Sichuan Draft for Comments Includes Chinese medicine retail pharmacies in the management of medical insurance agreements...

A few days ago, the Sichuan Provincial Medical Insurance Bureau publicly solicited opinions on the Implementation Opinions on Medical Insurance to Support the Inheritance and Innovative Development of Traditional Chinese Medicine (Draft for Comments) (hereinafter referred to as the "Draft Opinions"), which proposed to include Chinese medicine retail pharmacies in medical insurance and carry out procurement of proprietary Chinese medicines
.

 

Support the inclusion of traditional Chinese medicine service projects in the scope of medical insurance

 

The Draft Opinion proposes that qualified Chinese medicine (including integrated traditional Chinese and Western medicine, ethnic minority medicine, and traditional Chinese medicine clinics) medical institutions, Chinese medicine retail pharmacies, etc.
should be included in the management of medical insurance agreements in a timely manner, and "glass doors" and "invisible thresholds"
shall not be set.

 

In terms of promoting the price reform of traditional Chinese medicine services, the Draft Opinions proposes to carry out the procurement of proprietary Chinese medicines on the basis of provincial or inter-provincial regional alliances to promote the high-quality development
of proprietary Chinese medicine manufacturers.
For Chinese medicine tablets purchased by public medical institutions from formal channels, it is allowed to be sold
according to the purchase price of no more than 25%.
Non-drinking Chinese medicines are sold
in strict accordance with the actual purchase price of "zero difference rate".
The specific scope of Chinese medicine tablets is subject to the characterization of the drug regulatory authorities
.

 

Where public medical institutions are unable to provide the actual purchase receipts for Chinese medicine tablets, they may refer to the purchase price of social medicine points in the region as the basis for
supervision.
The traditional Chinese medicine tablets and the prepared Chinese medicine preparations used by medical institutions shall be independently priced
.
Explore the inclusion of traditional Chinese medicine formula granules purchased by public medical institutions into the centralized procurement of provincial pharmaceutical equipment and the online trading of the pharmaceutical price supervision platform, so as to promote the openness and transparency
of transactions.

 

The Draft Opinion makes it clear that the Chinese medicine tablets in the Drug Catalogue are managed according to the "Class A drugs" except for the Chinese medicine formula granules
.
The allocation and use of proprietary Chinese medicines that have been included in the medical insurance list through national negotiations will be included in the monitoring and evaluation
.
Make full use of the "dual-channel" drug management mechanism to expand the channels for insured patients to use drugs to designated retail pharmacies to better protect the drug needs
of the insured masses.

 

The position of the retail side is becoming increasingly important

 

For the overall industry of traditional Chinese medicine, in recent years, national favorable policies have been continuously introduced, covering medical insurance, graded diagnosis and treatment, clinic filing, quality standard management of traditional Chinese medicine tablets, clinical pilot work of famous prescriptions, and the construction of traditional Chinese medicine medical service system, etc.
, to promote industry innovation and high-quality development
in all aspects.

 

On May 20, the General Office of the State Council issued the 14th Five-Year Plan for National Health
.
The plan proposes to give full play to the role
of traditional Chinese medicine in health services.
Implement major projects
for the revitalization and development of traditional Chinese medicine.
Implement the health promotion action of traditional Chinese medicine and promote the upgrading
of the health project of traditional Chinese medicine for the treatment of pre-existing diseases.
Enrich the service connotation of TCM halls and promote the promotion and application
of appropriate technologies of TCM.
Explore rehabilitation service models
that are conducive to giving full play to the advantages of traditional Chinese medicine.

 

Previously, on March 29, the General Office of the State Council also issued the "14th Five-Year Plan for the Development of Traditional Chinese Medicine" to make comprehensive arrangements
for the work of traditional Chinese medicine during the "14th Five-Year Plan" period.
The plan proposes that by 2025, the health service capacity of traditional Chinese medicine will be significantly enhanced, the policy and system of high-quality development of traditional Chinese medicine will be further improved, the revitalization and development of traditional Chinese medicine will achieve positive results, and the unique advantages in the construction of a healthy China will be fully utilized
.
At the same time, specific development goals in terms of traditional Chinese medicine service system, characteristic talent team, inheritance and innovation, industrial and health service industry, culture, open development, and governance level are proposed, as well as fifteen major development indicators
.

 

At the same time, with the advancement of the collection of proprietary Chinese medicines in various places, the competitive pattern of the inner market of proprietary Chinese medicine hospitals will further change, and the position of the retail end will become more and more important
.
According to the latest data from Intranet, the sales of proprietary Chinese medicines in the terminals of physical pharmacies in Chinese cities in 2021 will be close to 111.
7 billion yuan, an increase of 4.
38% compared with 2020, and have returned to the pre-epidemic level
.
Under the stimulation of incremental varieties, the market size of proprietary Chinese medicines will rise
.
Under the continuous promotion of policies such as collection, prescription outflow, and dual channel, the market size of proprietary Chinese medicine pharmacies is expected to further expand
.

 

Implementation Opinions on Medical Insurance to Support the Innovative Development of Traditional Chinese Medicine (Draft for Solicitation of Comments)

 

In order to implement the spirit of the "Opinions of the CPC Central Committee and the State Council on Promoting the Inheritance and Innovative Development of Traditional Chinese Medicine" (Zhongfa [2019] No.
43) and the "Guiding Opinions of the State Medical Security Bureau and the State Administration of Traditional Chinese Medicine on Medical Insurance to Support the Inheritance and Innovative Development of Traditional Chinese Medicine" (Medical Insurance Letter [2021] No.
229), further promote the innovative development of traditional Chinese medicine in our province, and accelerate the construction of the national demonstration zone for the comprehensive reform of traditional Chinese medicine and the construction of a strong province of traditional Chinese medicine in Sichuan, the following opinions are put forward in combination with the actual situation
。

 

1.
Support the development of TCM medical institutions

 

(1) Support TCM medical institutions to be included in the designated scope of
medical insurance.
Timely bring qualified traditional Chinese medicine (including integrated traditional Chinese and Western medicine, ethnic minority medicine, traditional Chinese medicine clinics) medical institutions, traditional Chinese medicine retail pharmacies, etc.
into the management of medical insurance agreements, and must not set "glass doors" or "invisible thresholds"
.
Timely include qualified designated TCM medical institutions in the scope of direct settlement for off-site medical treatment, expand the scope of TCM services, and enhance the regional radiation and influence
of TCM medical institutions.

 

(2) Support the development
of traditional Chinese medicine for the healthy elderly.
Support the development of medical and nursing institutions with the characteristics of traditional Chinese medicine for the health and elderly, and include the qualified grass-roots medical and health institutions and rehabilitation hospitals, hospice care centers, nursing homes, and traditional Chinese medicine medical institutions within nursing institutions that meet the conditions for providing traditional Chinese medicine services into the designated scope of medical insurance, so as to promote the balanced development of high-quality resources of traditional Chinese medicine services and meet the health needs
of the people.

 

(3) Promote the development
of "Internet + Traditional Chinese Medicine".
Designated TCM medical institutions that have already carried out Internet diagnosis and treatment shall sign supplementary agreements with the medical insurance agencies in the co-ordination area in accordance with the regulations, and include the expenses of TCM such as online follow-up diagnosis and drugs of TCM that meet the requirements into the scope of payment of the medical insurance fund, and settle the accounts with the
administrative institutions of each co-ordinating area and the physical medical institutions on which they rely in accordance with the regulations.

 

Second, promote the price reform of traditional Chinese medicine services

 

(4) Support innovative technologies
in traditional Chinese medicine.
Improve the project management policy for the price of new traditional Chinese medicine (ethnic medicine) services, enrich the price projects of traditional Chinese medicine, normalize the review of new medical service price projects, and organize at least a batch of new medical service price projects of
traditional Chinese medicine (ethnic medicine) every year.
For the traditional technology of traditional Chinese medicine (ethnic medicine) derived from ancient classics, which is still widely used and has accurate curative effect, as well as the new technology of traditional Chinese medicine (ethnic medicine) with innovative and outstanding economic advantages, the review procedure for new price items is simplified and a green channel
is opened.

 

(5) Improve the dynamic adjustment mechanism for
medical service prices.
Organize a price adjustment assessment at least once a year, and when the conditions for price adjustment are met, do a good job of price adjustment in a sound and orderly manner, support the traditional Chinese medicine service projects that reflect the technical labor value of Chinese medical personnel, and give priority to the traditional Chinese medicine (ethnic medicine) medical service projects with obvious functional efficacy, wide acceptance by patients, outstanding characteristic advantages, long application history, and obvious deviations in cost and price
.

 

(6) Support the development of medical services
for special needs of traditional Chinese medicine.
Eligible public medical institutions are encouraged to carry out special medical services such as diagnosis and examination fees (special needs), traditional Chinese medicine physical fitness identification (special needs), and traditional Chinese medicine health care consultations (special needs) in accordance with regulations, and medical institutions may independently formulate different charging standards
according to different levels of traditional Chinese medicine physicians and on the basis of comprehensive consideration of factors such as the labor value of physicians, reputation and reputation.

 

(7) Promote the high quality and price
of traditional Chinese medicines.
On the basis of provincial or inter-provincial regional alliances, carry out the procurement of proprietary Chinese medicines with quantity and promote the high-quality development
of proprietary Chinese medicine production enterprises.
For Chinese medicine tablets purchased by public medical institutions from formal channels, they are allowed to be sold
at no more than 25% of the purchase price.
Chinese medicines that are not drinking tablets are sold
in strict accordance with the actual purchase price of "zero difference rate".
The specific scope of Chinese medicine tablets is subject to the characterization of the drug regulatory authorities
.
Where public medical institutions are unable to provide actual purchase receipts for Chinese medicine tablets, they may refer to the purchase price of social medicine in their respective regions as the basis for
supervision.
The traditional Chinese medicine tablets and the prepared Chinese medicine preparations used by medical institutions are independently priced
.
Explore the inclusion of traditional Chinese medicine formula granules purchased by public medical institutions into the centralized procurement of provincial pharmaceutical equipment and the online trading of the pharmaceutical price supervision platform, so as to promote open and transparent
transactions.

 

3.
Support the inclusion of traditional Chinese medicine services in the scope of medical insurance

 

(8) Promote the use
of traditional Chinese medicine.
In light of the actual conditions of our province, a dynamic adjustment mechanism will be established to include qualified ethnic medicines, traditional Chinese medicine tablets and traditional Chinese medicine preparations in medical institutions in the scope of payment of
basic medical insurance in our province in accordance with regulations.
The Chinese medicine tablets in the "Drug Catalog" are managed according to the "Class A drugs" except for the Chinese medicine formula granules
.
The allocation and use of proprietary Chinese medicines that have been included in the medical insurance list through national negotiations will be included in the monitoring and evaluation
.
Make full use of the "dual-channel" drug management mechanism to expand the channels for insured patients to sell drugs to designated pharmacies to better protect the drug needs
of the insured people.
Chinese medicine tablets that comply with the "Measures for the Administration of Prescriptions" and the "Regulations for the Administration of Traditional Chinese Medicine Tablets in Hospitals" but exceed the provisions of the "Pharmacopoeia of the People's Republic of China" and are prescribed in commonly used doses will be included in the scope of
medical insurance payment.
Non-TCM physicians who meet the conditions for proprietary Chinese medicine prescribed in accordance with the relevant provisions of the health administrative department shall be paid by
the medical insurance fund in accordance with the regulations.

 

(9) Strengthen the role of traditional Chinese medicine in the prevention and control of
the epidemic.
Pay attention to giving play to the positive role of traditional Chinese medicine in the prevention and control of major epidemics, and establish and improve the mechanism for
the cost of traditional Chinese medicine that meets the norms for the diagnosis and treatment of the epidemic situation to be included in the scope of medical insurance payment in accordance with regulations.
In the midst of major epidemics, proprietary Chinese medicines, traditional Chinese medicine tablets, traditional Chinese medicine diagnosis and treatment projects, and preparations of traditional Chinese medicine medical institutions approved by the provincial drug regulatory department are temporarily included in the scope of medical insurance payment in accordance with relevant provisions and managed
according to Class A drugs (projects).

 

(10) Support the use
of traditional Chinese medicine preparations in medical institutions.
In accordance with the provisions of the "Interim Measures for the Administration of Preparations for Medical Institutions with Basic Medical Insurance, Work-related Injury Insurance, and Maternity Insurance in Sichuan Province," unify the catalogue of preparations for basic medical insurance, work-related injury insurance, and maternity insurance medical institutions throughout the province (hereinafter referred to as the "medical insurance catalogue"), establish a dynamic adjustment mechanism, adjust it once a year in principle, and promptly include the traditional Chinese medicine preparations of medical institutions that meet the conditions in the scope of payment of
the medical insurance fund in accordance with regulations 。 According to the cost of preparation of traditional Chinese medicine preparations in medical institutions, the level of medical treatment in the region, the level of economic development, the affordability of medical insurance, the capacity of patients to bear and other factors, in accordance with the principles of scientific and reasonable, equal consultation and dynamic adjustment, the medical insurance payment standards are
formulated.
Where the traditional Chinese medicine preparations of medical institutions in the medical insurance catalogue are used within the scope of adjustment approved by the drug supervision and management department, they may be included in the scope of payment of the medical insurance fund in accordance with the procedures, and the promotion and use
of traditional Chinese medicine preparations in medical institutions shall be supported.

 

(11) Increase the inclination of medical service projects with advantages in traditional Chinese medicine
.
In a timely manner, the TCM diagnosis and treatment projects (including therapeutic rehabilitation projects) that have accurate curative effects, appropriate prices, safety and effectiveness, and embody the characteristics and advantages of TCM will be included in the scope of payment of
basic medical insurance in our province in a timely manner in accordance with regulations.
Gradually unify the medical insurance payment policy for TCM diagnosis and treatment projects in the province, standardize the use of TCM medical service projects, and set unreasonable restrictions on medical insurance payment, so as to ensure the accessibility of
the insured to enjoy traditional TCM diagnosis and treatment services.

 

Fourth, improve the payment policy suitable for the characteristics of traditional Chinese medicine

 

(12) Strengthen the budget management
of total medical insurance.
Improve the scientificity and rationality of the total budget of medical insurance, the total budget is appropriately inclined to maintain reasonable annual growth for traditional Chinese medicine medical institutions, and
increase support for grass-roots medical and health institutions to carry out traditional Chinese medicine services.
For the compact county medical community led by the TCM medical institutions, the total budget is appropriately tilted
.

 

(13) Promote the reform
of the payment method of traditional Chinese medicine medical insurance.
General TCM medical services can continue to be paid for on a per-project basis
.
Explore the implementation of TCM diseases to pay according to the value of the disease, select TCM diseases, reasonably determine the score, and implement dynamic adjustment
.
Select and publish diseases that conform to the actual conditions in Sichuan among the dominant diseases of traditional Chinese medicine issued by the state, give priority to the inclusion of payment by disease type, promote payment according to the value of Chinese medicine efficacy, and implement the same effect and price
of Chinese and Western medicine.
Encourage cities (states) to explore pilot
payment methods such as payment for the dominant diseases of traditional Chinese medicine and other types of diseases.
Traditional Chinese medicine medical institutions may temporarily not implement payment by disease diagnosis related group (DRG), and appropriately increase the coefficient and score of traditional Chinese medicine medical institutions and traditional Chinese medicine diseases in areas that have implemented DRG and pay by disease score, fully reflecting the characteristics and advantages
of traditional Chinese medicine services.
Selection of rehabilitation medical treatment, hospice care and other diseases that require long-term hospitalization and have a relatively stable average daily cost of traditional Chinese medicine are paid
by bed.
Promptly include the list of disease types in day wards formulated by the state into the payment of diseases, and reasonably determine the payment standards
.
In principle, payment by disease, bed-day payment, and item-based payment can be converted into points according to the price comparison relationship and included in the DRG/DIP payment range, further improving the policy system
of unified medical insurance payment.
Establish and improve incentive mechanisms to support reform and innovation, and encourage cities (states) to actively explore and carry out the reform
of traditional Chinese medicine medical insurance payment methods.

 

(14) Establish an incentive mechanism for
the clinical application of traditional Chinese medicine.
Strengthen the assessment of designated medical institutions in traditional Chinese medicine, and in the work of DRG/DIP payment and clearing, implement the incentive mechanism linking the diagnosis and treatment rate of traditional Chinese medicine medical institutions (hereinafter referred to as the treatment rate) with the payment of medical insurance, effectively promote the clinical application of traditional Chinese medicine services, reflect the value of traditional Chinese medicine, and promote the benign development
of traditional Chinese medicine medical institutions.
The treatment rate refers to the sum of the four incomes of inpatient Chinese medicine tablets, traditional Chinese medicine medical service items, proprietary Chinese medicines, and traditional Chinese medicine preparations in medical institutions accounted for the proportion
of inpatient medical income.

 

(15) Support primary medical institutions in providing traditional Chinese medicine services
.
Encourage designated TCM medical institutions to undertake the diagnosis and treatment of chronic diseases in medical insurance outpatient clinics within the scope of their diagnosis and treatment, and give full play to the role
of traditional Chinese medicine in the prevention and treatment of chronic diseases.
Carry out pay-per-person payment in eligible primary medical and health institutions, encourage family doctors to provide traditional Chinese medicine services, and encourage traditional Chinese medicine doctors and qualified traditional Chinese medicine clinics to form teams to carry out family doctor contract services
.
The medical insurance department strengthens the management of agreements, improves settlement methods, strengthens performance evaluation, improves the incentive policy for balance retention, and encourages and guides grass-roots medical and health institutions to provide appropriate traditional Chinese medicine services
.

 

(16) Promote the construction
of a close-knit medical association.
Support the construction of a close-knit medical consortium led by traditional Chinese medicine medical institutions, implement the payment policy of total payment, strengthen supervision and assessment, balance retention, and reasonable overexpenditure, promote the sinking of high-quality traditional Chinese medicine medical resources to grass-roots medical and health institutions, and improve the service capacity
of grass-roots traditional Chinese medicine.

 

(17) Give play to the role
of traditional Chinese medicine in the protection of outpatient mutual assistance.
Establish and improve the basic medical insurance outpatient mutual assistance guarantee mechanism, and expand the scope of protection of
the basic medical insurance pooling fund.
Include outpatient medical expenses (including TCM diagnosis and treatment items, Chinese medicine tablets, ethnic medicines and Chinese medicine preparations, etc.
) that meet the requirements of the medical security policy into the scope of payment of the pooled fund; The medical expenses of traditional Chinese medicine incurred by insured persons in designated medical institutions that should be borne by individuals shall be included in the scope of payment of the personal accounts of the basic medical insurance of employees, so as to reduce the burden of medical expenses on the use of traditional Chinese medicine by
the masses.

 

V.
Strengthen fund supervision

 

(18) Strengthen routine supervision and management
.
Improve the normal daily supervision mechanism, adhere to the in-depth promotion of special governance to combat fraud and insurance fraud, combine daily supervision and provincial-level flight inspection, and strengthen the management
of medical insurance fund expenditure of designated medical institutions of traditional Chinese medicine.
Focus on investigating and handling the false diagnosis and treatment of designated medical institutions of traditional Chinese medicine, with the direction of preventing fictitious medical service projects, set charges, and excessive medical treatment, strengthen the supervision of the illegal use of medical insurance funds by designated medical institutions of traditional Chinese medicine, promote the implementation of the main responsibility of designated traditional Chinese medicine institutions in the use of funds, rationally use medical insurance funds, and standardize the behavior of
traditional Chinese medicine diagnosis and treatment services.

 

(19) Improve intelligent monitoring systems
.
Continue to promote the construction of an intelligent monitoring system for medical insurance, establish and improve the intelligent monitoring knowledge base, rule base, and big data model
in view of the characteristics of the traditional Chinese medicine industry and the illegal use of medical insurance funds by designated medical institutions of traditional Chinese medicine.

 

(20) Complete comprehensive supervision systems
.
Establish and improve a comprehensive supervision system
in which the medical insurance department and the competent department of traditional Chinese medicine cooperate with each other and coordinate supervision.
Strengthen information sharing and interconnection, promote the coordinated use of regulatory results, improve the system of joint departmental meetings, establish joint working mechanisms, carry out joint inspections, strengthen the effectiveness of comprehensive supervision, and strictly investigate and deal with violations of laws and crimes
by all kinds of designated traditional Chinese medicine institutions in accordance with the law 。 Local medical insurance departments and departments in charge of traditional Chinese medicine should attach great importance to it, unify their thinking, strengthen organizational leadership, further clarify their tasks and responsibilities, and refine their work measures; It is necessary to do a good job in departmental coordination, improve the working mechanisms such as departmental linkage, coordinated supervision, and regular consultations, and coordinate and promote relevant measures for medical insurance to support the inheritance and innovation and development of traditional Chinese medicine; It is necessary to give full play to the role of traditional Chinese medicine medical institutions in the management of medical insurance payment, timely include relevant experts such as traditional Chinese medicine in the medical insurance expert database, and improve the expert decision-making consultation system
.
If the policy prior to the release of this document is inconsistent with this opinion, this opinion shall prevail
.
Major problems encountered in the implementation of the implementation of various localities should be promptly reported to the Provincial Medical Insurance Bureau and the Provincial Administration
of Traditional Chinese Medicine in accordance with the scope of their duties and functions.