随着全国统一的医保信息系统全面建成,高质量的医保数据形成聚集效应,智慧医保建设进入全新阶段。在数字中国战略和“人工智能+”行动深入推进的背景下,如何科学认识智慧医保的内涵,如何系统构建智慧医保的理论体系、知识体系和方法论体系,成为亟待回答的重要命题。本文在梳理智慧医保研究现状的基础上,分析建设智慧医保学科研究体系的现实紧迫性与行业刚需,系统探讨智慧医保作为交叉应用学科的定位、核心学科构成及主要研究方向。研究提出,智慧医保学科是一门以临床医学和药学为逻辑内核、以统计学与数据科学为分析方法、以公共管理学为治理框架、以计算机科学为技术支撑的交叉应用学科,应重点围绕技术与基础设施、服务与用户体验、基金运行风控与监管、支付与战略购买、决策与治理等五大方向开展系统研究。本文旨在为智慧医保的科学化发展提供理论支撑与实践参考,实现涵盖技术、管理、伦理的系统化知识学科发展框架和课程体系,推动形成具有中国特色的智慧医保学科体系。

With the full completion of the national unified medical insurance information system, high-quality medical insurance data has demonstrated an aggregation effect, marking that the development of smart medical insurance has entered a new stage. Against the background of the further implementation of the Digital China strategy and the "Artificial Intelligence Plus" initiative, scientifically defining the connotation of smart medical insurance, and systematically constructing its theoretical, knowledge and methodological systems constitute pressing issues that demand immediate attention. Based on reviewing the current research status of smart medical insurance, this paper analyzes the practical urgency and industry imperative of establishing a disciplinary research system for smart medical insurance, and systematically discusses its orientation as an interdisciplinary applied discipline, core disciplinary components and major research directions. It proposes that smart medical insurance is an interdisciplinary applied discipline with clinical medicine and pharmacy as logical core, statistics and data science as analytical methods, public administration as governance framework, and computer science as technical support. Systematic research should focus on five key areas: technology and infrastructure, services and user experience, fund operation risk control and supervision, payment and strategic purchasing, as well as decision-making and governance. This paper aims to provide theoretical support and practical references for the scientific development of smart medical insurance, realize a systematic framework and curriculum system for the development of knowledge disciplines, integrating technology, management, and ethics, and promote the formation of a smart medical insurance disciplinary system with Chinese characteristics.