某院医保药品限制支付条件管理实践与优化建议  

Management Practice and Optimization Suggestions of Restricted Payment Conditions for Medical Insurance Drugs in a Hospital

作　　者：刘晓雷 刘炜 陈敏 LIU Xiaolei;LIU Wei;CHEN Min(The First Affiliated Hospital,Air Force Medical University,Xi'an,Shaanxi,China 710032)

机构地区：[1]中国人民解放军空军军医大学第一附属医院,陕西西安710032

出　　处：《中国药业》2023年第7期25-27,共3页China Pharmaceuticals

基　　金：中国人民解放军空军军医大学第一附属医院学科助推计划项目[XJZT18ML28]。

摘　　要：目的 为医院医保药品限制支付条件政策的落地执行提供参考。方法 按梳理药品目录、设计限制支付条件管理流程、开发相关程序、管理考核工作的思路,设计、开发了医保药品限制支付条件报务管理系统及配套管理模式,比较实施前(2020年)和实施后(2022年)的医保药品管控率和医师审核填报准确率,总结存在的问题,并提出优化建议。结果 医保药品管控率和医师审核填报准确率分别从实施前的10.00%和60.00%升至实施后的90.00%以上。存在问题包括4个方面,管理体系有待进一步理顺,审核模式有待进一步优化,患者宣教有待进一步提升,专业细节有待进一步明确。建议与临床药事管理工作相结合,进一步提升管理效能。结论 医保药品限制支付条件管理具有较强的专业性和复杂性,与临床药事管理工作相结合将有助于推进合理用药和医保政策落实。Objective To provide a reference for the implementation of restricted payment condition policy for medical insurance drugs in hospitals.Methods The restricted payment conditions for medical insurance drugs reporting management system and supporting management mode were designed and developed by sorting out the drug catalogue,designing the process of restricted payment condition management,developing relevant procedures and managing assessment work.The control rate of medical insurance drugs and the accuracy rate of physicians'reviewing and reporting before the implementation of the above management system and supporting management mode(2020)and after its implementation(2022)were compared,the existing problems were summarized,and the optimization suggestions were put forward.Results The control rate of medical insurance drugs and the accuracy rate of physicians'reviewing and reporting increased from 10.00%and 60.00%respectively before the implementation of the above management system and supporting management mode to more than 90.00%after its implementation.The existing problems included that the management system needed to be further improved,the reviewing mode needed to be further optimized,the propaganda and education for patients needed to be further improved,and the professional details needed to be further clarified.It was suggested that the management of restricted payment conditions for medical insurance drugs should be integrated with the clinical pharmaceutical administration to further improve the management efficiency.Conclusion The management of restricted payment conditions for medical insurance drugs is highly professional and complex,and its integration with the clinical pharmaceutical administration will promote the rational drug use and the implementation of medical insurance policies.

关 键 词：医保药品 限制支付条件 管理实践 优化 建议 

分 类 号：R95[医药卫生—药学]