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left;">医疗保险治理现代化是一个当下时髦的名词。其实质是在国家治理现代化背景下，在医疗、医药和医?！叭搅被∩?，利用大数据、互联网、云计算、人工智能和区块链等现代信息统计分析手段，围绕着促进公众健康、增强人民的获得感和安全感，对医疗服务质量和医疗保险的保障功能进行分析和评价，最终实现健康中国的伟大目标、提升人民的幸福感而进行的一项系统工程。</p><p style="text-align:center;"><a href="/upload/resources/image/2018/01/04/2079954.jpg" target="_blank"><img src="/upload/resources/image/2018/01/04/2079954_500x500.jpg" title="timg (3)" alt="timg (3)" suffix="jpg"/></a></p><p style="text-indent: 2em; text-align: left;">医疗保险是民生问题，涉及人群广泛，权益保障普遍，利益分配效应显著，其政策执行、调整及完善对于我国改善民生、调整财富分配格局、增进公民福利、促进改革成果共享、促进社会公平正义意义重大，是当前国家治理的重要环节。作为社会保障治理现代化的重要组成部分，医疗保险治理是基于社会保障参保人信息和资金信息归集、分析基础上的社会保障费用征缴、资金运营、待遇计发、服务经办以及政策优化等一系列活动，包括参保—缴费—受益三环节相对应的政策优化。因而，医疗保险治理现代化离不开信息资源公开共享，部门间数据整合，信息系统统一。只有走出数据孤岛困局，才能实现智慧医保。</p><p style="text-indent: 2em; text-align: left;">目前，我国医疗、医保和医药卫生数据缺乏整合。从微观上看，容易出现骗保、重保、重复报销、企业恶意漏保少缴保费、居民真实收入情况无法核实等问题。有数据表明，我国基本医保的重复参保率一般在10%以上，个别省份在30%以上，而有些城市则超过了40%。重复参保直接导致了重复补贴。对此，28%的地级行政区正在探索城乡医保统筹。从宏观上看，政府部门间的信息共享方面滞后,例如部分应该纳入保障范围的城乡居民没进入覆盖范围；部分人员在死亡后却仍在“享受”养老保险和医疗保险待遇和低保待遇。目前，尚未实现全国网络的互联互通，各项保险业务之间信息化水平不平衡，各系统整合不充分，限制了信息化整体效力的发挥。</p><p style="text-indent: 2em; text-align: left;">为了有效推动医疗保障治疗现代化，应该加快如下两个方面的制度建设。</p><p style="text-indent: 2em; text-align: left;">首先，推动政府部门间信息共享。在医—保、医—患间信息不对称的状况下，可通过建立卫生服务信息发布制度，由医?；棺魑谌浇ǖ阋搅苹沟姆裰柿啃畔⒂枰怨?，通过信息的披露，指导参保人员理性地选择服务供方并激励供方增强竞争意识，提高效率降低成本。加快社会保障公共基础信息建设，建立信息共享机制，设立城乡居民社会保障公共基础信息交互中心，将涉及民政、人力资源和社会保障、工商管理、公安、国土资源和房屋管理、税务、银行等部门和单位的信息共享。例如社保资金管理机构,在办理相关业务时,提前将信息提交城乡居民信息交互中心进行分析比对,并出具分析比对结果报告,把好社会保障业务办理端口,防止不应享受社会救济、社会福利、社保待遇的人员骗取社保资金。</p><p style="text-indent: 2em; text-align: left;">其次，构建基于大数据的医疗保险基金预警平台。建立与医疗服务相衔接、与医疗保险相适应、与医?；鸺喙芟嘈鞯亩ǖ阋搅苹挂滴袷菘?，包括医师、医疗服务项目、医疗设备、药品、医用材料、疾病诊断等六大基础数据，实现医保管理和医疗卫生信息网络互联互通、无缝对接，使定点医院每一个医疗服务过程都能在网上全程跟踪或追溯。加速信息化建设，完善医保管理体系，强化医保基金监管，建立信息化监管下的医保总额预付制度，以医保支付改革为核心，以信息化为载体，尽快实现全民医保异地就医即时结算，加快构建分级诊疗模式，构建基于大数据的卫生预警平台，保障医改顺利推进。</p><p style="text-indent: 2em; text-align: left;">第三，建立全国统一的医疗保障信息系统和精算系统。通过推进信息系统建设，实现全国医疗保险数据互联互通，为医疗保险全国统筹提供技术保障；同时，推进各类医疗机构和医疗保险数据互联互通。通过建立精算系统，对各地区医疗保险财务状况、医疗服务状况和基金发展趋势进行科学预测，使管理工作更加精细、科学有效；通过进一步整合经办管理资源，推进经办机构省级以下垂直管理，为全国统筹提供组织保障，确保全国统筹的效果。</p><p style="text-indent: 2em; text-align: left;">（作者系全国政协委员、对外经济贸易大学保险学院副院长）</p> </div> <p class="Editor">编辑：李敏杰 </p> <div id="i2i2jyu4k" class="Paging"> </div> <p class="Keyword">关键词：医保数据信息</p> <h1 class="pv_title_2 mt_15"><a target="_blank" class="more mtb_14">更多</a><span id="i2i2jyu4k" class="t" id="a3"><a ><img src="http://www.rmzxb.com.cn/images/xg_t1.jpg" /></a></span></h1> <div id="i2i2jyu4k" class="pa_0_5_0_10"> <ul class="Related_ul bh_150"> <li><a 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