方面越来越复杂的情况,药品福利管理(Pharmacy Benefit Management, PBM)应运而生。药品福利管理(PBM)模式是一种专业化的第三方服务,主要利用市场的手段对药品费用进行管理,是美国商业保险公司对医疗保障基金控制的新型模式,以提高医保资金的利用效率为核心目标。药品福利管理公司(PBMs)作为第三方企业,平衡协调包括政府、保险机构、制药商和患者等多方的利益,渗透在整个医疗供应链条的各个环节中,提供的服务包括药品目录管理、药品邮购服务、处方赔付申请的处理、药品利用评价、推荐临床路径以及疾病管理等等。药品福利管理(PBM)模式的发展,在降低医药费用支出,综合评价药品信息,促进药品的合理使用,全面实施健康管理方面有着重要的作用,对美国市场化的保险制度产生了巨大的影响。目前,中国也面临着医疗卫生费用支出飞涨的困境,其医疗市场现状与七八十年代美国的情况非常相似,如何建立完善的全民社会医疗保险制度,同时寻求商业健康保险的发展空间与发展路径,是中国亟待解决的问题之一。尽管药品福利管理(PBM)模式在我国已经初现端倪,医疗保险和商业健康保险中都有所运用,但应用的仅仅是相互分离的某些部分,并没有进行整合。我国借鉴并应用PBM模式非常必要,但是PBM模式也存在一些问题,例如是否能够真正控制医疗保险费用增长的争议,独立药店的生存危机,并购对竞争产生的负面效应以及公开信息所产生的隐私问题等。此外,在我国现实国情下,想要发展PBM模式仍然还存在医药分业改革、行政化管理等诸多约束和问题。本文首先对美国药品福利管理(PBM)模式的相关知识进行了详细的介绍和说明,分析我国引入PBM模式的必要性,根据PBM模式目前在我国医疗保险和商业健康保险中的运用,探讨PBM模式在我国发展可能存在的问题,并针对存在的问题提出个人的建议,期望能对PBM模式在我国的有效运用,甚至在完善我国医疗体制改革,促进我国商业健康保险的发展等方面都能够产生积极的影响作用。本文分绪论、正文和结语三大板块。其中,正文主要分为五个部分：第一部分,首先针对美国药品福利管理(PBM)模式进行了详细的介绍和分析,在了解了药品福利管理模式(PBM)的概念之后,深入研究了药品福利管理(PBM)模式的战略工具以及所能发挥的作用,PBM模式提供的服务包括制定和管理处方集目录、提供药品邮购服务、鼓励使用通用药、实时处理处方单据、与制药企业谈判以获取折扣、疾病管理、药品利用评价、电子处方以及信息共享与传播等,在控制医疗费用支出、提高医疗服务质量方面有着积极的作用。此外,还介绍了药品福利管理(PBM)模式的发展历史,以及目前的发展状况和主要的药品福利管理公司(PBMs). 第二部分,根据我国的现实情况与市场需求,分析我国发展药品福利管理(PBM)模式的必要性以及建立的可行性。我国正值药品福利管理(PBM)模式高速发展的关键点,如果我国借鉴美国先进的模式,则能够使我国在进入快速发展期时,越过探索及完善的长期过程,有效控制医疗费用的支出。我国引入PBM模式,还能够降低赔付率,提高保险产品质量,促进我国商业健康保险的发展。另外,在推动我国医疗保障体系改革方面也有着举足重轻的作用。第三部分,分析药品福利管理(PBM)模式目前在我国医疗保险中建立医保基金智能管理平台的实例,探讨海虹控股与各地医保局合作所产生的积极作用,以及在商业健康保险中,平安保险公司整合“平安药网”、“平安医网”，提供药品邮购服务,建立起全新的全面健康管理服务平台。期望能将药品福利管理(PBM)模式在医疗保险与商业健康保险中进行整合,以建立完整的药品福利管理(PBM)模式。第四部分,借鉴美国完整的药品福利管理(PBM)模式,分析在我国建立与发展药品福利管理(PBM)模式可能出现的问题和改革难点。我国的国家基本医疗保险制度,现在还暂时处于水平低、覆盖广、浪费大、监管效率低的阶段。医药分业暂时难以突破,医院有着绝对的优势地位,加之行政化的管理模式,缺乏健全的法制和制度保障,这些都限制了市场化的药品福利管理(PBM)模式的发展。药品福利管理(PBM)模式在市场上还未得到较大的认可,盈利能力有限也是发展的难点。此外,药品福利管理(PBM)模式本身还存在其他的争议,例如能否真正控制医保费用、商业竞争的负效应、对医生处方权的干扰以及信息的保密与安全性等。最后一部分,提出在我国现实国情下,通过学习国外的先进经验,完善药品福利管理(PBM)模式所需要的可行方法和措施。首先要建立专业的药品福利管理机构,形成专业化的管理团体；其次,实行医药分业改革,完善对医疗方面的补偿机制；再次,要建立健全的法制和良好的制度运行保障。除此之外,发展药品福利管理(PBM)模式,还需要制定专业的处方集目录,鼓励医生和患者使用合理的处方集目录,在选择药品福利管理公司时要充分考虑公司本身的整体实力、发展情况和企业文化等多方面因素,加大力度完善健全的药品保障政策体系等。通过以上的方法和措施,期望我国能够建立起符合我国国情的药品福利管理模式。本文主要采用历史分析法、实例分析法和比较分析法,从全新的角度探索新模式在我国医疗保险与商业健康保险中的运用。但是由于该题目较新,国内相关文献较少,翻译外文文献容易出现偏差,加之该题目涉及的范围较广,除了保险还包括医疗制度、药品产业链等方面,因此还需要多搜集相关文献和资料,多了解相关制度和知识,充分结合我国的实际情况。
[Abstract]:The United States is one of the representative countries in the early implementation of the medical insurance market. In order to control the soaring medical expenses, it is difficult to use the insurance policy to solve the difficult choice of the insured person because of too many choices. The more complicated the insurance market is in operation, management and monitoring, the drug welfare management (Pharmacy Bene) Fit Management, PBM) emerge as the times require. The drug welfare management (PBM) model is a specialized third party service, which mainly uses the market means to manage the drug cost. It is the new model of the United States Business insurance company to control the medical security fund, and the core goal of improving the utilization efficiency of medical insurance funds. PBMs, as a third party enterprise, balanced and coordinated the interests of the government, insurance agencies, pharmaceutical companies and patients, permeates in all links of the whole medical supply chain, providing services including drug catalog management, drug mail order services, prescription claims processing, drug use evaluation, recommended clinical pathways and disease management. The development of the drug welfare management (PBM) model has played an important role in reducing medical expenses, comprehensive evaluation of drug information, promoting the rational use of drugs, and implementing health management in an all-round way. It has a great impact on the market based insurance system in the United States.
At present, China is also facing the plight of the soaring expenditure on medical and health expenses. The status of its medical market is very similar to that of the United States in 70s and 80s. How to establish a perfect social medical insurance system and seek the development space and development path of commercial health insurance is one of the problems to be solved in China.
Although the model of drug welfare management (PBM) has emerged in our country, medical insurance and commercial health insurance have been used, the application is only part of each other. It is not integrated. It is necessary for us to learn from and apply the PBM model, but there are some problems in the PBM model, for example, whether it can really control the medicine or not. The disputes on the growth of insurance costs, the survival crisis of independent drugstores, the negative effects of mergers and acquisitions on competition and the privacy problems arising from public information. In addition, there are still many constraints and problems in the development of PBM mode in our country's actual conditions. The relevant knowledge of PBM model is introduced and explained in detail, the necessity of introducing PBM model in China is analyzed. According to the application of PBM model in China's medical insurance and commercial health insurance, the possible problems of the development of PBM model in our country are discussed, and the personal suggestions are put forward to the existing problems, and the expectation can be made to the PBM The effective use of the model in China, even in the improvement of the reform of the medical system in China, and promote the development of China's commercial health insurance can have a positive impact.
This article is divided into three parts: introduction, text and conclusion. The body is divided into five parts.
The first part is a detailed introduction and analysis of the drug welfare management (PBM) model in the United States. After understanding the concept of the drug welfare management model (PBM), the strategic tools and functions of the drug welfare management (PBM) model are deeply studied. The services provided by the PBM model include the formulation and management of the prescription catalogues, Providing drug mail order services, encouraging the use of generic drugs, dealing with prescription documents in real time, negotiating with pharmaceutical companies to obtain discounts, disease management, drug use evaluation, electronic prescriptions and information sharing and dissemination, has a positive role in controlling medical expenses and improving the quality of medical services. The development history of the PBM model, as well as the current development situation and the main drug welfare management company (PBMs).
The second part, according to the reality and market demand of our country, analyzes the necessity and feasibility of developing the model of drug welfare management (PBM) in our country. China is the key point of the high speed development of the model of drug welfare management (PBM). If our country uses the advanced model of the United States for reference, it can make our country go over the period of rapid development. To explore and improve the long-term process to effectively control the expenditure of medical expenses, the introduction of PBM model in China can also reduce the rate of payment, improve the quality of insurance products and promote the development of China's commercial health insurance. In addition, it also plays a very important role in promoting the reform of China's medical security system.
The third part is to analyze the case of establishing the intelligent management platform of the medical insurance fund in the medical insurance of China (PBM), and discuss the positive effect of the cooperation between Haihong and the local medical insurance bureau. And in the commercial health insurance, the Ping An insurance company integrates the "safe medicine network", "safe medicine network", and provides drug mail. A new comprehensive health management service platform is set up. It is expected to integrate the PBM model in medical insurance and commercial health insurance to establish a complete PBM model.
In the fourth part, the possible problems and difficulties in the establishment and development of drug welfare management (PBM) model in China are analyzed for reference to the complete PBM model in the United States. The national basic medical insurance system in China is now at a stage of low level, wide coverage, large waste and low supervision efficiency. In order to break through, the hospital has an absolute dominant position, in addition to the administrative management mode, the lack of sound legal system and system guarantee, which all restrict the development of the market based drug welfare management (PBM) model. The model of drug welfare management (PBM) has not been greatly recognized in the market, and the limited profit ability is also the difficulty of the development. In addition, There are other disputes in the PBM model itself, such as whether it can really control medical insurance costs, the negative effects of business competition, the interference with the prescription rights of doctors, and the secrecy and security of information.
In the last part, we put forward the feasible methods and measures to improve the model of drug welfare management (PBM) by learning foreign advanced experience in the actual situation of our country. First, we should establish a professional medicine welfare management organization and form a specialized management group. Secondly, implement the reform of medical division and perfect the compensation machine for medical treatment. Thirdly, we should establish a sound legal system and a good system operation guarantee. In addition, the development of the drug welfare management (PBM) model requires the formulation of a professional prescription catalogue, encouraging doctors and patients to use a reasonable catalogue of prescriptions, and taking full consideration of the overall strength of the company itself and the development of the company in the choice of the drug welfare management department. It is expected that our country can establish a model of drug welfare management in accordance with the national conditions of our country through the above methods and measures.
This paper mainly uses historical analysis, case analysis and comparative analysis to explore the application of new model in China's medical insurance and commercial health insurance from a new angle. However, because of the new topic and less domestic related literature, the translation of foreign literature is prone to deviations, and the scope of the subject is wide, besides insurance. Including the medical system and the pharmaceutical industry chain, we need to collect more relevant literature and information, understand the relevant systems and knowledge, and fully integrate the actual situation of our country.

【学位授予单位】：西南财经大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R95;F842.684

【参考文献】