摘要
目的了解某三级医院住院医疗保险药品拒付情况,对比医保支付政策和用药合理依据差异,提出合理用药和医保药品拒付管控措施和建议。方法收集某三级医院2020年1月—2021年9月住院医保药品拒付明细数据,以《国家基本医疗保险、工伤保险和生育保险药品目录(2021年)》限定支付范围、药品说明书的适应证范围和国内相关指南为依据,结合具体病例,采用SQL server、Excel描述性统计分析拒付原因。结果复审后住院医保药品拒付比例平均为0.3%,违反医保限定适应证范围是最主要的拒付类型。拒付金额排名靠前的品种包括全身用抗感染药物(35.95%)、血液和造血器官药(15.68%)、消化道和代谢方面的药物(12.79%),拒付金额前10名药品中,9个药品医保限定支付范围小于说明书适应证。结论医院应针对重点品种建立“三医联动“的合理用药监管模式,分别建立用药合理性和报销合规性规则,在保证合理用药的基础上,降低药品的医保拒付率。
Objective To understand the current status of the refusal of medical insurance drugs in a tertiary hospital's inpatient services,to compare the difference between medical insurance payment policy and rational basis for drug use,and to propose measures and suggestions for rational drug use and medical insurance drugs refusal control.Methods According to the limited scope of payment in the National Catalogue of Medicines for Basic Medical Insurance,Work-related Injury Insurance,and Maternity Insurance(2021),the scope of indications in the drug instructions and relevant domestic guidelines,combined with specific cases,detailed data on inpatient medical insurance drug refusals in a tertiary hospital from January 2020 to September 2021 were collected.SQL Server and Excel were used for descriptive statistics,and some medical records were reviewed to analyze the reasons for refusal.Results After the review,the average refusal rate of inpatient medical insurance drugs was 0.3%.The most common type of refusal was violating the scope of medical insurance limited payment.The top-ranked categories of the amount of refusal include systemic anti-infective drugs(35.95%),blood and hematopoietic drugs(15.68%),and drugs for digestive tract and metabolism(12.79%).Among the top 10 drugs in the amount of refusal,9 drugs have a medical insurance limited payment scope smaller than the indications of drug instructions.Conclusion Hospitals should establish a"medical-insurance-medicine linkage"rational drug use supervision model for key categories,formulate separate rules for medication rationality and reimbursement compliance,and reduce the refusal rate of medical insurance drugs based on rational use.
作者
滕世伟
李天俊
杨华
卢静
孙麟
TENG Shiwei;LI Tianjun;YANG Hua;LU Jing;SUN Lin(Department of Medical Insurance,West China Hospital,Sichuan University,Chengdu 610041,China)
出处
《医药导报》
CAS
北大核心
2022年第12期1767-1771,共5页
Herald of Medicine
基金
成都市科技厅重点研发项目(2020-YF09-00117-GX)。
关键词
合理用药
医保药品拒付管理
原因分析
Rational drug use
Medical insurance drugs refusal management
Cause analysis
