Page 109 - 《中国药房》2022年5期

·药物经济学·

肺动脉高压纳入门诊特定病/慢性病报销政策的预算影响分析

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刘天怡 ，柳志红 ，刘 君 ，冯 元 ，李幸蓉 ，史睿智 [1.西安杨森制药有限公司市场准入与政府事务部，
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西安 710043；2.中国医学科学院阜外医院呼吸与肺血管疾病诊治中心，北京 100037；3.艾昆纬企业管理咨询
（上海）有限公司卫生经济与真实世界研究部，上海 200041]
中图分类号 R95 文献标志码 A 文章编号 1001-0408（2022）05-0611-06
DOI 10.6039/j.issn.1001-0408.2022.05.17

摘 要 目的 评估将肺动脉高压纳入门诊特定病和门诊慢性病（以下简称“门特门慢”）报销政策对医保基金的预算影响，为医保
报销决策提供参考。方法 从我国医保支付方角度出发，以1 000万人口的城市为例，通过构建预算影响分析模型，计算肺动脉高
压纳入门特门慢报销政策后3年（2021－2023年）对医保基金的影响；测算成本主要包括药品费用、门诊挂号和检查检验费用、住
院费用以及死亡事件费用。结果 2021－2023年每年预计有34～36名肺动脉高压患者使用靶向药物。针对现在门诊无统筹报销
政策的城市，将肺动脉高压纳入门特门慢报销政策后，每年医保基金的增量支出约为40 000元，平均每名患者的支出增加约1 000
元；对于门诊已经有统筹报销政策的城市，将肺动脉高压纳入门特门慢报销政策后，每年医保基金的增量支出约为80 000元，平均
每名患者的支出增加约2 000元；以上费用增量均逐年递减。结论 将肺动脉高压纳入门特门慢报销政策后的医保基金增量支出
可控，且随着门特门慢政策的落地，医保基金的增量支出将逐年缩减。
关键词 肺动脉高压；门诊特定病；门诊慢性病；医保报销；靶向药物；预算影响分析

Budget impact analysis of treatment for pulmonary arterial hypertension included in special and chronic
disease outpatient reimbursement policy
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LIU Tianyi ，LIU Zhihong ，LIU Jun ，FENG Yuan ，LI Hsingjung ，SHI Ruizhi（1. Section of Market Access and
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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

肺动脉高压是一种渐进性肺血管疾病，主要表现为 输出，导致患者出现呼吸困难、胸痛、血氧不足，最终导
[1]
肺动脉压异常升高，右心室需以更大的压力才能将血液 致心力衰竭甚至死亡 。肺动脉高压的患病率约为
15/1 000 000 ，多发于青壮年，我国患者的发病年龄多
[2]
＊硕士。研究方向：市场准入与卫生经济。E-mail：tliu60@its.jnj.
[1]
为 30～40 岁，且常见于女性 。根据《中国肺动脉高压
com
# 通信作者：硕士。研究方向：市场准入与卫生经济。E-mail： 诊断与治疗指南（2021 版）》，肺动脉高压危险分层在中
[1]
rshi4@its.jnj.com 危以上的患者推荐接受靶向药物联合治疗 。国内外也
中国药房 2022年第33卷第5期 China Pharmacy 2022 Vol. 33 No. 5 ·611 ·