王伟迪+都模勤+朱捷

[摘要] 目的 分析2015年医保预扣活血化瘀类药品，查明原因，采取措施，减少医保拒付费用，促进合理用药。 方法 将解放军第一五医院医保办放置在医院公共信息平台上公示的2015年每月医保预扣的活血化瘀类药品数据进行汇总、分类、分析，查阅部分病例分析其用药合理性。 结果 活血化瘀类药物预扣次数最多，达121次。抽查病例提示药物存在滥用情况。内分泌科预扣次数最多，为24次。不合理地使用限制性用药和明显不合理用药的费用预扣金额较多。 结论 活血化瘀类药物存在不合理用药。有循证依据，必须使用的，建议仅在发病早期使用，中晚期患者获益不大时尽量不用；对于无循证依据或指南支持使用的药品，尽量不用；存在滥用情况，严禁使用。

[关键词] 医保费用；合理用药；医院管理；医疗保险

[中图分类号] R197.3 [文献标识码] A [文章编号] 1674-4721（2016）10（c）-0170-05

[Abstract] Objective To analyze the drugs of promoting blood circulation and removing blood stasis which were refused to pay medical expenses by medical insurance in 2015， find out the reasons and take measures to reduce the medical expenses refused by medical insurance and promote rational drug use. Methods The monthly original data of those drugs which were published on the hospital public information platform by medical insurance office of the 105th Hospital of PLA were collected， classified and analyzed. Then， access to some cases and analyze the rationality of drug use. Results The number of refusing to pay medical expenses by medical insurance was high， up to 121 times. The drug abuse was discovered in same cases. There was 24 times which were refused to pay medical expenses in Department of Endocrinology. The medical expenses refused by medical insurance were high both in the use of drug which defined for a particular situation and in obviously irrational drug use. Conclusion There are irrational drug use in promoting blood circulation and removing blood stasis. If those drugs must be used and have evidence-based medicine， it is recommended to use only in the early stages of the disease. Advanced patients as far as possible don′t use because of little benefit. If those drugs don′t have evidence-based medicine or guidebook， as far as possible don′t use. If those drugs are abuse， strictly prohibit.

[Key words] Medical insurance expenses； Rational drug use； Hospital management； Medical insurance

近年来随着医改不断地深化，医保患者成为医疗机构中主要就医人群[1]，不同的医保类型，患者住院费用存在差异，朱娟娟等[2]研究对比了不同医保类型的高血压患者，其住院费用由高至低分别是职工医保、居民医保、新农合，指出影响住院费用差异的因素有医保类型、住院天数和年龄。由于医保政策的影响，职工医保会利用较多医疗资源，医务人员受利益驱使等而使用贵重药、做大检查等[3]。医保政策使广大患者获益的同时，也承担了一些不必要的损失。某些疾病病程长、病情复杂、不易治愈，消耗卫生资源较多，给患者带来了沉重的经济负担，同时加快了医保基金的支出[4]。……