德国药品参考价格体系对构建我国医保支付标准的启示

摘要

It is significantly important but difficult to establish healthcare payment standard system in case our country has cancelled government and government guidance prices. In 1989, Germany was the first country to intro-duce the medicine reference price system in Statutory Health Insurance. It does not only aim to regulate the medicine prices, but also defines a reimbursement level for a cluster of products considered to be therapeutically equivalent, and has a good influence on lowering the price of medicine. This paper systematically reviews the medicine reference price system in Germany, including four aspects:the reference price system overview, the reference price groups’ de-termination procedure, the reference prices calculation and the co-payment mechanisms. Based on the Germany refer-ence price system, we can establish healthcare payment standard in over-the-counter or chronic market first, then sci-entifically divide the reference price groups, formulate and adjust payment standard based on the market price, and perfect the co-payment mechanism to avoid moral hazard.%明确医保支付标准制定的程序、依据和方法等规则，是药品最高零售限价放开后价格管理工作的重点和难点。1989年德国率先在其法定医疗保险系统中实施药品参考价格制度，主要目的在于控制药品费用的持续上涨，提高药品价格管理工作的科学性和透明性。本文系统梳理了德国参考价格体系，包括参考价格体系概述、参考价格组划分准则、参考价格形成机制和药品部分负担四方面内容，以期对我国医保支付标准的实施提供借鉴。并指出我国可率先在非处方药市场或慢性病市场中基于参考价格建立医保支付标准，在合理划分参考价格组的基础上，依据市场价格制定和调整医保支付标准，并通过完善部分负担机制来规避患者和医疗机构的道德风险行为，保障医保基金的合理配置。