医保用药智能审核系统用于限定支付医保药品管控效果评价

Application Effect of Intelligent Review System for Medical Insurance Medication in Control of Restricted-Payment Medical Insurance Drugs

目的探索药师应用基于合理用药系统构建的医保用药智能审核系统对限定支付医保药品的管控效果。方法选取系统运行前(2021年8月至12月)医保药品拒付处方/病例,结合2021年版《国家基本医疗保险、工伤保险和生育保险药品目录》中的限定支付药品类型、药品说明书等进行分析,在合理用药系统中架构医保用药智能审核规则,设计审核触发点,设置违规拦截等级等,形成医保用药智能审核系统,对比系统运行前、运行后(2022年8月至12月)医保拒付药品条数及金额等。结果系统运行后,医保拒付条数及金额较系统运行前分别下降85.19%和92.41%(P<0.05)。结论基于合理用药系统构建的医保用药智能审核系统,可将医保、医疗和药品结合在一起进行精细化管控,能高效降低医保违规拒付风险发生率,且可提高医院医保管理的工作效率。

Objective To investigate the effect of pharmacists applying an intelligent review system for medical insurance medication based on the rational drug use system in the control of restricted-payment medical insurance drugs.Methods The prescriptions/cases with payment refusal of medical insurance drugs before the operation of system(August to December 2021)were collected and analyzed based on the restricted-payment drug types and drug instructions in the Medicine List for National Basic Medical Insurance,Work-Related Injury Insurance and Maternity Insurance(2021 Edition).The intelligent review rules for medical insurance medication in the rational drug use system were made,the review trigger points were designed,and the illegality interception levels were set,and an intelligent review system for medical insurance medication was formed.The item and amount of medical insurance drugs with payment refusal before the operation of system(August to December 2021)and after the operation of system(August to December 2022)were compared.Results Compared with those before the operation of system,the item and amount of medical insurance drugs with payment refusal decreased by 85.19%and 92.41%respectively after the operation of system(P<0.05).Conclusion The intelligent review system for medical insurance medication based on the rational drug use system can realize the refined control for medical insurance,medical treatment and drugs,effectively decrease the incidence of illegal payment refusal of medical insurance drugs,and improve the efficiency of medical insurance management in hospitals.