Drug access for the first time "national negotiations" health insurance face drug companies "bargaining" just need drugs is how to "talk" into health insurance

Release time:




Seeing the "trastuzumab" on the list, a stone in Chen Jun's (pseudonym) heart fell to the ground.

Chen Jun's mother had breast cancer and needed an injection of trastuzumab, commonly known as Herceptin. Previously, in China, the retail price of this drug produced by multinational pharmaceutical company Roche was as high as 20000 yuan. In a treatment cycle, patients have to inject at least 14. For patients, even if they can be partially reimbursed through medical insurance, it is also an unbearable huge expenditure.

A few days ago, the Ministry of Human Resources and Social Security announced the price negotiation results of 36 drugs after entering the medical insurance catalog, and simultaneously determined the medical insurance payment standards for these drugs, and Herceptin was among them. After negotiations, the payment standard for each drug was reduced to 7600 yuan, a decrease of nearly 70%.

Most of the drugs included in the category B scope of the National basic Medical Insurance, Industrial injury Insurance and Maternity Insurance Drug catalogue (2017 Edition) are tumor targeted drugs that patients are looking forward to, as well as drugs for major diseases such as cardiovascular disease and hemophilia. Compared with the average retail price in 2016, the average reduction of negotiated drugs reached 44%, and the highest reduction reached 70%.

This is the first national negotiation of China's medical insurance access. For patients, it is undoubtedly a "rain" to reduce the price of just needed drugs into medical insurance; for medical insurance funds and pharmaceutical companies, it can also gain a win-win situation.

Patients benefit from a big drop in drug prices

Apply for a visa, buy air tickets, currency exchange, bargaining, cold chain transport... 1 years ago, there was a netizen on the Internet to share their own to New Delhi, India to buy Herceptin experience. In order to buy a few drugs, all the way to toss, exhausted. Even so, the cost of buying drugs is lower than that of domestic drugs. Several netizens replied that after reading the "strategy" of buying medicine, they also planned to go to India to buy medicine.

Chen Jun said that he had the same idea, but he was afraid of buying fake drugs or expired drugs, and worried that the doctor would not give injections after returning home, so he did not make the trip.

However, after being included in the medical insurance catalogue this time, the single selling price of Herceptin has dropped to 7600 yuan. According to the minimum out-of-pocket payment ratio of insured patients, patients only need to spend 1500 yuan at least for each drug, which is equivalent to a one-way ticket to New Delhi.

Drugs like Herceptin are "targeted drugs" for the treatment of tumors ". The targeted drug refers to a drug capable of "targeting" a specific lesion site and accumulating or releasing an active ingredient at the target site. Due to its high efficacy and low side effects, targeted drugs have become ideal drugs for the treatment of cancer.

For a long time, some cancer patients have to rely on imported targeted drugs and some innovative drugs to extend their lives. However, these drugs are subject to patent restrictions, are often extremely expensive, and cannot be reimbursed by health insurance. Faced with the burden of "buying life with money", many people choose to give up, and some are forced to join the "drug purchasing army" and purchase imported drugs or low-cost "generic drugs" in neighboring countries such as India ".

Why is the price of China's imported patented drugs higher? Experts believe that, on the one hand, it is related to China's pharmaceutical patent system, on the other hand, it is also due to some super-national treatment of foreign-funded drugs. Even if some foreign-funded drugs have passed the patent protection period, they still enjoy the highest price level treatment in the process of centralized drug procurement in public hospitals, which takes full advantage.

Most of the 36 drugs successfully negotiated this time are still under patent protection. There are 31 western medicines and 5 Chinese patent medicines, of which anti-tumor drugs account for half of the country. The reporter's statistics found that these drugs involved more than 10 foreign pharmaceutical companies, and the sales of many drugs in China in 2015 alone were as high as hundreds of millions or even more than one billion yuan.

For example, the sales volume of Herceptin in 2015 was 1.912 billion yuan; Erlotinib, another Roche drug for the treatment of lung cancer, was reduced by 58% after negotiation, and the sales volume in 2015 was 0.624 billion yuan; in addition, the prices of some drugs of AstraZeneca, GlaxoSmithKline, Bayer and other well-known foreign pharmaceutical companies have also decreased to varying degrees.

For Class B drugs that enter the medical insurance catalog, patients only need to pay part of their own, and the specific reimbursement ratio varies according to local policies and specific drugs. Jin Hua, director of the Jilin Medical Insurance Bureau, said that patients pay a small part of their own expenses, and the medical insurance fund bears most of the expenses. The negotiated payment standard has greatly reduced the price of drugs and further reduced the financial burden of patients.

system innovation fair negotiation

The British "Financial Times" reported that pharmaceutical companies cut prices after "long" and "very difficult" negotiations, highlighting that the world's major pharmaceutical companies are cooperating with the Chinese government to reduce drug prices, although this has caused revenue growth for some products. Slow down.

In April this year, the Ministry of Human Resources and Social Security announced a list of 44 drugs to be negotiated. Judging from the final result, the success rate of the negotiations reached 81.8 per cent. It is reported that the negotiation site was very quiet and serious, and the price bargaining was particularly fierce, exceeding the expectations of the company. Some business people came out of the wall sweating profusely.

From preparation to implementation, how can we talk about results in just four months? Ding Jinxi, a professor at China Pharmaceutical University who was deeply involved in the negotiations, pointed out that as the first national negotiations on drug health insurance access, many of the work has no precedent to follow, and it is necessary to draw on international experience and make groundbreaking system design based on China's national conditions.

According to the relevant person in charge of the Ministry of Human Resources and Social Security and experts involved in the negotiation, before the negotiation, two groups of experts from the medical insurance side evaluated and calculated the economy of the drug and the affordability of the medical insurance fund. On the one hand, it analyzes the clinical value of drugs, the price of the surrounding market, the reference of similar drugs, etc.; on the other hand, it uses the "big data" of medical insurance operation to calculate the impact of the negotiated drugs on the medical insurance fund after they are included in the catalog, and on this basis, it puts forward suggestions as the main basis for negotiation.

Pharmaceutical companies, according to the declaration list to submit drug information, drug prices and other materials. At the same time, the medical insurance party will also feed back the conclusions of the expert review and evaluation, as well as the payment scope and policy conditions of the drugs after entering the catalogue, allowing the enterprises to propose amendments.

Entering the negotiation stage, the medical insurance institution organizes another negotiation expert to negotiate the price with the enterprise representative. The pharmaceutical company has two opportunities to make an offer, and if the lowest offer is more than 15 per cent higher than the price expected to be paid by health insurance, the negotiations are suspended; otherwise, the two sides can negotiate further. The final payment standard cannot exceed the expected payment standard of medical insurance.

Ding Jinxi said that the declaration, review, and negotiation are independent and mutually restricted, ensuring that the negotiations are fair, scientific, and reasonable.

To be sure, this drug access negotiation is just the beginning. People expect more just-needed drugs and life-saving drugs to enter the medical insurance catalogue, and regularize the drug negotiation mechanism and system.

Tao Libo, a researcher at the Institute of Pharmaceutical Economics of Sun Yat-sen University, believes that in this access negotiation, China's medical insurance began to adopt the idea of classified management: for ordinary new drugs, the traditional batch approval method is still adopted; for expensive, high innovation and less competition For new drugs, evidence-based negotiation is adopted. This laid the foundation for the evolution of health insurance access to "non-innovative drugs with reference to payment standards, innovative drugs to negotiate access.

Yan Qinghui, deputy director of the Department of Medical Insurance of the Ministry of Human Resources and Social Security, said, "Like patented drugs, exclusive varieties, the clinical value is relatively high, and the efficacy is also more accurate, the people really need. We hope to take advantage of the group purchase advantage of health insurance and negotiate the appropriate payment standard on the basis of equal consultation with enterprises."

Multi-party win-win needs to be implemented

Experts believe that the entry of high-priced just-needed drugs into the medical insurance drug catalog is a "win-win" for medical insurance, enterprises, and insured persons, and will promote the active transformation of the roles of medical insurance departments, drug producers, and doctors.

Wu Zhen, deputy director of the State Food and Drug Administration, said recently that China has become the world's second largest pharmaceutical consumer market. In 2016, the scale of China's pharmaceutical market exceeded 1495 billion yuan, which is expected to increase by more than 13%, of which the scale of the prescription drug market exceeded 800 billion yuan.

According to industry insiders, for medical insurance, with the increase in the payment of prescription drugs, it is necessary to "use limited money to buy the most cost-effective drugs" to ensure the smooth operation of the medical insurance fund and effectively control the medical insurance fund while ensuring the use of drugs by patients. Expenditure and burden of social medical expenses.

For pharmaceutical companies, the sales of drugs that have been negotiated into the medical insurance catalog are expected to further increase, realizing "price-for-volume". Especially for foreign pharmaceutical companies, with the increasingly fierce competition in the same indication market, they may also face domestic generic drug competition in the future. Therefore, participating in negotiations and including in the medical insurance catalog is the best choice. At the same time, the move can also encourage more domestic enterprises to invest in new drug research and development.

Just need drugs to reduce prices into the health insurance has made a good start, but whether the reform dividend can benefit the insured patients, still need to be implemented by the local health insurance departments. Tao Libo believes that the cooperation between national medical insurance and local medical insurance is the difficulty of further reform of the access mechanism in the future.

The Ministry of Human Resources and Social Security previously required that the basic medical insurance fund for 36 drugs and the proportion of insured persons should be determined by each overall planning area. According to previous regulations, the local medical insurance department has 15% of the adjustment right to the national category B medical insurance drug catalog, which can be transferred in or out, and the payment ratio is determined according to local conditions. However, this time the Ministry of Human Resources and Social Security has made it clear that the social insurance authorities of all provinces (autonomous regions and municipalities) shall not transfer the relevant drugs out of the catalog, nor shall they adjust the scope of payment.

Yan Qinghui said that the current payment standard is valid until December 31, 2019. During the validity period, if a generic drug is listed, the Ministry of Human Resources and Social Security will adjust the medical insurance payment standard of the corresponding drug according to the price level of the generic drug. All localities should encourage designated retail pharmacies to provide drugs for the insured, and give full play to the positive role of pharmacies in ensuring the supply of medical insurance drugs.

Ding Jinxi believes that the next step is to consider the compatibility of overall regional policies with existing policies, including docking with provincial medical insurance catalogues, linking up with the centralized procurement system of public hospitals, straightening out the procurement and distribution channels of social pharmacies, and solving the problems of outpatient deductible lines, capping lines and self-payment ratios, so as to maximize the social benefits of negotiation results.