Such medicines and equipment are not limited by DRG fees!The Medical Insurance Bureau opens the "green channel"

On the evening of July 19, the State Medical Insurance Bureau issued a notice to further do a good job in medical service price management.

The Medical Insurance Bureau's permissions on the price of medical services have been decentralized, requiring the specific rules of the dynamic adjustment mechanism at the provincial level, and developing green channels for major illness diagnosis and treatment plans or major innovation projects that fill the diagnosis and treatment gap.

The industry believes that this method of the National Medical Insurance Bureau is a response to some provinces' recent implementation of the DRG payment model. On July 13, the Beijing Municipal Medical Insurance Bureau issued a notice that innovation, clinical benefits, and a greater impact on the DRG disease group payment standards can have a great impact on the DRG paid model.

In other words, the use of innovative drugs is not limited by DRG's control, which is undoubtedly good news for a large number of innovative pharmaceutical companies.

According to Beijing, the company's declaration time is one month from July 20. As long as the enterprise's independent declaration and review of innovative drugs will no longer be suffered from the cost of controlling the cost of the DRG policy. At the same time, it will also rule out the concerns of the hospital's overrouts to use innovative drugs and medical insurance.

The cost control, at the same time does not crack down on innovation enthusiasm, this is the major benefit of the National Medical Insurance Bureau to the industry from an institutional design level to the industry.

The first time for the innovative medicine to loosen

In the new DRG regulations of the Beijing Medical Insurance Bureau, the declaration must be clearly defined on the "innovative product". The declaration must meet: within three years, the approval of new drugs, the medical insurance classification code, and the clinical effects have greatly improved.

Beijing was one of the 30 DRG pilot cities. In May 2019, the State Medical Insurance Bureau launched the DRG payment method reform. Three years of pilot, each selected city has accumulated experience.

On this basis, in November 2021, the National Medical Insurance issued a notice that it was clear that by the end of 2025, DRG paid covered all eligible medical institutions that met the qualified hospitalization services, and basically achieved full coverage of diseases and medical insurance funds. This marks that the policies of hospitals in Europe and the United States will also be officially implemented in China.

At that time, the industry was worried that if medical institutions wanted to survive in a new round of reforms, they would definitely strive for more patients and strictly control the cost of diagnosis and treatment. Otherwise, the hospital would not be eased, and the doctors' income would be affected. In order to reduce costs, medical staff must not dare to use innovative products with higher prices, and no one is willing to learn and use these new products and new technologies.

The regulatory layer quickly noticed this. Zheng Jie, the leader of the National Pilot Technology Guidance Group of CHS-DRG and the director of the Medical Insurance Center of the Beijing Medical Security Bureau, has publicly stated that it should not be limited by "medical insurance control" with innovative products with clinical value.

"Teng cage change birds" and "encourage innovation" are the core ideas of this round of medical reform. Since the establishment of the National Medical Insurance Bureau, more than 300 innovative drugs have been included in the medical insurance directory, and the fund pays for the entire innovative drug industry. Naturally, DRG should not be a reason to restrict innovative drugs.

This time, the Beijing pilot innovation medicine is not restricted by the CHS-DRG fee control. It is undoubtedly tore the development of the development of the biomedical industry, so that more doctors dare to use innovative products clinically. "Centered" medical reform ideas.

It is worth noting that the CHS-DRG pilot policy of innovative drugs can be seen in the future trend of national supervision. Analysts judge that if this policy can be successfully implemented, at least it can be promoted to pilot areas of all CHS-DRGs.

Nowadays, the medical insurance department is mainly encouraged for real innovation products and policies. Obviously, this must have a positive role in promoting future industrial development.

There is also a shelf life for the liberalization of the fees

On the surface, the Beijing DRG New Deal opened a mouth to innovative drugs and innovative medical equipment. However, some analysts have pointed out that there are not many varieties other than DRG payment reform supervision.

According to the Jianzhi Bureau, all of the above 6 criteria must be met in order to truly control the control fee.

First of all, the products declared must be "new". Either it was listed within 3 years, or a new indicator was added within 3 years, or the national medical insurance drug catalog was included in 3 years, or the newly charged instruments were newly charged due to price adjustment within 3 years. In the medical insurance negotiations in previous years, there were also "approval within 5 years". Some experts believe that the medical insurance fund encourages innovation at least if it is a new product.

Clinical efficacy must also be greatly improved compared to traditional treatment. The "Notice" requires that when the relevant enterprises and designated medical institutions are declared, they need to provide materials that can prove "clinical innovation" and describe their clinical effectiveness and innovation in detail. "Clinical Innovation".

In the end, whether the DRG restrictions can be exempted, expert demonstrations and data verification are also required. The requirements for data verification are: more than 50 cases of drug and device products must be more than 50 cases in the city; diagnosis and treatment items require more than 15 cases.

Only one mouthful is: rare diseases are not limited by cases.

Moreover, DRG is "shelf life" from DRG. The notice clearly states that drugs, medical devices and diagnosis and treatment projects within the scope will be valid in the next three years. Moreover, the Beijing Medical Insurance Center is settled in accordance with the real use of the situation every year.

In other words, the buffer of the Beijing DRG new regulations to innovative drugs and innovation equipment is 3 years.Three years later, what is the development of DRG across the country, will the National Medical Insurance Bureau have new policy changes, and now it is impossible to predict.However, at least Beijing's policy loosening will bring some benefits to the drug production enterprise, and dispel the doctors' concerns in clinical use, and will help the capital market to eliminate pessimism.

Some analysts pointed out that CHS-DRG control fees are loosened on innovative drugs, and regulatory policies such as cracking down on defrauding insurance and rectification clinical prescriptions are not conflicting. Once the medical insurance regulatory department finds violations, it is bound to punch it.Fortunately, otherwise it will lose the Beijing market.

#National Medical Insurance Bureau ## ###

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