药品不同准入价格对医保基金及个人可负担性的影响——以部分抗肿瘤靶向药物为例

目的:分析抗肿瘤靶向药物不同准入价格下,武汉市新农合基金和个人的可负担性,为制定医保准入价格提供依据。方法:选择肺癌靶向药物凯美纳和乳癌靶向药物赫赛汀,分析2012—2014年武汉市新农合数据、湖北省2011—2015年肿瘤监测数据;咨询临床专家形成专家共识价,参考江苏省准入价及国家谈判价,探讨不同价格下,两药医保准入后武汉市新农合基金结余情况及个人的可负担性。结果:凯美纳以国家谈判价准入后,2016—2018年武汉市新农合基本账户结余分别为-1 194.8万元、251.3万元和8 295.5万元。赫赛汀以国家谈判价医保准入后,2016—2018年基本账户结余分别为-2 690.1万元、-3 596.2万元和1 754.2万元。凯美纳和赫赛汀以国家谈判价准入前后致贫率分别由45.85%和46.00%下降到33.40%和45.42%。结论:两药以国家谈判价医保准入后武汉市新农合基金基本可负担,赫赛汀在此价格下个人可负担性较差。

Drugs administration and individual affordability under different medical insurance entry price: Example of Anti-tumor Targeted Medicare Drugs

Objective:To analyze the New Cooperative Medical System (NCMS) funds and Individual affordability of anti-tumor targeted drugs under different medical insurance entry price, and to provide the basis for establishing the access price for medical insurance. Methods:Choosing Conmana or Kemer (the lung cancer targeted drug) and Herceptin (breast cancer targeted drug) to analyze the Wuhan NRCMS operating status from 2012 to 2014, use tumor surveillance data from Hubei Province during the period from 2011 to 2015; consult clinical experts to form expert consensus price, refer to the Jiangsu Province Access Price and National Negotiation Price, and explore the fund balance and individual affordability when the afore-mentioned two kinds of drugs can be compensated by medical insurance under different price. Results:The basic account balances of NRCMS in Wuhan from 2016 to 2018 are-11.948 million Yuan, 2.513 million Yuan and 82.955 million Yuan when Kemer can be compensated by medical insurance under National Negotiation Price. Taking the compensation of Herceptin under National Price after the bargaining, the basic account balances are-26.901 million Yuan,-35.962 million Yuan and 17.542 million Yuan respectively. The rate of poverty caused by illness falls to 33.40% from 45.85% when Conmana can be compensated by Medical Insurance under National Negotiation Price, while this rate falls to 45.42% from 46.00% for Herceptin. Conclusion:The two kinds of drugs can be afforded by the Wuhan NRCMS after the medical insurance access price is negotiated by the government, but the individual affordability of Herceptin at the National Negotiation Price is worse.