Objective: The paper analyzes the distribution of hospitals' items beyond basic medical insurance payment limit and the reasons, providing a basis for promoting hospitals' rational diagnosis and treatment as well as refined management. Methods: The study collected the items beyond basic medical insurance payment limit of a specialized oncology hospital from 2020 to 2021, and analyzed the number and amount of items with methods of classification and comparative analysis. Results: The hospitals' items beyond basic medical insurance payment limit were classified into 6 major categories, including anti-tumor drugs, adjuvant drugs, surgery, examination and test, respiratory support, and intravenous injection. The number and amount of anti-tumor drugs and adjuvant drugs accounted for 99.24% and 99.45% of the number and amount of total items. The number and amount of adjuvant drugs (30410 and $1134342.95, respectively) was higher than anti-tumor drugs (4396 and $341061.85, respectively). Conclusion: The proportion of number and amount of drug items was relatively high, which may be related to inconsistency between requirements of medical insurance policy and doctors' judgment standards. Designated hospitals for healthcare security can strengthen rational use and management of drugs, and standardize diagnosis and treatment by interdisciplinary cooperation of medical insurance, hospital and drugs within the hospital to strengthen policy training, establishing a pre-audit system, and strengthening communication between hospitals and medical insurance departments.
Key words
rational diagnosis and treatment /
medical insurance payment standard /
refusal of medical insurance
{{custom_sec.title}}
{{custom_sec.title}}
{{custom_sec.content}}
References
[1] 国家卫生健康委.关于印发进一步规范医疗行为促进合理医疗检查的指导意见的通知[EB/OL].(2020-12-29)[2023-08-29].http://www.nhc.gov.cn/yzygj/s2911/202012/32d1e29d565944ecb263c54bf8f19ec6.shtml.
[2] 冯玉莹,蔡鑫宇.基于DRG支付的云南省定点医疗机构冠心病住院患者医疗费用分析[J].医学与社会,2021,34(03):102-106.
[3] 吴学智,李捷,邓淑娟,等.DRG付费改革对攀枝花市某三甲医院普外科医保患者费用的调控效果分析[J].医学与社会,2022,35(03):76-79.
[4] 国务院.医疗保障基金使用监督管理条例[EB/OL].(2021-02-19)[2023-08-29].http://www.gov.cn/zhengce/content/2021-02/19/content_5587668.htm.
[5] 李琦,张雨晴,俞乔.北京市海淀区社区医院的医保拒付原因分析及对策建议[J].中国卫生经济,2022,41(06):22-25.
[6] 锁珍静,俞群俊.昆明市某三甲医院基本医疗保险住院费用拒付原因及对策分析[J].经济研究导刊,2021(36):68-70.
[7] 于依水,刘爽,程吟楚,等.某三甲医院门诊药品医保拒付的现状分析[J].临床药物治疗杂志,2022,20(08):39-43.
[8] 邵芸,王增,陈凌亚,等.肿瘤专科医院合理用药管理系统的应用[J].海峡药学,2020,32(03):220-222.
[9] 冷家骅,刘忆,陈治水,等.北京市医药分开综合改革对肿瘤专科医院的影响——基于北京某肿瘤医院医保数据的实证分析[J].中国卫生政策研究,2017,10(12):15-21.
[10] 饶小平,洪亮亮,费燕,等.2017—2019年福建某医院超医保支付限定范围用药原因调查分析[J].福建医药杂志,2021,43(03):116-118.
[11] 田璞玉.2020年某院住院患者医保拒付药品情况分析[J].中国合理用药探索,2022,19(02):12-17.
[12] 郑树忠,龚忆莼,耿韬,等.过度医疗行为认定及医保监管指标研究[J].中国医疗保险,2022(12):23-28.
[13] 王宇,郑丹桂,孙俊如.医保智能审核中医保拒付原因及对策分析[J].现代医院,2022,22(04):595-597.
[14] National Comprehensive Cancer Network.NCCN clinical practice guidelines in oncology: non-small cell lung cancer (Version3.2022)[EB/OL].(2022-12-22)[2023-06-17].https://www.nccn.org/guidelines/guidelines-detail?category=patients&id=23.
[15] 苏奥南,朱佳英.PDCA质量管理工具对降低医保拒付率的效果[J].中国现代医生,2020,58(20):1-4.
[16] 罗芬,李一意,罗霞.2020年国家医保药品目录限定支付情况及变化趋势分析与优化建议[J].中南药学,2021,19(07):1479-1484.
[17] 李亚,谢姣,杨乾婷,等.三方联审工作模式用于医保特殊药品管理的成效分析——以陕西省某三甲医院为例[J].中国医疗保险,2022(06):90-93.
[18] 张夙,胡传文,葛琳,等.处方前置审核防范医保拒付的实践与效果分析[J].医院管理论坛,2021,38(07):19-22.
