在长三角某三甲医院的诊室里，67岁的李阿姨请医生开甲状腺超声检查单，系统自动弹出提示："您近3 个月已在社区医院完成甲状腺功能检测，本次检查属于重复申请。"医生随即撤回检查，并建议优先参 考社区检查结果。这一幕的背后，是医保结算数据与医院诊疗数据的联通在发挥作用。 医保部门与医疗机构常被认为是"监管与被监管"的对立关系，在一些案例中，甚至会出现医保部门为防 骗保而过度依赖事后稽核，医疗机构为控成本增营收，可能出现分解住院、过度检查等不当医疗行为。 如今，医保与医疗体系正在从被动衔接转向主动协同。而这一转向的核心密码，就藏在海量数据的流动 与整合之中。医保数据与医疗机构数据，一个是"医疗保障账本"，一个是"健康诊疗日志"。当二者打破 壁垒、深度融合，便形成了双向治理的数字引擎，既为医保基金安全筑牢防线，又为医疗服务提质增效 注入动能。 在辽宁大连，住院均次费用、检查检验和药品占比、月度费用变化、同病种费用结构均值……数据共享 帮助医院告别"经验决策"模式，智能监控系统的预警功能为精细化管理提供了有力保障；在福建福州， 通过数据可视化应用体系，定点医疗机构不仅能快速获取自身的汇总分析数据，还能获取医保公开的各 类 ...

Core Insights - The integration of medical insurance data and healthcare institution data is transforming the relationship from a regulatory one to a collaborative one, enhancing both fund security and service quality [1][2][3] Group 1: Data Integration and Collaboration - The connection between medical insurance data and healthcare data creates a dual governance digital engine, improving the efficiency of medical services while safeguarding insurance funds [1][2] - Medical insurance data serves as a barometer for healthcare needs, while healthcare data provides detailed insights into treatment processes and patient behaviors [2][3] - The establishment of data workgroups by the National Medical Insurance Administration aims to enhance transparency and communication regarding fund operations and service quality [3] Group 2: Impact on Healthcare Institutions - Healthcare institutions can optimize resource allocation by accessing real-time medical insurance payment data and patient flow information, moving away from a one-sided data access model [2][3] - Data sharing initiatives in regions like Dalian and Fuzhou have enabled hospitals to adopt data-driven decision-making, improving management and operational strategies [3] Group 3: Benefits to Insured Individuals - The ultimate goal of enhanced data flow and communication between medical insurance and healthcare providers is to benefit insured individuals, ensuring that medical services are more efficient and aligned with insurance regulations [4]