Strong sanctions, to expel drugs through re-evaluation

The HIRA’s External Research Service, Seoul National University Public Health Medical Center

It was suggested that strong sanctions to ban prescriptions as a way to expel drugs that have not been proven safe and effective through re-evaluation of benefits.

 

It is necessary to take effective administrative measures beyond the preparation of a plan for drug withdrawal by the Minister of Health and Welfare, based on the National Health Insurance Act.

 

This opinion was presented through the 'Research plan to improve the re-evaluation of preliminary benefits (Researcher Kwon Yong-jin, Seoul National University Public Health and Medical Center)', which was conducted as an external research service for the Health Insurance Review and Assessment Service.

 

Currently, the withdrawal of drugs is possible through the disposition of the Minister of Health and Welfare's reimbursed list deletion based on Article 13 of the Rules on National Health Insurance Benefits Standards.

 

However, the research team pointed out that, in the case of reimbursed list deletion, it is not a strong sanction means because the medical institution can arbitrarily delete the benefit of the benefit to the patient as non-reimbursement.

 

As a result, it was said that for effective administrative measures, it could be considered to indirectly impose prohibition obligations through disposition of unfair profit or disposition of business suspension to medical institutions that is acting as an evacuation plan.

 

However, according to Article 12 of the Medical Act, the implementation of medical technology by medical personnel cannot be interfered with unless there is a restriction by law.

 

He added that there should be clear regulations as a law to impose prohibition obligations on medical personnel or medical institutions while devising plan after reevaluating benefits.

 

Meanwhile, this study was conducted to prepare a plan to improve laws related to the preliminary benefit policy included in the health insurance coverage expansion policy (Moon Jae-in Care) announced by the government in August 2017.

 

The Positive list system is a policy that aims to put the targets that appear to be close to non-payment rather than cost-effectively into the framework of the reimbursement first, if the provisions are to be differentiated before the change of wages for a specific item.

 

In the case of the screening benefit, the ratio of copayment is 50%, 80%, but in the preliminary benefit, the ratio is further subdivided into 50%, 80%, and 90%, and drugs are included.

 

In the case of drugs, clinical usefulness (therapeutic effectiveness), cost effectiveness, replaceability, and social needs were comprehensively evaluated to determine the application rate and self-pay rate.

 

The research team said, "The basic purpose of re-evaluating Preliminary Reimbursement is to determine whether the reimbursement standards are met or not satisfied, and to determine the maintenance of reimbursement, preliminary reimbursement, and the suspension of benefits.

 

And it can be used as a basis for price renegotiation to minimize the impact on insurance finance."