A Study on the Cleaning of Real-World Medical Insurance Data&#x02014;&#x02014;Taking the &#x0201c;Cost of Medicines Included in the Payment Scope&#x0201d; of National Negotiated Drugs as an Example

doi:10.19546/j.issn.1674-3830.2025.7.003

China Health Insurance ›› 2025, Vol. 0 ›› Issue (7) : 23-31. DOI: 10.19546/j.issn.1674-3830.2025.7.003

A Study on the Cleaning of Real-World Medical Insurance Data——Taking the “Cost of Medicines Included in the Payment Scope” of National Negotiated Drugs as an Example

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Abstract

Objective: This study focuses on the quality issues of real-world medical insurance data, systematically constructs a data cleaning strategy for real-world medical insurance data, and evaluates the effectiveness of the data cleaning strategy using the statistics of the "cost of medicines included in the payment scope" of national negotiated drugs as an example. Methods: The study takes the original medical insurance settlement records database of anti-tumor drugs and immune regulators involved in the national medical insurance negotiation access in City A from January to September 2024 as the research object, and constructs a data cleaning strategy that includes establishing a verification dataset, text structuring, and handling of outliers. With the total cost of medicines and the cost of medicines included in the payment scope as effect indicators, the study compares and analyzes the changes in the observed indicators before and after data cleaning from multiple dimensions of different populations and medication scenarios. Results: After data cleaning, the total cost of medicines remained highly stable (deviation < 0.3%), while the cost of medicines included in the payment scope significantly decreased, with an absolute value reduction of approximately 2 million yuan, corresponding to a decrease of about 5%. Different deviations were observed across different populations (employees and urban and rural residents' medical insurance) and different medication scenarios (outpatient, inpatient, and retail pharmacies, as well as local and non-local medical treatment). Conclusion: The study verifies the effectiveness of the data cleaning strategy in improving the quality of medical insurance data and provides strong support for the scientific application of real-world medical insurance data. Meanwhile, the study reveals the heterogeneous distribution of medical insurance data quality issues, indicating that attention should be paid to data quality differences under different populations and medication scenarios in medical insurance data governance. In the future, it is necessary to further improve the medical insurance information system and strengthen cross-platform data governance to cope with the systemic challenges in medical insurance data governance.

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data cleaning / real-world medical insurance data / cost of medicines included in the payment scope

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A Study on the Cleaning of Real-World Medical Insurance Data——Taking the “Cost of Medicines Included in the Payment Scope” of National Negotiated Drugs as an Example[J]. China Health Insurance. 2025, 0(7): 23-31 https://doi.org/10.19546/j.issn.1674-3830.2025.7.003

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