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Multi-city landing "outpatient mutual assistance"! How to deal with the "100 billion market" of out-of-hospital retail?

 Last Update: 2022-11-04
 Source: Internet
 Author: User

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"Outpatient Mutual Assistance" accelerates the landing and flowering
.

On November 1, Shantou, Foshan, Hami, Liaoyang and other cities ushered in the implementation
of "outpatient mutual assistance".

In fact, since the State Council issued the Guiding Opinions on Establishing and Improving the Outpatient Mutual Assistance Guarantee Mechanism for Basic Medical Insurance for Employees (hereinafter referred to as the "Guiding Opinions") in April 2021, the exploration of the reform system of employee medical insurance individual accounts in various provinces and cities across the country is gradually launched, and the pharmaceutical industry has been paying great attention
to the policy trend of "outpatient mutual assistance".

In the eyes of the industry, the content of the outpatient mutual aid reform is summarized as the functional transformation through "one rise and one decrease", that is, improving the crediting method of employees' medical insurance personal accounts, reducing the allocation of personal accounts, simultaneously improving the outpatient mutual assistance protection mechanism of employee medical insurance, and improving the level of outpatient mutual assistance protection of
employee medical insurance.

With the reduction of personal account expenses, people will be cautious about going to pharmacies to pick up medicines, and more will tend to go to hospitals to see doctors and get medicines, and designated pharmacies will usher in a "decline in medical insurance income"
.

The reform of medical insurance personal accounts has been further accelerated, and the out-of-hospital market of the pharmaceutical industry is ushering in major changes
.

Another wave of "outpatient solidarity" has hit

The core of the reform of the Guiding Opinions is the transformation
from the original individual accumulation protection model on outpatient medical expenses to the fund mutual assistance protection model.
It is clear that it is necessary to establish and improve the medical insurance outpatient mutual assistance guarantee mechanism for employees, improve the method of crediting personal accounts, and require all provincial-level people's governments to introduce implementation plans and set a transition period
of about three years.

With the state requiring all localities to introduce the implementation measures of the outpatient mutual assistance system of basic medical insurance for employees, more than 30 provinces and cities such as Guangdong, Jiangsu, Shanghai, Chongqing, Sichuan, Henan, Anhui, Heilongjiang, Hunan, Beijing and Yunnan have successively introduced local employee medical insurance outpatient mutual assistance policies
.
Each city refines the program measures according to its own actual situation, and the specific implementation details are different
.

• Foshan: Color B-ultrasound items and medical consumables that citizens are concerned about are included in the scope of
medical insurance payment.
Implement the "three major catalogs" of medical insurance in Guangdong Province, and further expand the scope of reimbursement.
.
.

• Shantou: 2% of the average annual wage of urban employees in the city in the previous year, and 20%
higher for retired employees.
The reference adjustment of resident medical insurance participants is 1.
5% of the per capita disposable income of the city's residents in the previous year.
.
.

• Hami: The reimbursement rate of expenses exceeding the policy scope above the threshold payment standard for outpatient chronic diseases is 75%, and the reimbursement rate of retirees is 80%, and the expenses of first-class outpatient chronic diseases are reimbursed separately by the employee medical insurance pooling fund, and the maximum reimbursement limit is the maximum reimbursement limit of 100,000 yuan in the year of the pooled fund.
.
.

• Meizhou: The payment ratio of first-level and below designated medical institutions is 60%, the payment ratio of second-level designated medical institutions is 55%, the payment ratio of third-level designated medical institutions is 50%, and the proportion of retirees is increased by 5 percentage points.
.
.

• Chenzhou: The maximum payment limit of the general outpatient pooling fund is: 1,500 yuan/person for active employees and 2,000 yuan/person for retirees in a natural year.
.
.

• Liaoyang: The reimbursement rate of medical expenses in the employee outpatient unified medical insurance directory can reach 50% to 75%, the annual minimum payment standard is 300 yuan, and the payment limit is 3,000 yuan, and eligible resettlement personnel can also enjoy this treatment.
.
.

A series of adjustments in various provinces and cities will undoubtedly change the current medical status, patients' medical choices, hospital prescription flow and medication habits, and then leverage the market structure
of the entire pharmaceutical industry.

In the past, China's basic medical insurance system for employees focused on hospitalization, and the proportion of medical insurance reimbursement for hospitalization was relatively high
.
Except for specific diseases such as outpatient chronic diseases and special diseases, which are reimbursed by the medical insurance pooling fund, other general outpatient medical expenses can only be paid
through personal accounts.

With the economic and social development, the problems brought by personal accounts are becoming more and more prominent
.
According to the National Medical Insurance Bureau, by the end of 2021, the cumulative balance of the national basic medical insurance fund was 3.
6 trillion yuan, of which the cumulative balance of the employee's medical insurance personal account was 1.
1 trillion yuan
.
With the development of social economy and the improvement of medical demand, the limitations of personal accounts, accounting for nearly 1/3 of the medical insurance fund, have gradually become prominent, mainly due to insufficient protection functions, insufficient mutual assistance, and the effect of reducing burden is not obvious
.

In this regard, this year, the General Office of the State Council issued the "2022 Key Work Tasks for Deepening the Reform of the Medical and Health System", which once again clarified the reform goals
in the field of medical insurance this year.
The National Medical Insurance Bureau and other departments will also guide all localities to promote the coordination of general outpatient medical insurance for employees, implement differentiated payment policies for medical treatment in primary medical and health institutions, and gradually include ordinary outpatient expenses for frequent and common diseases into the scope of payment by
the pooling fund.

The market view believes that all these series of reforms are aimed at allowing medical insurance to better play its function of protecting serious diseases, improving the efficiency of the use of funds, and allowing medical insurance funds to focus on serving the groups in real need; In the next step, the direction of outpatient mutual aid reform is to further increase the reimbursement ratio and lower the reimbursement threshold
.

"In the past, outpatient medical treatment was paid out of pocket, but now the outpatient expenses in the hospital can be reimbursed by medical insurance, and the out-of-pocket part can use the funds in the
family's personal account.
" For insured employees and insured residents, "outpatient mutual assistance" is undoubtedly a policy
to benefit the people and facilitate the people to reduce the burden of medical treatment, obtain medical security, and improve the efficiency of the use of medical insurance funds.

However, as personal account fees decreased, patients were less willing to go to pharmacies and pharmacy sales declined
.
This will lead to a decline in the health insurance revenue of designated retail pharmacies and an increase in the difficulty
of drug sales.
At present, the implementation of the outpatient mutual assistance guarantee mechanism is being accelerated across the country, and a wave sweeping the pharmacy industry is accelerating
.

Personal account reform, outpatient mutual assistance.
.
.
How can retail pharmacies turn a corner?

According to the "2021 National Statistical Bulletin on the Development of Medical Security", the total medical expenses of employee medical insurance participants in 2021 were 1,499.
737 billion yuan, an increase of 12.
2% over the previous year, of which 1,293.
645 billion yuan were incurred by medical institutions and 206.
092 billion yuan
were spent in pharmacies in personal accounts.
According to industry data, the sales scale of the national pharmacy retail market will be 491.
6 billion yuan in 2021, and medical insurance will account for about
42% of retail revenue.

The implementation of outpatient mutual assistance and medical insurance personal account reform has quietly changed the development ecology
of the industry.

"The reform will affect the way personal accounts are used, change personal drug purchasing behavior, affect the expenditure structure of personal accounts, and then affect the sales volume of
retail pharmacies.
" In the eyes of the industry, after the reform of medical insurance personal accounts, the disposable funds of insured personnel to buy drugs in pharmacies are reduced, coupled with the psychology of "cherishing money", they will be more cautious in purchasing drugs, and the advantage is to reduce the "abuse" and "random spending" of personal medical insurance cards, coupled with the increase in supervision, the "indiscriminate swiping" of medical insurance cards in retail pharmacies will be effectively curbed
.

However, for pharmacies, it is not all negative
.
Although there is less money in the account, the scope of use of the account has been relaxed
.

After the reform, the purchase of medicines, medical equipment, and medical consumables at designated pharmacies can be paid by the personal accounts of the employees of family members, which has broadened the scope of use of personal accounts, and many outpatient expenses originally paid by personal accounts have been included in the pooling fund, which has further improved the payment ability
of personal accounts.
This provides opportunities for targeted retail pharmacies to increase sales
.

A person in charge of a chain pharmacy analyzed that the impact of the medical insurance personal account reform on pharmacies has three aspects: First, the scale of account accumulation has been reduced, the resources that can buy drugs by themselves have decreased, and pharmacy sales may shrink accordingly; Second, the scope of personal account expenditure is limited, especially in some regions, the price of drugs in the medical insurance catalogue of pharmacies must be consistent with the centralized procurement price, and the state has expanded the centralized procurement of large-volume drugs and high-value consumables, and the sales of drugs in the medical insurance catalogue of designated pharmacies will be affected; Third, self-medication practitioners "counter-flow" to outpatient clinics to buy medicines, and the source of customers in designated pharmacies has decreased
.

The personal account reform will have an impact of about 10% on the revenue of pharmacies, and the net profit may lose about
3%.
"In fact, for larger chains, the impact is bearable, but it has a great impact on small and medium-sized chains with weak financial strength or a single business model, but this is also conducive to accelerating industry integration
.
" The head of the above-mentioned chain pharmacy said
.

"If you are poor, you will change", and industry upgrading and transformation is an inevitable trend
.
All walks of life have basically reached a consensus on the general trend of medical insurance personal accounts to outpatient coordination, and for retail terminals, it is necessary to change the traditional concept of just selling drugs, from the past to fight for medical insurance and price to fight for services
.
Provide value-based services and win more consumers
by providing patients with medical consultation, pharmacy services, online drug purchase, health management, health insurance and other services.

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