Core Points - The National Healthcare Security Administration (NHSA) has announced a plan to implement intelligent supervision of at least 50 types of key monitored drugs that are prone to resale and return to the medical insurance system by the end of December 2025 [1][2] - By June 2026, the supervision will expand to at least 100 types of these drugs across all provinces and regions, with full coverage expected by December 2026 [1] - The focus will be on three categories of drugs: those frequently involved in illegal use of medical insurance funds, those with high payment amounts and abnormal spending growth, and those with high resale demand and profit margins [1] Drug Supervision - The supervision will target abnormal purchasing behaviors, including excessive purchases without legitimate reasons, repeated purchases across institutions without significant changes in medical conditions, and frequent or fraudulent purchases [1][2] - The NHSA emphasizes the need to distinguish between legitimate medical needs and fraudulent behaviors related to excessive prescriptions and resale of drugs [2] Key Institutions and Personnel - The plan will also monitor three categories of institutions and personnel: insured individuals suspected of abusing medical insurance for excessive prescriptions, medical institutions with concentrated excessive prescription behaviors, and medical staff suspected of assisting or inducing others in fraudulent prescription practices [2]

Core Viewpoint - The National Healthcare Security Administration (NHSA) is advancing the intelligent regulation of medical insurance funds, emphasizing the importance of big data and smart supervision in ensuring the effective use of these funds [1][6]. Group 1: Historical Development of Intelligent Regulation - Since 2019, NHSA has initiated the construction of intelligent monitoring "demonstration points" across 32 cities, laying a solid foundation for the management of the knowledge and rules databases [2][3]. - In March 2022, NHSA issued a management approach for the intelligent audit and monitoring knowledge and rules databases, aiming to enhance regulatory efficiency and promote effective fund usage [2][3]. - The framework for the knowledge and rules databases was officially published in May 2023, marking a significant step towards a unified and transparent intelligent regulatory system [3][6]. Group 2: Implementation of the Knowledge and Rules Databases - The first batch of rules and knowledge points was released on May 23, 2023, covering 11,290 detailed knowledge points related to gender and age-specific medication and medical services [5]. - Subsequent batches addressed issues such as improper pricing for surgical projects and restrictions on drug usage for specific insurance types, ensuring compliance with national pricing regulations [5][6]. - The continuous release of these databases indicates a shift towards a more intelligent and refined regulatory phase for medical insurance funds [3][5]. Group 3: Importance of Intelligent Regulation - The traditional regulatory methods are becoming inadequate due to the increasing complexity and volume of healthcare data, necessitating a shift to intelligent monitoring systems [6][8]. - The establishment of a nationwide intelligent regulatory system is crucial for real-time tracking of fund usage behaviors, enhancing the protection of public healthcare funds [6][8]. - The intelligent regulation system serves as a first line of defense for medical institutions, promoting compliance and reducing the occurrence of fraudulent activities [9]. Group 4: Collaboration Between NHSA and Medical Institutions - The "two databases" are reshaping the relationship between NHSA and medical institutions, facilitating a win-win scenario through standardized and efficient management [9]. - Medical institutions can integrate the intelligent regulation databases into their systems, allowing for proactive compliance checks and reducing the likelihood of non-compliant behaviors [9]. - As these rules become embedded in hospital information systems, healthcare providers will receive real-time alerts to correct potential issues related to inappropriate prescriptions or charges [9].

Core Viewpoint - The National Healthcare Security Administration (NHSA) has announced a pilot program for intelligent supervision reform, selecting 92 trial regions and 359 designated medical institutions to enhance compliance and reduce violations in the use of medical insurance funds [1] Group 1: Pilot Program Details - The pilot program includes 92 regions, with provinces such as Tianjin, Hebei, Shandong, Hainan, Guizhou, Qinghai, and Ningxia participating at the full provincial level [1] - A total of 359 designated medical institutions have been selected for the pilot program [1] Group 2: Implementation Strategy - The NHSA aims to utilize the "Two Databases" rules and knowledge points to enhance the intelligent supervision reform pilot [1] - The designated medical institutions will serve as a "testing ground" for the development and public disclosure of the "Two Databases" [1] - The initiative seeks to improve the effectiveness of the provincial intelligent supervision subsystems, aiming to prevent violations of medical insurance fund usage from the source [1]

Core Viewpoint - The article emphasizes the importance of intelligent supervision of medical insurance funds as a crucial measure for ensuring the safe, reasonable, and efficient operation of these funds, highlighting its role in preventing risks and promoting sustainable healthcare systems [1][10]. Summary by Sections Policy Background of Intelligent Supervision - The complexity and risk associated with medical insurance fund usage necessitate a digital transformation in supervision, supported by various national policies [2]. - In 2021, the National Medical Insurance Administration and other departments issued regulations to establish a comprehensive fund supervision system [2]. - By the end of 2023, all regions are expected to implement intelligent supervision systems, creating a nationwide monitoring network [2]. Pain Points and Core Features of Intelligent Supervision - Intelligent supervision utilizes technologies such as big data, AI, cloud computing, and blockchain to create a comprehensive and dynamic regulatory system for medical insurance funds [4]. - Key features include data-driven approaches, closed-loop processes, and technology serving business needs, enabling real-time monitoring and rapid response to issues [4]. Pathways and Models for Intelligent Supervision System - Data governance is essential for establishing a robust intelligent supervision framework, requiring standardized data management and interconnectivity among various healthcare data sources [6]. - Emphasis on "human-machine collaboration" is crucial for enhancing regulatory precision and efficiency [6]. - The creation of an integrated intelligent supervision platform that fosters collaboration across multiple departments and levels is necessary for effective oversight [6]. Future Outlook and Recommendations - There is a need to improve legal frameworks and data standards to support intelligent supervision [7]. - The integration of intelligent supervision platforms should be accelerated to enhance cross-regional and cross-departmental collaboration [7]. - Strengthening talent development and technological innovation is vital for improving regulatory efficiency [9]. - Encouraging social collaboration in fund governance can create a supportive environment for safeguarding medical insurance funds [9]. - The trend towards proactive measures in intelligent supervision aims to prevent violations and enhance the overall quality of healthcare services [9]. Conclusion - Intelligent supervision is positioned as a foundational element for the safe and efficient operation of medical insurance funds, with a focus on digital transformation and public health [10].