自费创新药械“进院”再迎利好，国家医保局发文完善“特例单议”

Core Viewpoint - The recent reforms in medical insurance payment methods, particularly the special single negotiation mechanism, aim to support the use of innovative drugs and medical devices, addressing concerns about high costs in medical institutions [1][3][4]. Group 1: Special Single Negotiation Mechanism - The special single negotiation mechanism is designed to provide reasonable compensation for medical services when the costs exceed three times the payment standard [2][4]. - The mechanism will be refined in conjunction with national policies supporting the development of innovative drugs and medical devices, indicating a commitment to support medical institutions in treating complex and critical patients [3][4]. - The number of cases eligible for special single negotiation should not exceed 5% of the total discharged cases under the DRG or DIP payment systems [4]. Group 2: Impact on Innovative Drugs - The reforms are expected to benefit drugs listed in the commercial health insurance innovative drug directory, particularly those with high clinical value and patient benefits [5][6]. - The introduction of the commercial health insurance innovative drug directory is anticipated to provide a framework for local authorities to evaluate and implement the special single negotiation policy effectively [5][7]. - Local governments, such as those in Hainan and Guangzhou, are developing their own innovative drug directories to enhance the support for innovative drugs and medical devices [8][9]. Group 3: Regional Initiatives - Regions with relatively abundant medical insurance funds, like Shanghai and Zhejiang, have already launched local supportive directories for innovative drugs and devices [8][10]. - The Zhejiang Medical Security Bureau has established a list of innovative medical technologies eligible for payment incentives, focusing on drugs that have recently entered the basic medical insurance directory [11][12]. - Shanghai has implemented a strategy to adjust payment standards for cases involving new technologies, allowing for full payment without a control ratio for high-cost cases [12].