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筑牢医保数据质量防线
Sou Hu Cai Jing· 2025-09-30 07:54
神秘未知医生大量开药、73岁老人被开展"无痛取卵"、男性患者出现宫腔镜结算记录……这些看似荒诞的操作,竟都是数据质量"掉链子"闹的。近期,国家 医保局依托全国统一的医保信息平台,精准查处多起异常数据典型案例,医保数据对监管的赋能作用持续凸显。 | 性别: | | --- | | 姓名: 女性 年龄:73岁 | 图片来源:国家医保局微信公众号 大数据时代,任何违法违规行为都难逃"数据慧眼"。医保基金是群众的"救命钱",其安全高效运转,同样离不开数据质量这一"基石"。此次国家医保局披露 的典型案例,看上去只是偶然的数据失误,实则揭示了部分定点医药机构在数据质量管理上仍存在短板和漏洞。而医保数据一旦出现差错,不仅会触发监管 警报,还会引发医保现场飞检,最终导致医保监管和医药机构管理成本的双重浪费。 守护群众"看病钱""救命钱",需要定点医药机构、医保部门形成合力,筑牢医保数据质量防线,堵住医保基金流失漏洞,确保救命钱用在刀刃上。 定点医药机构必须当好数据质量第一责任人,确保医保数据规范填报,完善日常动态校核,像"筛沙子"一样把数据隐患消除在源头,才能避免因小失大。各 级医保部门需发挥技术优势,完善智能监控与交叉校验 ...
提升全民健康获得感的关键所在——从2025年中国卫生发展论坛看“三医”协同
Xin Hua She· 2025-09-27 14:24
新华社北京9月27日电 题:提升全民健康获得感的关键所在——从2025年中国卫生发展论坛看"三 医"协同 "下一步要持续推动中医药融入分级诊疗体系,发挥其在治未病、重大疾病和康复中的独特作 用。"严华国说。 新华社记者 李恒、彭韵佳 推动"三医"协同发展和治理,是深化医改、提升全民健康获得感的关键所在。 9月27日,2025年中国卫生发展论坛在京举行,主题聚焦"'三医'协同发展和治理:跨部门行动与改 革"。相关部门负责人围绕医疗、医保、医药三大体系的深度融合展开深度对话,并探讨下一步发展方 向。 医疗:从"以治病为中心"转向"以健康为中心" 国家卫生健康委副主任、国家疾控局局长沈洪兵指出,"三医"协同不仅是深化医改的重要目标,更 是推动卫生健康事业高质量发展的关键路径。 党的十八大以来,我国医疗卫生服务体系持续优化,全国已设置13个类别26个国家医学中心、125 个国家区域医疗中心和114个省级医疗中心,优质医疗资源不断向中西部和基层下沉。 "当前,全国338个地市(州、盟)实现医学检查结果互认,互认项目超过200项;紧密型城市医疗 集团和县域医共体建设加快,2024年双向转诊人次达3600万,较2020年增 ...
医保新规下!2025年开始,这5项费用或将不能再报销
Sou Hu Cai Jing· 2025-09-18 22:38
Core Insights - The new healthcare regulations set to take effect in 2025 will lead to the exclusion of certain medical expenses from insurance reimbursement, impacting patients financially [1][2][10] - The adjustments are necessary due to the increasing financial pressure on the healthcare insurance fund, driven by an aging population and rising medical costs [1][7] Summary by Categories Changes in Reimbursement - Five categories of expenses are likely to be removed from insurance coverage, including: 1. Certain auxiliary examinations and premium medical services, such as high-end health check packages and non-essential imaging tests [4] 2. Inefficient or replaceable medications, particularly those with low clinical value or cheaper alternatives [5] 3. Non-essential rehabilitation treatments and medical devices that do not directly impact disease treatment [6] 4. Specific traditional Chinese medicine treatments that are not deemed essential [6] 5. Non-emergency cross-regional medical services that do not follow referral procedures [6] Rationale Behind Adjustments - The adjustments aim to alleviate the financial strain on the healthcare fund by focusing resources on essential medical services [7] - The policy changes are designed to encourage rational medication use and medical service selection, reducing unnecessary healthcare expenditures [7] - The adjustments also promote the development of the domestic pharmaceutical industry by encouraging the use of innovative and cost-effective medications [7] Strategies for Patients - Patients are advised to understand the new insurance policies and their local variations to avoid unexpected costs [8] - Emphasizing tiered medical care by initially visiting primary healthcare facilities can enhance reimbursement rates [8] - Choosing medications and treatments within the insurance directory can significantly reduce personal expenses [8] - Staying informed about policy changes is crucial for adapting healthcare choices accordingly [8] - Considering supplemental commercial health insurance can provide additional coverage for high-end medical services or specialized medications [9] Positive Signals - Despite the exclusion of certain items from coverage, there are positive developments, such as the inclusion of new cancer drugs and rare disease medications in the insurance directory [10] - The adjustments reflect ongoing efforts to balance the sustainability of the healthcare fund with the medical needs of the population [10]
个人账户缩水28%?2.3万亿缺口待补,2025年委托投资扩至2.4万亿救局
Sou Hu Cai Jing· 2025-09-14 19:20
Core Viewpoint - The article discusses the challenges and potential solutions in China's healthcare insurance reform, particularly focusing on the imbalance in personal account funds between different age groups and the need for strategic investment to address a significant funding gap in the system [1][10]. Group 1: Structural Issues in Personal Accounts - By 2025, the contribution standard for employee health insurance personal accounts has decreased by 28% compared to historical peaks, with those under 35 seeing their contribution rate reduced to 2% [4]. - The aging population is leading to a significant disparity, with retirees having a hospitalization rate nearly four times that of currently employed individuals, while those over 80 have an average personal account balance of less than 200 yuan [4]. - In some developed regions, individual health insurance accounts have accumulated balances exceeding 120,000 yuan, exacerbating the intergenerational financial burden on the healthcare system [4]. Group 2: Investment Strategies and Fund Management - As of March 2025, the entrusted investment scale of the basic pension insurance fund has surpassed 2.4 trillion yuan, marking a 20% increase from the previous year [7]. - The investment strategy is shifting towards a higher allocation in equity assets, aiming to reach a policy limit of 15%, which could potentially generate an additional 180 billion yuan in annual investment returns based on historical market performance [7]. - Innovative mechanisms for regional balance, such as directing 30% of investment returns to cover current fund deficits, have already resulted in increased monthly benefits for retirees in certain provinces [7]. Group 3: Technological Enhancements in Oversight - The use of blockchain technology for real-time monitoring of investment projects has been implemented, covering 92% of investment activities and enabling rapid tracking of fund flows [8]. - A smart risk control system developed by a major state-owned bank successfully intercepted 23 potential abnormal transactions within three months, preventing over 800 million yuan in potential losses [8]. Group 4: Challenges and Future Trends - There exists a cognitive gap among younger insured individuals regarding the "family mutual aid" mechanism, with 43% believing that personal account funds are private property, which poses a challenge for reform implementation [9]. - The introduction of a dynamic adjustment mechanism for fund allocation will link the distribution of healthcare accounts to key indicators like aging rates, enhancing the system's adaptability [14]. - Future trends indicate a rise in service penetration rates, with community service stations expected to exceed 65%, and AI investment advisors managing over 40% of pension fund assets for personalized risk-reward matching [12].
织密医疗保障网
Core Insights - The national unified medical insurance information platform has achieved millisecond-level response times and has connected 644,000 designated medical institutions across provinces, facilitating "cross-province handling" for eight high-frequency services [1] - The implementation of big data and artificial intelligence technologies is enhancing the accessibility of medical insurance services while also making it harder for fraudulent activities to occur [1] - The medical insurance fund regulatory system has been fully established, with over 100 billion yuan recovered from fraudulent activities [1] Group 1 - Since the beginning of this year, flying inspections have covered all planning areas and various medical insurance fund users [1] - The government is actively addressing historical issues related to "returning drugs" and has launched special actions to combat fraud and illegal activities using traceability codes [1] - Cumulatively, during the 14th Five-Year Plan period, medical insurance funds have disbursed 12.13 trillion yuan, providing financial support for medical reimbursements and the development of the pharmaceutical industry [1] Group 2 - The National Medical Insurance Administration aims to effectively manage and utilize medical insurance funds to protect public health while also injecting strong momentum into the development of related industries, including pharmaceuticals [1] - The ongoing efforts are part of a broader initiative to support the construction of a healthier China at a higher level [1]
决胜“十四五” 打好收官战|织密医疗保障网——我国基本医保制度不断完善
Xin Hua She· 2025-08-24 12:19
Core Insights - The article emphasizes the importance of healthcare insurance in safeguarding the public's health and financial well-being, highlighting the efforts made during the "14th Five-Year Plan" to enhance and expand insurance coverage for all citizens [1] Group 1: Universal Coverage - The national basic medical insurance coverage rate has stabilized at around 95% during the "14th Five-Year Plan," with nearly 20 billion people benefiting from insurance reimbursements from 2021 to 2024 [2] - Innovations such as allowing newborns to enroll in insurance using birth certificates and relaxing household registration restrictions have marked a new phase in universal coverage [3] Group 2: Maternity Insurance Expansion - By June 2025, approximately 253 million people are expected to participate in maternity insurance, with cumulative expenditures reaching 438.3 billion yuan, benefiting 96.14 million people [3] - Nearly 60% of regions have begun directly issuing maternity benefits to insured female employees, with plans to enhance services in maternal and pediatric care [3] Group 3: Major Illness Insurance and Medical Assistance - During the "14th Five-Year Plan," medical assistance policies have benefited 673 million rural low-income individuals, reducing their financial burden by over 650 billion yuan [3] - Full funding for insurance for special hardship groups and orphans ensures that vulnerable populations receive necessary medical coverage [3] Group 4: Expanding Benefit Coverage - The introduction of the "medical insurance wallet" allows insured individuals to transfer personal account funds to family members for medical expenses, breaking provincial limitations [4] - The establishment of a comprehensive outpatient mutual aid mechanism and the inclusion of assisted reproductive services in insurance coverage are part of broader efforts to enhance benefit offerings [4] Group 5: Healthcare Service Upgrades - The number of designated medical institutions has reached 1.1 million, with 435 types of drugs included in centralized procurement, further alleviating the financial burden on citizens [5] - The total number of drugs in the insurance catalog has reached 3,159, reflecting ongoing adjustments to improve healthcare service accessibility [5] Group 6: Digital Transformation in Healthcare - The implementation of a unified national medical insurance information platform has significantly improved service efficiency, allowing for cross-province processing of high-frequency matters [7] - Advanced technologies such as big data and artificial intelligence are enhancing the accessibility of medical insurance services [7] Group 7: Fund Management and Oversight - The healthcare fund regulatory system has been fully established, recovering over 100 billion yuan in misused funds [8] - Comprehensive inspections have covered all regions and types of fund usage, addressing historical issues of fund misappropriation [8] Group 8: Economic Impact of Healthcare Insurance - Cumulative healthcare fund expenditures have reached 12.13 trillion yuan during the "14th Five-Year Plan," providing financial support for both public health and the pharmaceutical industry [9] - The ongoing management of healthcare funds aims to bolster the development of related industries while safeguarding public health [9]
推进医保数据与医疗数据更好联通
Ren Min Ri Bao· 2025-08-22 01:09
Core Viewpoint - The integration of medical insurance data and healthcare institution data is transforming the relationship between regulatory bodies and healthcare providers from a passive connection to an active collaboration, enhancing both the safety of insurance funds and the quality of medical services [1][2][3]. Group 1: Data Integration and Collaboration - The integration of medical insurance data, which includes information on over 1.3 billion insured individuals, and healthcare data, which encompasses detailed medical records, is crucial for effective governance [2]. - The establishment of a full-chain regulatory system through the connection of insurance settlement data, hospital information systems, and drug traceability data allows for precise oversight by insurance departments [2][3]. - The National Medical Insurance Administration has initiated a new phase of data sharing, requiring local insurance data working groups to regularly disclose fund operation conditions and engage with healthcare institutions [3]. Group 2: Impact on Healthcare Institutions - Healthcare institutions can optimize resource allocation by accessing timely data on insurance payments, patient flow, and drug usage, which was previously unavailable to them [2]. - Data sharing has enabled hospitals to move away from experience-based decision-making to data-driven management, enhancing operational efficiency [3]. - The use of data visualization tools allows healthcare institutions to quickly access their performance metrics and compare them with industry standards, facilitating targeted operational strategies [3]. Group 3: Benefits to Insured Individuals - The ultimate goal of improved data flow and communication between insurance and healthcare sectors is to benefit insured individuals by providing more efficient and compassionate medical services [4].
推进医保数据与医疗数据更好联通(无影灯)
Ren Min Ri Bao· 2025-08-21 22:04
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]
伯克希尔二季度调仓:低位布局联合健康,加地产钢铁,减科技与银行
Investment Rating - The report indicates a neutral investment rating for the industry, reflecting a cautious approach towards high valuation sectors such as technology and banking while seeking value in cyclical sectors [7][10]. Core Insights - Berkshire Hathaway's portfolio value decreased slightly to $257.5 billion, with the top ten positions accounting for 87.3% of the total [7][9]. - The most significant investment was in UnitedHealth, acquiring 5.04 million shares valued at approximately $1.57 billion, following a significant price drop of over 40% year-to-date [8][9]. - The report highlights a strategic shift towards real estate, construction, and energy sectors, with new positions in Lamar Advertising, Allegion, Nucor, Pool, and Chevron [9][10]. - Notable sell-offs included large-cap stocks such as Apple and Bank of America, with reductions of 20 million shares (-6.7%) and 26.3 million shares (-4.2%) respectively, aimed at locking in profits and reducing concentrated risks [10][11]. Financial Summary - For Q2, revenue fell by 1.2% year-on-year to $92.52 billion, while net income plummeted by 59.2% to $12.37 billion, primarily due to a $3.76 billion impairment from Kraft Heinz and a 73.5% decline in investment gains [11]. - Operating earnings decreased by 3.8% to $11.16 billion, with cash and cash equivalents at $344 billion, indicating a cautious approach to stock buybacks since May 2024 [11].
2025全国智慧医保大赛启动:面向创新药等十余领域
Core Viewpoint - The National Healthcare Security Administration (NHSA) is leveraging healthcare data to drive innovation in the medical and health sectors, launching the "2025 National Smart Healthcare Competition" to address public welfare challenges through digital means [1][2]. Group 1: Competition Overview - The competition, initiated on August 1, 2025, is the third annual event organized by NHSA, aiming to transform innovative solutions into practical applications [1]. - This year's competition adopts a new format without specific tracks, allowing participation across over ten fields including healthcare innovation, financial insurance, and public service [2][3]. Group 2: Data Integration and Collaboration - The competition emphasizes three guiding principles: "Connecting," "Integrating," and "Opening," focusing on activating healthcare data to empower various industries [2][3]. - It will feature cross-regional integration of healthcare data from the Yangtze River Delta, providing a secure data environment for participating teams [3][6]. - NHSA aims to foster collaboration by integrating healthcare data with public data from Shanghai, enhancing the quality of data available for competition [3][5]. Group 3: Application and Future Directions - The competition will explore applications in areas such as innovative drug development, healthcare services, and intelligent fund supervision, supporting the integration of healthcare data into broader economic sectors [4][6]. - Participants will have access to real-world data, enabling them to address practical challenges in healthcare and policy adaptation [7].