Source: China Medical Insurance          Author: Tao Libo PUHSC

On June 8, 2020, the National Medical Security Administration issued the "Interim Measures for the Management of Medical Consumables for Basic Medical Insurance (Draft for Solicitation of Comments)" (hereinafter referred to as the "Draft for Solicitation of Interim Measures for Management") to solicit opinions from all walks of life.

Anyone familiar with this field knows that the management of medical consumables in my country's medical insurance has long been lack of overall standards. Therefore, the formulation and future implementation of the draft for consultation have the meaning of a "milestone" in this field and will have a profound impact on related industries.

Looking at the draft of the newly released "Interim Measures for Management" for comments, it can be seen that there are many highlights, and one of the most eye-catching contents is the introduction of "access management" methods in the field of medical consumables. In Chapter 1, Article 3 clearly stated: "[Access Management] The medical security administrative department of the State Council comprehensively considers the functional role of medical consumables, clinical value, cost level, medical insurance fund affordability and other factors, and adopts the access law to formulate " The Basic Medical Insurance Medical Consumables Catalogue (hereinafter referred to as the Basic Medical Insurance Medical Consumables Catalogue) is regularly updated and dynamically adjusted. The medical consumables in the Basic Medical Insurance Medical Consumables Catalogue are included in the medical insurance fund payment scope according to regulations."

In the field of medical consumables in our country, the previous management method of national medical insurance is in principle "non-prohibition and entry", that is, unless the medical insurance department has clear regulations that certain medical consumables are not included in reimbursement, or certain consumables (mainly high-value The pricing and use of consumables must meet the special requirements of medical insurance. Otherwise, most medical consumables can be directly included in the scope of medical insurance, and can be charged and reimbursed separately or included in medical service items. This is what people call the "blacklist" method.

With the continuous deepening of China’s medical reform, when the reform of the pharmaceutical sector continues to be strengthened, drug costs have been controlled to a certain extent, especially when the "proportion of drugs" is strictly monitored, the use and amount of medical consumables have appeared compensatory. The rapid growth has swallowed some of the fruits of the drug reform. Therefore, some departments and regions have also put forward the management idea of ​​"consumption ratio" monitoring, trying to control the disorder in the field of medical consumables.

In fact, the use of rigid indicators such as the proportion of drugs and the proportion of consumption to forcibly evaluate and constrain complex and changeable medical behaviors has always been criticized. To straighten out the use and payment of medical consumables, a more complete management strategy is needed. In the draft of the "Interim Measures for Management", we have seen that the medical insurance department, referring to the reform experience of drug access management, comprehensively proposed a management method for consumables access, which embodies such a management thinking change.

The access management of medicines has accumulated long-term experience in my country's medical insurance. The core of admission management is catalog management. Only those who are included in the catalog can get the use and payment within the scope of medical insurance, which is the so-called "white list" system. To be able to enter and stay in the catalog, it is necessary to abide by a series of regulations on pricing, purchase, use, and reimbursement of medical insurance, thus forming a clear management standard. In this regard, a complete system has been established in drug management.

In the draft of the "Interim Measures for Management", the catalog management of medical consumables was comprehensively regulated. In fact, this is also the most important content in this document, including "Chapter II "Basic Medical Insurance Medical Consumables Catalog" Confirmation, "Chapter 3 Use of "Basic Medical Insurance and Medical Consumables Catalog"" and "Chapter 4 Medical Insurance Payment of Medical Consumables" constitute a complete system.

In the determination mechanism of the consumables catalog, the "Interim Measures for Management" draft for comments clarifies the three parts of inclusion, non-inclusion, and recall. Obviously, the lessons learned from the long-term "include only, no recall" in the management of the drug catalog have been absorbed here. At the same time, the Office has also clarified the expert review mechanism and access coding mechanism in the development and adjustment of the catalog.

Especially worthy of attention here is the consumable coding mechanism. Compared with drugs that can be managed based on their generic names, it is very difficult to manage the classification and coding of a wide variety of medical consumables. Fortunately, after hard work, China’s Medical Insurance Bureau has formulated its own consumables coding system. Therefore, it is clearly stipulated here: “Newly listed medical consumables shall first be coded in accordance with the The codes of medical consumables are consistent and automatically belong to the scope of payment by the medical insurance fund, and the payment policies and rules are consistent with the medical consumables with the same codes in the catalog."

However, due to the complexity and diversity of medical consumables, there is also a way to deal with specific problems: "If the code of the medical consumable is inconsistent with the code of the medical consumable in the catalog, the medical security administrative department of the State Council will organize experts to review in a timely manner to determine whether to include Catalog of Basic Medical Insurance and Medical Consumables "". It is expected that there will be complex games in this area, and more detailed specifications will be required.

In the use mechanism of the consumables catalog, the draft of the "Interim Measures for Management" clarifies that the consumables used by public hospitals must undergo centralized procurement, and the consumables for negotiating access can be directly purchased online, and medical institutions must be given priority to use centralized procurement Varieties, thus linking up with the centralized procurement of medical consumables.

At the same time, in the catalog use mechanism, the update method of consumable codes is also emphasized. As mentioned earlier, the classification and coding system of consumables is the focus of medical insurance consumables management.

In the payment mechanism for consumables, the draft of the "Interim Measures for Management" clarifies the conditions of payment and non-payment, and emphasizes the payment of "implantable consumables beyond the scope of reasonable use" and "implantable consumables beyond the actual number of implants." Non-payment for unreasonable use of consumables is worthy of the attention of medical institutions and consumable manufacturers.

At the same time, the medical insurance payment standards for consumables are clearly stipulated here. "Exclusive products, in principle, determine the first medical insurance payment standard through negotiation", "non-exclusive products, in principle, determine and adjust the payment standard through centralized procurement". On the premise that it is clear that the payment standards for consumables are set by the national medical insurance department, the specific payment method and payment ratio are set by the local medical insurance department, which reflects the flexibility of management.

Finally, the payment method for consumables also pointed out: "Support all localities to include medical consumables in the catalog into the scope of packaged payment by disease type and disease diagnosis-related grouping", thus leaving an interface for the connection with DRGs and other payment method reforms. Of course this The specific specifications in this regard need to be further clarified.

In addition, in other parts of the draft of the "Interim Measures for Management", other related content of consumables access management, such as supervision work, has also been standardized, forming a complete management specification.

In short, in this draft of the "Interim Measures for Management", the management of medical consumables by my country's medical insurance will move toward "whitelist" access management. If the official policy is finally implemented, this will be a major change in the management of medical insurance consumables in my country, and will have a profound impact in related fields. Looking at the relevant content in the document, the principles and methods of consumables access management mainly come from relevant practices in the pharmaceutical field. It is a good thing to have previous experience for reference, but it is also necessary to see the huge differences between medical consumables and drugs. Therefore, the admission management of medical consumables still needs to carry out fine institutional arrangements to achieve good reform effects. It is expected that this aspect Work will continue in depth in the future.