Judge Juan Manuel Padilla Garcia, ChatGPT, and a controversial medicolegal milestone

Chat Generative Pre-Trained Transformer (ChatGPT) has revolutionized how we perceive artificial intelligence (AI).: Judge Juan Manuel Padilla Garcia created history by mentioning its use while passing judgment about an autistic child and payment for his medical treatment by his insurance company. The use of AI is not new and is helping the judiciary system in many ways. However, this judgment given on January 30, 2023, has ignited controversy among Judge Garcia’s peers and the global community (a Google search produced more than 70 million hits on February 5, 2023). EU has established guidelines that are to be followed before calling any AI tool trustworthy. This requires stringent compliance with the verification and due diligence process. In this instance, ChatGPT was used within 2 months of its launch, even when it has been shown to give incomplete, incorrect, and misleading answers in many instances. Hasty adaption of unproven technology, however good it may be, should not be our path. This might fuel the misguided fear amongst people about robots taking over from human judges.

Analysis on the difference between the payment limitations of anti-cancer drugs and the application scope of drug indications / 中国药房

OBJECTIVE To analyze the difference between the payment limitations of anti-cancer drugs and application scope of drug instructions， so as to better implement the payment policy of medical insurance drugs. METHODS The differences between the payment limitations of anti-cancer drugs and application scope of drug instructions in the National Catalogue of Drugs for Basic Medical Insurance， Industrial Injury Insurance and Maternity Insurance （2022） were compared and analyzed； the evidence-based basis of the difference was discussed， and the scope of limited payment was interpreted. RESULTS Totally 118 drugs had payment limitations； limitations scope mainly included limited evidence of gene detection results， limited indications， limited second-line and above treatment， limited payment duration， limited specialist prescription， limited medical institution grade， etc. Among them， 43 drugs had differences between the payment limitations and drug instructions， and the indications of 31 drugs were greater than payment limitations； for seven drugs， the drug indications beyond the payment limitations were recommended by the guidelines. The payment limitations of 75 drugs were consistent with drug instructions. The second-line and multi-line treatment was ineffective or intolerable with first-line drugs. There was a certain relationship between locally advanced， advanced or metastatic tumor and tumor stage， but different tumors had different criteria. Systemic treatment mainly referred to systemic treatment with drug. The results of limited genetic test required that the result was positive or negative. In addition， six kinds of TCM injections were limited to the level of medical institutions； the payment of two drugs did not exceed 12 months； when lenalidomide was combined with isazomide citrate， the medical insurance only paid for one of the drugs. CONCLUSIONS The payment limitations of some anti- cancer drugs are inconsistent with the drug indications. The drug payment limitations should be expanded according to the actual situation of clinical medication and the recommendations of guidelines. At the same time， the payment limitations should be formulated accurately and in detail， thus clinical and medical insurance staff can understand it and fully protect the interests of patients.

Study on value-based medical insurance access and pricing methods of multi-indication drugs / 中国药房

OBJECTIVE To discuss medical insurance access and pricing methods for multi-indication drugs. METHODS The access situation of multi-indication drugs in China’s medical insurance negotiation over the years was sorted out. Referring to the economic theory of value-based pricing and the relevant experience of other countries， five applicable pricing methods of 3 categories for multi-indication drug in China were summarized. Taking ceftazidime-avibactam（CAZ-AVI） as an example， cost- utility analyses were performed for different indications， and appropriate pricing methods were applied. RESULTS & CONCLUSIONS All multi-indication drugs in China adopted a single pricing method. The pricing methods that could be explored include product-based pricing， such as single pricing based on the lower-value indication or mixed/weighted single pricing； indication-based pricing， such as developing a new agreement for single pricing under different discounts and listing with different brands and pricing of the same medicine for different indications； and compensation for access restrictions. Each method has its advantages and limitations. The case of CAZ-AVI showed that it is necessary to estimate the value of each indication for multi- indication drugs， and comprehensively consider appropriate access conditions and pricing methods based on value. Although single pricing is simple to operate， it is different to reflect the value entirely. The indication-based pricing and compensation for access restrictions all depend on the information collection system and the cooperation of multiple departments. China is supposed to carry out the value-based pricing of multi-indication drugs and constantly explore reasonable access methods to improve overall social welfare.

Comments on research status and future of rare diseases in China / 中国热带医学

@#Rare diseases, also known as "orphan diseases", refer to diseases with very low incidence. Countries and regions define rare diseases according to epidemiological standards, economic standards of rare drugs and disease severity. The World Health Organization (WHO) has suggested the prevalence rate of less than 6.5 to 10 per 10 000 people to define rare diseases. In May 2018, "China's First List of Rare Diseases" was released, including 121 rare diseases. Most rare diseases are hereditary diseases with early onset, severe disease, and poor prognosis. About 75% of rare genetic diseases occur in the neonatal period or childhood, which are important part of human birth defects and brings a huge burden to society and families. The effective prevention and treatment of rare diseases is one of the important goals of building a "Healthy China". With the development of molecular biology technology and the continuous research and development of advanced medical products in the field of gene therapy, the level of clinical diagnosis and treatment of rare diseases has risen to a new level, which provides a possibility for the cure of some rare diseases. In China, most rare diseases rely on imported drugs, which cost a lot and bring heavy economic burden to patients. Improving the medical insurance system for rare diseases has become a difficult point in the current medical reform. This paper mainly discusses the definition of rare diseases, the research status, efforts and future development direction of rare diseases in China, in order to deepen the understanding and response of medical workers and the whole society to rare diseases.

Analysis of medical insurance access policy for rare disease drugs in the United Kingdom and enlightenment to China / 中国药房

OBJECTIVE To provide reference for the access to medical insurance for rare diseases in China based on the existing access pathway and framework by analyzing the access policy of medical insurance for rare diseases in the United Kingdom （UK）. METHODS After collecting relevant guidelines and policy documents related to drug use for rare diseases in the UK， content analysis method was used to analyze the evaluation mechanism of drug use for rare diseases， reimbursement decision- making standards， stakeholder participation， coping strategies for dealing with uncertainties and risks， and policy implementation effects， and extract the key points of medical insurance access for drug use for rare diseases in the UK， to provide some suggestions for the establishment of medical insurance access system for rare diseases in China. RESULTS & CONCLUSIONS From the perspective of access， the UK had adopted a separate approach and clear criteria to assess and reimburse drugs for rare diseases. From the perspective of evaluation mechanism， multi-stakeholders such as doctors， patients and applicants participated in the decision-making process in the UK. The UK addressed uncertainty and risk by gathering better clinical evidence and using the patient access programme. After the implementation of the policy related to drug use for rare diseases， the UK had achieved remarkable results in terms of funding for drug use for rare diseases， the reimbursement rate of drug application， and the number of funded patients. It is suggested that in the process of establishing and improving the evaluation and reimbursement system for rare diseases drugs in China， the availability of rare diseases drugs should be improved by establishing a separate access assessment path for rare diseases drugs and involving more stakeholders.

Study on French medical insurance payment policy for innovative medical products paid under DRG / 中国药房

OBJECTIVE To analyze the implementation experience of France’s additional list system for innovative medical products， and to provide reference for China to support medical institutions to use innovative medical products. METHODS Taking France as a case study， using policy analysis method， this paper systematically studied the practice of establishing additional list system to compensate for innovative medical products in France under diagnosis-related group （DRG） payment， including the establishment background， selection procedure and implementation effect. The suggestions were provided on the medical insurance payment methods for innovative medical products in China. RESULTS & CONCLUSIONS The additional list system established a compensation and payment system for innovative medical products with significant clinical efficacy but high treatment cost， covering four stages： application， evaluation， payment and adjustment， which effectively reduced the drug burden on medical institutions， promoted the use of innovative pharmaceutical products by medical institutions， and stimulated the innovation drive of the pharmaceutical industry， but at the same time brought payment pressure to the medical insurance fund. With the rapid spread of our DRG/diagnosis-intervention packet payment reform of China， some regions have also explored the establishment of a compensation and payment mechanism for innovative medical products， but there are still imperfections. We can refer to the implementation experience of the French additional list system and establish an effective compensation and payment system for innovative medical products starting from the establishment of selection criteria， the selection of compensation mode and the implementation of dynamic adjustment.

Landing practices of national medical insurance negotiated drugs in tertiary medical institutions of Zhejiang province / 中国药房

OBJECTIVE To provide reference for the subsequent landing of national medical insurance negotiated drugs （referred to as “national negotiated drugs”） at the provincial level. METHODS By reviewing the data publicly released by the official websites of National Healthcare Security Administration and the Healthcare Security Administration of Zhejiang Province， combined with policy documents， the descriptive analysis was conducted on the number of tertiary medical institutions， the actual allocation of national negotiated drugs， the availability rate of national negotiated drugs， the allocation rate of national negotiated drug varieties， and the allocation rate of medical institutions of various cities in Zhejiang province. The Spearman rank correlation test was used to analyze the correlation between the number of types of national negotiated drugs equipped in tertiary medical institutions in Zhejiang province and the per capita disposable income， the number of tertiary medical institutions equipped with national negotiated drugs， and the implementation time of disease diagnosis-related grouping （DRG） of various cities in Zhejiang province. RESULTS As of the first quarter of 2022， 135 tertiary medical institutions in Zhejiang province were equipped with a total of 261 types of national negotiated drugs， accounting for 94.91% of the 2021 edition of the National Negotiated Drugs Catalogue （275 types）. The allocation rates of Goserelin acetate sustained-release implant， Sacubitril valsartan sodium tablets， Alteplase for injection and other varieties were at high level， and the types of national negotiated drugs equipped were highly coincident with the top 10 causes of death with disease of urban and rural residents in Zhejiang province. The tertiary medical institutions in Hangzhou had the most types of national negotiated drugs， with 230 types， while Quzhou had the lowest， with only 34 types； allocation rate of national negotiated drugs in medical institutions of Zhoushan was the highest （100%）， while that of Lishui was the lowest （57.14%）. The types of national negotiated drugs equipped were positively correlated with per capita disposable income in various cities and the number of tertiary medical institutions equipped with national negotiated drugs （P＜0.01）， and there was no significant correlation with the length of implementation of DRG （P＞0.05）. CONCLUSIONS mail：lanyao@mails.tjmu.edu.cn The landing of national negotiated drugs in Zhejiang province is generally good， with a high rate of equipping tertiary medical institutions with national negotiated drugs and a high rate of equipping drug varieties. Therefore， it is recommended that the provincial implementation of national negotiated drugs should be multi-faceted， and policy-making departments should adopt a dual-channel of “unbundling” and “driving” to smooth the drug chain into hospitals. The health insurance sector should improve the “dual channel” management mechanism to share the pressure on hospitals to use drugs. At the same time， it should also improve the multi-level medical security system and raise the level of reimbursement of medical insurance for national negotiated drugs.

Analysis on the implementation effect of single disease payment policy for day surgery based on difference-in-differences model / 中华医院管理杂志

Objective:To analyze the implementation effect of single disease payment policy for day surgery (hereinafter referred to as the policy), for references for the reform of medical insurance payment.Methods:By collecting the information of inpatients from 2017 to 2019 in a tertiary hospital, the research group took patients with colorectal benign tumor and nodular goitre as the policy implementation group and the control group respectively. 2017-2018 was the pre implementation stage of the policy, and 2019 was the post implementation stage of the policy. The difference-in-differences (DID) model was used to analyze the changes in indicators such as length of stay and hospitalization expenses after policy implementation, under whether the policy is implemented or not, as well as before or after policy implementation.Results:A total of 2 419 patients were included, including 927 patients with nodular goiter in the control group and 1 492 patients with colorectal benign tumors in the policy implementation group (688 patients before the policy implementation and 804 patients after the policy implementation). The results of DID showed that the hospital days for patients with colorectal benign tumor decreased by 56.53%, the hospitalization expenses decreased by 26.51%, the out-of-pocket expenses decreased by 26.66%, the treatment expenses increased by 11.96%, the drug expenses decreased by 50.29% and the consumables expenses decreased by 20.23% after the implementation of the policy.Conclusions:The implementation of the policy could reduce length of stay, hospitalization expenses and out-of-pocket expenses, optimize the structure of hospitalization expenses, improve the efficiency of hospital diagnosis and treatment, and help the hospital realize its transformation from a size expansion to a quality and benefit expansion.

Analysis of factors influencing the medical insurance balance of hospitalization expenses for gastric cancer surgery patients under DRG payment / 中华医院管理杂志

Objective:To analyze the influencing factors of the medical insurance balance of hospitalization expenses for gastric cancer surgery patients under DRG payment, for reference for promoting the reform of DRG payment in public hospitals and controlling hospitalization expenses reasonably.Methods:The gastric cancer patients enrolled in the gastroenterology department of a tertiary comprehensive hospital from January to July 2022 were selected as the research subjects. The indicators such as patient age, medical insurance balance, hospitalization expenses and their composition were extracted from the hospital information management system and the medical insurance settlement system a certain city. Descriptive analysis was conducted for all data, and stepwise multiple linear regression was used to analyze the influencing factors of patients′ medical insurance balance. Monte Carlo simulation method was used to simulate different combination scenarios of various influencing factors to analyze the probability of medical insurance balance.Results:A total of 205 patients were contained, including 117 in the medical insurance balance group and 88 in the loss group. The difference in hospitalization expenses and medical insurance balance between the two groups of patients were statistically significant ( P<0.05). The intervention of medical insurance specialists, correct DRG enrollment, parenteral nutrition preparation costs, anti infective drug costs, examination costs, and consumables costs were the influencing factors of patient medical insurance balance ( P<0.05). Through Monte Carlo simulation verification, patients with different cost parenteral nutrition preparations, or different anti infective drug schemes had the higher probability of medical insurance balance in the scenario where the medical insurance commissioner intervenes and the DRG enrollment was correct. Conclusions:The hospital adopted interventions from medical insurance specialists to ensure the correct DRG enrollment of patients, accurate use of parenteral nutrition and anti infective drugs, and reasonable control the cost of examinations and consumables, which could increase the probability of medical insurance balance for gastric cancer surgery patients. In the future, hospitals should further promote the procurement of drug consumables in bulk, reduce unnecessary examinations, develop standardized perioperative nutritional interventions and anti infection treatment pathways, ensure the accuracy of DRG enrollment, optimize clinical diagnosis and treatment pathways to improve the efficiency of medical insurance fund utilization and provide high-quality medical services for patients.

Enlightenment of the DRG payment reform in the United States on the reform of China′s medical insurance payment methods / 中华医院管理杂志

In order to curb the excessive growth of medical expenses, the United States has initiated payment reform of diagnosis-related groups (DRG) since 1983, and developed a series of complementary measures to address issues such as overcoding and declining healthcare service quality which were exposed during the reform. The authors discussed the implementation of DRG payment reform in the United States, namely the case-mix specialization of medical institutions and the reduction of costs, as well as the relationship between the two. On this basis, the authors suggested that when implementing reforms to the medical insurance payment system in China, it is imperative to avoid such loopholes as overcoding by medical institutions and excessive pursuit of efficiency at the expense of quality control, as well as the decline of comprehensive rescue capability and quality of care incurred by the exacerbated specialization.

Game analysis on hospital outpatient payment methods of Chinese basic health insurance based on principle-agent theory / 中华医院管理杂志

As the major means of outpatient payment for basic medical insurance (the insurance for short) relies on fee-for-service, it tends to encourage unreasonable growth of medical expenses. Based on the principal-agent theory, this paper analyzed the principal-agent relationship between the insurance handling agencies and the hospitals designated by the insurance, and constructed a benefit game model of outpatient payment methods and the supporting supervision game model. This practice aims to explore the optimal and balanced benefit of the insurance payment methods and supporting supervision mechanism, and provide decision support for promoting the reform of medical insurance outpatient payment in China. The analysis results of the benefit game model of payment methods showed that a system mixing the post-payment and pre-payment could optimize and maximize the total benefits and interests of all the stakeholders within the system. Specifically, the practice recommended was a mixed payment integrating ambulatory-payment-classification, fee-for-service and global-budget-payment. The analysis of the supporting regulatory game model found that the factors that must be considered to ensure the expected utility of the above mixed payment mode as follows: the gap between the unreasonable income obtained by the hospital by out-of-control charging and the reward obtained by under-control charging, the size of the penalty after the unreasonable income of the hospital was discovered, the size of the regulatory cost and the loss of benefits of the government and the insured group. It is suggested to adopt the mixed payment method mainly based on the ambulatory-payment-classification supported by fee-for-service and global-budget. At the same time, medical insurance agencies can improve their supervision mechanism from such aspects as perfecting penalties, reducing supervision costs, leveraging government administrative power and advocating public supervision.

Analysis of compliance issues and management countermeasures of medical insurance fund in clinical research / 中华医学科研管理杂志

Objective:Clinical research is widely carried out in medical institutions, and there are differences in the use of research and conventional medical funds. This paper aimed to analyze the compliance issues of insurance fund in clinical research and explore the management strategies in the institutions conducting clinical trials or research.Methods:By consulting the literature, questionnaire, and work practice, this paper analyzed the current situation and existing problems of the compliance of the medical insurance fund in domestic clinical trials, proposed targeted management measures for the use of funds, and standardizes the corresponding workflow.Results:This paper summarized three payment methods of research-related funds and analyzed the main problems at present, including the definition of trial requirements, the payment of combined drugs specified in the protocol, the particularity of medical device trials, the payment of adverse events in clinical trial, the insurance of post-marketing research and clinical trial. According to the regulatory requirements and work practices, the corresponding management countermeasures were sorted out, including that the project funds and insurance audit should be carried out inside the medical institution. Clinical research, medical insurance management departments, ethics committees, and other departments should collaborate on establishing and improving a compliance management system. The research team should strengthen the management of adverse events, strengthen the publicity and education of the participants, and make good use of the sharing platform.Conclusions:The research institution should establish standardized and feasible processes, the research team should strengthen the management, and the use of the sharing platform is conducive to ensuring the compliance of the medical insurance fund and protecting the interests of the participants.

Social support status and influencing factors among schizophrenics in remission in Northeast Sichuan / 四川精神卫生

ObjectiveTo investigate the social support status and influencing factors of schizophrenics in remission in Northeast Sichuan， and to provide ideas for improving their social support. MethodsFrom May to September 2020， a total of 533 patients who met the diagnosis criteria of the International Classification of Diseases， tenth edition （ICD-10） for schizophrenics in remission at the mental health institutions in Guangyuan， Bazhong and Dazhou cities were selected for the survey， and patients were assessed by self-made demographic and clinical data inventory and Social Support Rating Scale （SSRS）. Then the social support status of schizophrenic in remission and influencing factors were analyzed， meantime， the impact of the second round reimbursement policy of medical insurance benefits on their social support was addressed particularly. Results①The SSRS total score， objective support， subjective support， and utilization of support scores of schizophrenics in remission were lower than those of the national norm （t=5.065~30.382， P<0.01）. ②Univariate analysis showed that SSRS score was relatively high among patients with female gender （t=-3.632）， retired status （F=5.951）， married status （F=5.951）， spouse as primary caregiver （F=23.841）， annual household income >5 000 yuan （F=15.892）， patient's economic income （t=4.083）， and outpatient or online follow-up （F=3.954）， with statistically significant differences （P<0.05 or 0.01）. ③The total and dimensional scores of SSRS in patients with access to the second round medical insurance reimbursement were significantly higher than those without （t=10.195~25.103， P<0.01）. ④Multiple linear regression analysis denoted that gender， work status， marital status， primary caregivers， annual family income， economic income， follow-up visits and the second round medical insurance reimbursement were the factors influencing social support status of schizophrenics in remission （β=0.201~2.115， P<0.05 or 0.01）. ConclusionThe social support of schizophrenics in remission in Northeast Sichuan is below the national average， furthermore， their social support levels are affected by the gender， work status， marital status， primary caregivers， annual family income， economic income， follow-up visits and the second round medical insurance reimbursement， and the second round medical insurance reimbursement may ameliorate the social support status of patients.

Evidence-based medical evidence change of the payment limitation of antitumor drugs in national medical- insurance negotiation / 中国药房

OBJECTIVE To study the changes in medical-insuran ce payme nt limitations of anti tumor drugs in national medical- insurance negotiation （hereinafter referred to as “national negotiation ”）and recommendations of diagnosis and treatment guidelines corresponding to tumor issued by Chinese Society of Clinical Oncology （CSCO），so as to provide reference for the performance of national negotiation. METHODS The annual list of anti tumor drugs in national negotiation were summarized ；CSCO diagnosis and treatment guidelines were searched according to the tumor types restricted by the medical- insurance payment limitations of antitumor drugs in national negotiation ；the evidence evolution of the payment limitations of medical insurance for anti tumor drugs and CSCO diagnosis and treatment guidelines were analyzed quantitatively. RESULTS & CONCLUSIONS Finally，46 antitumor drugs in the agreement period were included ；seven of their payment limitations of medical insurance had changed ；and there were differences among the payment limitation of medical insurance ，drug labels and recommendations of CSCO diagnosis and treatment guidelines for 13 varieties；the recommendations ，strength of evidence ，recommendation level of CSCO diagnosis and treatment guidelines were changing for 28 varieties anti tumor drugs in different years ；the number of anti tumor drugs recommended by CSCO diagnosis and treatment guidelines differed significantly among different cancer varieties. The medical insurance payment limitations of anti tumor drugs in national negotiation have been gradually expanded ，and the corresponding recommendations ，strength of evidence， recommendation level in guidelines have been constantly improved. However ， the payment limitation of B-19-H-20200622） medical insurance for most drugs are limited to the indicationsof drug labels and drugs for some cancers are scarce ，such as 85420393。E-mail：oushunlong@sohu.com esophageal cancer and nasopharyngeal carcinoma.

Analysis of outpatient choice and its influencing factors of hypertensive patients with medical insurance in Beijing / 中华医院管理杂志

Objective:To investigate the current status and influencing factors of outpatient institution choice for hypertensive patients with basic medical insurance in Beijing, for reference to promote the implementation of the hierarchical medical system and guiding hypertensive patients to seek healthcare in primary care.Methods:Based on data of hypertensive outpatients from the basic medical insurance database of Beijing from April 2019 to January 2020, we analyzed major demographic characteristics of hypertensive patients, the selection of outpatient institutions and its influencing factors. The chi square test was used for comparison between groups, and the multivariate logistic regression model was used to analyze influencing factors.Results:2.842 1 million outpatients with hypertension were enrolled. 39.03% of them chose primary healthcare institutions, 5.16% chose secondary healthcare institutions, and 17.34% chose tertiary healthcare institutions, while the rest 38.47% chose two or more types of healthcare institutions. Gender, age, type of medical insurance, place of residence, utilization of Chinese herbal drugs, utilization of Chinese patent drugs, polypharmacy, needs of outpatient tests and examinations were the influencing factors for their selection of primary healthcare institutions for hypertensive outpatients under Beijing basic medical insurance.Conclusions:At present, the primary institutions have become the first choice for the majority of hypertensive patients with medical insurance in Beijing, but there are still many influencing factors on their choice of institutions. In the future, we should optimize the allocation of medical resources, promote the reform of medical insurance payment methods, strengthen the construction of primary medical institutions, expand the coverage of contracted services of family doctors, and reasonably guide the patients to seek healthcare in primary healthcare institutions.

Construction and empirical study of clue enrichment model of excessive medical behavior based on the rank assignment method / 中华医院管理杂志

Objective:To construct and verify a model of excessive medical behavior clues enrichment, for the technical support for the safe and rational use of medical insurance fund.Methods:A model of excessive medical behavior clues enrichment was constructed by the rank assignment method. The inpatient transaction records of medical insurance for employees and residents in 5 tumor hospitals in Beijing from 2016 to 2019 were obtained to verify the validity of the model. The patients were grouped according to age and gender, and each transaction record was converted into a standardized score V(0-100 scores), all transactions were divided into 22 groups according to V value. The Cochran-Armitage trend test was used to analyze the variation trend of enrichment rate with the increase of V value. Chi-square test was used to compare the chargeback rates of different groups. The correlation between the standardized score V and the amount of chargeback was tested by Pearson.Results:There were 872 599 and 86 356 hospitalization transactions for employee and resident medical insurance patients, with included 1 164 and 103 chargeback records respectively. The average score and median of V-value of employee and resident medical insurance transactions were scores of 49 and 50 respectively.When V>0, the enrichment rates of the employee and resident medical insurance were on the rise with the increasing of V( Z=23.86, P<0.001; Z=11.02, P<0.001), the refusal rates among different groups was significant different( χ2=1 307.16, P<0.001)and the correlation between V value and the chargeback amount was statistically significant( r=0.29, P<0.001; r=0.30, P=0.003). Conclusions:This study established a clue enrichment model of excessive medical behavior based on the rank assignment method. By analyzing a large number of medical insurance transaction records, the model can focus on the medical insurance transaction with suspected excessive medical treatment behavior, and has a certain guiding role in the management of medical insurance fund.

Design and application of medical institutions′ intelligent medical insurance audit system / 中华医院管理杂志

In recent years, the medical insurance coverage of China has been increased significantly, and the medical insurance policies have been launched continuously, so the traditional manual audit method is unable to support medical institutions to effectively supervise the medical insurance fund. In view of this situation, a tertiary hospital in Beijing had successfully built an intelligent medical insurance audit system for drugs, diagnosis and treatment projects under key supervision, realized the prior audit and in-process control of the illegal use of medical insurance funds, through the establishment of intelligent audit rules, the design of audit trigger points and the interception level of illegal medical orders, and the establishment of a pre-operational preparation system and continuous improvement mechanism. In March 2021, the hospital officially launched the system. After the application of the system, the amount and quantity of outpatient medical insurance refusal from April to September 2021 were 10 587 yuan and 72 respectively, which decreased by 79.21% and 77.50% compared with the same period in 2020. This system effectively improved the quality and efficiency of medical insurance fund supervision.

Practice and exploration of whole scene intelligent management of medical insurance in public hospitals / 中华医院管理杂志

With the reform of medical insurance payment mode and the promotion of medical insurance policy, medical insurance management has become the core of public hospital operation and management. According to the business scenario of medical insurance management in public hospitals, medical insurance intelligent management can be divided into three levels: automatic medical insurance intelligent management engine based on rules, digital medical insurance management assistance based on dialogue user interface and hospital medical insurance management brain based on deep learning. In August 2020, under the requirements of hospital intelligent management standards, a tertiary hospital broke through the traditional medical insurance management mode to launch the practice of digital enabled panoramic scene intelligent management of medical insurance, which included medical insurance intelligent business audit, medical insurance intelligent reconciliation, medical insurance intelligent cost control and medical insurance intelligent management cockpit. These measures had realized the intellectualization and standardization of medical insurance management and improved the overall operation efficiency of the hospital.

Real Situation of Rehabilitation Therapy from the Viewpoint of Medical Service Fees / The Japanese Journal of Rehabilitation Medicine

Purpose：The older population in Japan is increasing faster than that in the rest of the world. As a result of the increasing number of elderly patients, rehabilitation treatment has become very important, resulting in rehabilitation-related medical expenses increasing, However, it is unclear which age groups are administered rehabilitation treatments. In this study, we investigated the age distribution of patients receiving rehabilitation treatment in Japan.Methods：We investigated the age distribution of patients receiving rehabilitation treatment using insurance data.Results：Rehabilitation fees for cardiovascular, cerebrovascular, and musculoskeletal diseases peaked in the early 80 years age group, whereas those of disuse syndrome, respiratory diseases, and cancer peaked in the late 80 years. Male patients with cardiovascular diseases were twice as common until 80 years of age. Regarding cerebrovascular diseases, the number of male patients peaked in the late 70s, and there were more male patients in the following age groups. More female patients in the late 80 years age group had disuse syndrome. Rehabilitation fees for musculoskeletal diseases had the highest number of units calculated, with 2.5 times as many female patients as male patients. As for respiratory diseases, more male patients were present in the late 80 years age group. Among patients with cancer, males were about twice as common as females.Conclusion：The peak age of patients receiving rehabilitation treatment was in the 80 years age group, and the number of patients increased every year.

Analysis of Factors Contributing to the Hesitation of Pharmacists to Address Prescription-Related Questions in Pharmacies / 社会薬学

Owing to the fear of worsening their relationship with physicians, several pharmacists hesitate to contact physicians regarding prescription-related questions. We investigated the personal factors of pharmacists contributing to their hesitation to contact physicians regarding prescription-related questions. We analyzed the responses of 213 pharmacy pharmacists. A comparison of the degree of hesitation to contact physicians regarding prescription-related questions revealed that the most hesitant questions were pertaining to “the same prescription content from before”; insurance questions (3.37) were higher than medical questions (3.20) (P＝0.006). The multiple regression analysis results revealed that “pharmacy work is busy and there is no time” was influenced by regular employees (medical (β＝−0.181, P＝0.030) and insurance (β＝−0.257, P＝0.002)). “A co-pharmacist said no questions needed” was influenced by the sex of pharmacists (medical (β＝0.194, P＝0.011) and insurance (β＝0.177, P＝0.020)). Overall, type of questions (medical or insurance) and individual backgrounds (prescription issuing medical institution, pharmacy scale, location, age, sex, employment type, years of service, current management pharmacist, and hospital work experience) have a complex effect on the pharmacists’ psychology. To facilitate pharmacists to contact physicians regarding prescription-related questions, physicians and pharmacists should share information and communicate on a daily basis, such as actively participate in joint training programs. It is also important to create an environment where regular employees and female pharmacists can work comfortably. The smooth resolution of prescription-related questions by relieving the psychological pressure of pharmacists will improve patient safety.