国家谈判药品门诊医保待遇现状、问题及完善措施

Status,problems and improvement measures of health insurance reim⁃bursement of national negotiated drugs used in outpatients

2017‒2019年国家医保目录准入谈判有效缓解了高值创新药品的“看病贵”难题。但“重住院、轻门诊”医保现状使得谈判药品门诊实际报销水平较低,进而影响患者的健康福利。本文以97个谈判药品、337个统筹市为统计样本,实证分析门诊用药的医保报销情况,结果显示有40个品种在大部分统筹市(统筹市占比超过70%)的实际报销水平低于50%。进一步探究门诊待遇低的原因发现未纳入门诊特殊政策、或门诊特殊政策不完善是其主要原因。最后,本文基于国内各统筹市门诊补偿政策经验提出提高门诊保障待遇的建议与方案,认为各统筹市可通过实现门诊统筹、完善门诊特殊政策、探索创新支付等手段提高谈判药品门诊保障待遇,确保医保目录准入谈判结果落地工作的顺利实施。

The access negotiations of National Reimbursement Drug List(NRDL)in China from 2017 to 2019 effectively improved the availability and affordability of high-value innovative drugs.However,the actual outpatient reimbursement of most negotiated drugs is lower,which affects the patients'health insurance funds.In this paper,97 negotiated drugs in 337 overall planning cities were selected as samples to analyze the outpatient reimbursement for negotiated drugs.The results showed that the reimbursement level of 40 negotiated drugs was less than 50%in over 70%cities,which can be mainly interpreted as absence or imperfection of outpatient reimbursement policies for special diseases.Finally,this paper puts forward suggestions and protocols for improving the outpatient medical insurance through realizing outpatient overall planning,improving outpatient reimbursement policies for special diseases,and exploring innovative payment,ensuring the achievement of the access to NRDL.