【作者】 涂洪谊；

【导师】 孙鹤；

【作者基本信息】 天津大学 ， 药事管理， 2009， 博士

【摘要】 药品费用由药品价格、药品使用量和药品使用结构三部分因素决定,与这三部分因素最为相关的医疗保险药品费用控制政策分别为药品定价与补偿政策、药品目录管理政策和药品选择使用政策。而我国城镇职工基本医疗保险药品管理政策中与这三个政策对应的管理办法还有很多值得改进的地方,具体表现在:药品定价主体错位,定价补偿机制缺乏充足的科学性依据;医疗保险药品目录采用通用名和剂型为标准,没有进一步就商品名、规格、价格等因素进一步进行分类限制;医疗保险在具体药品品种选择和药品使用管理上缺乏有效手段措施等方面。这种药品管理职能性的不足可能是造成城镇职工基本医疗保险体系药品费用支出一直维持在较高位势的原因,这也就使得在新医改背景下如何有效控制药品费用的过快增长成为了医疗保险改革面临的巨大挑战。本研究主要针对城镇职工基本医疗保险管理体系中的药品费用控制机制现状,从医疗保险药品费用控制政策的整体效益评价出发,应用天津市城镇职工基本医疗保险住院患者报销数据,以医保患者住院费用、个人负担、药品费用和药品个人负担为观察指标,综合采用描述性统计和计量经济学方法对影响药品费用的相关政策(2004版药品目录调整、药品价格调整和药品选择使用)调整的效果进行实证检验。研究结果发现:①如果药品费用变动一个百分点则医保患者住院费用就会变动0.5371个百分点,医保患者个人负担则会变动0.5639个百分点,这说明无论是对住院费用还是个人负担而言,药品费用都在其中占有极其重要的作用;②针对整体费用报销比例的政策设计比单纯针对药品费用设计的报销比例政策更为敏感有效,因为研究结果显示药品自付比例每增加一个百分点会使得药品费减少1.085个百分点,而针对患者住院费用报销的个人自付比例每增加一个百分点则会使得药品费下降1.465个百分点;③药品目录调整后医保患者的住院费用比调整前降低了4.32%,而次均个人负担在药品目录调整后增加了19.92%,次均住院药品费在药品目录调整后则降低了4.28%,次均药品个人负担在药品目录调整后则显著增加了23.61%;④呼吸系统患者抗微生物药品价格调整和肿瘤患者抗肿瘤药品价格调整效果的研究表明,在国家对药品价格进行调整后医疗提供方出于维持自身经济利益,选用了一些高层次的药品或/和增加药品使用量等方式来规避价格调整政策带来的不利影响,这样也就使得多次降价政策在实践中没有达到预期的政策效果;⑤实证结果表明医保肿瘤患者在临床中每多使用一种原研药品就会使得次均住院费用增加9.96%,次均个人负担则会相应增加9.18%,而次均药品费会增加20.96%,导致的药品个人负担则会增加44.28%;而原研药品费用每增加一个百分点就会使得住院费用增加0.1369个百分点,而个人负担则会增加0.1137个百分点,药品费增加0.2232个百分点,药品个人负担增加0.5380个百分点;而通用名药品与相应变量间的弹性系数显著小于原研药品,并且与患者个人负担间还有显著的负向关系。这说明在存在相同通用名药品的前提下,原研药品的使用会导致医保肿瘤患者的过高住院费用和过重经济负担。最后,基于城镇职工基本医疗保险药品目录、药品定价与补偿、药品选择和使用管理等方面都需要从整体效益的角度进行完善的现状,我们主要针对药品消费提供方从间接管理和直接管理两方面对医疗保险药品效益管理体系进行了初步设计。本研究主要有以下创新之处:首先,从影响药品费用因素的整体出发,对影响医疗保险药品费用变动的关键政策进行全面分析评价;第二,应用面板数据模型对住院费用、个人负担与药品费用间的弹性关系进行了计量估计,并应用混合横截面模型对药品价格调整、药品目录调整进行了政策调整效果的初步评估;第三,我们首次应用医保报销数据从原研药品使用的种类数目和药品费用两个角度对原研药品对医保患者住院费用和个人负担的影响进行了计量分析;第四,结合实证研究结果,应用药品效益管理理念设计从间接管理和直接管理两方面提出了适合我国城镇职工基本医疗保险体制的药品效益管理体系。更多还原

【Abstract】 Drug expenditures are decided by price, utilization and the structure factor, and drug pricing and reimbursement, drug formulary and drug selection of generics are three important cost containment strategies in medical insurance. But there need some improvement in these policies of china’s medical insurance for urban empolyee. For example, the drugs which were selected in formulary of medical insurance ignored the difference of trade name, package and price, but only by the generic name and dose forms. The malposition of agent in drug pricing, and the shortage of scientific basement in drug pricing and reimbursement made the pricing of drugs on a fault mechanism. And had no effective measures to control the usage of drugs and to affect the rational use of drugs. These showed there are no an idea of effective evaluation in drug management and policy adjustment of medical insurance in china.The study used descriptive statistics methods and econometric methods to evaluate the effectiveness of insurance drug policies such as the practice of new formulary in 2004 and price adjustment, and the objective was to design a more effective drug management system based on the idea of pharmacy benefit management and results of the study.The results showed that, firstly, the cost of drugs played an important role in the out-of-pocket and the cost of hospitalization of the patients. Secondly, if the proportion of drugs paid by patients rise one percentage, then the cost of drugs would be reduced 1.085 percentages, and if the proportion of cost of overall paid by patient rise one percent, then the cost of drugs would be reduced 1.465 percentages, that means the patient were more sensitive to the reimbursement of overall cost than the reimbursement of drugs. Thirdly, the selection of drugs for formulary, the structure design of formulary, and the reimbursement ratio of drugs in formulary need an improvement to get better effect in controlling the cost of drugs. Fourthly, because of health care providers chose more expensive drugs for substitution, or/and increased the usage of drugs, the price adjustment of antimicrobial drugs and antitumor drugs didn’t get the desired effects to reduce the out-of-pocket of patients. Fifthly, if the tumor patients used one more kinds of brand antitumor drugs, the cost of hospitalization would be increased 9.96 percentages, the out-of-pocket would be increased 9.18 percentages, the cost of drugs would be increased 20.96 percentages, and the out-of-pocket for drugs would be increased 44.28 percentages. And if the cost of brand antitumor drugs be increased one percentage, the cost of hospitalization would be increased 0.1369 percentages, the out-of-pocket would be increased 0.1137 percentages, the cost of drugs would be increased 0.2232 percentages, and the out-of-pocket for drugs would be increased 0.5380 percentages. These showed that usage of brand antitumor drugs would lead to high cost of hospitalization and high out-of-pocket in patient.Based on the effects of new drug formulary, price adjustment, and choice of generic drugs in the medical insurance, the study designed a pharmacy benefit management system for the medical insurance in direct and indirect ways, which with the aim to affect the health care providers and to improve the effectiveness of drug management of medical insurance.There is some innovation in our study. Firstly, we conducted a comprehensive analysis on three important cost containment policies, which related to price, utilization and the structure factor of drug expenditures. Secondly, we used panel data model to estimate the elasticity coefficient between the drug expenditure and the cost of hospitalization, and the out-of-pocket. And we used the cross-sectional model to assessment of the effect of drug formulary adjustment and price adjustment. Thirdly, we used the medical claims data to estimate the effect of usage of brand drugs to the cost of hospitalization, and the out-of-pocket of patient for the first time. Fourthly, we designed a pharmacy benefit management system from indirect and direct approaches.更多还原