本文選題：藥品福利管理 + 醫(yī)療保險��； 參考：《西南財經(jīng)大學(xué)》2014年碩士論文

【摘要】：美國是早期推行醫(yī)療保險市場化的代表性國家之一,為了控制飛漲的醫(yī)藥費用支出,解決參保人因選擇過多而難以抉擇,無法合理使用保險政策的難題,改善保險市場在運作、管理和監(jiān)控方面越來越復(fù)雜的情況,藥品福利管理(Pharmacy Benefit Management, PBM)應(yīng)運而生。藥品福利管理(PBM)模式是一種專業(yè)化的第三方服務(wù),主要利用市場的手段對藥品費用進行管理,是美國商業(yè)保險公司對醫(yī)療保障基金控制的新型模式,以提高醫(yī)保資金的利用效率為核心目標。藥品福利管理公司(PBMs)作為第三方企業(yè),平衡協(xié)調(diào)包括政府、保險機構(gòu)、制藥商和患者等多方的利益,滲透在整個醫(yī)療供應(yīng)鏈條的各個環(huán)節(jié)中,提供的服務(wù)包括藥品目錄管理、藥品郵購服務(wù)、處方賠付申請的處理、藥品利用評價、推薦臨床路徑以及疾病管理等等。藥品福利管理(PBM)模式的發(fā)展,在降低醫(yī)藥費用支出,綜合評價藥品信息,促進藥品的合理使用,全面實施健康管理方面有著重要的作用,對美國市場化的保險制度產(chǎn)生了巨大的影響。 目前,中國也面臨著醫(yī)療衛(wèi)生費用支出飛漲的困境,其醫(yī)療市場現(xiàn)狀與七八十年代美國的情況非常相似,如何建立完善的全民社會醫(yī)療保險制度,同時尋求商業(yè)健康保險的發(fā)展空間與發(fā)展路徑,是中國亟待解決的問題之一。 盡管藥品福利管理(PBM)模式在我國已經(jīng)初現(xiàn)端倪,醫(yī)療保險和商業(yè)健康保險中都有所運用,但應(yīng)用的僅僅是相互分離的某些部分,并沒有進行整合。我國借鑒并應(yīng)用PBM模式非常必要,但是PBM模式也存在一些問題,例如是否能夠真正控制醫(yī)療保險費用增長的爭議,獨立藥店的生存危機,并購對競爭產(chǎn)生的負面效應(yīng)以及公開信息所產(chǎn)生的隱私問題等。此外,在我國現(xiàn)實國情下,想要發(fā)展PBM模式仍然還存在醫(yī)藥分業(yè)改革、行政化管理等諸多約束和問題。本文首先對美國藥品福利管理(PBM)模式的相關(guān)知識進行了詳細的介紹和說明,分析我國引入PBM模式的必要性,根據(jù)PBM模式目前在我國醫(yī)療保險和商業(yè)健康保險中的運用,探討PBM模式在我國發(fā)展可能存在的問題,并針對存在的問題提出個人的建議,期望能對PBM模式在我國的有效運用,甚至在完善我國醫(yī)療體制改革,促進我國商業(yè)健康保險的發(fā)展等方面都能夠產(chǎn)生積極的影響作用。 本文分緒論、正文和結(jié)語三大板塊。其中,正文主要分為五個部分： 第一部分,首先針對美國藥品福利管理(PBM)模式進行了詳細的介紹和分析,在了解了藥品福利管理模式(PBM)的概念之后,深入研究了藥品福利管理(PBM)模式的戰(zhàn)略工具以及所能發(fā)揮的作用,PBM模式提供的服務(wù)包括制定和管理處方集目錄、提供藥品郵購服務(wù)、鼓勵使用通用藥、實時處理處方單據(jù)、與制藥企業(yè)談判以獲取折扣、疾病管理、藥品利用評價、電子處方以及信息共享與傳播等,在控制醫(yī)療費用支出、提高醫(yī)療服務(wù)質(zhì)量方面有著積極的作用。此外,還介紹了藥品福利管理(PBM)模式的發(fā)展歷史,以及目前的發(fā)展狀況和主要的藥品福利管理公司(PBMs). 第二部分,根據(jù)我國的現(xiàn)實情況與市場需求,分析我國發(fā)展藥品福利管理(PBM)模式的必要性以及建立的可行性。我國正值藥品福利管理(PBM)模式高速發(fā)展的關(guān)鍵點,如果我國借鑒美國先進的模式,則能夠使我國在進入快速發(fā)展期時,越過探索及完善的長期過程,有效控制醫(yī)療費用的支出。我國引入PBM模式,還能夠降低賠付率,提高保險產(chǎn)品質(zhì)量,促進我國商業(yè)健康保險的發(fā)展。另外,在推動我國醫(yī)療保障體系改革方面也有著舉足重輕的作用。 第三部分,分析藥品福利管理(PBM)模式目前在我國醫(yī)療保險中建立醫(yī)�；鹬悄芄芾砥脚_的實例,探討海虹控股與各地醫(yī)保局合作所產(chǎn)生的積極作用,以及在商業(yè)健康保險中,平安保險公司整合“平安藥網(wǎng)”、“平安醫(yī)網(wǎng)”，提供藥品郵購服務(wù),建立起全新的全面健康管理服務(wù)平臺。期望能將藥品福利管理(PBM)模式在醫(yī)療保險與商業(yè)健康保險中進行整合,以建立完整的藥品福利管理(PBM)模式。 第四部分,借鑒美國完整的藥品福利管理(PBM)模式,分析在我國建立與發(fā)展藥品福利管理(PBM)模式可能出現(xiàn)的問題和改革難點。我國的國家基本醫(yī)療保險制度,現(xiàn)在還暫時處于水平低、覆蓋廣、浪費大、監(jiān)管效率低的階段。醫(yī)藥分業(yè)暫時難以突破,醫(yī)院有著絕對的優(yōu)勢地位,加之行政化的管理模式,缺乏健全的法制和制度保障,這些都限制了市場化的藥品福利管理(PBM)模式的發(fā)展。藥品福利管理(PBM)模式在市場上還未得到較大的認可,盈利能力有限也是發(fā)展的難點。此外,藥品福利管理(PBM)模式本身還存在其他的爭議,例如能否真正控制醫(yī)保費用、商業(yè)競爭的負效應(yīng)、對醫(yī)生處方權(quán)的干擾以及信息的保密與安全性等。 最后一部分,提出在我國現(xiàn)實國情下,通過學(xué)習(xí)國外的先進經(jīng)驗,完善藥品福利管理(PBM)模式所需要的可行方法和措施。首先要建立專業(yè)的藥品福利管理機構(gòu),形成專業(yè)化的管理團體；其次,實行醫(yī)藥分業(yè)改革,完善對醫(yī)療方面的補償機制；再次,要建立健全的法制和良好的制度運行保障。除此之外,發(fā)展藥品福利管理(PBM)模式,還需要制定專業(yè)的處方集目錄,鼓勵醫(yī)生和患者使用合理的處方集目錄,在選擇藥品福利管理公司時要充分考慮公司本身的整體實力、發(fā)展情況和企業(yè)文化等多方面因素,加大力度完善健全的藥品保障政策體系等。通過以上的方法和措施,期望我國能夠建立起符合我國國情的藥品福利管理模式。 本文主要采用歷史分析法、實例分析法和比較分析法,從全新的角度探索新模式在我國醫(yī)療保險與商業(yè)健康保險中的運用。但是由于該題目較新,國內(nèi)相關(guān)文獻較少,翻譯外文文獻容易出現(xiàn)偏差,加之該題目涉及的范圍較廣,除了保險還包括醫(yī)療制度、藥品產(chǎn)業(yè)鏈等方面,因此還需要多搜集相關(guān)文獻和資料,多了解相關(guān)制度和知識,充分結(jié)合我國的實際情況。
[Abstract]:The United States is one of the representative countries in the early implementation of the medical insurance market. In order to control the soaring medical expenses, it is difficult to use the insurance policy to solve the difficult choice of the insured person because of too many choices. The more complicated the insurance market is in operation, management and monitoring, the drug welfare management (Pharmacy Bene) Fit Management, PBM) emerge as the times require. The drug welfare management (PBM) model is a specialized third party service, which mainly uses the market means to manage the drug cost. It is the new model of the United States Business insurance company to control the medical security fund, and the core goal of improving the utilization efficiency of medical insurance funds. PBMs, as a third party enterprise, balanced and coordinated the interests of the government, insurance agencies, pharmaceutical companies and patients, permeates in all links of the whole medical supply chain, providing services including drug catalog management, drug mail order services, prescription claims processing, drug use evaluation, recommended clinical pathways and disease management. The development of the drug welfare management (PBM) model has played an important role in reducing medical expenses, comprehensive evaluation of drug information, promoting the rational use of drugs, and implementing health management in an all-round way. It has a great impact on the market based insurance system in the United States.
At present, China is also facing the plight of the soaring expenditure on medical and health expenses. The status of its medical market is very similar to that of the United States in 70s and 80s. How to establish a perfect social medical insurance system and seek the development space and development path of commercial health insurance is one of the problems to be solved in China.
Although the model of drug welfare management (PBM) has emerged in our country, medical insurance and commercial health insurance have been used, the application is only part of each other. It is not integrated. It is necessary for us to learn from and apply the PBM model, but there are some problems in the PBM model, for example, whether it can really control the medicine or not. The disputes on the growth of insurance costs, the survival crisis of independent drugstores, the negative effects of mergers and acquisitions on competition and the privacy problems arising from public information. In addition, there are still many constraints and problems in the development of PBM mode in our country's actual conditions. The relevant knowledge of PBM model is introduced and explained in detail, the necessity of introducing PBM model in China is analyzed. According to the application of PBM model in China's medical insurance and commercial health insurance, the possible problems of the development of PBM model in our country are discussed, and the personal suggestions are put forward to the existing problems, and the expectation can be made to the PBM The effective use of the model in China, even in the improvement of the reform of the medical system in China, and promote the development of China's commercial health insurance can have a positive impact.
This article is divided into three parts: introduction, text and conclusion. The body is divided into five parts.
The first part is a detailed introduction and analysis of the drug welfare management (PBM) model in the United States. After understanding the concept of the drug welfare management model (PBM), the strategic tools and functions of the drug welfare management (PBM) model are deeply studied. The services provided by the PBM model include the formulation and management of the prescription catalogues, Providing drug mail order services, encouraging the use of generic drugs, dealing with prescription documents in real time, negotiating with pharmaceutical companies to obtain discounts, disease management, drug use evaluation, electronic prescriptions and information sharing and dissemination, has a positive role in controlling medical expenses and improving the quality of medical services. The development history of the PBM model, as well as the current development situation and the main drug welfare management company (PBMs).
The second part, according to the reality and market demand of our country, analyzes the necessity and feasibility of developing the model of drug welfare management (PBM) in our country. China is the key point of the high speed development of the model of drug welfare management (PBM). If our country uses the advanced model of the United States for reference, it can make our country go over the period of rapid development. To explore and improve the long-term process to effectively control the expenditure of medical expenses, the introduction of PBM model in China can also reduce the rate of payment, improve the quality of insurance products and promote the development of China's commercial health insurance. In addition, it also plays a very important role in promoting the reform of China's medical security system.
The third part is to analyze the case of establishing the intelligent management platform of the medical insurance fund in the medical insurance of China (PBM), and discuss the positive effect of the cooperation between Haihong and the local medical insurance bureau. And in the commercial health insurance, the Ping An insurance company integrates the "safe medicine network", "safe medicine network", and provides drug mail. A new comprehensive health management service platform is set up. It is expected to integrate the PBM model in medical insurance and commercial health insurance to establish a complete PBM model.
In the fourth part, the possible problems and difficulties in the establishment and development of drug welfare management (PBM) model in China are analyzed for reference to the complete PBM model in the United States. The national basic medical insurance system in China is now at a stage of low level, wide coverage, large waste and low supervision efficiency. In order to break through, the hospital has an absolute dominant position, in addition to the administrative management mode, the lack of sound legal system and system guarantee, which all restrict the development of the market based drug welfare management (PBM) model. The model of drug welfare management (PBM) has not been greatly recognized in the market, and the limited profit ability is also the difficulty of the development. In addition, There are other disputes in the PBM model itself, such as whether it can really control medical insurance costs, the negative effects of business competition, the interference with the prescription rights of doctors, and the secrecy and security of information.
In the last part, we put forward the feasible methods and measures to improve the model of drug welfare management (PBM) by learning foreign advanced experience in the actual situation of our country. First, we should establish a professional medicine welfare management organization and form a specialized management group. Secondly, implement the reform of medical division and perfect the compensation machine for medical treatment. Thirdly, we should establish a sound legal system and a good system operation guarantee. In addition, the development of the drug welfare management (PBM) model requires the formulation of a professional prescription catalogue, encouraging doctors and patients to use a reasonable catalogue of prescriptions, and taking full consideration of the overall strength of the company itself and the development of the company in the choice of the drug welfare management department. It is expected that our country can establish a model of drug welfare management in accordance with the national conditions of our country through the above methods and measures.
This paper mainly uses historical analysis, case analysis and comparative analysis to explore the application of new model in China's medical insurance and commercial health insurance from a new angle. However, because of the new topic and less domestic related literature, the translation of foreign literature is prone to deviations, and the scope of the subject is wide, besides insurance. Including the medical system and the pharmaceutical industry chain, we need to collect more relevant literature and information, understand the relevant systems and knowledge, and fully integrate the actual situation of our country.

【學(xué)位授予單位】：西南財經(jīng)大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2014
【分類號】：R95;F842.684

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