2022版国家医保药品目录分类代码和限定支付条件分析

Analysis on the Classification Codes and Limited Payment of the 2022 Medical Insurance Drug List in China

目的解析《2022版国家医保药品目录》代码分类原则及限定支付条件情况,利于从业人员及时了解医保药品代码分类规则、限定支付的新规及新旧医保目录的差异。方法分析医保药品分类代码、品种数、药品限定支付条件等方面的基本情况,对比《2021版国家医保药品目录》分析变化。结果《2022版国家医保药品目录》中医保编码有一定规则目录中药品限定支付条件共计670条,其中单条件限定支付药品有314种,多条件356条。与《2021版国家医保药品目录》对比,《2022版国家医保药品目录》中限定支付条件变化较多,取消限定支付条件124条,修改内容43条。结论国家医保药品编码前6位采用国家医保药品目录的药品分类码,方便管理与使用。《2022版国家医保药品目录》将更多药品纳入医保支付范畴,限定支付条件管理更为规范,逐步恢复至药监部门批准的药品说明书的范围。限定支付条件在实际执行过程中存在一定的疑问,建议在统筹考虑基金的永续发展,结合临床诊疗指南和患者实际需要,加快调整和完善限定支付相关政策,考虑将更多药品的支付范围恢复至药品说明书范围。加强药师在医保药品使用过程中合理用药主体作用。利用信息化与大数据手段增强医保监管效能。

Objective To analyse the coding principles and limited payment conditions of the 2022MedicalInsurance DrugList,in order to facilitate timely understanding of the new rules for code classification and limited payment for medical insurance drugs by practitioners,and the differences between the new and old medical insurance catalogs.Methods Analyse the basic situation regarding the medical insurance drug codes,Number of drug varieties,the limited Payment of drugs.Compare the changes with the 2021MedicalInsurance DrugList.Results The 2022MedicalInsuranceDrugList in China has a specific rule for the coding of medicine.The list includes a total of 670 drugs with limited payment,out of which 314 are restricted to single limited payment and 356 to multiple.In comparison to the MedicalInsuranceDrug List,the 2022MedicalInsuranceDrugList has undergone several changes in its limited payment,with 124 being cancelled and 43 being modified.Conclusion The first six digits of Medicare drug reimbursement codes adopts the drug classification code in the medical insurance drug directory for easy management and use.The 2022 MedicalInsuranceDrug List will include more drugs,with limited payment for more standard management,gradually returning to the scope of the drug instructions approved by NMPA.There are some questions about the limited payment in the actual implementation process.It is recommended to consider the sustainable development of the fund comprehensively,combine clinical guidelines and the actual needs of patients,accelerate the adjustment and improvement of policies related to limited payment,and consider restoring the payment scope of more drugs to the scope of drug instructions.Strengthen the role of pharmacists as the main body of rational drug use in the process of medical insurance drug use.Use information technology and big data to enhance the efficiency of medical insurance supervision.