Medical insurance reform has been promoted in an all-round way： affecting six categories of pharmaceutical companies
DRG/DIP firepower is fully open, and the pharmaceutical market will be shuffled.
Source | New Kangjie(Reprinted by Cybertron)
workZhe | Xin Kangjie
This paper will explore the impact of DRG/DIP implementation on the medical industry, medical insurance, patients and other related stakeholders from the perspective of the medical industry and related stakeholders.
To analyze the impact of DRG/DIP, we should first make clear its underlying logic or core idea, that is, use the principles of health economics to measure the optimal cost performance, standardize the behavior of clinical diagnosis and treatment with economic leverage, and make more people afford it at the most reasonable cost.
01 Impact on the pharmaceutical industry
The pharmaceutical industry in a broad sense can be divided into three parts: pharmaceutical industry, pharmaceutical circulation and medical service industry. The influence of DRG on the pharmaceutical industry can be analyzed from these three parts:
(1) Pharmaceutical industry
The pharmaceutical industry is located in the upstream of the industrial chain and can be divided into seven sub-industries, including chemical raw materials, chemical preparations, Chinese herbal pieces, Chinese patent medicines, biological agents, sanitary materials and medical devices. This paper focuses on the impact on innovative drugs, Chinese patent medicines and traditional Chinese medicine injections, medical devices and other fields.
1. Innovative drugs
Common diseases, frequently-occurring diseases and some major diseases with high incidence are usually included in the scope of DRG diseases, which makes medical institutions and doctors tend to use mature products with high cost performance.Doctors may give up the use of some innovative drugs actively or passively, especially for medical insurance users, so it is bad for most innovative drugs to implement DRG.
2. Chinese patent medicines and traditional Chinese medicine injections
As we all know, traditional Chinese medicine and traditional Chinese medicine injection have the characteristics of slow onset, uncertain curative effect, relatively expensive price and mostly auxiliary drugs, while DRG clinical grouping has strict regulations on what drugs patients should take for different hospitalization days and diagnosis results, and the amount of drugs to take.Therefore, it is difficult for traditional Chinese medicine and traditional Chinese medicine injection to meet the requirements of DRG in clinical use.
3. Generic drugs
Under the clinical practice of DRG standardization, a part of the original share of adjuvant drugs will be released, which is beneficial to generic drugs. At the same time, hospitals will prefer to use low-priced generic drugs that have passed the consistency evaluation in order to control costs. However, affected by the VBP policy, relevant data show that the first three batches of countries organized drug collection of 112 drugs, and the average drug price decreased by 54%.In the case of a general decline in the unit price of generic drugs, even if the sales volume increases, the overall sales volume may not increase.
4. Medical devices
DRG may limit diagnosis, increase the cost risk of updating diagnostic equipment in hospitals, and then make hospitals reluctant to update diagnostic equipment, so they may choose to entrust some diagnoses to third-party laboratories.In-hospital sales of medical device enterprises will be frustrated.
(2) Circulation of medicines
From the perspective of pharmaceutical circulation industry, it will promote the development of emerging channels such as retail, internet hospitals and out-of-hospital markets. The development of the out-of-hospital market has ushered in new opportunities. In order to control medical bills, hospitals may gradually tend to export more prescriptions to out-of-hospital pharmacies to reduce the in-hospital medical bills. At the same time, hospitals will shorten the average length of stay of a large number of patients, but patients still need drugs after discharge. Through online follow-up prescriptions, pharmacist review, logistics and distribution, patients’ demand for drugs for rehabilitation or chronic diseases will be transferred to out-of-hospital, and new channels such as Internet hospitals and DTP pharmacies will undertake prescriptions for patients with chronic diseases in-hospital to reduce.
The standardized clinical pathway of DRG may stifle individualized treatment, and the drugs used in individualized treatment, such as innovative drugs, auxiliary drugs, nutritional drugs and high-priced products with therapeutic value, are often distributed in the out-of-hospital market, and this part of patients’ needs will be drained to self-funded pharmacies or DTP. After DRG, these products sold outside the hospital will vigorously develop the out-of-hospital sales system.
(3) Pharmaceutical service industry
As the policy bearer of DRG/DIP payment system reform, the change from "payment by project" to "payment by disease" will have a great impact on the operation and development of hospitals.
From the management mode of medical institutions, DRG considers the requirement of higher quality of inpatient services on the premise that the hospital can reach the cost less than the payment amount. The focus of hospital management will shift from the original extensive operation, focusing on income growth, to reducing costs, promoting the standardization and standardization of clinical management, strengthening operational management, and achieving cost reduction and efficiency improvement.
From the point of view of hospital financial management, under the previous "project-based payment" mode, most hospitals adopted an expansionary strategic model. Now, under the DRG/DIP payment mode, the part exceeding the medical insurance payment standard will be borne by the hospital. Only by strengthening medical cost control and widening the gap between cost and income can the hospital get more balance. This is a high requirement for hospital informatization and data capability. Both DRG and DIP are essentially big data application tools, and the construction and transformation of hospital informatization is a prerequisite for implementing DRG/DIP.
The implementation of DRG is good news, especially for medical institutions run by the society (private hospitals). Under the DRG payment method, hospitals at the same level have the same disease and the same price, which gives medical institutions run by the society (private hospitals) a fair development opportunity in the market environment.
02 Stakeholder impact analysis
From the perspective of relevant stakeholders, it involves the impact on medical insurance, medical institutions, pharmaceutical companies, patients and other relevant stakeholders (see above for the impact on medical institutions and pharmaceutical companies, so I won’t go into details here).
(A) the impact on medical insurance
Relieve the pressure on medical insurance funds. From the experience of foreign implementation, for the payer, the implementation of DRG can alleviate the pressure of medical insurance funds to a certain extent, control the growth of medical expenses, and at the same time facilitate the medical insurance settlement between the payer and the hospital by paying for diseases, greatly improving the settlement efficiency. DRG can produce systematic disease data and improve the management efficiency of medical insurance supervision.
(B) the impact on patients
Reduce expenses and improve medical quality. For patients, the implementation of DRG can not only reduce the cost of medical treatment, but also promote medical institutions to improve the quality of medical treatment. Hospitals and doctors are optimistic about the disease with the best and most economical resources, and at the same time, the problems of "big prescription" and "pan-examination" criticized by society will be curbed; Solve the problem of "difficulty in seeing a doctor" to a certain extent. DRG urges the hospital to optimize the diagnosis and treatment plan and shorten the hospitalization time of patients, thus increasing the ability to receive patients and enabling more patients to enjoy high-quality medical resources; The optimized diagnosis and treatment scheme under the strict clinical path further enhances the patients’ sense of acquisition of disease treatment.