Policy Effect of the Medicines Procurement Based on Health Insurance Reimbursement Standards in Fujian Province / 中国药学杂志

OBJECTIVE: To analyze the effects of "adjusting structure and vacating space" of the transparent medicines procurement basing health insurance reimbursement standards, through comparing medicines consumption structure of health insurance designated health facilities of Fujian province. And to generate evidence as well as to propose recommendations for policy improvement and experience promotion. METHODS: Based on the 2016 and 2017 provincial medicines pooled procurement database, adopting the pivot table statistical functions of EXCEL software, the consumption value and value in proportion of Class and Ⅱ chemical products (Fujian provincial medicines procurement list therapeutic classification for chemical products), as well as active pharmaceutical ingredients, consumption value and volume (standardized units in tablet/bottle/vial) of originator and generics were analyzed and compared. The consumption value of Class formulations of traditional Chinese medicines (Fujian provincial medicines procurement list therapeutic classification for formulations of traditional Chinese medicines) was also analyzed and compared. RESULTS: Nearly 2.38 billion yuan procurement budget was saved in 2017 through adjustment of the medicines procurement list in Fujian province. There were a certain changes of the consumption structure of medicines. The procurement value of adjuvant and nutraceutical medicines dramatically reduced. The procurement value of medicines for treatment of chronic diseases like hypertension and cancers significantly increased. The procurement volume of generics started to surpass that of the originator, and showed potential competitiveness of generic substitution. However, the originator still dominated the market of quite a number of medicines. Prices of both generics and originators decreased. CONCLUSION: The effect of “adjusting structure and vacating space” has been demonstrated. Fully implementation of the health insurance reimbursement standards will make the above effect more apparent. To promote effective generic competition, Fujian should set the same health insurance reimbursement standard for originator and its generics (quality and efficacy validated) to promote generics substitution.

Determination of Health Insurance Fee Schedule and Strengthening Policy for Health Insurance Coverage / 대한내과학회지

The resource-based relative value scale (RBRVS) was introduced in Korea as a payment system in 2001. However, the health insurance fee schedule had many problems. Unbalanced insurance fee schedules still occur, and the relative value was not divided between physicians' work and practice expenses. Furthermore, malpractice fees were not included in the total RBRVS. The first refinement project of the health insurance relative value scales was conducted in 2003 and the second project started in 2010. In the first project, final relative values were calculated under budget neutrality by medical departments, and imbalances within the departments were resolved. However, imbalances still existed between departments. In the second project, final relative values were classified and computed by the type of medical treatment. The final RBRVS has been applied step by step since 2017 and the imbalance problem of the insurance fee schedule has been partially resolved. The government recently announced strengthening the plan for health insurance coverage. The current coverage rate for total medical costs by national health insurance is 63%. The purpose of this plan was to increase the coverage rate by up to 70%. The government has suggested detailed plans but there remain many controversial issues and limitations with regard to the practical aspects. Thus, further research and suggestions are needed.

Remuneración a los proveedores de servicios de salud en Bogotá / Payment to providers of health services in Bogotá

RESUMEN Objetivo Revisar los conceptos, desarrollos y efectos de los mecanismos de pago utilizados en diversos países, con el fin de proponer una metodología de pago aplicable para los hospitales de Bogotá. Método Se efectuó una revisión bibliográfica de tres aspectos de interés: conceptos esenciales, desarrollos alcanzados y efectos derivados de los mecanismos de pago utilizados en diversos países. Luego se efectuaron sesiones de trabajo entre los autores y con diversos grupos y equipos de la secretaria de salud de Bogotá, los hospitales, la academia y las autoridades nacionales en salud, para el diseño metodológico de un esquema de pago aplicable a los hospitales de la red adscrita de salud en Bogotá. Resultados La revisión bibliográfica permitió establecer los ejes de trabajo para un esquema de pago prospectivo por red con incentivos de desempeño, basado en optimización de la eficiencia técnica (provisión de servicios de salud a menor costo) y locativa (optimización de la mezcla de los servicios de salud) y en mejores resultados de atención. Discusión El esquema de reconocimiento planteado debe ser un factor integrador del proceso de atención al paciente y redundar en una mejor operación del aseguramiento, la prestación de servicios y la gobernanza de la atención en salud, al tiempo que optimiza el flujo de recursos y la sostenibilidad local del sistema.(AU)

ABSTRACT Objective To review the concepts, developments and effects of the payment mechanisms used in different countries to propose a payment methodology applicable to hospitals in Bogotá. Method Literature review in which essential concepts, developments and effects derived from payment mechanisms used in different countries were analyzed. The authors and various groups and teams of the Bogotá Health Department participated, hospitals, academia and national health authorities held work sessions with the intention of creating a methodological design for a payment scheme that could be applied to the hospitals attached to the health network in Bogotá. Results The literature review allowed establishing work axes for a prospective payment scheme per network that included performance bonuses based on the optimization of technical efficiency (provision of health services at lower cost, locative efficiency (optimization of the mix of health services), and on better care outcomes. Discussion The proposed payment scheme should be an integrating factor in the patient care process, and should also result in a better operation, service delivery and health care governance, while optimizing the flow of resources and local sustainability.(AU)

Prediction for TNF Inhibitor Users in RA Patients According to Reimbursement Criteria Based on DAS28

OBJECTIVE: The purpose of this study is to examine the difference between the numbers of patients in rheumatoid arthritis (RA) who are eligible to TNF inhibitors by the past Korean National Health Insurance reimbursement guideline and by the disease activity score with 28-joint assessment (DAS28) based criteria. METHODS: Data were obtained from a multi-center registry for biologics users in Korean RA patients, BIOlogics Pharmacoepidemiologic StudY (BIOPSY). DAS28 was calculated based on either ESR or CRP, and DAS28 of more than 5.1 or between 3.2 and 5.1 with radiographic changes was defined as a cut-off point for the initiation of TNF inhibitors. For the maintenance criteria, we used both of improving in DAS28 score (>1.2) and low disease activity (DAS 28<3.2). Differences between the numbers in each step by two criteria were described with Chi-square test and Kappa agreement. RESULTS: Of the 489 patients in BIOPSY, 299 were included in this study. Among them, 278 patients (93.0%) were eligible of TNF inhibitors when we applied the new initiation criteria with DAS28-ESR, and 244 patients (81.6%) were indicated for TNF inhibitors with DAS28-CRP. For the maintenance criteria, a low disease activity (DAS28<3.2) in 3 months after starting TNF inhibitors is too strict for achieving (33.6% with DAS28-ESR and 50.0% with DAS28-CRP). Instead, decreasing DAS28 by more than 1.2 is more reasonable as a tool for deciding early responsiveness of TNF inhibitors in RA patients (81.2% both with DAS28-ESR and DAS28-CRP). CONCLUSION: Our results show that the candidates for TNF inhibitors will be enormously changed according to a change in the reimbursement criteria. To define appropriate patients to receive TNF inhibitors, a further study with regard to the impact of changes in the reimbursement criteria on the outcomes of RA patients will be required.

Nutritional therapy in hospital

Globally, the prevalence of malnutrition in hospitals is high. In Korea, a recent national survey in which 28 general hospitals throughout the country participated showed a 22% prevalence of hospital malnutrition. Malnutrition is associated with adverse outcomes including immune suppression, muscle wasting, delayed wound healing, infectious complications, longer hospital stays, high medical costs, and even increased mortality. Early implementation of nutritional therapy might improve medical outcomes. For early recognition of malnutrition and early nutritional intervention, a qualified nutrition support team (NST) is necessary. In Korea, 110 NSTs were at work as of 2013, mostly affiliated with large high-ranking hospitals. Since the activity of an NST and enteral formula are not reimbursed by the National Health Insurance Corporation, the potential for expansion of NSTs to rather small hospitals remains limited. To improve the quality of care for hospitalized patients and reduce medical expenses nationally, it is time to reform the system for alleviating in-hospital malnutrition.

Clinical Characteristics of Korean Rheumatoid Arthritis Patients with Indications for TNF-alpha Blocker

OBJECTIVE: The aim of this study was to examine clinical characteristics of Korean rheumatoid arthritis (RA) patients with clinically indications for TNF-alpha blocker, and to compare their clinical parameters with the Korean National Health Insurance reimbursement criteria. METHODS: Data were obtained from a registry of RA patients who visited rheumatology clinics of Hallym University affiliated hospitals. Among patients who were previously prescribed DMARDs for more than three months, rheumatologists selected patients clinically indicated for TNF-alpha blocker. The clinical characteristics at the time TNF-alpha blocker use was deemed indicated were examined. Radiographic damage was quantified by Modified Sharp van der Heijde score in hand and foot simple AP radiograph. RESULTS: From August 2010 to January 2013, five rheumatologists in four hospitals selected 109 patients clinically indicated for TNF-alpha blocker. When TNF-alpha blocker was considered, mean DAS28 was 5.2 (range 2.1~8.05), mean swollen joint count was 6 (range 0~22), mean tender joint count was 10.6 (range 0~28), mean ESR was 43.2 mm/hr (range 1~140) and mean CRP was 2.5 mg/dL (range 0.1~18.3). The mean total modified Sharp van der Heijde score was 32.72 (range 0~240). Eighty one percent of subjects did not have enough active joints to satisfy the Korean National Health Insurance reimbursement standard. CONCLUSION: Our results show that patients with clinically indications for TNF-alpha blocker had a broad range of disease activity and clinical parameters, and the majority did not meet the Korean National Health Insurance reimbursement criteria.

Comparison Korean National Health Insurance Reimbursement and Other Guidelines for TNF-alpha Blocker in Rheumatoid Arthritis

OBJECTIVE: The aim of this study was to examine how many Korean rheumatoid arthritis (RA) patients fulfilling the 2008 American College of Rheumatology (ACR) recommendation, 2007 British Society for Rheumatology (BSR) guideline and 2010 Japan College of Rheumatology (JCR) guideline for TNF-alpha blocker, meet the Korean National Health Insurance reimbursement criteria and to evaluate the reasons for failing the Korean National Health Insurance reimbursement criteria. METHODS: Data were obtained from a registry of RA patients who visited rheumatology clinics of Hallym university affiliated hospitals. Patients who were previously prescribed with methotrexate or leflunomide for more than 3 months and had at least one DAS28 examination were included in the present study. RESULTS: Of 642 patients included, 118 episodes meeting ACR guideline for using TNF-alpha blocker were identified in 88 patients (13.7%). In addition, 19 episodes meeting BSR guideline in 17 patients (2.6%) and 21 episodes meeting JCR guideline in 21 patients (6.2%) were identified. Four episodes (4.8%) meeting ACR recommendation, 0 episodes meeting BSR criteria and 5 episodes (12%) meeting JCR criteria, respectively, were eligible for TNF-alpha blocker according to the Korean National Health Insurance reimbursement guideline. The most common reason for failing the Korean National Health Insurance reimbursement criteria was the number of active joint counts (92.6%). CONCLUSION: Our results show that the majority of RA patients satisfying the ACR guideline, BSR and JCR guideline for use of the TNF-alpha blocker did not meet the Korean National Health Insurance reimbursement criteria. Patients most often failed due to active joint count criteria.

Satisfaction with High Deductible Policies among Patients with Diabetes in the Korean General/University Hospital System / 임상당뇨병

The Korean government implemented a new policy on October 1st, 2011, requiring that patients with type 2 diabetes in the general or university hospital system pay 40% or 50% rather than 30% of total prescription drug costs. The Diabetes Association of Korea performed a survey regarding satisfaction with the new policy among patients with diabetes from August 24th to September 2nd, 2011. A total of 548 patients participated in the survey through one-to-one interviews. About 90% of patients with diabetes regarded diabetes as a serious disease, while only 4.5% regarded diabetes as a mild disease. The reasons why patients regarded diabetes as a serious disease were risks of developing diabetic complications (64.3%), difficulty of diabetes care (18.0%), and difficulty of cure (15.1%). About 70% of patients felt burdened by the increased prescription drug costs and deductibles, while only 12% did not. Finally, 85% of patients thought that the new policy was unfair to patients with diabetes and about 75% of patients regarded the new policy as inappropriate. In conclusion, the Korean government's new high deductible policy for patients with diabetes in the general/university hospital system should be withdrawn immediately.

Promotion of Commitment of Clinicians in Pharmacovigilance in Japan / 薬剤疫学

Although the two regulatory bodies, Pharmaceutical and Medical Devices Agency (PMDA) and Ministry of Health, Labour & Welfare (MHLW) cooperate in pharmacovigilance in Japan, presence of clinicians in the two bodies is surprisingly limited with only about twenty medical doctors compared more than 300 in CDER/CBER. The lack of doctors in PMDA, resulting from several factors including low social status and hard work, make them to review drugs and devices in which they are not expertised at all. For example, a paediatric cardiologist is obliged to review a drug for overactive bladder because no urologist is available for drug review in PMDA. Such a case would make the reviewer guilty of professional negligence. These critical issues make a PMDA reviewer rather dangerous than unexciting job. On the other hand, most Japanese doctors, heavily dependent on PMDA and pharmaceutical companies for drug information, would not commit in the drug review or pharmacovigilance. To make Japanese doctors more committed in pharmacovigilance, there are several measures to be implemented. First, better benefit, i.e. income, working hours, holidays. Second, escape clause for the reviewers. Third, more doctors to the Office of Safety rather than the Offices of New Drug. People outside PMDA can also contribute to pharmacovigilance with better media literacy and better understanding of PMDA.