创新高值医用耗材及其配套医疗服务价格项目医保准入管理研究  

Research on Medical Insurance Admission Management for Innovative High-Value Medical Consumables and Their Supporting Medical Service Price Projects

作　　者：艾亚萍 胡善联[2] 赵琨 陈英耀[4] 王海银 刘君 刘海娇 金春林 

机构地区：[1]艾昆纬企业管理咨询(上海)有限公司,上海200041 [2]复旦大学公共卫生学院,上海200032 [3]清华大学万科公共卫生与健康学院,100084 [4]复旦大学公共卫生学院,国家卫生健康委员会卫生技术评估重点实验室(复旦大学),上海200032 [5]上海市卫生和健康发展研究中心,200031

出　　处：《中国医疗保险》2025年第2期68-76,共9页China Health Insurance

摘　　要：目的:创新高值医用耗材及其配套医疗服务价格项目的医保准入规则设定,是推动创新技术临床应用、实现价值购买的关键。本研究从分类管理、准入流程、评估指标等方面入手,提出完善我国创新高值医用耗材及其配套医疗服务价格项目医保准入管理的建议,为相关项目纳入医保报销提供参考依据。方法:本研究梳理了国内外创新高值医用耗材及其配套医疗服务价格项目医保准入的管理经验,形成初步建议,并结合专家访谈进一步验证其适用性和可操作性。结果:研究发现,澳大利亚、中国台湾等地通过分类准入、规范窗口期和评估周期,并设置差异化评估流程与指标,有效提升了医疗服务价格项目的评估效率,促进了创新医疗技术的及时应用。在医用耗材医保准入方面,澳大利亚、日本、韩国等已形成成熟经验,均采用分类管理,评估内容的差异主要在于是否需要进行经济性评估或完整的卫生技术评估。受访专家则从分类、准入流程和评估标准进一步提出具有适用性、可操作性的建议。结论:本研究提出了优化我国创新高值医用耗材及其配套医疗服务价格项目医保准入的管理方法和路径建议,旨在为规范相关项目的医保准入、促进创新技术的及时且合理使用提供政策参考。Objective:The establishment of medical insurance admission rules for innovative high-value medical consumables and supporting medical service pricing projects is the key to promoting the clinical application of innovative technologies and realizing value purchases.This study proposes suggestions for improving the medical insurance admission management of innovative high-value medical consumables and supporting medical service price projects in China from the aspects of classification management,admission process,and evaluation indicators,providing a reference for relevant projects to be included in medical insurance reimbursement.Method:This study reviewed the management experience of medical insurance admission for innovative high-value medical consumables and supporting medical service price projects at home and abroad,formed preliminary suggestions,and further verified their applicability and operability through expert interviews.Results:The study found that Australia,Taiwan Province of China and other places effectively improved the evaluation efficiency of medical service price items and promoted the application of latest innovative medical technology through classified access,standardized window period and evaluation cycle,and set up differentiated evaluation processes and indicators.In terms of medical consumables medical insurance access,Australia,Japan,the Republic of Korea and other countries have formed mature experience and adopted classified management.The difference in evaluation content mainly lies in whether economic evaluation or complete health technology evaluation is needed.The interviewed experts further proposed applicable and feasible suggestions based on classification,admission process,and evaluation criteria.Conclusion:This study proposes management methods and path suggestions for optimizing the medical insurance admission of innovative high-value medical consumables and supporting medical services in China,providing policy references for regulating the medical insurance admission of re

关 键 词：创新高值医用耗材 医疗服务价格项目 医保准入 

分 类 号：F840.684[经济管理—保险] C913.7[社会学]