肺动脉高压纳入门诊特定病/慢性病报销政策的预算影响分析

Budget impact analysis of treatment for pulmonary arterial hypertension included in special and chronic disease outpatient reimbursement policy

目的评估将肺动脉高压纳入门诊特定病和门诊慢性病(以下简称“门特门慢”)报销政策对医保基金的预算影响,为医保报销决策提供参考。方法从我国医保支付方角度出发,以1000万人口的城市为例,通过构建预算影响分析模型,计算肺动脉高压纳入门特门慢报销政策后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、门诊挂号和检查检验费用、住院费用以及死亡事件费用。结果2021-2023年每年预计有34~36名肺动脉高压患者使用靶向药物。针对现在门诊无统筹报销政策的城市,将肺动脉高压纳入门特门慢报销政策后,每年医保基金的增量支出约为40000元,平均每名患者的支出增加约1000元;对于门诊已经有统筹报销政策的城市,将肺动脉高压纳入门特门慢报销政策后,每年医保基金的增量支出约为80000元,平均每名患者的支出增加约2000元;以上费用增量均逐年递减。结论将肺动脉高压纳入门特门慢报销政策后的医保基金增量支出可控,且随着门特门慢政策的落地,医保基金的增量支出将逐年缩减。

OBJECTIVE To evaluate the budget impact on medical insurance fund upon the treatment of pulmonary arterial hypertension(PAH)included in the outpatient special and chronic disease management policy(hereinafter refer to as the Policy),so as to provide reference for medical insurance reimbursement decision-making.METHODS Based on the perspective of medical insurance payer,a budget impact model with 10 million people was built to calculate the budget impact on the medical insurance fund in the next three years(2021-2023)after PAH treatment included in the Policy.The measured cost mainly included the cost of medicine,outpatient registration,examinations,hospitalizations,and death events.RESULTS A total of 34-36 patients with PAH per year were expected to use targeted therapy during 2021-2023.For cities with outpatient costs not covered by the pooling fund of basic medical insurance,upon the treatment of PAH included the Policy,the annual expenditure of the medical insurance fund increased by about 40000 yuan,i.e.an increase of about 1000 yuan per patient.For cities with outpatient costs covered by the pooling fund,the annual expenditure of the medical insurance fund increased by about 80000 yuan,which was equal to 2000 yuan increase per patient.The increment of above cost decreased year by year.CONCLUSIONS The incremental expenditure of the medical insurance fund is controllable after the treatment of PAH included the Policy;with the implementation of the Policy,the incremental expenditure of the medical insurance fund will be reduced year by year.