Analysis of Drug Medical Insurance Access Pricing Based on the Perspective of Binary Equilibrium

Objective To study the influencing factors in the process of national medical insurance negotiation and drug pricing from the dualistic equilibrium perspective,and to provide reference for the harmonious management of drug pricing in China.Methods Through the literature analysis and policy review,the pricing subject,pricing basis and price control system in the pricing process of medical-accessed medicines were analyzed from the perspective of binary equilibrium and harmonious management.Results and Conclusion It is found that four balances in the drug pricing process,two balances in pricing basis and three balances in price control system need to be considered,respectively.Drug pricing is the key content of national medical insurance access,which is also the hotspot of the policy in the pharmaceutical fields in recent years.Drug pricing not only reflects the value of drugs,but also reflects a lot of top-level designs of binary equilibriums in medical insurance policy.While the rational design of drug pricing requires the joint efforts of the government,pharmaceutical companies and relevant experts to comprehensively consider many equilibriums,so as to improve the relevant systems.

Inspiration of Foreign Innovative Drug Pricing Methods and Medical Insurance Payment Standards to China

Objective To study the innovative drug pricing methods and medical insurance payment standards in foreign countries and to provide reference for China’s government.Methods The official websites were searched for information and related literature,and literature review was used.Results and Conclusion In foreign countries,the clinical value of innovative drugs and their impact on medical insurance funds were comprehensively evaluated based on factors such as quality-adjusted life years,clinical benefit,and improvement of clinical benefit.Then,the evaluation results were taken as an important basis for whether innovative drugs were admitted to the medical insurance catalog and establishing medical insurance payment standards.By using international experience for reference,innovative drug pricing methods and medical insurance payment standards for China’s national conditions can be improved by establishing a basic database of clinical value and drug economic evaluation of innovative drugs,as well as innovative drug payment models based on decision thresholds.

The Impact of Population Aging on the Expenditure of Medical Insurance Fund for Urban Workers in China

Objective To explore the impact of population aging on the expenditures of medical insurance funds against the background that great changes in population structure influences economic development.Methods Through analyzing the impact of the population aging,the income and accumulated balance of the medical insurance fund,and other related factors on the expenditure of the medical insurance fund,development status of the medical insurance fund for urban employees in China since 2003 was obtained.Stata 16.0 was used to perform multiple linear regression analysis on related factors to determine the correlation between population aging and the change in medical insurance expenditures.Results and Conclusion The factors that have a greater impact on the expenditure of the medical insurance fund are the amount of income from the medical insurance,followed by the number of people over the age of 65 in China and the urban retired employees participating in medical insurance.We should focus on the sustainable development of the urban employee medical insurance fund to deal with the threat of aging.

Analysis of inpatient payments of breast cancer patients with different medical insurance coverages in China(mainland) in 2011–2015

Objective： An understanding of the levels and trends of medical cost is made for breast cancer patients with different medical insurance coverages in China（mainland）, in an attempt to offer a clue to further control the costs.Methods： The inpatient payments of 9,716,180 breast cancer patients spent in medical institutions of different types and grades during 2011–2015 were collected from the inpatient medical record home page（IMRHP） dataset.The data were then processed with SAS（Version 9.3; SAS Institute, Cary, NC, USA）. Indicators like means,increase（decrease） percentages were used to descriptively analyze the average hospitalization expense of each time（AHEET） and its trends of breast cancer patients with different medical insurance coverages treated in medical institutions of different types and grades.Results：In 2011–2015,the AHEET borne by breast cancer patients in China had been constantly increasing.Specifically,the self-pay inpatients had the largest increase,inpatients covered by Urban Employee Basic Medical Insurance（UEBMI）and Urban Resident Basic Medical Insurance（URBMI）were the next,and those covered by New Rural Cooperative Medical System（NRCMS）had the least increase.Breast cancer inpatient treated in public hospitals had quite greater increase and higher expenditure level than those in private hospitals.The AHEET borne by the inpatients in Grade 3 hospitals had greater increase and higher cost than those in Grade 2 hospitals.Conclusions：The inpatient payments of breast cancer patients will be wisely controlled by reducing the number of self-pay inpatients,taking advantage of restriction mechanism of the medical insurances,and promoting healthy competition between private hospitals and public hospitals.The economic burden imposed on the society by breast cancer can be relieved through further control of inpatient payments of UEBMI-and URBMI-covered breast cancer patients and of Grade 3 hospitals.

Software Process Modeling with UML in Development of Medical Insurance MIS

This paper describes how to use the Unified Modeling Language (UML) to modeling software processes in medical insurance MIS, and compares UML Modeling method with classic PO(Process Oriented) Modeling method. It indicates that the whole performance of application system model described by UML is much better than the one described by PO.

An Ensemble Methods for Medical Insurance Costs Prediction Task

The paper reports three new ensembles of supervised learning predictors for managing medical insurance costs.The open dataset is used for data analysis methods development.The usage of artificial intelligence in the management of financial risks will facilitate economic wear time and money and protect patients’health.Machine learning is associated withmany expectations,but its quality is determined by choosing a good algorithm and the proper steps to plan,develop,and implement the model.The paper aims to develop three new ensembles for individual insurance costs prediction to provide high prediction accuracy.Pierson coefficient and Boruta algorithm are used for feature selection.The boosting,stacking,and bagging ensembles are built.A comparison with existing machine learning algorithms is given.Boosting modes based on regression tree and stochastic gradient descent is built.Bagged CART and Random Forest algorithms are proposed.The boosting and stacking ensembles shown better accuracy than bagging.The tuning parameters for boosting do not allow to decrease the RMSE too.So,bagging shows its weakness in generalizing the prediction.The stacking is developed using K Nearest Neighbors(KNN),Support Vector Machine(SVM),Regression Tree,Linear Regression,Stochastic Gradient Boosting.The random forest(RF)algorithm is used to combine the predictions.One hundred trees are built forRF.RootMean Square Error(RMSE)has lifted the to 3173.213 in comparison with other predictors.The quality of the developed ensemble for RootMean Squared Error metric is 1.47 better than for the best weak predictor(SVR).

The Enlightenment of EU Real-World Evidence Supporting the Inclusion of Rare Disease Drugs in Medical Insurance Decisions to China

Objective To study the use of real-world evidence by EU and its member states for establishing a strategy for rare diseases and provide references for the inclusion of orphan drugs in China’s medical insurance.Methods A case analysis method was used to introduce the EU’s decision to include rare disease drugs in medical insurance by using real-world evidence because clinical data of rare diseases were difficult to obtain.Results and Conclusion China can use real-world evidence to make medical insurance decisions based on the experience of the EU and continue to invest more in rare diseases,which can solve the problem of few drugs for patients with rare disease.

Comparative Study on the Development of Urban Basic Medical Insurance in 14 Cities of Liaoning Province

Objective To put forward some suggestions for the development of urban basic medical insurance of Liaoning by comparing the development situations in 14 cities of Liaoning Province.Methods Relevant data of urban basic medical insurance from 2008 to 2018 in 14 cities were collected to make a comparative analysis,and the 5 why analysis chart was drawn to investigate the development differences in 14 cities.Results and Conclusion The average growth rate of the number of urban residents covered by urban basic medical insurance varied greatly from 2014 to 2018.The range of average growth rate of urban residents’medical insurance is 19.1%,and the range of average growth rate of urban workers’medical insurance is 9.1%.Funding standards are basically the same.It is suggested each municipal government should attach importance to this issue.They can make full use of information technology to coordinate with various authorities and ensure the smooth development of medical insurance.Besides,they must actively adapt to their conditions to better develop the urban basic medical insurance of Liaoning.

Research on Social Medical Insurance of College Students in Shenyang

Objective To discuss the methods of improving the social insurance of college students by taking the application of college students’social insurance in Shenyang as an example.Methods The investigation and literature method were applied mainly.Results and Conclusion Through the questionnaire,the main problems for college students’medical insurance were analyzed in this paper,and proposals such as compulsory insurance,improving the level of medical services in colleges and hospitals,and strengthening commercial insurance and publicity were finally put forward.

Should Medical Insurance Cover Stop-Smoking Drugs?

At a seminar discussing ways to prevent chronic disease held in Shanghai on March 31, 2012, Chen Zhu, Minister of Health, revealed that the ministry was planning to include expenditures on counseling to stop smoking into the basic medical insurance system provided by the govern- ment, and would pay for drugs that help reduce dependence on tobacco.

Research on Reimbursement Management of Innovative Drugs Abroad and Its Enlightenment to China

Objective To analyze the reimbursement policies of innovative drugs in some developed countries,and to provide reference for future reimbursement management in China.Methods Literature research method was used to study the policies related to the reimbursement management of innovative drugs in Germany,France and Japan,and their successful experience was summarized.Results and Conclusion China should establish an open and transparent value evaluation standard to improve the medical insurance reimbursement management of innovative drugs.Besides,the value of innovative drugs should be taken as an important basis for reimbursement decisions,and an independent third-party value evaluation agency must be established.

Analysis on Medical Expenses of Hypertensive Inpatients in Urban Areas from 2010 to 2013-Evidence from Two Provinces in South of China

Along with the development of society and the rapid economic growth in the past decades, hypertension and other chronic diseases have become important reasons for people＇s poverty caused by illness in China. This study collected a total of 5857 people from 2010 to 2013 randomly from the database of the Medical Insurance Department （MID）, including 3229 people in Hubei province and 2628 people in Guangdong province. One-way ANOVA was used to compare the total medical expense, out-of-pocket （OOP） expense and hospital stay between variables. A multiple linear regression analysis was done to identify possible risk factors of total medical expense. The results showed that the average total medical expense per capita was 5709.89 yuan, and the medical expense per capita was 7053.58 and 4555.97 yuan in Guangdong province and Hubei province, respectively. The medical expense of hypertensive inpatients decreased from 7222.32 yuan in 2012 to 4894.66 yuan in 2013. There were no significant differences in medical expenses between different genders of hypertensive patients （P〉0.05）. People of different ages, provinces, medical insurances and medical institution levels showed significant differences in medical expenses. The government should increase the investment in chronic disease management and treatment in the central and western regions to narrow the gap with the eastern region. Medical insurance fund payment should be improved to ensure the fairness of the use of medical services in different medical insurances. And measures should be taken to encourage chronic patients to visit primary medical institutions to effectively reduce medical expenses.

Characteristics of Patients Sponsored by the Internet Platforms of Medical Mutual Aid

The morbidity and mortality of life-threatening diseases such as cancers are increasing year by year in China. Although the national medical insurance has been improved a lot, it still falls short of expecting “universal medical insurance”. To help the families of patients with cancer and other serious diseases to resolve the unaffordable medical cost, several internet platforms of “Peer to Peer Medical Mutual Aid” have gradually emerged recently. In the form of low threshold insurance combined with public support, these platforms provide subsidies to families of patients suffering from serious financial burden and then partly compensate them for the limit of national medical insurance. This article summarized the characteristics of declared patients sponsored by several medical mutual aid internet platforms. The results showed that the sponsored patients were mostly cancer patients (90.1%), aged 21 - 60 (88.4%), and the average amounts of financial support had a trend to decrease with the increase of age. In particular, the reported cases of thyroid cancer were increased dramatically recently, however, with a lowest average mutual aid fund. Given these data, it is urgent to list out a detailed rule for the use of national medical insurance on the treatment of cancer, to heighten the healthcare system for the occupational population, age from 21 to 60, and to establish the credit system for Medicare and Medicaid services.

The impact of the COVID-19 outbreak on Australia’s public health and medical industry in 2020

In 2020,the sudden new crown(COVID-19)virus swept the world.Countries have adopted different epidemic prevention measures.The COVID-19 has brought an extraordinary impact on the economic and social health of all countries.Australia,located in the southern hemisphere,promptly adopted the closure and other epidemic prevention policies in late January.The whole people mobilized to actively fight against the epidemic.Compared with the passive immunization of developed countries such as the United Kingdom and the United States,it has experienced several twists and turns and achieved relatively successful results.However,the epidemic has profoundly affected public health and medical care.They are mainly manifested in mental and psychological,hand hygiene,respiratory diseases,surgical spectrum,cancer screening,and changes in national leadership’s response methods and medical insurance policies.Australia’s early physical distancing measures,relatively high per capita testing rates,political stability,national wealth and geographic isolation are among the explanatory factors.The country’s response to the COVID-19 pandemic has,thus far,been among the most successful in the world.

开展医疗保障经办机构飞行检查的问题及其产生因素的质性研究

目的梳理总结我国开展医疗保障(以下简称“医保”)经办机构飞行检查的问题及其产生因素,为完善我国医保基金飞行检查机制,加强对医保经办机构的监管提供建议和参考。方法于2022年7—9月,采用典型抽样法,选取4个省份的医保专家进行半结构式访谈,样本量的确定以不再出现新的信息为标准,运用colaizzi七步分析法对获取的资料进行归纳分析。结果通过对11名专家访谈资料的分析,归纳提炼开展医保经办机构飞行检查的问题,包括力度不足、队伍构成不健全、缺乏具体内容及标准等,以及导致问题产生的因素,包括选择效应、缺乏标准化做法、区域差异等。结论医保经办机构的行为及工作效率影响着医保基金安全,对其进行监管十分必要,但开展医保经办机构飞行检查的过程中存在诸多问题。建议推进制度建设,加大飞行检查力度;丰富队伍构成,提升飞行检查质量;完善指标建立,规范飞行检查内容。

我国医院远程医疗服务收费情况分析

目的分析我国医院远程医疗服务收费情况,以完善远程医疗服务收费制度,推动远程医疗规范化发展。方法2020年10—11月面向全国26个省(自治区、直辖市)组织开展线上问卷调查。选取问卷中远程医疗服务收费项目及其与医疗保险对接情况、收费标准制定、收费依据、费用支付与结算方式等内容,统计分析不同地区医院远程医疗服务收费情况。结果71.3%的医院开展了远程医疗服务收费,收费项目主要为远程会诊、远程教育、远程病理诊断、远程影像诊断和远程心电诊断。主要按照医院级别和专家职称收费,分别有59.1%的东部地区医院、69.2%的中部地区医院和68.5%的西部地区医院收费标准由行政管理部门统一制定。此外,34.6%的收费医院将远程医疗纳入医疗保险报销范畴。结论大部分医疗机构开展了远程医疗服务收费,但收费机制相对模糊,与医疗保险的对接政策也相对缺乏,应加快远程医疗服务收费政策制定,合理化远程医疗服务收费,建立健全远程医疗服务收费机制,促进远程医疗服务收费工作的规范化发展。

国家医保谈判对公立医院抗肿瘤药物采购费用、数量及结构的影响:以EGFR-TKI靶向药物为例

目的分析国家医保药品目录准入谈判(以下简称“国谈”)政策对某省公立三级医院非小细胞肺癌EGFRTKI靶向药物采购费用、数量及结构的影响,为相关政策制定提供依据。方法收集2018年1月—2020年12月某省公立三级医院EGFR-TKI靶向药物每月采购数据,利用中断时间序列模型分析采购费用、数量、药品结构及日均费用的变化趋势。结果阿法替尼、奥希替尼、吉非替尼、埃克替尼、厄洛替尼5种EGFR-TKI靶向药物总体采购量及费用以稳定为主,2018年国谈准入品种采购量及费用上升。5种EGFR-TKI靶向药物药品结构变化明显,呈即刻上升趋势;各品种日均费用出现不同程度的下降。结论国谈政策的实施增加了靶向药物的使用,国谈准入药物品种逐步进入临床,患者的用药负担进一步减轻。

Foreign Experience and Enlightenment of Reimbursement Management of Multi-indication Drugs

Objective To provide reference for China’s medical insurance reimbursement plan of multi-indication drugs.Methods By referring to relevant foreign literature,the implementation process and conditions of different reimbursement management modes of multi-indication drugs were analyzed to provide suggestions for reimbursement of multi-indication drugs in China.Results and Conclusion It is suggested to further explore the suitable conditions and select the corresponding mode in China.Payment standards should be set according to value pricing and budget impact analysis.Besides,data collection and analysis mechanism must be improved.Lastly,reward and punishment mechanism can be adopted to improve management efficiency.

新型冠状病毒肺炎疫情下我国互联网诊疗的发展

梳理我国互联网诊疗的相关政策,综述我国互联网诊疗发展的现状和趋势,挖掘目前互联网诊疗行业可能存在的信息技术、医疗保险支付、行业监管、发展方向4个方面的主要问题,针对这些问题提出相关的政策建议。

“十四五”时期我国卫生健康事业发展展望

“十四五”时期,我国卫生健康事业步入新的历史阶段。在这一时期,公共卫生能力建设应成为发展重点,通过优化医疗卫生资源配置,实现大健康观下的医防结合。推动以医疗为中心的医疗联合体转变为以预防和健康管理为中心的健康联合体,使医疗保险为公众的健康结果而非医疗卫生服务买单。完善健康服务体系,实现健康联合体内部上下联动。建立以健康结果为导向的医疗保险支付方式,倒逼服务供给侧改革,推动医疗保险基金形成战略性购买机制。充分发挥信息时代互联互通的优势,深化健康大数据的治理与应用,助力公众健康管理。