Bleecker G C
Health Technology Associates, Inc., Washington, DC 20004.
Am J Hosp Pharm. 1993 Jul;50(7 Suppl 3):S27-30.
Problems associated with reimbursement for biotechnology agents and strategies for solving these problems are reviewed. Because of the many different insurers in the U.S. health care system, a variety of reimbursement strategies have been developed for the biotechnology drugs that are now reaching the market. These strategies can vary by insurer, contract, treatment setting, and patient condition. With the advent of high-cost biotechnology drugs, pharmacists have taken on the additional roles of institutional educators and reimbursement specialists. Case studies involving three biotechnology agents illustrate how insurers deal with reimbursement for these drugs. Thrombolytic agents are reimbursed under Medicare, but the diagnosis-related-group (DRG) payment for myocardial infarction was not changed until two years after alteplase was marketed. Septic shock therapies potentially face similar reimbursement problems, which are compounded because the drugs can be lifesaving--leading to longer hospital stays. When filgrastim is administered, the amount reimbursed depends on the treatment setting. When claims for biotechnology agents are denied, the institution or provider should contact the payer to provide the needed information (in the case of missing information) or to discuss payer policies that may need review. Through proper case management, pharmacists and other institutional personnel can ensure reimbursement for these lifesaving biotechnology therapies.
回顾了与生物制剂报销相关的问题及解决这些问题的策略。由于美国医疗保健系统中有众多不同的保险公司，针对目前正在进入市场的生物药物已制定了多种报销策略。这些策略可能因保险公司、合同、治疗环境和患者病情而异。随着高成本生物药物的出现，药剂师承担了机构教育者和报销专家的额外角色。涉及三种生物制剂的案例研究说明了保险公司如何处理这些药物的报销问题。溶栓剂在医疗保险下可报销，但在阿替普酶上市两年后，心肌梗死的诊断相关分组（DRG）支付才发生变化。感染性休克治疗可能面临类似的报销问题，而且由于这些药物可挽救生命，导致住院时间延长，问题更加复杂。使用非格司亭时，报销金额取决于治疗环境。当生物制剂的报销申请被拒绝时，机构或提供者应联系付款人，以提供所需信息（如信息缺失的情况）或讨论可能需要审查的付款人政策。通过适当的病例管理，药剂师和其他机构人员可以确保这些挽救生命的生物疗法能够得到报销。
