医保限用药使用全流程管理的实践与探索

Practice and Exploration on the Whole Process Management of Restricted Payment Medicine in Healthcare Security

目的加强医保限用药使用全流程管理,提升合规用药水平。方法事前开展医保政策培训。开发限用药限定支付范围提醒及“医保”“自费”属性选择程序。事中建立医保限用自定义规则300余条(组),对不合规用药进行系统拦截或不同级别的警示提醒。事后每月系统提取限用药相关数据,导入至Access进行数据关联,导出到Excel表格,建立函数关系判断是否在限定支付范围使用,并进行相应提醒处置。结果经过不断加强管理和持续改进,合规用药水平取得极大改善。结论医保限用药的管控,既有很强的专业性,又有强烈的管理属性。综合运用药学、医保、计算机等多学科的知识和技能,把药学相关工作做得更好。

OBJECTIVE To strengthen the whole process management of restricted payment medicine in healthcare security,and improve the level of medicine used with regulations.METHODS To carry out medical insurance policy training in advance,and develop a program to remind the limited scope of payment of healthcare security medicine and select the attributes of“medical insurance”and“self-paying”.During the process,more than 300 custom rules(groups)of medical insurance limits were established,and systematic interception or different levels of warnings were carried out for non-compliant medication.Afterwards,the system extracted the data related to restricted payment medicine every month,imported it to Access for data association,exported it to Excel,established function relation to judge whether it was used within the limited payment scope,and made corresponding disposal reminder.RESULTS Through continuous management and improvement,the level of medicine used with regulations has been greatly improved.CONCLUSION The control of restricted payment medicine in healthcare security has both strong professional and management attributes.Multidisciplinary knowledge and skills of pharmacy,health care,computer etc.should be combined to do better pharmacy-related work.