以大数据应用提升医保治理能力的探索——基于衢州市的实践

Application of Big Data to Improve the Ability of Medical Insurance Governance

提升医保管理效能和推进医保治理现代化,其必由之路是以信息化为支撑、以大数据分析为决策依据。衢州市医保局成立后,积极构建大数据在医保决策、经办服务、支付机制改革、智能监管等全流程运用体系,取得初步效果。通过部门业务和联办业务智能化,推进公共服务数字化;通过实施DRGs点数法,推进支付精准化;通过建设国家医保智能监控示范点,推进监管智能化;通过形成医疗服务价格改革腾空间方案,推进决策科学化。但通过大数据应用提升医保治理能力任务艰巨,衢州市医保大数据应用仍处在“建基地、夯基础”阶段,既需要顶层明确国家、省、市在信息化建设中的定位,也需要推进医保数据库建设,等等。

To improve the efficiency and modernization of medical insurance management,we must take informatization as the support and big data analysis as the decision-making basis.After the establishment of Quzhou healthcare insurance bureau,it has actively constructed the whole process application system of big data in medical insurance decision-making,handling service,payment mechanism reform,intelligent supervision,and achieved preliminary results.The achievements include promoting the digitalization of public services through the intellectualization of department business and joint business,promoting the accuracy of payment through the implementation of DRGs points method,promoting the intellectualization of supervision through the construction of national medical insurance intelligent monitoring demonstration point,and promoting the scientization of decisionmaking through the formation of medical service price reform space program.However,the task of improving medical insurance governance ability through big data application is arduous.Quzhou medical insurance big data application is still in the basic stage,which requires the top level to clarify the positioning of the country,province and city in the information construction,and also needs to promote the construction of medical insurance database.