三方联审工作模式用于医保特殊药品管理的成效分析——以陕西省某三甲医院为例  

Effectiveness Analysis of Tripartite Joint Audit Mode on Special Drug Management of Medical Insurance ——Based on Data from a Tertiary Hospital in Shaanxi Province

作　　者：李亚[1] 谢姣 杨乾婷 史蕾 卢刚 曹婷 张淑群[1] 张抗怀[1] 

机构地区：[1]西安交通大学第二附属医院,西安710004

出　　处：《中国医疗保险》2022年第6期90-93,共4页China Health Insurance

基　　金：吴阶平医学基金会临床科研专项资助基金(320.6750.2021-10-74)。

摘　　要：目的:探索药师参与医保特殊药品审核的必要性和可行性。方法:以合理用药为基础,结合国家医保政策,建立以药师为审核主体的医保药品三方联审工作模式(医师-药师-医保),对特殊药品进行事前审核。结果:2019年11月—2021年5月,共审核特殊药品4652人次,通过率82%。其中申报材料不全623人次,超医保限定条件211人次,涉及违规金额1200余万元。结论:药师参与特殊药品医保审核,既减少了医保基金的不合理支出,又提高了特殊药品的合理使用率,同时也为其他医疗机构医保精细化管理提供参考。Objective: This study attempted to explore the necessity and feasibility of pharmacists’ participation in the audit of special drugs of medical insurance. Methods: Based on rational drug use, this study established a three-party joint audit mode(physician-pharmacist-medical insurance personnel) of medical insurance drugs with pharmacists as the main auditors to conduct "prior audit" of special medical insurance drugs in hospital according to national policies of medical insurance. Results: During the period from November 2019 to May 2021,a total of 4652 cases were reviewed by pharmacists, with a passing rate of 82%. Among them, 623 cases were rejected due to incomplete declaration materials, and 211 cases were rejected due to exceeding the medical insurance qualification, and the total amount involved in the rejected cases was more than 12 million yuan. Conclusion: The participation of pharmacists in the audit of national negotiated drugs can help reduce the unreasonable expenditure of medical insurance fund and improve the reasonable utilization rate of national negotiated drugs. This study also provides a reference for the refined management of medical insurance in other medical institutions.

关 键 词：医保特殊药品 药师 三方联审 精细化管理 

分 类 号：F840.684[经济管理—保险] C913.7[社会学]