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 ...

Core Points - The new healthcare policy in China will take effect from October 2025, significantly altering the reimbursement landscape for various medical expenses [1][3][4] - The policy aims to alleviate pressure on the medical insurance fund, which has been strained by rising healthcare costs and an increasing number of insured individuals [1][10] Summary by Categories Changes in Reimbursement Policy - Six categories of expenses will no longer be reimbursed by medical insurance starting October 2025, including non-essential nutritional supplements, special medical services, cosmetic surgery, non-therapeutic diagnostic tests, expensive traditional Chinese medicine, and services provided by non-medical institutions [3][4][5][8][10] - Non-medical essential nutritional supplements, such as vitamins and protein powders, will now be self-paid [3][4] - Special medical services that offer enhanced comfort and reduced wait times will also be excluded from reimbursement [4] - Cosmetic procedures aimed at improving appearance will not be covered, reinforcing previous regulations that were not strictly enforced [4][5] - Preventive diagnostic tests requested by individuals rather than prescribed by doctors will not be reimbursed [5][6] - Certain high-cost traditional Chinese medicine items will be removed from the reimbursement list, continuing a trend observed in previous adjustments [8] Implications for Healthcare Financing - The new regulations are expected to reduce the financial burden on the medical insurance fund, which has been under pressure due to rising medical expenses [5][10] - The healthcare market, particularly in cosmetic procedures, has seen significant growth, with the market size exceeding 450 billion yuan in the first half of 2025, indicating a shift towards self-funded healthcare options [5][8] - The policy reflects a broader challenge of balancing the sustainability of the medical insurance fund with the growing healthcare demands of an aging population [10] Public Awareness and Response - A significant portion of the insured population is unaware of the specifics of their medical insurance coverage, with surveys indicating that 67% do not understand the reimbursement scope [10][12] - Recommendations for the public include planning for medical expenses, considering supplementary commercial health insurance, and staying informed about policy changes to avoid unexpected costs [10][12]

人民健康是社会文明进步的基础。9月18日，湖北省政府新闻办召开"决胜收官'十四五'谋篇布局'十五 五'"系列新闻发布会第十二场：全民健康篇，介绍"十四五"期间湖北省全民健康的相关情况，并回答记 者提问。 "十四五"时期，湖北坚持以人民健康为中心，全面落实健康优先发展战略，促进健康融入所有政策，大 力推进健康湖北建设，卫生健康事业发展取得长足进步。相比2020年，2024年全省人均预期寿命从78岁 增长到79岁，各项指标均优于全国平均水平，保持在中部地区前列，居全国第一方阵。同时，基本医保 参保率稳定在95%以上，累计有13.8亿人次享受医保报销，基金支出约4680亿元。 展望"十五五"，湖北将紧紧围绕加快建成中部地区崛起重要战略支点的目标，实施健康优先发展战略、 完善人口发展战略，通过高效能的治理、高质量的发展、高品质的服务，全方位全周期保障人民健康， 努力实现人民群众追求健康生活的美好愿景。 成功搭建城市10分钟急救圈 "十四五"以来，湖北在医疗资源服务供给扩增的基础上，全力打造医疗高峰高地，2024年争取国家"两 重""两新"资金总量全国第一、项目数量全国第二。 截至目前，全省共有医疗卫生机构3.89万家 ...

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]

Core Viewpoint - The new healthcare insurance regulations in 2025 will exclude five categories of expenses from reimbursement, impacting medical costs and patient experiences significantly [1]. Summary by Category Changes in Reimbursement - Five categories of expenses will no longer be reimbursed by health insurance, including high-value medical consumables, non-disease-related cosmetic services, nutritional supplements, unnecessary medical examinations, and off-label drug use [1][3][4][6]. Financial Impact - As of mid-2025, the total expenditure of the health insurance fund reached 897.5 billion yuan, with a year-on-year increase of 12.3%, indicating ongoing pressure on the fund [1]. - The exclusion of high-value medical consumables, which accounted for 186.5 billion yuan (12.7% of total expenditure) in 2024, will increase out-of-pocket expenses for patients [3]. - The anticipated increase in annual medical expenses for an average family of three due to these changes is estimated to be between 1,000 to 3,000 yuan [6][7]. Regulatory Adjustments - The new regulations aim to promote the sustainable development of the healthcare insurance system by reducing unnecessary expenditures and reallocating resources to essential medical needs [7]. - Specific examples of excluded items include high-end imported prosthetics, cosmetic procedures for aesthetic purposes, various nutritional supplements, redundant medical tests, and drugs used outside their approved indications [3][4][6]. Recommendations for Patients - Patients are advised to stay informed about local healthcare policies, prioritize necessary treatments, manage health proactively, and consider purchasing supplementary commercial health insurance to cover non-reimbursed expenses [9].

"以前交医保得骑电动车跑到镇上，现在在村里就能办，顺便还能取养老金，太方便了！"山东聊城阳谷 县张秋镇李堤口村村民王桂兰捧着刚申领的医保电子凭证，对村口助农服务点的"一站式"服务赞不绝 口。这是中国人民银行聊城市分行推动"金融+医保"服务下沉乡村的一个缩影。 据了解，中国人民银行聊城市分行以推动农村支付服务高质量发展为核心，创新"金融服务+医疗保 障"融合模式，有效提升农村地区普惠金融覆盖面和民生服务便利度，为乡村振兴注入强劲动能。截至 今年6月末，聊城市共建成2204个标准化Ⅰ类助农取款服务点，覆盖93%的行政村，其中80%以上具备 综合支付功能，服务内容涵盖基础取款、转账扩展以及医保服务等多元化场景，让200余万农村居民实 现"金融医保业务不出村"。 标准化筑基 构建农村支付服务新生态 走进李堤口村"农商银行+医保"服务点，标准化公示的12项服务清单清晰罗列小额取款、转账、城乡居 民医保登记、异地就医备案及电费代缴等便民业务，让村民一目了然。超市老板兼服务点服务专员刘大 姐一边熟练操作着"农金通"机具，一边向记者介绍着："你看这统一培训过的操作流程就是顺手，像医 保凭证申领这类新业务，借助系统提供的标准化 ...

办案不是目的，推动治理才是根本。该县纪委监委向县医保局和县卫生健康局发出纪检监察建议书，督 促扎实开展专项整治，全面排查212家定点医疗机构，指导自查自纠，重点整治过度诊疗、分解收费、 挂床住院等行为。督促将全县319个村卫生室全部接入"村医通"系统，实现城乡居民门诊统筹报销、城 镇职工个人账户刷卡等医保高频事项"结算不出村"。推动主管部门建立完善医保基金监管、医疗服务项 目价格申报等制度机制5项。 只有管住关键人、关键处，才能防止类似问题发生。该县纪委监委会同医保、卫健、市场监管、公安等 部门开展"专业+专责"联动监督，完善周会商、月调度研判机制。采取制发工作提示等方式，压实主管 部门责任，制发违法违规使用医保基金典型问题清单，及时核查高频次就诊记录、异常结算等疑点数 据，联合第三方专业机构对医院HIS系统进行数据分析。公开选聘7名社会监督员，开展医保报销、基 金监管、投诉举报等政策宣传。建成远程监控系统，将终端延伸至125家定点医药机构，动态监测医药 服务行为真实性，推动"事后查处"向"事前预防"转变。 四川省南江县纪委监委坚持系统思维，把风腐同查同治理念要求贯穿案件查办、整改纠治、警示教育等 各方面，紧 ...

Group 1: Healthcare System Development - The establishment of a national medical insurance cloud index in Hubei Province allows for seamless access to patient imaging data across different healthcare facilities, enhancing convenience for patients [1] - The "14th Five-Year Plan" emphasizes the comprehensive promotion of health in China, aiming to improve the quality of healthcare services and ensure better access for the public [1][2] - The construction of a tiered diagnosis and treatment system is underway, with 2,188 counties advancing the establishment of closely-knit county medical communities, facilitating mutual recognition of results between primary and higher-level medical institutions [2] Group 2: Medical Insurance and Financial Support - In Guangzhou, over 7,000 mothers spent less than 100 yuan on childbirth after insurance reimbursement, highlighting the financial relief provided by the medical insurance system [3] - The coverage of medical insurance has expanded significantly, with the reimbursement rates for inpatient expenses reaching 80% for employee insurance and 70% for urban and rural residents [3] - The 2024 National Medical Insurance Directory includes 3,159 types of drugs, significantly increasing access to essential medications for various diseases [3] Group 3: Public Health System Enhancement - The integration of disease control and prevention personnel into hospitals is being expanded, with 254 cities participating in the pilot program to enhance public health monitoring [4] - The per capita financial subsidy for basic public health services has reached 99 yuan, reflecting increased public financial support for health initiatives [4] - The health literacy rate among residents has improved from 17.06% in 2018 to 31.87% in 2024, indicating a growing societal emphasis on health [4]

Core Viewpoint - The Guangdong Provincial Medical Security Bureau and the Health Commission have initiated a comprehensive reform of medical insurance payment for tightly-knit county medical communities, aiming to enhance grassroots medical service capabilities and improve accessibility for insured individuals [1][6]. Group 1: Reform Objectives - The reform aims to shift the focus from "treatment-centered" to "health-centered" care, allowing insured individuals to access quality medical services locally, thereby addressing issues of difficulty and high costs in seeking medical care [1]. - The reform emphasizes city-level coordination and adheres to principles of "income-based expenditure, balanced revenue and expenditure, with slight surplus" [1]. Group 2: Payment Mechanism - The annual total payment amount for medical communities will be determined based on the average medical expenses over the previous three years, with adjustments for annual growth [2]. - A 3% annual guarantee fund and a 2% risk adjustment fund will be established within the total payment amount [2]. - Payments will be made monthly, with year-end settlements based on performance evaluations of medical services [3]. Group 3: Risk Sharing - A mechanism for shared responsibility regarding surplus and reasonable overspending will be established, with a risk adjustment fund covering initial overspending due to public health emergencies [4]. - The specific rules for surplus retention and overspending sharing will be developed by local medical insurance and health departments [4]. Group 4: Referral Mechanism - The reform includes the establishment of a dual-direction referral mechanism, where referrals within the medical community are treated as a single hospitalization, requiring only one deductible payment [5][6]. Group 5: Case Study - Yangxi Medical Community - Yangxi County, a pilot area for the reform, has successfully transitioned from a deficit to a surplus in its medical insurance fund, achieving a surplus of 36.47 million yuan in 2023, up from a deficit of 41 million yuan in 2018 [8][9]. - The county's medical community has implemented measures to reduce disease prevalence and medical expenses, thereby enhancing health management and service efficiency [8][9].

Core Insights - The article highlights the improvements in the healthcare insurance system in Baoji City, emphasizing reduced costs and increased transparency for patients [1][2][3][4][5][6] Group 1: Fund Management and Efficiency - Baoji City has implemented a multi-faceted approach to enhance the safety and efficiency of the medical insurance fund, including revenue generation, scientific management, and regulatory measures [1][2][3] - The average monthly contribution for employed individuals has increased by 550 yuan, resulting in an additional 120 million yuan in the employee medical insurance fund over the year [2] - The city has achieved a participation rate of 96.8%, with 3.1034 million insured individuals [2] Group 2: Cost Reduction and Patient Benefits - The introduction of a disease-based payment reform has led to a 10.5% decrease in average hospitalization costs, with a 14% reduction in medical insurance fund expenditures and an 8% decrease in personal financial burden [3] - The cumulative balance of the urban residents' medical insurance fund can cover 7.35 months of payments, placing Baoji City in a leading position within the province [4] Group 3: Smart Regulation and Oversight - The launch of a smart medical insurance regulatory platform has improved oversight of 1,380 retail pharmacies, significantly reducing fund expenditures by 466.4 million yuan, a 40% decrease [5] - The platform allows for real-time tracking of drug prices and sources, enhancing transparency and consumer protection [5] Group 4: Anti-Corruption Measures - Baoji City has intensified efforts to combat fraud in the medical insurance sector through stringent regulatory measures, including joint inspections and smart monitoring [6] - The city has adopted a comprehensive approach to safeguard the medical insurance fund, ensuring that resources are used effectively and efficiently [6]