The medical insurance payment standard is the benchmark for the payment of the medical insurance fund, one of the means to guide the reasonable pricing of drugs and realize the rational use of drugs, and it is also an important starting point for promoting the reform of medical insurance. Since the establishment of the National Health Insurance Administration in 2018, a series of measures have been carried out to promote the payment standards for medical insurance drugs, and some drug medical insurance payment standard rules have been preliminarily constructed, that is, the medical insurance payment standard for exclusive drugs is determined through negotiation and access, and the medical insurance payment standard for non-exclusive drugs is determined through national volume procurement and bidding.
In June 2022, the National Health Insurance Administration (NHSA) issued the first new non-exclusive drug bidding rules outside the catalogue. In the process of forming the payment standard for bidding drugs, the medical insurance party organizes experts to calculate the medical insurance payment standard for the generic drugs that apply for bidding access, and the enterprises participating in the declaration submit quotations, if there is a quotation greater than or equal to 1 enterprise is not higher than the payment standard calculated by the medical insurance party, the generic drug will be included in the medical insurance bidding drug catalog, and the lowest of the quotations of each enterprise shall be taken as the payment standard for the generic drug, and the market price of the participating quotation enterprises shall not be higher than the last quotation. In order to avoid vicious competition, the bidding rules also include a fallback mechanism, if the company's quotation is lower than 70% of the willingness to pay for medical insurance, 70% of the willingness to pay for medical insurance will be used as the payment standard for the drug. Drugs whose actual price is lower than the payment standard will be reimbursed by medical insurance at the actual price, and drugs whose actual price is higher than the payment standard will be borne by the insured patients.
The implementation of the bidding access policy not only provides a policy window for non-exclusive drugs to access the medical insurance catalog, but also provides innovative ideas for the exploration of non-exclusive drug payment standards.
It has been more than a year since the implementation of the policy, what impact has the policy had on the market competition pattern of non-exclusive bidding access drugs? Has the medical insurance payment standard guided the manufacturers to set prices reasonably, and what is the impact of different price relationships on hospital procurement behavior? In order to answer the above questions, the author took 17 non-exclusive drugs (payment standard expiration date: March 1, 2023 to December 31, 2024) that were approved by auction in 2022 as the research objects (Table 1), and used the drug statistics of IQVIA hospitals with more than 100 beds in China to find the answers to the above questions.
Since the implementation time of the payment standards for the 17 generic drugs admitted by auction in 2022 is March 1, 2023, the author selected the data of 6 months before and after the implementation of the payment standards (i.e., September 2022 to August 2023) for analysis. It focuses on observing the number and price of manufacturers of generic drugs, as well as the changes in purchase volume and purchase amount under different price relationships. On this basis, the disease domain subgroups were further distinguished, and whether there were differences in the impact of the implementation of payment standards on drugs in different disease domains.
Table 1 Basic information of 17 competitive drugs in 2022
The impact of non-exclusive medical insurance drug payment standards on the market competition pattern
From the perspective of the number of purchasing manufacturers, compared with before and after the implementation of the policy, the average number of purchasing manufacturers for bidding drugs before the implementation of the payment standard was 2.2 (median 2), and increased to 3.7 (median 3) after the implementation (Table 2). It can be seen that the number of manufacturers has increased after the drug has been admitted through bidding, and the policy has stimulated the vitality of market supply, which may have stimulated the vitality of enterprises with original approval numbers but not production and supply. A new market pattern has been formed after the competitive access of each drug (Figure 1).
Table 2 Changes in the number of purchasing manufacturers in the six months before and after the bidding of non-exclusive drugs
Figure 1 The number of manufacturers purchasing each drug 6 months after the non-exclusive drug bidding was approved
The impact of non-exclusive medical insurance drug payment standards on manufacturers' pricing behavior
The non-exclusive drug bidding rules determine the medical insurance payment standard for drugs, but do not restrict enterprises from setting prices independently, so this part explores the price behavior of manufacturers from the actual purchase price of each drug medical institution. We used the payment standard as the benchmark to obtain the ratio of the actual purchase price of the drug to the payment standard, and used it as the evaluation index to observe the dynamic change relationship between the drug market price and the payment standard. The average value of the ratio of the actual purchase price to the payment standard was 2.9 (median 2.6) before the implementation of the payment standard, and decreased to 1.4 (median value 1.0) in the first half of the year (Table 3).
By analyzing the multiples of the actual purchase price and the payment standard after the bidding access, it can be seen that the purchase price range of most drugs is reduced to the payment standard level or lower, which shows that the payment standard has a normative effect on the actual purchase price. In particular, when the original drug (e.g., palbociclib capsules) participates in the auction, the generic drug automatically lowers the price below the payment standard. However, there are also cases where the original drug (e.g., Ringer bicarbonate injection) participates in the bidding, but the generic drug is more expensive (Table 4).
Table 3 Changes in the ratio of the actual purchase price to the payment standard in the six months before and after the bidding of non-exclusive drugs
Table 4 Multiples of the actual purchase price of bidding drugs and the payment standard of medical insurance
The impact of non-exclusive medical insurance drug payment standards on hospital procurement behavior
This section explores how the procurement behavior of hospitals has changed under the ratio of price to payment standard, i.e., whether hospitals purchase drugs with relatively high prices, or drugs with prices close to or below the payment standards?
We used the number of defined drug doses (DDDs) (i.e., the number of doses purchased per month divided by the daily dose for adults) as an indicator of the number of doses purchased. On the whole, after the implementation of the medical insurance payment standard, the total purchase volume of 17 competitive access drugs increased significantly month by month, with an increase of 162.0% in half a year, and the market volume increased significantly. The main source of the increase in procurement volume is the actual purchase price of drugs equal to or lower than the payment standard, and the purchase volume increases month by month, and the proportion of this part of the drug purchase volume increases to 70.2% half a year after the implementation of the medical insurance payment standard, while the actual purchase price is higher than the payment standard, the purchase volume of drugs does not change significantly (Figure 2, Table 5).
From the perspective of each disease field subgroup, the overall purchase volume increased significantly, and the actual purchase price was lower than the payment standard of drugs and medical insurance payment standards The purchase volume increased the most within 6 months after the implementation of the medical insurance payment standard, especially for nervous system drugs. Among antineoplastic drugs, nervous system drugs, cardiovascular and anti-infective drugs, drugs below the payment standard are the main sources of procurement. In the areas of gastrointestinal and metabolic drugs, blood and hematopoietic organ drugs, and others, drugs above the payment standard remain the main source of procurement (Figure 3). Specifically, in the digestive tract and metabolism of drugs, the largest proportion of procurement volume is compound potassium hydrogen phosphate injection, and in blood and hematopoietic organ drugs, the largest proportion of procurement volume is sodium bicarbonate Ringer injection, the main source of procurement of both are generic drugs, and the actual purchase price is more than twice the payment standard, which shows that some hospitals have the behavior of purchasing generic drugs whose actual price slightly exceeds the payment standard.
Fig. 2 The total amount and proportion of purchases in each month under different ratio ranges between the actual purchase price and the payment standard after the implementation of the medical insurance payment standard
Table 5 Changes in the purchase volume under different ratio ranges between the actual purchase price and the payment standard in the 6 months after the implementation of the medical insurance payment standard
Fig. 3 Changes in the purchase volume of different disease subgroups in different ratio ranges of actual purchase price to payment standard 6 months after the implementation of the medical insurance payment standard
Secondly, from the perspective of procurement amount, after the implementation of the medical insurance payment standard, the total procurement amount of the 17 competitive access drugs increased month by month, and increased by 27.4% in half a year. The main source of the increase in the purchase amount is the actual purchase price of drugs lower than the payment standard, and the proportion of this part of the drug purchase amount has increased to 46.3% after the implementation of the medical insurance payment standard for half a year. However, the purchase amount of drugs whose actual purchase price is higher than the payment standard decreases month by month, especially for drugs whose actual purchase price is more than twice the payment standard (Figure 4, Table 6).
From the perspective of each disease field subgroup, except for blood and hematopoietic organ drugs, the overall procurement value of each disease field showed an upward trend, and the purchase value of drugs below the payment standard increased the most. Similar to the results of the purchase volume analysis, there is a downward trend in the purchase amount of drugs higher than the payment standard in blood and hematopoietic organ drugs, antineoplastic drugs and other categories, such as the antineoplastic drug tofacitinib citrate sustained-release tablets, under the influence of the implementation of the payment standard, the purchase volume of the original drug of tofacitinib higher than the payment standard has decreased significantly, which reduces the purchase amount of the drug, which further reflects that the payment standard of medical insurance drugs guides the procurement behavior. In addition, among antineoplastic drugs, nervous system drugs, and anti-infective drugs, the proportion of drug procurement below the payment standard is the largest (Figure 5).
Fig. 4 The total amount and proportion of the monthly purchase amount in different ratios between the actual purchase price and the payment standard in the 6 months after the implementation of the medical insurance payment standard
Table 6 Changes in the purchase amount under different ratio intervals between the actual purchase price and the payment standard in the 6 months after the implementation of the medical insurance payment standard
The analysis results show that after the implementation of the medical insurance payment standard, the overall purchase volume and purchase amount of bidding drugs have increased significantly, and the phenomenon of market volume increase has appeared. In some therapeutic areas (blood and hematopoietic drugs, antineoplastic drugs, and others), the purchase volume and purchase amount of drugs whose actual purchase price is more than twice the payment standard are significantly reduced.
It can be seen that the implementation of the non-exclusive drug medical insurance payment standard for bidding access has a benign guiding effect on the market competition pattern of bidding drugs, the pricing behavior of manufacturers and the procurement behavior of hospitals. From a broader point of view, the medical insurance payment standard is not only an important means of value payment, but also an important mechanism to promote the return of drug prices to a reasonable level, which is related to the burden of medical insurance funds, patient burdens, enterprise benefits and market changes.
Author | Jing Wu, Xiaoning He, Jie Tian, Tianjin University
Source | China Medical Insurance
Edit | Fu Meiru buys Xiaofei
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