医院处方点评制度下的医保药品合理应用研究  

Rational Application of Medical Insurance Drugs Under Hospital Prescription Review System

作　　者：马燕[1] 申新田 朱晓倩 MA Yan;SHEN Xintian;ZHU Xiaoqian(Dept.of Medical Insurance Management,Health Care Shenzhen Bao'an Maternal and Child Health Hospital,Guangdong Shenzhen 518101,China)

机构地区：[1]深圳市宝安区妇幼保健院医疗保险管理科,广东深圳518101

出　　处：《中国医院用药评价与分析》2021年第8期1000-1002,1006,共4页Evaluation and Analysis of Drug-use in Hospitals of China

摘　　要：目的:通过处方点评,规范医师合理用药行为,避免医保违规,降低医保拒付率。方法:2020年7月,深圳市宝安区妇幼保健院(以下简称“我院”)医疗保险管理科联合药学部、门诊部对门诊医保医师处方进行点评。利用医院信息管理系统,抽取联合处方点评前(2020年1—5月)门诊医保处方197200张、联合处方点评后(2021年1—5月)门诊医保处方384688张,对联合处方点评前后门诊医保处方违规使用限制性医保药品数据、医保药品拒付情况进行点评与分析。结果:与联合处方点评前(2020年1—5月)相比,联合处方点评后(2021年1—5月)我院门诊医保拒付处方数降低99.50%(由1602张降至8张);门诊医保拒付处方金额降低99.71%(由114556.78元降至329.29元);医保违规方式为超范围用药的科室数降低81.82%(由11个科室减少为2个科室);违规使用的医保范围内的药品数降低75.00%(由4个药品减少为1个药品)。结论:通过医保、药学联合监管控制,利用处方点评制度,将医保限制性使用药品适应证纳入处方点评,可保证临床合理用药,又可避免医保违规,规范临床用药行为,避免医保拒付的发生,使医保药品费用得到合理控制,保证医保制度持续、健康发展。OBJECTIVE: To standardize the rational drug use behavior of medical insurance physicians through prescription reviews,so as to avoid the medical insurance violations and reduce the rate of medical insurance refusal.METHODS: In Jul. 2020,the medical insurance management department, pharmacy department and outpatient department of Shenzhen Bao ’ an Maternal and Child Health Hospital( hereinafter referred to as “our hospital ”)performed the review of the prescriptions of outpatient medical insurance physicians. Through the hospital information system,197 200 outpatient medical insurance prescriptions before intervention( from Jan. to May 2020) and 384 688 outpatient medical insurance prescriptions after intervention( from Jan.to May 2021) were extracted.The data of illegal use of restricted medical insurance drugs and refusal of payment of medical insurance drugs in outpatient medical insurance prescriptions before and after joint prescription review were reviewed and analyzed. RESULTS: Compared with before intervention( from Jan.to May 2020),the number of prescription refused by medical insurance in outpatient department of our hospital decreased by 99. 50%( from 1 602 prescriptions to 8 prescriptions) after intervention( from Jan.to May 2021);the cost of drugs refused by medical insurance decreased by 99. 71%( from 114 556. 78 yuan to329. 29 yuan);the number of departments where medical insurance violation methods are over-range medication decreased by 81. 82%( from 11 departments to 2 departments);the number of drugs used in violation of medical insurance coverage decreased by 75. 00%( from 4 drugs to 1 drug).CONCLUSIONS: Through the joint supervision and control of medical insurance and pharmacy,and the prescription review system,the indications of medical insurance restrictive use of drugs can be included in the prescription review,which can ensure the clinical rational use of drugs,avoid medical insurance violations,regulate clinical drug use and avoid the occurrence of medical insurance refusal,so as to

关 键 词：合理用药 处方点评 医保医师 医保违规 

分 类 号：R969.3[医药卫生—药理学] R97[医药卫生—药学]