Xinhua News Agency, Beijing, Dec. 14 (Xinhua) -- Reporter's note: Behind the game of medical insurance negotiations.
Xinhua News Agency reporters Peng Yunjia, Wen Jinghua, Lin Miaomiao.
Looking back on the past six years, the annual national health insurance negotiations will kick off every time the year is cold. In the open room, the medical insurance side and the enterprise side sit opposite each other, on the one hand is the national medical insurance usage, on the other hand is the lowest ** of the enterprise, and the volume is exchanged for price", and the negotiations of offensive and defensive tug-of-war, or repeated contests are "staged" here.
The focus of the confrontation is just a small "pill", but it is this small "pill" that carries the hopes of patients, considers the burden of medical insurance, involves the interests of enterprises, and embodies the countless painstaking efforts and efforts behind the negotiation to promote this negotiation.
Let "orphan drugs" no longer be out of reach.
Children with rare diseases are already desperate to have no medicine, and it is even more desperate to have drugs that cannot be purchased than to have them", "just to make medicines available to people who have no medicines, not to reduce prices......".
This is the heartfelt words of the representatives of both sides during the negotiation of rare disease drugs this year, and it also expresses the original intention of the medical insurance negotiation: to return medicine to the essence of saving people, so that patients can use and afford it.
Paroxysmal nocturnal hemoglobinuria (PNH), as an acquired hemolytic disease, afflicts many patients with PNH with complications such as recurrent hemolysis, hemoglobinuria, renal impairment, and high incidence of thrombosis.
The negotiation site of the 2023 National Medical Insurance Drug List. Photo by Xinhua News Agency reporter Peng Yunjia.
At this year's negotiation site, a drug that can be used for **3 rare diseases, eculizumab, has attracted much attention. Eculizumab was first marketed abroad in 2007 and had an obvious effect on rare diseases such as paroxysmal nocturnal hemoglobinuria, atypical hemolytic uremic syndrome, and refractory generalized myasthenia gravis, but the annual cost at that time reached 3 million yuan.
3 million yuan a year, it will be used for a lifetime, how many people can afford it?During the interview, Han Bing, chief physician of the Department of Hematology in Beijing, asked.
As an expert in paroxysmal nocturnal hemoglobinuria, Han Bing is well aware of the significance of eculizumab to patients, and over the years, she has repeatedly connected with drug companies that have developed eculizumab and appealed for drugs for patients, but the company assessed that the domestic payment ability was insufficient at that time, and chose to give up entering the Chinese market, and patients passed by hope again and again.
Many people are waiting to use this medicine, but only about 10 patients are able to stick to it so far. Han Bing said that after more than ten years, eculizumab was finally marketed in China, with an annual cost of about 500,000 yuan, and there are still very few people who can really afford the drug.
To enter or not to enter medical insurance, it is like standing at a crossroads of fate for patients.
In November 2023, after nearly 1 hour of negotiations, eculizumab was successfully negotiated, and the price reduction was superimposed on medical insurance reimbursement, bringing double "burden reduction" benefits to patients with paroxysmal nocturnal hemoglobinuria.
Now, more than 1.3 billion insured people as a single purchaser allow China's medical insurance to face the bottleneck of rare diseases and other drugs, and 15 rare disease drugs have entered the national medical insurance catalog this year.
Let innovative drugs enter the medical insurance faster.
At the scene of medical insurance negotiations in 2023, a new drug with a generic name of "glutametinib" attracted attention.
How "new" can this new drug be?It was approved on March 8, 2023 for ** locally advanced or metastatic non-small cell lung cancer targeting MET, and is a Class 1 new drug.
This is not unique in this year's negotiations, the 4-day 2023 medical insurance negotiations have held a total of 148 exclusive drug negotiations, 126 new drugs have been successfully entered into the medical insurance, and 57 are new drugs launched this year.
The acceleration of the entry of innovative drugs into medical insurance is a life-saving speed contest.
Before 2017, there was not a single tumor targeted drug in the National Medical Insurance Catalog, and it was difficult for innovative drugs to benefit more patients. In 2018, the National Health Insurance Administration was established and established a dynamic adjustment mechanism of "one adjustment per year", which shortened the adjustment cycle from a maximum of 8 years to 1 year, and the scope of the declaration mainly focused on newly listed drugs within 5 years, giving the possibility of new drugs entering the medical insurance in the "shortest time".
Corporate negotiators negotiate on the sidelines. Photo by Xinhua News Agency reporter Peng Yunjia.
Compared with hepatitis B, hepatitis C is more insidious and can also develop cirrhosis or liver cancer. Known as the "terminator of hepatitis C", Epclusa (sofosbuvir velpatasvir tablets) has a high ** rate of all hepatitis C virus genotypes or unknown genotypes.
In 2019, sofosbuvir velpatasvir tablets successfully entered the national medical insurance catalog, ** from a course of nearly 70,000 yuan to the "thousand-yuan era" - until today, that moment is still fresh in the memory of many patients.
In the past six years, the National Medical Insurance Catalogue has transferred a total of 395 drugs with uncertain efficacy, easy abuse, and clinical elimination or imminent withdrawal.
In the past six years, a total of 744 drugs have been added to the national medical insurance catalog, 100 drugs for tumors, and 93 drugs for chronic diseases such as hypertension, diabetes, and mental illness.
Incorporate more exciting new drugs and good drugs, the national medical insurance negotiation is in a race against time, and every cent of medical insurance is spent on the blade, and the game is not confined to temporary interests, but to bring hope to more people in the long-term cycle.
Running in both directions, for the anticipation of every patient.
The negotiation process is also a "two-way rush" to seek a win-win situation
Before the formal negotiation, the National Health Insurance Administration will fully communicate with the enterprises participating in the negotiation, so that the enterprises can understand the ideas of drug payment standard calculation. Entering the negotiation process, the medical insurance party will open a sealed envelope on the spot, which contains the "envelope price" of the negotiated drug, that is, the negotiated reserve price. The reserve price is calculated by experts organized by the medical insurance department, and the cost effect of the drug, the budget impact, and the burden of medical insurance are comprehensively considered to form the most affordable for medical insurance.
The medical insurance negotiator opened the envelope containing the negotiated drug reserve price on the spot. Photo by Xinhua News Agency reporter Peng Yunjia.
After confirming the reserve price, 115% of the reserve price is the first line, if the enterprise cannot enter after two **, then the negotiation fails;Otherwise, it will enter the negotiation process, and the final transaction price will not be higher than the "envelope price". The reason why this method is adopted is to strive for more preferential treatment for the people within the range that can be tolerated and accepted by the enterprise.
This year, 25 medical insurance negotiators were divided into 5 groups to undertake medical insurance negotiations for 148 exclusive drugs, many of which lasted more than 30 minutes and some even more than 2 hours, testing the physical strength and patience of both parties.
During the negotiation process, the repeated "pulling" between the medical insurance side and the enterprise side made people feel even more anxious, and no one could predict the final result in advance.
After participating in a number of medical insurance negotiations, the reporter noticed that almost every time the negotiation is successful, the medical insurance negotiators and business representatives will breathe a sigh of relief, and after each negotiation failure, both sides are full of regrets, because behind every game, there are countless patients and families looking forward to it.
Although the success of the negotiation is only reflected in whether the enterprise can enter the "envelope price", from the formulation of program rules to the declaration of the enterprise, from the expert review to the special calculation, and then to the final negotiation link, behind the successful entry of a drug into the medical insurance is the efforts and efforts of countless people.