Social security internal medicine and social security surgery

When introducing medical insurance, brokers often mention several concepts to customers, such as class A, B and C drugs, social security drugs for external use, and purchased drugs. Today, I will focus on explaining these concepts.

Class A drugs: drugs that are necessary for clinical treatment, widely used, with definite curative effect and lower price among similar drugs. Social Security Directory 100% reimbursement.

Class B drugs: drugs that are available for clinical use and have definite curative effect, and the price of similar drugs is slightly higher than that of "Class A drugs". Reimbursement in a certain proportion in the social security catalogue.

Class C drugs: valuable drugs that are not necessary for clinical treatment. Outside the social security catalogue, it is basically not reimbursed, and millions of medical insurance can be reimbursed.

Purchased drugs: drugs purchased by patients in pharmacies outside the hospital with prescriptions after being prescribed by doctors, and social security and millions of medical insurance cannot be reimbursed.

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Social security external medicine

According to the above, the drugs used in social security are Class A drugs and Class B drugs. The National Catalogue of Drugs for Basic Medical Insurance, Work Injury Insurance and Maternity Insurance (2020) shows that the total number of drugs in the catalogue is 2,800.

Social security drugs for external use can be simply understood as class C drugs. According to the data of the State Administration of Pharmaceutical Products, there are 3903 kinds of domestic drugs 15005 1 species and imported drugs, totaling 153954 species.

That is to say, Class A and Class B drugs that can be reimbursed by social security account for 1.000% of drugs outside social security, and Class C drugs that are self-funded account for more than 98%. From the perspective of drug costs alone, the scope of social security reimbursement is very limited.

Therefore, those who still feel that social security is enough should pay attention: at present, there are hundreds of millions of people participating in the insurance, but there are still few examples of easily raising money in the circle of friends? Don't they have social security? Yes, but the national social security has only achieved "wide coverage" and "low security", so commercial insurance that can reimburse social security drugs for external use is the real guarantee for large medical expenses.

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Drugs purchased

So can all drugs that enter the social security catalogue be reimbursed? The result is also negative. There are mainly the following two situations.

First, the scope of payment for some drugs is limited.

The medical insurance catalogue downloaded by the National Medical Insurance Bureau shows that in addition to the classification of drugs, there is also a column of "Remarks", and some drugs can only be reimbursed by social security if they meet the requirements.

For example, human albumin in class B drugs is widely used in clinic. It can be used for shock, edema and liver cirrhosis caused by various reasons, as well as the auxiliary treatment of cardiopulmonary bypass, burns and hemodialysis, or to enhance the immunity and resistance of patients. However, it is stipulated in the social security that "only patients with hydrothorax and ascites caused by rescue, serious illness or liver cirrhosis or cancer and albumin below 30g/L" can use human blood protein for reimbursement, and the rest need to be reimbursed at their own expense.

There are also expensive anti-tumor drugs, and the remarks are more harsh. For example, for the treatment of liver cancer, the remarks clarify the treatment method of patients, "limited to patients with unresectable liver cancer who have not received systematic treatment before"; Patients who have received systematic treatment can only pay for themselves.

Lenvartinib costs more than 600 thousand a year.

Two, because of "the proportion of drugs", "medical insurance control fees", "medical insurance centralized procurement" and other reasons, the hospital can not prescribe drugs.

As mentioned earlier, there are hundreds of millions of people insured in China, the problem of aging in China is becoming more and more obvious, and the medical insurance cost is increasing year by year. It is conceivable that the pressure of national medical insurance is great. Medical insurance fee control is bound to be a policy that needs long-term adherence. The medical insurance funds distributed by hospitals are limited, and those who exceed the limit must pay by themselves. In this case, the hospital can only try not to open or even purchase expensive drugs. It is becoming more and more common to prescribe drugs for patients to buy outside the hospital.

Recently, the centralized purchase of medical insurance is also one of the hot spots that everyone pays attention to. After tens of thousands of drugs enter the centralized procurement catalogue, the price can be reduced to several hundred. How did this happen? Because "group buying by the whole people" promises a large number of purchases, it ensures a stable annual purchase and saves the cost of enterprise marketing and promotion. This also means that doctors must give priority to the centralized procurement of drugs in the catalogue when prescribing drugs, otherwise they will not be able to achieve the goal of large annual consumption and continue to purchase next year. Moreover, most of the drugs in the centralized procurement catalogue are generic drugs, because the original research drugs with research and development expenses exceeding several billion dollars cannot achieve such an exaggerated price reduction. But the adaptability of patients to generic drugs varies from person to person.

As can be seen from the above, the medical insurance policy has a great influence on social security reimbursement and millions of medical insurance linked to social security.

Suppose a customer buys millions of medical insurance, what may he face if he gets sick? Take Lao Zhang as an example.

Lao Zhang bought millions of medical services as social security, and asked for the best medicine to see a doctor. However, doctors can only prescribe Class A drugs, because there are restrictions under social security, and doctors should give priority to prescribing drugs in the medical insurance catalogue.

When Lao Zhang renewed his insurance in the second year, he was insured without social security status. He asked for the best medicine when he saw a doctor, but doctors can only prescribe Class A medicine, because doctors should first consider the medicines in the medical insurance catalogue, because of the proportion of medicines, centralized procurement of medical insurance, hospital indicators and other issues.

In the third year, Lao Zhang fell ill again. After eating generic drugs prescribed by the hospital, the effect is average, so I can only study the drugs at my own expense. As a result, the hospital did not purchase at all, because the hospital needed to control costs. Finally, it had to write a prescription for Lao Zhang to buy at the drugstore outside. For Lao Zhang, outsourcing drugs is time-consuming and laborious, and the cost is high. Although he bought millions of medical insurance, he could not reimburse it.

How to solve the problem of drug outsourcing? In fact, high-end medical insurance can reimburse the drugs purchased, and some have added services such as overseas drugs and direct delivery from pharmacies.

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The range of drugs that can be reimbursed by different medical insurance.

We divide the medical insurance in the market into millions of medical care and middle and high-end medical care. In fact, according to the explanation in today's article, these three kinds of medical insurance should be distinguished like this:

Millions of medical care = basic medical care, limited to general departments of public hospitals, covering external use of social security drugs;

Mid-range medical care = special medical care, limited to general departments and special departments of public hospitals, covering social security drugs for external use+purchased drugs;

High-end medical care = international medical care, including public hospitals, private hospitals, your hospital and overseas hospitals, covering social security drugs for external use+purchased drugs+domestic unlisted drugs+new drugs.