肿瘤靶向药物纳入医保支付范围可行性研究

摘要

The drugs for serious disease are expensive and most of them not listed in the medical insurance directory, which has caused a heavy economical burdens on the patients. How to solve the problems is an issue worth studying. By learning the practice of health insurance in Henan Province, we have established a negotiation process for tumor targeting drugs to be included in the list of medical insurance directory, selected representative drugs and diseases, and measured the pressure of paying tumor targeting drugs on medical insurance fund. Then we suggested establishing a sharing cost mechanism by governments, enterprises and individuals; establishing a special drugs negotiation mechanism at provincial level; and building a payment mechanism for special drugs which combines the basic medical insurance and serious illness insurance.%重特大疾病治疗药物价格昂贵，大部分不在医保目录，对患者造成了沉重的医疗费用负担，如何解决患者医疗费用负担是一个值得探索的问题。本文以河南省城镇医保为例，建立了肿瘤靶向药物纳入医保支付谈判流程，选取代表性病种和药物，并对肿瘤靶向药物费用对河南城镇医保基金压力进行测算。提出建议：第一，建立政府、企业和个人分担的特药三方共付机制，合理确定支付比例，防止医保基金穿底；第二，建立以省级为主体的特药谈判机制；第三，建立基本医保和大病保险相结合的特药纳入医保支付机制。