From the perspective of the pharmaceutical industry and relevant stakeholders, this paper will explore the impact of DRG/DIP implementation on the pharmaceutical industry, medical insurance, patients and other relevant stakeholders.
For DRG/DIP impact analysis, the first thing to be clear is its underlying logic or core idea, that is, to use the principles of health economics to measure the optimal cost performance, to drive the behavior of clinical diagnosis and treatment with economic leverage, and to make more people affordable with the most reasonable cost.
I. Impact on the pharmaceutical industry
The broad pharmaceutical industry can be divided into three parts: pharmaceutical industry, pharmaceutical circulation and medical service industry. The impact of DRG on the pharmaceutical industry can be analyzed from the following three parts:
(1) The pharmaceutical industry
The pharmaceutical industry is located in the upstream of the industrial chain and can be divided into seven sub-industries, including chemical raw materials, chemical preparations, Chinese herbal medicines, proprietary Chinese medicines, biological preparations, health materials, and medical devices. The impact on innovative drugs, proprietary Chinese medicines and traditional Chinese medicine injections, generic drugs and medical devices is discussed.
1. Innovative drugs
The diseases included in the scope of DRG are usually common diseases with high morbidity, frequent-onset diseases, and some major diseases, which encourages medical institutions and doctors to tend to use cost-effective market mature products, and doctors may actively or passively give up the use of some innovative drugs, especially in the face of medical insurance users, so the implementation of DRG for most innovative drugs is negative.
2. Proprietary Chinese medicine and traditional Chinese medicine injection
As we all know, TCM and TCM injections have the characteristics of slow onset, uncertain efficacy, relatively expensive price and most of them are adjunct drugs. However, DRG clinical grouping has relatively strict regulations on what drugs should be taken by patients with different hospitalization days and diagnosis results, and the amount of drugs taken, so it is difficult for TCM and TCM injections to meet the requirements of DRG in clinical use.
3. Generic drugs
Under the DRG standard clinical operation, part of the original adjuvant drug share will be released, which is favorable for generic drugs. Meanwhile, in order to control costs, hospitals will prefer to use low-priced generic drugs that have passed the consistency evaluation. However, affected by the VBP policy, according to relevant data, the first three batches of national organization of drug collection 112 drugs, the average drug price fell by 54%, in the case of generic drug unit price decline, even if sales increase, but the overall sales may not rise.
4. Medical devices
DRG may lead to limited diagnosis, increase the cost risk of hospitals to update diagnostic equipment, resulting in hospitals unwilling to update diagnostic equipment, and may choose to entrust some diagnostics to third-party laboratories, which will frustrate hospital sales of medical device companies.
(2) Distribution of medicine
From the perspective of the pharmaceutical circulation industry, it will promote the development of emerging channels such as retail, Internet hospitals, and out-of-hospital markets. Out-of-hospital market development ushered in new opportunities, in order to control medical bills, hospitals may gradually tend to outflow more prescriptions to out-of-hospital pharmacies to reduce hospital medical bills, and hospitals will shorten the average length of hospital stay of a large number of patients, but patients still need to use drugs after discharge, through online prescription review, pharmacist review, logistics distribution, patient recovery or chronic disease drug needs transferred to the outside of the hospital. New channels, such as Internet hospitals and DTP pharmacies, will accept the prescriptions of chronic patients in hospitals to reduce the pressure of hospital medical bills;
DRG standardized clinical pathway may stifles personalized treatment, and the drugs used in personalized treatment such as innovative drugs, adjuvant drugs, nutritional drugs and high-priced products with therapeutic value are often distributed in the out-of-hospital market, and this part of patient demand will be diverted to self-funded pharmacies or DTP, and these out-of-hospital sales products will vigorously develop the out-of-hospital sales system after DRG.
(3) Pharmaceutical service industry
As the policy implementer of the DRG/DIP payment system reform, the change from "pay per project" to "pay per disease" will have a significant impact on the operation and development of hospitals.
From the perspective of the management mode of medical institutions, DRG considers that the hospital can meet the requirements of higher quality of hospitalization service on the premise that the cost is less than the payment amount. The hospital will shift from the original extensive operation, pay attention to revenue growth, and shift the management focus to reducing costs, promote the standardization and standardization of clinical management, and strengthen operation management to achieve cost reduction and efficiency increase.
From the perspective of hospital financial management, under the previous "pay-per-project" mode, most hospitals adopted the expansion strategy mode. Now, under the DRG/DIP payment mode, the part exceeding the medical insurance payment standard will be borne by the hospital. Only by strengthening medical cost control and widening the gap between cost and income can the hospital obtain more balance. High requirements for hospital informatization and data capabilities, no matter DRG or DIP, are essentially big data application tools, and the construction and transformation of hospital informatization is a prerequisite for the implementation of DRG/DIP.
The implementation of DRG is especially good news for social (private hospital) medical institutions. Under the DRG payment mode, hospitals at the same level pay the same price for the same patient, giving social (private hospital) medical institutions a fair opportunity for development in the market environment.
2. Stakeholder impact analysis
From the perspective of relevant stakeholders, it involves the impact on relevant stakeholders such as medical insurance, medical institutions, pharmaceutical companies, and patients (see the above for the impact on medical institutions and pharmaceutical companies, and will not be detailed here).
(1) Impact on medical insurance
Ease the pressure on medical insurance funds. From the experience of foreign implementation, for payers, the implementation of DRG can alleviate the pressure of medical insurance funds to a certain extent, control the growth of medical costs, and facilitate the payment of medical insurance between payers and hospitals by disease type, greatly improving the settlement efficiency. DRG can generate systematic disease data and improve the management efficiency of medical insurance supervision.
(2) The impact on patients
Reduce costs and improve the quality of care. For patients, the implementation of DRG can not only reduce the cost of seeing a doctor, but also promote medical institutions to improve the quality of medical care, hospitals and doctors with the best and most efficient resources to look forward to the disease, and at the same time, the social criticism of "prescription", "general examination" and other problems will be contained; To a certain extent to solve the problem of "difficult to see a doctor". DRG promotes hospitals to optimize diagnosis and treatment plans and shorten the length of hospital stay, thereby increasing the capacity of receiving patients and enabling more patients to enjoy high-quality medical resources. The optimal diagnosis and treatment plan in strict accordance with the clinical path further improves the sense of gain of patients' disease treatment.