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国家谈判药品门诊医保待遇现状、问题及完善措施

陈烨, 丁锦希, 柳婷, 唐迪, 吴方, 吴丽萍, 段婉婷, 徐杨燕

陈烨, 丁锦希, 柳婷, 唐迪, 吴方, 吴丽萍, 段婉婷, 徐杨燕. 国家谈判药品门诊医保待遇现状、问题及完善措施[J]. 中国药科大学学报, 2020, 51(5): 628-634. DOI: 10.11665/j.issn.1000-5048.20200516
引用本文: 陈烨, 丁锦希, 柳婷, 唐迪, 吴方, 吴丽萍, 段婉婷, 徐杨燕. 国家谈判药品门诊医保待遇现状、问题及完善措施[J]. 中国药科大学学报, 2020, 51(5): 628-634. DOI: 10.11665/j.issn.1000-5048.20200516
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CHEN Ye, DING Jinxi, LIU Ting, TANG Di, WU Fang, WU Liping, DUAN Wanting, XU Yangyan. Status, problems and improvement measures of health insurance reimbursement of national negotiated drugs used in outpatients[J]. Journal of China Pharmaceutical University, 2020, 51(5): 628-634. DOI: 10.11665/j.issn.1000-5048.20200516
Citation: CHEN Ye, DING Jinxi, LIU Ting, TANG Di, WU Fang, WU Liping, DUAN Wanting, XU Yangyan. Status, problems and improvement measures of health insurance reimbursement of national negotiated drugs used in outpatients[J]. Journal of China Pharmaceutical University, 2020, 51(5): 628-634. DOI: 10.11665/j.issn.1000-5048.20200516
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国家谈判药品门诊医保待遇现状、问题及完善措施

  • 中国药科大学国际医药商学院，南京 211198

Status, problems and improvement measures of health insurance reimbursement of national negotiated drugs used in outpatients

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    摘要
  • 摘要: 2017?2019年国家医保目录准入谈判有效缓解了高值创新药品的“看病贵”难题。但“重住院、轻门诊”医保现状使得谈判药品门诊实际报销水平较低，进而影响患者的健康福利。本文以97个谈判药品、337个统筹市为统计样本，实证分析门诊用药的医保报销情况，结果显示有40个品种在大部分统筹市（统筹市占比超过70%）的实际报销水平低于50%。进一步探究门诊待遇低的原因发现未纳入门诊特殊政策、或门诊特殊政策不完善是其主要原因。最后，本文基于国内各统筹市门诊补偿政策经验提出提高门诊保障待遇的建议与方案，认为各统筹市可通过实现门诊统筹、完善门诊特殊政策、探索创新支付等手段提高谈判药品门诊保障待遇，确保医保目录准入谈判结果落地工作的顺利实施。
    Abstract: The access negotiations of National Reimbursement Drug List (NRDL) in China from 2017 to 2019 effectively improved the availability and affordability of high-value innovative drugs. However,the actual outpatient reimbursement of most negotiated drugs is lower,which affects the patients" health insurance funds. In this paper,97 negotiated drugs in 337 overall planning cities were selected as samples to analyze the outpatient reimbursement for negotiated drugs. The results showed that the reimbursement level of 40 negotiated drugs was less than 50% in over 70% cities,which can be mainly interpreted as absence or imperfection of outpatient reimbursement policies for special diseases. Finally,this paper puts forward suggestions and protocols for improving the outpatient medical insurance through realizing outpatient overall planning,improving outpatient reimbursement policies for special diseases,and exploring innovative payment,ensuring the achievement of the access to NRDL.
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    • 参考文献(3)
  • [1] .［2019-11-29］. http：//finance.sina.com.cn/money/insurance/bxdt/2019-11-29/doc-iihnzhfz 2422958.shtml.
    [2] National Health Commission of the People''''s Republic of China. Publication of the first list of rare diseases（关于公布第一批罕见病目录的通知）［EB/OL］.［2018-06-08］.http：//www.nhc.gov.cn/yzygj/s7659/201806/393a9a37f39c4b458d6e830f40a4bb99.shtml.
    [3] NHSA. Four national ministries jointly issued the Guiding Opinions on Improving the Medical Insurance Mechanism for Outpatient Use of Hypertension and Diabetes in Urban and Rural Residents（四部门印发《关于完善城乡居民高血压糖尿病门诊用药保障机制的指导意见》）［EB/OL］.［2019-10-10］. http：//www.nhsa.gov.cn/art/2019/10/10/art_37_1842.html.
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出版历程
  • 收稿日期:  2020-09-15
  • 修回日期:  2020-09-29
  • 刊出日期:  2020-10-24

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