China’s latest version of the National Medical Insurance Drug List was updated not long ago, and scenes of "soul bargaining" reappeared during medical insurance negotiations.

A rare disease treatment drug priced at 700,000 yuan per injection slashed to 33,000 yuan per injection, a diabetes treatment drug dropped from 15 yuan per tablet to 5.39 yuan per tablet… Behind these instances of "soul bargaining" lies the true practice of the principle of "people first, life first."

What untold stories are behind the scenes of medical insurance negotiations? What mysteries lie behind the success of "soul bargaining?" In an episode of CCTV's program "Speak Out," Liu Guoen, one of the participants in the national medical insurance negotiation process and director of the Peking University Institute for Global Health and Development, shares the stories behind these negotiations.

1)   How is the bottom price in medical insurance negotiations' "mysterious envelope" calculated?

In the program, Liu Guoen mentioned that every "soul bargaining" has a scientific basis to ensure better drugs are included in national medical insurance, alleviate people's financial burdens, and allow enterprises to obtain reasonable returns. Three expert groups are involved:

The first expert group is the clinical group. They assess the clinical necessity of drugs by updating and adjusting the directory.

The second expert group is the economics group, which Liu Guoen is a part of. They are responsible for evaluating how much cost is incurred and how much health benefit can be obtained when patients use the drugs.

The third expert group is the Medical Insurance Fund Estimation Group. They are responsible for calculating whether there is enough money to pay once a drug is included in the medical insurance drug list.

After integrating the recommended prices calculated by these three expert groups, relevant regulatory departments review them. Only then does the "bottom price" written in the envelope opened by negotiators at the scene take shape.

2)   A participant shares her "magical" experience participating in calculating the medical insurance fund.

A participant shared that one day, she received a call from an unknown number, claiming to be from the National Medical Insurance Administration. The other end informed her that she had been selected to participate in medical insurance negotiations and instructed her to buy tickets to a designated location. "My first reaction at the time was that I was being scammed."

After understanding the situation, she arrived at the designated location and was taken by bus to a remote hotel, where she began her calculation work for half a month.

Participant: There were no other guests in the hotel, only four or five staff members. I stayed for 15 days, spending each day from morning till night alone in the room, unable to communicate with anyone from the outside world.

She recalled that although she had received formal documents from the relevant department before deciding to participate in the medical insurance negotiations, the entire experience still seemed a bit "magical."

This is because of the absolute confidentiality nature of the national medical insurance negotiation work. The staff member mentioned that the national medical insurance negotiation is a major event that attracts nationwide attention every year. Relevant departments ensure maximum protection for their calculation work from outside interference.

3)   Is a life-saving drug priced at 33,000 yuan per injection worth it? What is the significance of medical insurance negotiations?

Using the example of the 2021 medical insurance negotiations, Liu Guoen explained that a drug called Nusinersen, used to treat the rare disease spinal muscular atrophy, was slashed from 700,000 yuan per injection to 33,000 yuan per injection.

Liu Guoen mentioned that this might be the case with the largest single drug price reduction. It was not decided arbitrarily because of the involvement of the three expert groups mentioned earlier. From an economic perspective, is a drug priced at 33,000 yuan per injection worth it?

He stated that many children suffering from this disease face high medical expenses, and the chances of these children being able to stand up or even survive to school age are not high.

Liu Guoen: In pharmacoeconomics, there's an unwritten standard referenced by most countries, set by the World Health Organization. When a new medical technology is applied to patients, if it can increase one year of quality life expectancy rather than being in a vegetative state, and the cost of medical technology, treatment, or drugs does not exceed three times the country's per capita GDP, then the World Health Organization considers it a medical technology worth purchasing and paying for.

Liu Guoen mentioned that one vial of Nusinersen costs around 33,000 yuan. Six vials are required for the first year, amounting to nearly 200,000 yuan in expenses. This already exceeds the current per capita income in China. When experts recommend prices, they have already considered that this is a rare disease and have considered the care of children, thus raising the payment standard significantly.

"In this sense, I want to express special thanks to the experts behind the 'envelope.' The price they proposed may seem like a 'soul bargaining' at first glance but based on China's current real payment ability and the care given to children with rare diseases, it still has a scientific basis and is a reliable recommendation standard."

(Interpreted by Waverly Shi)