溃疡性结肠炎纳入门诊特殊病种和门诊慢性病报销的预算影响分析  

Budget Impact Analysis of Treatments for Ulcerative Colitis with Implementation of Special and Chronic Disease Outpatient Management Policy

作　　者：史睿智 刘天怡 王进 张巍 刘君 冯元 张宁芮 SHI Rui-Zhi;LIU Tian Yi;WANG Jin;ZHANG Wei;LIU Jun;FENG Yuan;ZHANG Ning-Rui(Government Affairs and Market Access Department,Xian Janssen Pharmaceutical Ltd.,Beijing 100025,China;Real World Solutions,IQVIA,Shanghai,200020,China)

机构地区：[1]西安杨森制药有限公司市场准入和政府事务部,北京100025 [2]艾昆纬企业管理咨询(上海)有限公司真实世界研究团队,上海200020

出　　处：《中国药物经济学》2021年第7期36-43,共8页China Journal of Pharmaceutical Economics

摘　　要：目的探讨溃疡性结肠炎纳入门诊特殊病种和门诊慢性病(简称"门特门慢")政策后对我国基本医保基金预算的影响,为完善溃疡性结肠炎的保障制度提供证据参考与建议。方法本研究基于我国医保视角,通过构建1000万人的预算影响分析模型,计算溃疡性结肠炎纳入"门特门慢"后,未来3年(2021—2023年)对医保基金的影响;测算成本主要包括药品费用、门诊挂号及检查检验费用、住院费用、手术费用、术后管理以及合并用药费用。考虑到全国各省市和地区统筹区报销情况的差异,有相当一部分统筹区针对溃疡性结肠炎药品的报销政策欠佳或缺失,经过统计,本研究采用的统筹基金药品最高支付限额为3500元。结果2021—2023年每年预计有47~53例溃疡性结肠炎患者使用生物制剂,在溃疡性结肠炎被纳入"门特门慢"病种之前,医保基金每年预计在溃疡性结肠炎患者支出992719~1134862元。相对于溃疡性结肠炎未被纳入"门特门慢"的情景,纳入"门特门慢"后,医保基金每年整体支出可以节省152431~174257元,平均每例患者支出减少3268元。结论将溃疡性结肠炎纳入"门特门慢"政策后,虽然增加了药品费用,但是生物制剂可以良好控制疾病进展,患者发生住院、手术、术后管理事件以及合并用药的费用得以明显降低,填补了药品上额外的支出。因此,即便在没有门诊统筹政策的地区,"门特门慢"政策依然可以帮助实现节省医保基金整体支出的目标。同时从长期来看,患者发生住院和手术的情况大幅下降,从而实现对医疗卫生资源的有效配置、优化医疗产业格局、帮助医保制度健康持续发展。Objective The study analyzed the budget impact on Basic Medical Insurance Funds after admission of ulcerative colitis into Special and Chronic Disease Outpatient Management Policy("the policy"),and provided critical economic evidence to support and recommend the admission.Methods From the healthcare perspective,we built a budget impact analysis model with a sample size of 10 million population.The model has forecasted the well-being of Health Insurance Funds in the next three years(2021-2023)upon admission of ulcerative colitis into the policy.The model has taken consideration of cost of medicine,outpatient visits,surgical operation,post-operative care,and combinational therapy.Considering heterogeneity among different cities and provinces,we have observed a substantial issue of under-performing reimbursement policy or lack of policy implement for ulcerative colitis disease in the cohort of investigation population.Statistical data has suggested the ceiling line to be 3,500 CNY for total drug costs under medical insurance funds.Results We anticipated an annual 47-53 ulcerative colitis patients prescribed with biologics therapy within the year 2021-2023.Before the admission of ulcerative colitis into the policy,health insurance funds are expected to pay off 992,719-1,134,862 CNY for ulcerative colitis patients annually.While upon disease admission,an annual saving of 152,431-174,257 CNY of health insurance funds and a saving of 3,268 CNY from per patient out-of-pocket expense can therefore be achieved.Conclusion Although the admission of ulcerative colitis into the policy could result in an increase in the drug cost of using innovative biologics therapy,the increase is counteracted by the reduced cost of potential hospitalization,surgical operation,post-operative care,and combinational therapy.Therefore,even for places without implement of the outpatient department integration policy,medical savings on health insurance funds could still be accomplished.In the long run,the policy would lead to continued reduction o

关 键 词：门诊特殊病种和门诊慢性病政策 溃疡性结肠炎 预算影响分析 

分 类 号：R574.62[医药卫生—消化系统] R956[医药卫生—内科学]