Shanghai Implements Fixed-Amount Reimbursement Model for 11th NVBP Drugs – Patients Bear Excess Costs Above Winning Prices

The Shanghai Municipal Healthcare Security Bureau issued the “Notice on Optimizing Payment Coordination for the 11th National Volume-Based Procurement (NVBP) Drugs”, effective May 1, 2026. The policy implements a “fixed-amount reimbursement” model that caps insurance coverage at NVBP winning prices, with patients responsible for any excess costs.

Policy Framework & Reimbursement Structure

Key Policy Components

Fixed-Amount Reimbursement Model

• Generic Name Basis: Reimbursement standards determined by generic name (including formulation)
• NVBP Price Cap: Winning NVBP prices serve as reimbursement ceiling
• Patient Financial Responsibility: Excess costs above winning prices borne entirely by patients
• OOP Classification: Excess amounts counted toward patient’s out-of-pocket category

Five Indication-Based Volume Procurement Drugs

The following drugs receive special treatment with enhanced patient cost-sharing:

1. Olaparib oral solid dosage form
2. Dapagliflozin oral solid dosage form
3. Avatrombopag maleate oral solid dosage form
4. Eltrombopag olamine oral solid dosage form
5. Nintedanib esylate oral solid dosage form

For these drugs, non-winning “high-priced” versions trigger 20-30% higher OOP ratios depending on drug classification.

Institutional Incentives & Procurement Guidelines

• Price Adjustment Encouragement: Non-winning manufacturers urged to align prices with similar products
• Procurement Priority: Medical institutions encouraged to prioritize drugs priced at or below reimbursement standard
• DRG/DIP Savings Retention: Rational drug use savings retained as institutional incentives upon settlement
• Primary Care Flexibility: Primary facilities supported in stocking non-winning drugs based on clinical needs
• No Ratio Requirements: No procurement ratio mandates for non-winning drugs in primary care for NVBP-targeted varieties

Enhanced Primary Care Access

• Class B Drug Reimbursement: Class B drugs reimbursed using Class A rules in primary care settings
• Full Coverage Below Standard: Costs under reimbursement standard fully covered with no patient OOP
• Medication Access Assurance: Policy ensures continued patient access to necessary medications

Market Impact & Stakeholder Implications

Pharmaceutical Manufacturers

Winning Companies:

• Guaranteed market access with full insurance coverage
• Competitive advantage through price-based reimbursement structure

Non-Winning Companies:

• Significant pricing pressure to match or approach NVBP winning prices
• Risk of market share erosion unless price adjustments are implemented
• Potential need to restructure commercial strategies for Shanghai market

Healthcare Providers

Hospitals & Clinics:

• Financial incentives to select cost-effective NVBP drugs
• DRG/DIP savings retention creates direct economic benefit from rational prescribing
• Reduced administrative burden through simplified reimbursement calculations

Primary Care Facilities:

• Enhanced flexibility in drug selection while maintaining patient affordability
• Improved ability to meet diverse clinical needs without compromising access

Patients & Payers

Patient Impact:

• Clear cost transparency with predictable OOP expenses
• Potential financial burden for choosing non-NVBP drugs without clinical justification
• Maintained access to necessary medications through primary care provisions

Insurance Fund Benefits:

• Predictable expenditure control through fixed reimbursement ceilings
• Reduced overall drug spending while maintaining therapeutic outcomes
• Alignment with national cost-containment objectives

Strategic Significance for China’s Healthcare Reform

This Shanghai policy represents a critical evolution in China’s volume-based procurement implementation, moving beyond simple price competition to comprehensive payment coordination. The fixed-amount reimbursement model creates powerful market signals that reinforce NVBP objectives while maintaining patient access through carefully designed safety nets.

The policy demonstrates Shanghai’s role as a pioneer in healthcare payment reform, potentially serving as a template for other provinces implementing similar NVBP coordination measures.

Forward‑Looking Statements
This brief contains forward-looking statements regarding policy implementation, market impacts, and stakeholder responses. Actual outcomes may vary based on execution effectiveness, stakeholder adaptation, competitive dynamics, and evolving regulatory frameworks.-Fineline Info & Tech