医疗保险不同组织类型下的药品支付标准制定规则与启示

Rules and Enlightenment for the Formulation of Drug Payment Standards under Different Types of Medical Insurance Organizations

国际上,英国、澳大利亚、德国、日本、美国和中国台湾等国家和地区的医保药品支付标准制定各具特色,且与其各自的医疗保险组织类型密切相关。本文对这六个国家和地区的医疗保险组织类型与其药品支付标准制定方法的关联进行深入分析和总结发现:可将这些地区的医保组织类型分为单一型支付者、分散型支付者和过渡型支付者;所有支付者均按药品分为创新药品和非创新药品来制定不同的支付政策。其中,单一型支付者大多根据证据制定支付决策,分散型支付者主要依靠市场议价形成支付价格,而过渡型支付者兼具两者的特点。目前已有越来越多的国家将不同方法相互融合,取长补短。我国可考虑明确创新药品和非创新药品的界定界限,综合使用循证决策和市场议价的方法,建立和完善药品支付标准的制定和调整机制。

The methods for drug payment rate determination in UK, Australia, Germany, Japan, U.S,Taiwan of China are distinctive and related to their organizations. This paper analyzed and compared different medical insurance organization and related drug payment methods in above regions, finding that these regions can be divided into three categories, including single-payer, decentralized-payer and intermediate-payer. All kinds of payers distinguish different pricing methods for innovative and non-innovative drugs. Single-payers determine the payment rate based on evidence, while decentralized-payers usually use the market negotiation. Intermediate-payers combine different methods from single and decentralized payers, and more and more regions use combined methods. We should clarify the definition of innovative and non-innovative drugs, use evidence and market negotiation in combination, as well as improve adjustment mechanism for drug payment rate.