肺動脈高壓納入門診特定病/慢性病報銷政策的預(yù)算影響分析

劉天怡 柳志紅 劉君 馮元 李幸蓉 史睿智

中圖分類號 R95 文獻(xiàn)標(biāo)志碼 A 文章編號 1001-0408（2022）05-0611-06

DOI 10.6039/j.issn.1001-0408.2022.05.17

摘 要 目的 評估將肺動脈高壓納入門診特定病和門診慢性病（以下簡稱“門特門慢”）報銷政策對醫(yī)保基金的預(yù)算影響，為醫(yī)保報銷決策提供參考。方法 從我國醫(yī)保支付方角度出發(fā)，以1 000萬人口的城市為例，通過構(gòu)建預(yù)算影響分析模型，計算肺動脈高壓納入門特門慢報銷政策后3年（2021-2023年）對醫(yī)保基金的影響;測算成本主要包括藥品費用、門診掛號和檢查檢驗費用、住院費用以及死亡事件費用。結(jié)果 2021-2023年每年預(yù)計有34～36名肺動脈高壓患者使用靶向藥物。針對現(xiàn)在門診無統(tǒng)籌報銷政策的城市，將肺動脈高壓納入門特門慢報銷政策后，每年醫(yī)保基金的增量支出約為40 000元，平均每名患者的支出增加約1 000元;對于門診已經(jīng)有統(tǒng)籌報銷政策的城市，將肺動脈高壓納入門特門慢報銷政策后，每年醫(yī)保基金的增量支出約為80 000元，平均每名患者的支出增加約2 000元;以上費用增量均逐年遞減。結(jié)論 將肺動脈高壓納入門特門慢報銷政策后的醫(yī)保基金增量支出可控，且隨著門特門慢政策的落地，醫(yī)保基金的增量支出將逐年縮減。

關(guān)鍵詞 肺動脈高壓;門診特定病;門診慢性病;醫(yī)保報銷;靶向藥物;預(yù)算影響分析

Budget impact analysis of treatment for pulmonary arterial hypertension included in special and chronic disease outpatient reimbursement policy

LIU Tianyi1，LIU Zhihong2，LIU Jun3，F(xiàn)ENG Yuan3，LI Hsingjung3，SHI Ruizhi1（1. Section of Market Access and Government Affairs， Xi’an Janssen Pharmaceutical Co.， Ltd.， Xi’an 710043， China; 2. National Center for Respiratory and Pulmonary Vascular Disease Diagnosis and Treatment， Fuwai Hospital， Chinese Academy of Medical Sciences， Beijing 100037， China; 3. Real World Solutions， IQVIA， Shanghai 200041， China）

ABSTRACT? ?OBJECTIVE To evaluate the budget impact on medical insurance fund upon the treatment of pulmonary arterial hypertension （PAH） included in the outpatient special and chronic disease management policy （hereinafter refer to as the Policy）， so as to provide reference for medical insurance reimbursement decision-making. METHODS Based on the perspective of medical insurance payer， a budget impact model with 10 million people was built to calculate the budget impact on the medical insurance fund in the next three years （2021-2023） after PAH treatment included in the Policy. The measured cost mainly included the cost of medicine， outpatient registration， examinations， hospitalizations， and death events.? RESULTS A total of 34-36 patients with PAH per year were expected to use targeted therapy during 2021-2023. For cities with outpatient costs not covered by the pooling fund of basic medical insurance， upon the treatment of PAH included the Policy， the annual expenditure of the medical insurance fund increased by about 40 000 yuan， i.e. an increase of about 1 000 yuan per patient. For cities with outpatient costs covered by the pooling fund， the annual expenditure of the medical insurance fund increased by about 80 000 yuan， which was equal to 2 000 yuan increase per patient. The increment of above cost decreased year by year. CONCLUSIONS The incremental expenditure of the medical insurance fund is controllable after the treatment of PAH included the Policy; with the implementation of the Policy， the incremental expenditure of the medical insurance fund will be reduced year by year.

KEYWORDS? ?pulmonary arterial hypertension; outpatient special disease; outpatient chronic disease; medical insurance reimbursement; targeted drug; budget impact analysis

肺動脈高壓是一種漸進(jìn)性肺血管疾病，主要表現(xiàn)為肺動脈壓異常升高，右心室需以更大的壓力才能將血液輸出，導(dǎo)致患者出現(xiàn)呼吸困難、胸痛、血氧不足，最終導(dǎo)致心力衰竭甚至死亡[1]。……