中药饮片医保限用规则的建立与持续改进

Establishment and Continuous Improvement on Restricted Payment Rules of Chinese Medicine Pieces in Medical Insurance

目的提升医保限用中药饮片的合规使用水平。方法根据医保药品目录,在合理用药管理系统上对中药饮片维护“单用限制”或“不限制”的医院自定义属性。建立药品自由自定义规则,对于医保患者门急诊处方和病区医嘱,如果“单用限制”的药品没有与“不限制”的其他药品联合使用,则判定为不合规,进行系统警示。医院使用的中药饮片品种增加时,对增加品种医院自定义属性及限用规则进行维护。结果经系统测试和实际使用,应用取得成功。结论通过系统手段加强中药饮片医保限用管理,使医保患者中药饮片在限定支付范围内使用,保障了中药饮片使用的医保合规。

OBJECTIVE To improve the proper use of Chinese medicine pieces limited in medical insurance.METHODS According to the medical insurance drug catalog,the hospital establishes limit rules for Chinese medicine pieces within the management system.Within this system,if restricted payment medicine by used alone is not prescribed with other not restriction medicine,the emergency prescription and medication orders are judged as unregulated and will receive a systemic warning.When new kinds of medicine are adding to the collection,the limit rules and customize property of hospital should also be maintained.RESULTS After systematic testing and practical use,the application was successful.CONCLUSION Through systematic means,the management of medical insurance restriction payment of Chinese medicine pieces is strengthened,so that medical insurance patients can use it within the limited payment range,which ensures the compliance of its usage for medical insurance.