摘要
大数据在医保管理中的核心驱动作用日益凸显,挖掘技术呈现出多元平台、多源数据、交互操作三大特点,挖掘结果为医保政策制定和完善提供数据支撑。近年来,国家医保局高度重视医保大数据的发展应用,在顶层设计、信息平台发布、业务编码规范等方面进行总体部署。本文分析国内外数据挖掘在医保管理中的典型应用案例。国际经验从医保基金分配、资源管理和基金监管等方面进行梳理,国内以上海、重庆、海南等地为例,梳理其组织架构、平台建设经验,以及应用场景探索的成果。最后通过SWOT分析提出目前我国在医保大数据应用方面存在的不足以及在大数据发展过程中面临的挑战,从平台搭建、多方联动、数据挖掘、应用层面提出相应的意见建议,助力实现医保服务更高效、监管更智能、决策更科学。
The driving role of big data in medical insurance management has become increasingly prominent.The mining technology presents characteristics of multi-platform,multi-source data and interactive operation,and the results provide data support for the formulation and improvement of medical insurance policies.In recent years,China's National Healthcare Security Administration attaches great importance to the development and application of medical insurance big data,and carries out overall deployment in various aspects such as top-level design,information platform release,and business coding specifications.This paper analyzes the typical application cases of data mining in medical insurance management at home and abroad,summarizes international experience from aspects of medical insurance fund allocation,resource management,and fund supervision.Taking Shanghai,Chongqing,Hainan as examples,the paper reviews their organizational structure,platform construction experience,and application scenario exploration.Finally,by means of SWOT analysis,the shortcomings in the application of medical insurance big data and the challenges that will be encountered in the development of big data are put forward from the aspects of platform construction,multi-linkage,data mining and application,so as to realize more efficient medical insurance services,smarter supervision and more scientific decision-making.
出处
《中国医疗保险》
2023年第9期48-54,共7页
China Health Insurance
基金
首都医科大学国家医疗保障研究院开放性课题“医疗保障大数据挖掘处理新技术及应用案例研究”(YB2022B03)。
关键词
大数据
医疗大数据
数据挖掘
医保管理
big data
medical big data
data mining
medical insurance management
