特需药品纳入医疗保障必要性可行性与可及性分析——基于福州地区参保人员肺癌治疗实践

Analyzing on the Necessity, Feasibility and Accessibility of Special Drugs Added to Medical Insurance Directory——Based on the Practice of Lung Cancer Treatment in Fuzhou

目的 :研究特需药品纳入医疗保障必要性、可行性与可及性,为完善重特大疾病保障机制提供参考依据。方法:分析福建省本级、福州市医保管理中心2012-2014年度参保肺癌患者住院和门诊大病数据,按年度统计医疗费用构成及用药情况。结果 :统计期间治疗人次、医疗费用年复合增长率(CAGR)分别为17.65%、19.63%;不同治疗方案的年人均医疗费用区别有统计学意义(P<0.001),经慈善援助后的靶向一线治疗年人均费用约为放疗或化疗的3/4;治疗费用与药品费用占医疗费用比例分别为10.72%、59.76%;肺癌诊疗指南推荐用药占药品总费用比例为19.80%,其中目录外的EGFR-TKIs占药品总费用比例为2.48%,人次、金额年复合增长率分别为103.96%、148.79%。结论与建议:EGFR-TKIs等特需药品未纳入医疗保障范围是其适用患者得不到有效治疗和个人负担过重的主要原因,特需药品纳入医疗保障范围具有必要性、可行性和可及性。

Objective：To study on the necessary, feasibility and accessibility of special medicine added to medical insurance directory to provide evidence for improving the security mechanism for major diseases insurance. Methods： Using the data of inpatients and outpatients with lung cancer collected by Fujian province, Fuzhou Health Insurance Management Center during the year of 2012-2014 to compare their annual medical expense constitutions and medication. Results：The person-time and combined annual growth rate（CAGR） were 17.65% and 19.63%, respectively; the difference of annual per capita medical cost of different treatment regimens is statistically significant（P 0.001）; the annual per capita medical cost of targeted first-line treatment with charity aid was about 3 / 4 of that of radiotherapy or chemotherapy; the cost of treatment and drug expenditure accounted for 10.72% and 59.76% of the total medical expenditure, respectively. The Lung Cancer Treatment Guidelines recommending medicines accounted for 19.82% of total medical expenditure, of which, the cost by EGFR TKIs, which is not in the directory, accounted for 2.48% of the total expenditure of drugs; person-time and amount of annual compound growth rate were 103.96% and 148.79%, respectively. Conclusions and recommendations： EGFR TKIs and other special drugs not included in medical coverage is the main reason for patients without effective treatment and with heavy personal burden, it has necessity, feasibility and accessibility to add special drugs into the scope of medical security.