In recent years, China's healthcare security authorities have continuously promoted the construction and optimization of a dynamic adjustment mechanism for the medical insurance drug catalog. By including newly approved drugs, adjusting drug coverage, payment standards, and renewing expired agreements for drugs, while simultaneously removing drugs with low clinical value, replaceable alternatives, market withdrawals, or insufficient supply from the catalog, the structure of the drug catalog has gradually been optimized. However, issues such as insufficient standardization and normalization persist in the current drug re-evaluation and dynamic adjustment mechanisms, leading to some drugs with uncertain clinical value or significant discrepancies between real-world efficacy and clinical trial results still benefiting from policy incentives. The re-evaluation process also requires further standardization. This study focuses on optimizing the drug re-evaluation and dynamic adjustment mechanisms in China's medical insurance catalog, systematically analyzing the policy framework and existing challenges for drug re-evaluation among the three departments—medical products administration, health commission, and healthcare security—under the current governance system of coordinated development and regulation of medical insurance, medical services, and pharmaceuticals. By reviewing policy experiences from typical countries such as the UK, Canada, Germany, Japan, and South Korea in medical insurance drug re-evaluation and adjustment mechanisms, the study extracts practical insights for reference. Building on this, the study proposes optimization suggestions for China's medical insurance drug re-evaluation and dynamic adjustment mechanisms based on the national conditions, covering trigger conditions, evaluation processes, assessment criteria, adjustment rules and pathways, as well as appeal and review mechanisms. Additionally, the study integrates China's "Real-World Comprehensive Value Assessment for Medical Insurance" series of initiatives to provide theoretical and practical references for further policy adjustments.
Key words
real-world data /
re-evaluation of drugs /
medical insurance catalog /
dynamic adjustment
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