Model Analysis on Budget Impact and Patients’ Burden of National Price-Negotiated Drugs and Different Reimbursement Payment Modes in China: Hyperkalemia As an Example

OBJECTIVES: To assess the budget impact on basic medical insurance funds and the financial burden on patients associated with different insurance payment models for the hyperkalemia treatment sodium zirconium cyclosilicate (SZC). The findings will serve as a reference for the stock of national price-negotiated drugs in China.

METHODS: From a payer perspective, a measurement model was constructed to predict the budget impact and financial burden over the subsequent three years, using 2023 as the reference year. Three key scenarios were considered, including general outpatient policy, outpatient chronic and special critical disease payment policy, and special reimbursement policy under dual-channel management. Policy documents and drug prices were from the official website. Epidemiological data were obtained from academic databases.

RESULTS: For SZC, the expenditure of basic medical insurance was highest (319.53 million yuan, 379.00 million yuan, 436.21 million yuan) when incorporated into special reimbursement policy under dual-channel management, however, this management resulted in the least financial burden on patients. Taking 2024 as an example, the out-of-pocket expenses after reimbursement in three different scenarios were 580.53 yuan, 405.04 yuan and 395.73 yuan among resident patients. For employee patients, the out-of-pocket expenses were 634.29 yuan, 325.80 yuan and 390.36 yuan. Sensitivity analysis showed that results were influenced by the proportion of dialysis patients with at least one attack annually, the payment limit for resident patients with general outpatient treatment, and the reimbursement thresholds for residents under the dual-channel management and the outpatient chronic and special critical disease policy.

CONCLUSIONS: The budget impact of SZC on medical insurance funds and the financial burden on patients with hyperkalemia varies from three different payment models in China. It’s suggested that SZC could be included in the special reimbursement under the dual-channel management for the financial burden on patients and drug accessibility.