日韩医保支付标准调整方式对我国谈判药品简易续约规则的启示  

Enlightenment of the adjustment methods of medical insurance payment standards in Japan and South Korea on the simple renewal mechanism for negotiated drugs in China

作　　者：唐璋淳 卢钰琼 代展菁 许佳艺 虞杰 路云[1] 常峰[1] TANG Zhangchun;LU Yuqiong;DAI Zhanjing;XU Jiayi;YU Jie;LU Yun;CHANG Feng(School of International Pharmaceutical Business,China Pharmaceutical University,Nanjing 211198,China)

机构地区：[1]中国药科大学国际医药商学院,南京211198

出　　处：《中国药房》2024年第13期1552-1557,共6页China Pharmacy

基　　金：中国博士后科学基金第74批面上资助项目(No.2023M743897)。

摘　　要：目的 借鉴日本和韩国医保支付标准调整的实践经验,为我国简易续约规则的完善提供参考。方法 检索中国知网的相关文献、日本和韩国政府官网的相关政策文件等,从调整条件和调整公式两个方面归纳总结目前日韩调整医保支付标准的做法,并与我国现行简易续约规则进行对比,明晰我国简易续约规则可优化之处,提出政策建议。结果与结论 在调整方式上日韩与我国相似,对于超量药品根据超量情况计算药品降幅并实施调整;但具体的调整条件和调整公式又有所不同,日韩针对目前超量较大的药品采取线性降价的方式,而我国针对目前和预期均超量较大的药品采取梯度降价的方式。对比分析结果显示,我国已初步建立了符合国情和医保实际的简易续约规则,并采取了一些创新举措,包括考量药品目前与预期的超量情况和在调整公式中引入降幅减半机制;但同时也存在一定不足,如调整条件的指标设置较为单一、调整公式的梯度降价区间过于宽泛,未能充分体现“以量换价”的市场化机制。建议我国医保部门在简易续约时增加对药品基金支出大小的考量、细化调整公式的梯度降价区间、加大对特殊品类药品在新增适应证时的政策倾斜,进一步完善简易续约规则。OBJECTIVE To learn the practical experience of medical insurance payment standards adjustment in Japan and South Korea,which will serve as a reference for the improvement of simple renewal mechanism in China.METHODS Retrieving relevant literature from CNKI and related policy documents from official websites of Japan and South Korea,the medical insurance payment standards adjustment practice in Japan and South Korea would be elucidated from 2 perspectives of adjustment criteria and formulas,and then were compared with the current simple renewal mechanism in China to clarify the areas where simple renewal mechanism in China can be optimized and propose several suggestions.RESULTS&CONCLUSIONS In terms of adjustment methods,Japan and South Korea were similar to China.For excessive drugs,the reduction rate of drugs was calculated based on the situation of excess and adjustments were implemented;however,there were differences in the specific adjustment criteria and formulas.Japan and South Korea adopted a linear price reduction approach for drugs with significant oversupply,while China adopted a gradient price reduction approach for drugs with both current and expected oversupply.The results of the comparative analysis show that China has initially established simple renewal mechanisms that are in line with the national conditions and the actual medical insurance situation,and has taken some innovative measures,including considering the current and expected oversupply of drugs and introducing a halving mechanism in the adjustment formula.However,there are also certain shortcomings,such as a relatively single set of indicators for adjusting conditions and a too broad range of gradient price reduction in adjustment formulas,which fail to fully reflect the market-oriented mechanism of“volume for price”.It is recommended that China’s medical insurance department increase consideration of drug fund expenditures,refine the gradient price reduction range of adjustment formulas,increase policy preferences for special cat

关 键 词：医保谈判 简易续约 医保支付标准调整 医保基金支出 

分 类 号：R95[医药卫生—药学]