长护险智能监管困境及优化路径研究&#x02014;&#x02014;以浙江省杭州市为例

刘晓婷; 石连忠; 刘嘉欣

doi:10.19546/j.issn.1674-3830.2025.12.010

中国医疗保险 ›› 2025, Vol. 0 ›› Issue (12) : 78-85. DOI: 10.19546/j.issn.1674-3830.2025.12.010

长护险智能监管困境及优化路径研究——以浙江省杭州市为例

刘晓婷¹, 石连忠², 刘嘉欣¹

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The Dilemmas and Optimization Pathways of Intelligent Supervision in Long-Term Care Insurance——Based on the Experience of Hangzhou City, Zhejiang Province

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摘要

随着长期护理保险制度的推进,服务内容多元化、参与主体复杂化与监管链条延长等特点,使传统人工监管面临效率低、覆盖面不足与道德风险加剧等挑战。以人工智能为代表的智能技术为提升长护险监管效能提供了新路径。本文基于对杭州市长期护理保险智能监管实践的考察,系统梳理了其在信息孤岛、流程分散、过程不可视及责任边界模糊等方面的主要困境,分析了智慧医保平台、机构自建系统在身份核验、过程监管、风险预警与费用结算中的应用成效与现存短板。在此基础上,研究构建了涵盖事前预防、事中监控与事后追责的全流程智能监管框架,设计了监管端与服务端的功能分工与数据交互架构,并提出多主体协同治理与人文关怀融入技术应用等优化路径。最后,本文提出未来监管体系建设的五大方向：智能闭环监管、平台深度融合、多主体智慧协同、服务友好导向及数据驱动的奖惩机制,以构建技术可行、责任清晰、运行高效且兼具伦理温度的长护险智能监管体系,为国家层面推进长护险高质量发展提供实践参考。

Abstract

The ongoing expansion of China’s long-term care insurance (LTCI) system, characterized by diversified services, complex stakeholders, and extended supervision chains, has exposed the limitations of traditional manual supervision, including inefficiency, inadequate coverage, and heightened moral hazard. Intelligent technologies, represented by artificial intelligence (AI), offer a novel approach to enhancing LTCI supervision efficacy. Based on the investigation of the intelligent supervision practices in Hangzhou City, this study systematically identifies key dilemmas in areas such as information silos, fragmented processes, lack of procedural visibility, and blurred responsibility boundaries. It analyzes the practical applications and shortcomings of the smart medical insurance platform and institution-built systems in identity verification, process supervision, risk warning, and cost settlement. Building on this analysis, the paper constructs a comprehensive closed-loop intelligent supervision framework encompassing pre-event prevention, in-process monitoring, and post-event accountability. It designs a functional division and data interaction architecture between the supervisory and service ends and proposes optimization pathways involving multi-agent collaborative governance and the integration of humanistic care into technological applications. Finally, the study outlines five directions for future supervision system development: intelligent closed-loop supervision, deep platform integration, smart multi-agent collaboration, service-friendly orientation, and data-driven incentive and penalty mechanisms, in order to establish a technically feasible, responsibility-defined, operationally efficient, and ethically conscious intelligent supervision system for LTCI, providing practical insights for promoting the high-quality development of LTCI at the national level.

导出引用

刘晓婷, 石连忠, 刘嘉欣. 长护险智能监管困境及优化路径研究——以浙江省杭州市为例[J]. 中国医疗保险. 2025, 0(12): 78-85 https://doi.org/10.19546/j.issn.1674-3830.2025.12.010

The Dilemmas and Optimization Pathways of Intelligent Supervision in Long-Term Care Insurance——Based on the Experience of Hangzhou City, Zhejiang Province[J]. China Health Insurance. 2025, 0(12): 78-85 https://doi.org/10.19546/j.issn.1674-3830.2025.12.010

中图分类号： F840.684 C913.7

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