In the long run, the separation of Chinese medicine will be the general trend, the retail channel prescription drug share continued to improve, which will lead to China's PBM layout focus gradually shifted to retail channels. In addition, with the domestic PBM industry chain pharmacies and the increase of maturity and the mutual effect of the show, such as CVS and Caremark merged to form the "+PBM pharmacy" giants, PBM and chain pharmacies mutual penetration, and through the possibility of equity cooperation business integration is rising
What is PBM
There was such an event, in the United States, a patient who was diagnosed with diabetes, the hospital for the prescribed price to $10 thousand, but this time a terminal in the diagnosis and treatment history database are found in low cost but effective drugs, after the replacement of total drug price will be reduced to $5 thousand, will immediately pop prompt modify the prescription, so the patient, insurance companies have saved $5 thousand of expenses. You know, in China, medicine and medicine are difficult to separate. When will such a thing happen in China? What institutions are so humane?
Yes, this is PBM, in the salary levels of medical insurance to commercial insurance, the vast majority of medical expenses shall be borne by the third party insurance company, gradually derived from the medical cost management professional organization PBM (Pharmacy Benefit Management). What is its function? Simply saying, "medicine" and "medicine" are separated so as to make the medical process more transparent. The core value of the PBM business model is to reduce health care costs, control the growth of medical costs, and save the payment of funds.
PBM operates primarily in integrated health care systems (such as Kaiser or VA), some retail pharmacies (such as CVS pharmacies or Rite-Aid), and some insurance companies (such as joint health group). As of 2016, PBM had helped 266 million Americans benefit from medical benefits. Although there are fewer than 30 companies, the three major PBM companies account for 78% of the market and cover 180 million americans.
In 2015, the top five U.S. PBM company and its major financial data such as below: (the amount of millions) top three pharmaceutical benefits management of the parent company were Silvis CVS Health health and fast prescription Expresss and United Health Group UnitedHealth Group
Silvis health CVS Health
Silvis CVS Health health group, was founded by Stanley, Sidney, Ralph three people in 1963 in Lowell, Massachusetts, engaged in health and beauty care products sales in the convenience store CVS, now headquartered in the U.S. state of Rhode Island woonsocket. The group now consists of four departments, respectively (CVS/pharmacy CVS, CVS/caremark (Pharmacy) CVS health CVS/specialty (CVS mark), and CVS/minuteclinic (Professional) CVS fast in clinic, CVS pharmacy).
The main business of the group is divided into two categories, namely retail pharmacies and drug business benefits management business PBM; CVS/pharmacy is the world's largest pharmaceutical retailer, with more than 7800 retail stores in 42 states, with more than 40 years working experience in retail pharmacy industry; CVS/ Caremark is the leading global pharmaceutical benefits management company (PBM), with more than 65 million members, fiscal year 2015 revenues of more than $100 billion, the year the group revenue reached $153 billion 290 million.
CVS Health ranked thirty-fifth in the global fortune list, ranking tenth in the fortune 500.
Quick prescription Expresss
Express scripts holding company Express s from Medicare Glaser chain pharmacies and health systems company Sanus1986 incorporated, headquartered in Missouri, Saint Louis, mainly engaged in all aspects of the comprehensive medical benefits management services, is the world's largest independent drug benefits management (PBM) company, with nearly 75 million in the United States and Canada signed an exclusive membership. ESI group in fiscal year 2015 revenues of more than $101 billion 750 million, but also the 2013 annual U.S. Fortune 100 twentieth.
United Health Group UnitedHealth Group
United Health Group UnitedHealth Group was founded in 1974 and is headquartered in Minnetonka, Minnesota, USA. United Health Group is mainly divided into United, Healthcare and Optum two business segments. UnitedHealthcare is the company's health insurance business, insurance and Optum as extension, mainly by the health management company (Optum Health), the health information technology services company (OptumInsight) and pharmaceutical benefits management company (OptumRX) three subsidiaries.
PBM developments in China
Since the PBM industry has developed so well in the United States, is there any possibility in China?
In the United States, hospitals have only the right to treat and diagnose, and do not have the right to sell drugs. The separation of medicines provides the prerequisite for the development of PBM.
However, China is dominated by public hospitals, while public hospitals are temporarily unable to change the status of medical care. In addition, the medical insurance system is dominated by the state health care system, and no private enterprises attach importance to the cost control. However, as the government continues to make significant breakthroughs in structural reforms in the supply side of the health care system, we can foresee that PBM will also play an irreplaceable role in China's national health care system in the not too distant future.
Solve the excessive consumption of health insurance fund chaos:
National insurance fund tight, on the one hand, the expansion of the number of insured, on the other hand, in its own funds management problems, resulting in annual about 20% of the funds are wasted." According to an expert in China, according to the current size of 1 trillion and 300 billion yuan of funds, the amount of money wasted each year is about 2000-3000 yuan.
The industry generally believes that the health insurance fund has been wasted from three main sources:
The first is the hospital pianbao phenomenon. The current medical insurance system is not perfect, the regulation of doctors' behavior is poor, and payment methods are difficult to play a normative role, and the number of regulators can not keep up with the expansion of medical insurance objects.
At the same time, the interests of hospitals and medical insurance agencies in two different hedging phenomenon to management, resulting in potentially fraudulent phenomenon, such as excessive medical treatment, the hospital let doctor of patients with prescription drug overdose, unreasonable examination, in order to cheat the health insurance fund, which is also one of the reasons of doctor-patient contradiction expanding.
The second is the potentially fraudulent behavior of the insured. If the insured medical insurance to the drugstore to buy medicine, pharmacy for self serving, prescription drugs on the invoice for the customer, and the actual sale is health care products or patients with shampoo, prescription and pharmacy purchased invoices for Medicare reimbursement, this behavior has been very common in china.
Third of the medical institutions and the insured "conspiracy" pianbao. Such as the "nominal hospital", the insured is not hospitalized, the hospital inpatient medical records, made a series of false false treatment project of treatment, and to apply for reimbursement of medical insurance department, the benefit from.
It is precisely because of these "pit father" phenomenon, China's insurance companies for health insurance once "flinch"". An executive Chinese Paul said, at present the basic health insurance and property insurance bundling, separate commercial health insurance can not be implemented, mainly in the insurance company did not understand how the various segments of disease control costs, how to prevent the occurrence of potentially fraudulent phenomenon. "Since the central development of commercial health insurance's mood is very urgent, we are going to try to throw off the arm. But the premise of the attempt is to introduce PBM business, otherwise it is easy to be pit." The executives said.
The so-called PBM business, that is, the medical welfare management business, helps to solve the problem of commercial health insurance control fees.
According to the current situation of China's medical system, the introduction of PBM and the combination of medical and electronic commerce mainly play a two role in domestic commercial insurance:
The first is to improve the risk management ability of commercial health insurance. China's commercial health insurance fraud losses accounted for about 10% of the total health insurance premium, through the introduction of PBM business, the mature electronic information platform based on the establishment of the corresponding commercial insurance drug reimbursement list, can provide cost control scheme for insurance companies, including claims management, insured registration, greatly improve the the ability to control risk.
The second is to improve the profitability of insurance companies. The insurance company for a long time and hospital not close cooperation, incidence, medical expenses and other information of some major diseases, insurance companies have no access, making the insurance premium therefore the lack of scientific basis, to ensure the profitability of health insurance products. After the introduction of PBM into commercial insurance, PBM mature medical e-commerce management system can be used to centrally manage the insured's medical information and reduce the cost of commercial insurance payment.
American PBM drug welfare management model for China's reference
(I) pilot of PBM drug welfare management model in China;
The national health reform plan and the reform practice of medical insurance payment in various parts of the country have begun to draw on the experience of PBM. Ping An insurance plan for triple play ("three" refers to the drug safety net, medical network and information network) to build a healthy industry chain, through insurance and medical health industry channel, the future will form a competitive advantage of service entity integration internet medical services and B2B2C and the line, has formed the embryonic form - PBM mode use their vast network the development of information insured the sale of drugs and other new business, and optimize their own health insurance business.
(II) the main problems faced by domestic pilot PBM
In the construction of PBM mode in China need to pay attention to the two countries there are significant differences between the two extremes of the main reasons of the differences in the market of medical insurance and national health insurance, the United States is highly market-oriented health care model, all kinds of commercial insurance coverage is low but high level supervision and high efficiency; China is the national basic medical insurance system under the low level, wide coverage, high waste, low efficiency of supervision. In addition, China's medicine is at an exploratory stage, and the "medical support and medical treatment" has not been fundamentally solved from the system