药品价格改革形势下医保药品支付标准的研究

发布时间：2018-05-17 19:01

本文选题：医疗保险 + 药品　；参考：《东南大学》2017年硕士论文

【摘要】：目的为贯彻落实国家发展改革委、国家卫生计生委、人力资源和社会保障部等七部门《关于印发推进药品价格改革意见的通知》精神,探索建立新的引导药品价格合理形成的机制,建立与之相适应的医保药品支付标准制定的程序、方法和依据,促进医疗卫生事业健康发展,满足人民群众不断增长的医疗卫生服务需求。方法通过查阅相关的文献资料,了解其他国家和地区药品价格形成机制,以及我国部分地区医疗保险支付标准建立的实践经验和相关政策。应用焦点人物访谈、小组访谈法和历史资料收集等获取资料,收集药品交易销售量和价格等相关数据,共获得36种通用名,75种商品名,7111条药品的信息,应用Excle软件和SPSS软件,建立数据库,进行描述性统计分析。结果1.医保药品支付标准应该包括两方面的内容:一是药品的医保支付价格,二是医保药品支付方式。2.药品的医保支付价格测算应该包括现在正在使用的药品、新上市药品、创新药和专利药品医保支付价格的确定办法,以及药品医保支付价格的调整办法。(1)对于正在使用的药品,可以根据其有效成分、药理作用、治疗效果等因素,从治疗学或药理学上具有相似作用的药品中选择多家生产、充分竞争、临床用量较大、对医保基金影响较大的药品,按照通用名和规格进行分类,计算同类药品的加权平均价格,中位数价格或者中标价作为医保药品支付标准。(2)对新上市药品医保药品支付标准的制定,可以应用"类似药效比较方法"和"成本计算方法"。(3)创新药和专利药的医保支付价格,可以由医保部门和药品生产企业通过谈判共同制定。(4)医保药品支付标准的调整办法可以参照日本和台湾地区的做法。日本的医保支付价格根据市场情况每两年调整一次,其依据是医保价格和医疗机构采购药品的价格,多采用R-zone方法。台湾地区给付目录内药品支付价格调整,充分发挥了医疗机构与药商谈判主动性。保险人仅在固定时间采集市场价格数据,按照《全民健康保险药品价格调整作业办法条文》规定进行加权平均计算支付价。3.药品的支付方式分为两部分:一是医保部门与患者的费用分担方式;二是医保部门与医疗机构的费用结算方式。与患者的费用分担方式可以采用按比例支付和基准价支付相结合的方式;与医疗机构的费用结算方式可以采用总额控制下的多种预付制方式相结合。4.医保药品支付标准实施的前提条件包括药品零加成政策、城乡医保统筹、公开透明的药品交易平台,以及医院和医生积极性的调动等等。5.参照国外或地区的医保制度是有条件的。首先是医与药分离,澳大利亚和德国都是传统的实行医药分离的国家,而日本和台湾地区也在以药养医体制出现种种弊端之后实施了医药分业的改革。其次是完善的药物经济学评标体系,德国,澳大利亚,日本和台湾地区都将药物经济学评价作为药品定价的重要参考。在制定药品价格时,不能只考虑其成本和安全性,还应考虑到其经济性。第三是充分考虑病人负担,德国在实行医药费用分担制度的同时为了控制病人的医药负担,规定患者承担的费用,最低不少于5欧元,最多不超过10欧元。台湾地区避免个人分担过重,设定了个人分担封顶标准,规定个人负担200元封顶。第四是分工明确、职责清晰的药品定价机构,澳大利亚的药品定价组织管理与技术支持部门包括药品保险定价机构、药品保险咨询委员会和澳大利亚国家治疗性药品管理局;日本有厚生劳动省负责国家的医疗卫生和社会保障事宜,其下设医政局经济课,是日本的药品价格管理部门,负责医药品价格调查和特定保险医疗材料价格调查等事务;台湾地区由健保局负责健保药品价格的制定和调整等工作。第五是对医生行为的控制和对医疗机构的激励要有相应的机制。结论合理的制定医保药品支付标准,对于加快完善现代市场体系和转变政府职能,规范药品市场价格行为,促进医疗卫生事业和医药产业健康发展,满足人民群众不断增长的医疗卫生需求,减轻患者不合理的医药费用负担,具有重大的意义,是加快完善现代市场体系和转变政府职能的重要举措。
[Abstract]:Aim to carry out the notifications of the seven departments, such as the State Development and Reform Commission, the National Health Planning Commission, the Ministry of human resources and social security, and other departments of the Ministry of human resources and social security, to explore and establish a new mechanism for the rational formation of drug prices, and to establish the procedures, methods and methods for the formulation of medical insurance drug payment standards. To promote the healthy development of medical and health services and to meet the increasing demand for medical and health services of the people. Methods through consulting relevant documents, understanding the mechanism of drug price formation in other countries and regions, as well as the practical experience and related policies established in the medical insurance payment standards in some areas of our country. Interview, group interview method and historical data collection, collect data, collect related data such as sales volume and price of drug trade, obtain 36 general names, 75 commodity names, 7111 information, use Excle software and SPSS software, establish database, and carry out descriptive analysis. Results 1. the standard of payment for medical insurance should include two parties Content: one is the medical insurance payment price for drugs, and the two is that the medical insurance payment price of the.2. medicine should include the drugs that are now being used, the newly listed drugs, the method for determining the price of the medical insurance of the innovative and patent medicines, and the adjustment of the price of the medical insurance payment. (1) the use is being used. Drugs, according to their effective components, pharmacological effects, therapeutic effects, and other factors, from a drug with similar effects in therapeutics or pharmacology, choose a number of production, full competition, a large amount of clinical use, a drug that has a greater impact on the medical insurance fund, classified according to the general name and specification, and calculate the weighted average price of the same kind of drugs. 2. (3) the price of medical insurance payment for innovative and patent medicines can be formulated by the medical insurance department and the pharmaceutical production enterprise through negotiation. (4) medical insurance medicine. The adjustment method of the standard of payment can be referred to the practice in Japan and Taiwan. The price of medical insurance payment in Japan is adjusted every two years according to the market situation. It is based on the price of medical insurance and medical institutions purchasing drugs, and the R-zone method is adopted. The adjustment of the price of the drug payment in the Taiwan area is given full play to the medical machine. The insurer has the initiative to negotiate with the drug dealers. The insurer only collect the market price data at a fixed time. The payment methods of the.3. drugs are divided into two parts according to the provisions of the national health insurance drug price adjustment provisions. The first is the cost sharing mode between the medical insurance department and the patient; the two is the medical insurance department and the medical treatment. The mode of cost settlement of the institution. The way of sharing the cost with the patients can be combined with the proportion of payment and the base price payment; the precondition for the implementation of the.4. Medicare payment standard in combination with the cost settlement of the medical institutions can be combined with a variety of prepayment systems under total control, including the zero addition of the drug policy, the city's policy, Rural medical insurance, open and transparent drug trading platform, and the mobilization of hospitals and doctors, and so on.5. refer to the medical insurance system of foreign countries or regions. First, the separation of medicine and medicine, Australia and Germany are traditional medical separation countries, and the Japanese and Taiwan areas are also in the medicine system. After the malpractice, the reform of Pharmaceutical Division has been implemented. The second is the perfect evaluation system of pharmaco economics. In Germany, Australia, Japan and Taiwan, the evaluation of pharmacoeconomics is regarded as an important reference for drug pricing. In the formulation of drug prices, the cost and safety of drugs should not be considered only, and their economy should be taken into account. Third is a full examination. Considering the burden of the patients, in order to control the medical cost sharing system in Germany, in order to control the medical burden of the patients, the cost of the patient is not less than 5 euros, up to no more than 10 euros. The Taiwan area avoids the heavy share of individuals, sets the personal sharing of the cap and the individual burden of 200 yuan. Fourth is clear division of labor, The drug pricing agency with clear responsibilities, the Australian drug pricing organization management and technical support department, including the drug insurance pricing agency, the drug insurance advisory committee and the Australian National therapeutic drug administration, and the Ministry of health and health in Japan, are responsible for the health and social security of the country, and the economic course of the medical administration bureau is set up. The drug price management department in Japan is responsible for the medical price survey and the specific insurance medical material price investigation and so on. The Taiwan regional health insurance bureau is responsible for the formulation and adjustment of the health insurance price of the health insurance. Fifth is the control of the doctor's behavior and the corresponding mechanism for the incentive of medical institutions. The standard of drug payment is of great significance to improving modern market system and changing government functions, standardizing the price behavior of drug market, promoting the healthy development of medical and health industry and medical industry, meeting the growing medical and health needs of the people and reducing the burden of unreasonable medical expenses for the patients. It is of great significance to speed up the improvement of modern times. An important measure of the market system and the transformation of government functions.
【学位授予单位】：东南大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R95

【参考文献】