医保限定支付药品的信息化管理及效果评价  

Information management and effectiveness evaluation of medical insurance limited-payment drugs

作　　者：李少强 孔旭东[1] 刘莹[1] 李朋梅[1] LI Shaoqiang;KONG Xudong;LIU Ying;LI Pengmei(Department of Pharmacy,China-Japan Friendship Hospital,Beijing 100029,China)

机构地区：[1]中日友好医院药学部,北京100029

出　　处：《临床药物治疗杂志》2024年第11期67-72,共6页Clinical Medication Journal

基　　金：国家重点研发计划主动健康和老龄化科技应对重点专项资助(2020YFC2005504)。

摘　　要：目的 基于信息化管理减少医保限定支付药品的医保拒付情况,促进药品合规使用。方法 以处方前置审核功能为依托,制订医保限定支付药品结构化规则进行系统审查,收集中日友好医院2021年9月至2024年6月门诊处方医保审查相关数据,并进行描述性统计分析。结果 自定义医保审查规则后,规则累计条目逐年增加,系统审查不合理率增加。2022年系统审查不合理率最高,为0.49%,2024年较为平稳,为0.47%;月均拦截频次与金额并没有在规则制订后随着时间的延长而降低,反而呈上升趋势。截至2024年6月,月均拦截频次为1075次,月均拦截金额为49.49万元。结论 信息化管理对促进医保限定支付药品的合规使用有效且必要,医院可建立“三医联动”的方式提高审查的准确率。Objective To reduce the refusal of medical insurance for limited-payment drugs based on informatization control and promote the rational use of drugs.Methods Based on Prescription Automatic Screening System,structured rules for limited-payment drugs were formulated for review,and the relevant data of medical insurance review of outpatient prescriptions from September 2021 to June 2024 were collected for descriptive statistical analysis.Results After the implementation of customized medical insurance review rules,the number of rule entries has been increasing year by year,leading to a rise in the system's rate of unreasonable reviews.The highest rate of unreasonable reviews occurred in 2022,reaching 0.49%,while in 2024,the rate became relatively stable at 0.47%in 2024.Contrary to expectations,the monthly frequency and amount of intercepted cases did not decrease over time following the establishment of the rules;instead,they exhibited an upward trend.As of June 2024,the average monthly interception was 1,075 times and the average monthly interception was 494,900 yuan.Conclusion Informatization control is effective and necessary to promote the rational use of limited-payment drugs.The hospital establishes the linkage among medical insurance,medical treatment and medicine to improve the accuracy of medication review.

关 键 词：信息化管理 医保 药品 

分 类 号：R954[医药卫生—药学]