强化诊疗审核与药学干预提升医保限制性药品使用的规范性实践  

Enhancing the Standardization of the Use of Medical Insurance Restricted Drugs through Strengthened Diagnosis and Treatment Audit and Pharmaceutical Intervention

作　　者：魏业东 崔倩倩 昝莹 司继刚[1] 任霄剑 Wei Yedong;Cui Qianqian;Zan Ying;Si Jigang;Ren Xiaojian(Zibo Center Hospital,Zibo 255036,China)

机构地区：[1]淄博市中心医院,淄博255036

出　　处：《中国药事》2025年第4期479-484,共6页Chinese Pharmaceutical Affairs

基　　金：淄博市重点研发计划(编号2020ZC010112)。

摘　　要：目的:探索《国家基本医疗保险、工伤保险和生育保险药品目录》下限制性药品的多学科管理方法,建立规范诊疗审核中心管控医保限制性药品的药学干预模式。方法:通过建立事前提醒和拦截干预、事中互动审核干预、事后处方(医嘱)点评和现场督导干预的全流程干预模式,对干预模式实施前(2020年1月1日-2021年12月31日)与实施后(2022年1月1日-2023年12月31日)的市医保局飞行检查涉及医保限制性药品违规金额、医保专项检查医保限制性药品支付合理率和疑似超限用药违规自查情况进行分析和对比。结果与结论:规范诊疗审核中心干预模式实施后,市医保局飞行检查涉及医保限制性药品违规金额、医保专项检查医保限制性药品支付合理率和疑似超限用药违规情况明显改善。通过规范诊疗审核中心药学干预可有效促进药品的合理使用,助力医保限制性药品的管理。Objective:To explore the multidisciplinary management method of restricted drugs under the national medical insurance catalog,and to establish a pharmaceutical intervention mode to control medical insurance restricted drugs by standardized diagnosis and treatment audit center.Methods:Through the establishment of the whole process intervention mode of pre reminder and interception intervention,in-process interactive audit intervention,post prescription(medical order)comment and on-site supervision intervention,the amount of delinquent medical insurance restricted drugs involved in the flight inspection of the municipal medical insurance bureau before the implementation of the intervention mode(January 1,2020~December 31,2021)and after the implementation(January 1st,2022-December 31st,2023)were analyzed and compared,as well as the reasonable payment rate of medical insurance restricted drugs in the special inspection of medical insurance,and the self-examination of suspected exceed-indication drug use.Results and Conclusion:After the implementation of the intervention mode of the standardized diagnosis and treatment audit center,the amount of delinquent medical insurance restricted drugs involved in the flight inspection of the municipal medical insurance bureau,the reasonable payment rate of medical insurance restricted drugs in the special medical insurance inspection,and the suspected exceed-indication drug use were significantly improved.By the pharmaceutical intervention in the standardized diagnosis and treatment audit center,it effectively promoted the rational use of drugs and helped the management of medical insurance restricted drugs.

关 键 词：规范诊疗审核中心 药学干预 医保限制性药品 超限用药 

分 类 号：R95[医药卫生—药学]