本文選題：醫(yī)療保險(xiǎn) + 藥品��； 參考：《東南大學(xué)》2017年碩士論文

【摘要】：目的 為貫徹落實(shí)國家發(fā)展改革委、國家衛(wèi)生計(jì)生委、人力資源和社會(huì)保障部等七部門《關(guān)于印發(fā)推進(jìn)藥品價(jià)格改革意見的通知》精神,探索建立新的引導(dǎo)藥品價(jià)格合理形成的機(jī)制,建立與之相適應(yīng)的醫(yī)保藥品支付標(biāo)準(zhǔn)制定的程序、方法和依據(jù),促進(jìn)醫(yī)療衛(wèi)生事業(yè)健康發(fā)展,滿足人民群眾不斷增長的醫(yī)療衛(wèi)生服務(wù)需求。方法 通過查閱相關(guān)的文獻(xiàn)資料,了解其他國家和地區(qū)藥品價(jià)格形成機(jī)制,以及我國部分地區(qū)醫(yī)療保險(xiǎn)支付標(biāo)準(zhǔn)建立的實(shí)踐經(jīng)驗(yàn)和相關(guān)政策。應(yīng)用焦點(diǎn)人物訪談、小組訪談法和歷史資料收集等獲取資料,收集藥品交易銷售量和價(jià)格等相關(guān)數(shù)據(jù),共獲得36種通用名,75種商品名,7111條藥品的信息,應(yīng)用Excle軟件和SPSS軟件,建立數(shù)據(jù)庫,進(jìn)行描述性統(tǒng)計(jì)分析。結(jié)果1.醫(yī)保藥品支付標(biāo)準(zhǔn)應(yīng)該包括兩方面的內(nèi)容:一是藥品的醫(yī)保支付價(jià)格,二是醫(yī)保藥品支付方式。2.藥品的醫(yī)保支付價(jià)格測(cè)算應(yīng)該包括現(xiàn)在正在使用的藥品、新上市藥品、創(chuàng)新藥和專利藥品醫(yī)保支付價(jià)格的確定辦法,以及藥品醫(yī)保支付價(jià)格的調(diào)整辦法。(1)對(duì)于正在使用的藥品,可以根據(jù)其有效成分、藥理作用、治療效果等因素,從治療學(xué)或藥理學(xué)上具有相似作用的藥品中選擇多家生產(chǎn)、充分競(jìng)爭、臨床用量較大、對(duì)醫(yī)保基金影響較大的藥品,按照通用名和規(guī)格進(jìn)行分類,計(jì)算同類藥品的加權(quán)平均價(jià)格,中位數(shù)價(jià)格或者中標(biāo)價(jià)作為醫(yī)保藥品支付標(biāo)準(zhǔn)。(2)對(duì)新上市藥品醫(yī)保藥品支付標(biāo)準(zhǔn)的制定,可以應(yīng)用"類似藥效比較方法"和"成本計(jì)算方法"。(3)創(chuàng)新藥和專利藥的醫(yī)保支付價(jià)格,可以由醫(yī)保部門和藥品生產(chǎn)企業(yè)通過談判共同制定。(4)醫(yī)保藥品支付標(biāo)準(zhǔn)的調(diào)整辦法可以參照日本和臺(tái)灣地區(qū)的做法。日本的醫(yī)保支付價(jià)格根據(jù)市場(chǎng)情況每兩年調(diào)整一次,其依據(jù)是醫(yī)保價(jià)格和醫(yī)療機(jī)構(gòu)采購藥品的價(jià)格,多采用R-zone方法。臺(tái)灣地區(qū)給付目錄內(nèi)藥品支付價(jià)格調(diào)整,充分發(fā)揮了醫(yī)療機(jī)構(gòu)與藥商談判主動(dòng)性。保險(xiǎn)人僅在固定時(shí)間采集市場(chǎng)價(jià)格數(shù)據(jù),按照《全民健康保險(xiǎn)藥品價(jià)格調(diào)整作業(yè)辦法條文》規(guī)定進(jìn)行加權(quán)平均計(jì)算支付價(jià)。3.藥品的支付方式分為兩部分:一是醫(yī)保部門與患者的費(fèi)用分擔(dān)方式;二是醫(yī)保部門與醫(yī)療機(jī)構(gòu)的費(fèi)用結(jié)算方式。與患者的費(fèi)用分擔(dān)方式可以采用按比例支付和基準(zhǔn)價(jià)支付相結(jié)合的方式;與醫(yī)療機(jī)構(gòu)的費(fèi)用結(jié)算方式可以采用總額控制下的多種預(yù)付制方式相結(jié)合。4.醫(yī)保藥品支付標(biāo)準(zhǔn)實(shí)施的前提條件包括藥品零加成政策、城鄉(xiāng)醫(yī)保統(tǒng)籌、公開透明的藥品交易平臺(tái),以及醫(yī)院和醫(yī)生積極性的調(diào)動(dòng)等等。5.參照國外或地區(qū)的醫(yī)保制度是有條件的。首先是醫(yī)與藥分離,澳大利亞和德國都是傳統(tǒng)的實(shí)行醫(yī)藥分離的國家,而日本和臺(tái)灣地區(qū)也在以藥養(yǎng)醫(yī)體制出現(xiàn)種種弊端之后實(shí)施了醫(yī)藥分業(yè)的改革。其次是完善的藥物經(jīng)濟(jì)學(xué)評(píng)標(biāo)體系,德國,澳大利亞,日本和臺(tái)灣地區(qū)都將藥物經(jīng)濟(jì)學(xué)評(píng)價(jià)作為藥品定價(jià)的重要參考。在制定藥品價(jià)格時(shí),不能只考慮其成本和安全性,還應(yīng)考慮到其經(jīng)濟(jì)性。第三是充分考慮病人負(fù)擔(dān),德國在實(shí)行醫(yī)藥費(fèi)用分擔(dān)制度的同時(shí)為了控制病人的醫(yī)藥負(fù)擔(dān),規(guī)定患者承擔(dān)的費(fèi)用,最低不少于5歐元,最多不超過10歐元。臺(tái)灣地區(qū)避免個(gè)人分擔(dān)過重,設(shè)定了個(gè)人分擔(dān)封頂標(biāo)準(zhǔn),規(guī)定個(gè)人負(fù)擔(dān)200元封頂。第四是分工明確、職責(zé)清晰的藥品定價(jià)機(jī)構(gòu),澳大利亞的藥品定價(jià)組織管理與技術(shù)支持部門包括藥品保險(xiǎn)定價(jià)機(jī)構(gòu)、藥品保險(xiǎn)咨詢委員會(huì)和澳大利亞國家治療性藥品管理局;日本有厚生勞動(dòng)省負(fù)責(zé)國家的醫(yī)療衛(wèi)生和社會(huì)保障事宜,其下設(shè)醫(yī)政局經(jīng)濟(jì)課,是日本的藥品價(jià)格管理部門,負(fù)責(zé)醫(yī)藥品價(jià)格調(diào)查和特定保險(xiǎn)醫(yī)療材料價(jià)格調(diào)查等事務(wù);臺(tái)灣地區(qū)由健保局負(fù)責(zé)健保藥品價(jià)格的制定和調(diào)整等工作。第五是對(duì)醫(yī)生行為的控制和對(duì)醫(yī)療機(jī)構(gòu)的激勵(lì)要有相應(yīng)的機(jī)制。結(jié)論合理的制定醫(yī)保藥品支付標(biāo)準(zhǔn),對(duì)于加快完善現(xiàn)代市場(chǎng)體系和轉(zhuǎn)變政府職能,規(guī)范藥品市場(chǎng)價(jià)格行為,促進(jìn)醫(yī)療衛(wèi)生事業(yè)和醫(yī)藥產(chǎn)業(yè)健康發(fā)展,滿足人民群眾不斷增長的醫(yī)療衛(wèi)生需求,減輕患者不合理的醫(yī)藥費(fèi)用負(fù)擔(dān),具有重大的意義,是加快完善現(xiàn)代市場(chǎng)體系和轉(zhuǎn)變政府職能的重要舉措。
[Abstract]:Aim to carry out the notifications of the seven departments, such as the State Development and Reform Commission, the National Health Planning Commission, the Ministry of human resources and social security, and other departments of the Ministry of human resources and social security, to explore and establish a new mechanism for the rational formation of drug prices, and to establish the procedures, methods and methods for the formulation of medical insurance drug payment standards. To promote the healthy development of medical and health services and to meet the increasing demand for medical and health services of the people. Methods through consulting relevant documents, understanding the mechanism of drug price formation in other countries and regions, as well as the practical experience and related policies established in the medical insurance payment standards in some areas of our country. Interview, group interview method and historical data collection, collect data, collect related data such as sales volume and price of drug trade, obtain 36 general names, 75 commodity names, 7111 information, use Excle software and SPSS software, establish database, and carry out descriptive analysis. Results 1. the standard of payment for medical insurance should include two parties Content: one is the medical insurance payment price for drugs, and the two is that the medical insurance payment price of the.2. medicine should include the drugs that are now being used, the newly listed drugs, the method for determining the price of the medical insurance of the innovative and patent medicines, and the adjustment of the price of the medical insurance payment. (1) the use is being used. Drugs, according to their effective components, pharmacological effects, therapeutic effects, and other factors, from a drug with similar effects in therapeutics or pharmacology, choose a number of production, full competition, a large amount of clinical use, a drug that has a greater impact on the medical insurance fund, classified according to the general name and specification, and calculate the weighted average price of the same kind of drugs. 2. (3) the price of medical insurance payment for innovative and patent medicines can be formulated by the medical insurance department and the pharmaceutical production enterprise through negotiation. (4) medical insurance medicine. The adjustment method of the standard of payment can be referred to the practice in Japan and Taiwan. The price of medical insurance payment in Japan is adjusted every two years according to the market situation. It is based on the price of medical insurance and medical institutions purchasing drugs, and the R-zone method is adopted. The adjustment of the price of the drug payment in the Taiwan area is given full play to the medical machine. The insurer has the initiative to negotiate with the drug dealers. The insurer only collect the market price data at a fixed time. The payment methods of the.3. drugs are divided into two parts according to the provisions of the national health insurance drug price adjustment provisions. The first is the cost sharing mode between the medical insurance department and the patient; the two is the medical insurance department and the medical treatment. The mode of cost settlement of the institution. The way of sharing the cost with the patients can be combined with the proportion of payment and the base price payment; the precondition for the implementation of the.4. Medicare payment standard in combination with the cost settlement of the medical institutions can be combined with a variety of prepayment systems under total control, including the zero addition of the drug policy, the city's policy, Rural medical insurance, open and transparent drug trading platform, and the mobilization of hospitals and doctors, and so on.5. refer to the medical insurance system of foreign countries or regions. First, the separation of medicine and medicine, Australia and Germany are traditional medical separation countries, and the Japanese and Taiwan areas are also in the medicine system. After the malpractice, the reform of Pharmaceutical Division has been implemented. The second is the perfect evaluation system of pharmaco economics. In Germany, Australia, Japan and Taiwan, the evaluation of pharmacoeconomics is regarded as an important reference for drug pricing. In the formulation of drug prices, the cost and safety of drugs should not be considered only, and their economy should be taken into account. Third is a full examination. Considering the burden of the patients, in order to control the medical cost sharing system in Germany, in order to control the medical burden of the patients, the cost of the patient is not less than 5 euros, up to no more than 10 euros. The Taiwan area avoids the heavy share of individuals, sets the personal sharing of the cap and the individual burden of 200 yuan. Fourth is clear division of labor, The drug pricing agency with clear responsibilities, the Australian drug pricing organization management and technical support department, including the drug insurance pricing agency, the drug insurance advisory committee and the Australian National therapeutic drug administration, and the Ministry of health and health in Japan, are responsible for the health and social security of the country, and the economic course of the medical administration bureau is set up. The drug price management department in Japan is responsible for the medical price survey and the specific insurance medical material price investigation and so on. The Taiwan regional health insurance bureau is responsible for the formulation and adjustment of the health insurance price of the health insurance. Fifth is the control of the doctor's behavior and the corresponding mechanism for the incentive of medical institutions. The standard of drug payment is of great significance to improving modern market system and changing government functions, standardizing the price behavior of drug market, promoting the healthy development of medical and health industry and medical industry, meeting the growing medical and health needs of the people and reducing the burden of unreasonable medical expenses for the patients. It is of great significance to speed up the improvement of modern times. An important measure of the market system and the transformation of government functions.
【學(xué)位授予單位】：東南大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R95

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