过度医疗行为认定及医保监管指标研究

Research on the Confirmation of Medical Overuse Behavior and Medical Insurance Supervision Rules

过度医疗是医疗服务中长期存在的痼疾,“过度”存在着认知差异和模糊地带,以致在医保基金监管中易引起争议,存在界定难、识别难与处置难的现实困境。本文通过文献综述梳理过度医疗的内涵与边界,并以此为基础通过对医保监管文本资料与定点医疗机构监管过程中发现的过度医疗行为深入挖掘,形成过度医疗行为指标体系(5个一级指标、30个二级指标、67个三级指标),并以国际经验为借鉴,为优化、加强过度医疗医保监管规则提供建议与循证依据。

Medical overuse is a persistent problem in medical insurance services.Differences in perception and interpretation of"overuse"lead to controversies in the supervision of medical insurance funds,and it is difficult to define,identify and deal with overuse problems.This paper compares the connotation and boundary of medical overuse through a literature review.Based on this,we form a system of medical overuse indicators,including 5 first-level indicators,30 second-level indicators,and 67 third-level indicators,by digging deeper into the medical insurance supervision texts and the medical overuse behaviors seized during the supervision process of designated medical institutions.The system is based on international experience and provides suggestions and an evidence-based basis for optimizing and refining the application of medical overuse supervision rules.