At present, the phenomenon of large prescriptions, over-examination, and repeated medications in hospitals still exists to a certain extent. This is not only an important cause of “expensive medical treatmentâ€, but also a waste of medical insurance funds. As a pilot city for national medical reform, Liuzhou City, Guangxi Province, explored the establishment of a medical insurance intelligent supervision platform, set pre-audit through the formulation of rules, and used the “electronic eye†to supervise the doctor's diagnosis and treatment process. The supervision of medical insurance funds went from extensive to precise.
Medical insurance fund management is a difficult problem
The extensive use of drugs and over-examination has put pressure on the medical insurance fund while causing the burden on the general public. The medical insurance fund can pay for the low number of months when there are many places. In the 2014 medical insurance year (from July to June of the following year), the Liuzhou Medical Insurance Fund could not receive more than 100 million yuan in the year.
The medical insurance fund can't make ends meet, but there are also medical institutions that use weak supervision funds. In 2011 alone, the Liuzhou Social Insurance Bureau investigated the behaviors of 12 medical institutions and 2 pharmacies, including collection, overcharge, over-examination and treatment, and was refused to pay more than 3.5 million yuan.
“At first we were manually checking for violations. However, a hospital has tens of thousands to hundreds of thousands of documents a year. It can only find and investigate violations through reports and random checks.†Lan Zhicheng, deputy director of the Liuzhou Municipal Social Security Bureau said For the vast documents, supervision seems to be powerless.
In July 2012, Liuzhou went online to use the medical insurance intelligent supervision platform. The system established a set of rules to comprehensively review and monitor medical insurance documents, and automatically “capture†violations for supervision and accountability. However, the problem was immediately exposed. There were millions of documents reviewed each year, and the number of suspected violations was huge.
“We run the system once a month or quarterly. There are always tens of thousands or even hundreds of thousands of suspected violations, and most of them are 'false positives'. It is also a needle in a haystack to screen the problem items one by one.†Lan Zhicheng said, “ Even if the suspected violation of the documents is found, the hospital and the doctor should be informed to bring the original documents to accept the inquiry. Sometimes it is only the problem of hospital data entry for a long time, and some document problems are difficult to explain, resulting in fierce medical insurance and hospital conflicts."
Liuzhou has also adopted the “doctor's fee ranking†method to check violations in the same way as some other areas, and through this measure to verify and seriously deal with illegal medical personnel, but this does not guarantee that doctors who prescribe less drugs will not have large prescriptions, etc. problem.
"Whether the doctor's examination and treatment are reasonable, is it excessive? All of them are in the doctor's pen. There is no one that can be used as a standard ruler." As early as 2014, Xinhua News Agency reporters investigated the case of taking a medical insurance fund together. When Zhicheng, he said so helplessly.
"Electronic Eyes" helps doctors use "pens"
For more than 10 years, he has been engaged in the supervision of medical insurance funds. Lan Zhicheng and his colleagues believe that it is necessary to pre-alert and limit the links in the intelligent audit system. If the medication rules are not met according to the clinical path, the doctor cannot prescribe the prescription. Only in this way can the doctor To the precise management of the medical insurance fund.
Chen Zhaoshu, director of the fixed-point management section of the Social Security Bureau of Liuzhou City, introduced the new intelligent supervision platform of the Liuzhou Social Security Bureau in 2014, with the joint efforts of the Social Security Bureau and relevant agencies. This system has built-in complete medical insurance rules and clinical path rules. If the doctor's prescription breaks through the rules set up based on the knowledge base, the system will prompt the doctor, and the doctor can give up the action that may be violated according to the prompt. If he thinks that the clinical need to have such a prescription, you can choose to force By 'and explaining the reasons, the medical insurance department only needs to focus on such a situation."
In the Department of Neurology, Liuzhou Workers' Hospital, resident Mo Chongyang showed the reporter the process of prescribing medicine. He submitted a "injection-injected sugar" to a patient diagnosed with kidney stones. The page immediately showed a pop-up window saying "violation of limited use (conditions) medication". The reason for the violation was "rescue patients who were unable to use glucose due to insulin resistance." ".
"If you have to use this medicine, you can fill in the reasons below and force it to save; if you don't have to use it or you are prompted to find out that you have prescribed a drug, you can go back and modify it." Mo Chongyang said that the medical insurance rules and medication rules are many and often change. The system can prompt the doctor to pay attention during the prescribing process, and can prevent the doctor from prescribing the drug. He said that the built-in prescriptions and rules helped him a lot and became a doctor's assistant.
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