A few days ago, Xiaojin Pharmacist participated in the review of medical insurance complaints prescriptions in the Beijing region.
The basic situation is that some time ago, the Medical Insurance Bureau screened the doubts about the prescription data of Sino -Pharmaceuticals and sent it to various medical units.After receiving it, each medical unit appealed and sent it back to the Medical Insurance Bureau.Our work is to review these appeals as experts.
Medical units and doctors involved in these data, I dont know.The time and place of this work cannot be said.What I can say is the experience of participating in this work.There are two goals, first, to convey some information about the rational medication of Chinese medicines.Second, warn everyone that the review and review of Chinese medicines and medical insurance control costs will only be deeper and more accurate.
Give up fantasies and make preparations early is the right way.
Okay and officially start.
Medical Insurance Data (Figure Source Network)
(1)
As you know, a prescription of a proprietary Chinese medicine is very unreasonable, and there are many potential unreasonable possibilities. Indications, usage dosage, combined medication, taboos, etc. are all. What I participated in this review is indication review .
The main process is that the medical insurance screening has a large number of diagnosis that does not meet the proprietary Chinese medicine manual, and sends it to various medical units as a doubt.Medical units believe that some of them are reasonable, and they will initiate an appeal and fill in the appeal.
Of course, when all medical units do this, whether to follow strict medical theory and medical evidence to appeal, or to avoid refusal to pay for all the complaints, is it?The level of medical units and public minds.From the perspective of expert review, we found that many medical units may choose the latter, so the entire data seems to be relatively rough, and the traces of copying the paste are obvious.
This approach will cover up the reasonable diagnosis of truly misjudgment, increasing the invalid working time of review experts, but not conducive to the passing of reasonable appeal.
So, I hope that everyone will be more fair and rigorous in the future when appealing in the future.
According to the requirements, during the review, I will strictly determine whether the appeal diagnosis is reasonable according to the drug instructions of Chinese medicines .Of course, the exactly the same diagnosis as the instructions will not appear in the appeal, so what I see is the same diagnosis concept as the instructions.
So, how to judge that these are not exactly the same diagnosis as the instructions reasonable or unreasonable?
In fact, when introducing the book "Sino -Pharmaceutical Prescription Review Essentials", we have analyzed this problem in detail and gave some solutions.When I reviewed this time, it was performed in accordance with this scheme.
The specific operation is that Finding the equivalent concept of the instructions for the instructions is deemed to be a reasonable diagnosis. If such diagnosis occurs, it is misjudgment, and the appeal comments are agreed.
Diagnosis Information (Figure Source Network)
As an example, the description of the oral solution of Lan Bao reads "clearing heat and detoxifying, which is beneficial to pharyngeal swelling. It is used for acute pharyngitis, throat, dry pharynx, and throat burning."
So,
First, from the perspective of the diagnosis of traditional Chinese medicine certificates, the manual is "lung and stomach heat syndrome".The key to this is not "lung" or "stomach", but "heat".Therefore, I will screen all the diagnosis of "heat" in the diagnosis of the appeal, and then determine them one by one.Such as "wind heat criminal", "wind and heat attack", "heat poison syndrome", "thermal poisoning lung" and even "external cold internal heat", will be regarded as a reasonable diagnosis.
Second, from the diagnosis of the name of the western medicine, the manual is "acute pharyngitis".The key to this is an acute upper respiratory infection.Therefore, I will screen all the diagnosis of "inflammation" in the diagnosis of the appeal, and then determine them one by one.Such as "acute tonsillitis", "acute upper respiratory tract infection" and even "tonsillitis", "pharyngitis", and "pneumonia", they will be regarded as a reasonable diagnosis.
Why is "pneumonia" a reasonable diagnosis?It is very simple. In the official new coronary pneumonia diagnosis and treatment, some of the Lanqi oral solution is recommended.In 2020, the "Pharmaceutical Consensus of the Early Chinese P Chinese Medicine Intervention" published by us was collected by the 18 Chinese medicines mentioned in the diagnosis and treatment plan of the country and provinces and cities at that time, of which the Lanqi oral solution was available.
Expert Consensus (Figure Source Network)
Third, single obedienceAccording to the perspective of the soup, the oral solution of Lan Bao is the compatibility structure of "four bitterness and one acid".
The heartfire is anchored, and we can do some equivalent expansion.
For example, from the perspective of evidence and evidence: (1) the heart opens the tongue;The main diagnosis of the heart fire certificate; (4) clinical reports of treating oral ulcers.Therefore, I will treat the "mouth sores", "oral ulcers", and "stomatitis" in the diagnosis of appeal diagnosis as a reasonable diagnosis.
For example, from the perspective of evidence -based on evidence: (1) According to the treatment ideas of the external sensation of the six prostitution, Xin can remove the wind and cold, bitter heat and heat, acid can remove dryness and heat, heat and heat, heat can be removed.The "four bitter and one sour" Lan Bao oral solution can be used to treat the external sensation caused by the heat and evil to violate the human body; (2) there is a clinical report for treating colds.Therefore, even if it does not contain Xinwei medicine, the ability to solve the table is weak, but I still treat the concepts such as "cold" (except for the gastrointestinal cold) and "influenza" in the diagnosis of the appeal, which is also considered a reasonable diagnosis.
These are reasonable diagnosis.
It should be noted that the idea of this review is not a reasonable diagnosis, but as long as a reasonable diagnosis appears, it is considered reasonable.Of course, this idea is incomplete, and we look forward to continuing to be improved in the future.
The important value of the basic theory of traditional Chinese medicine (Figure source network)
(2)
So which diagnosis is not reasonable?
The first category, unreasonable Chinese medicine certificate diagnosis.
I remember particularly clearly that in the diagnosis of Lanqi oral solution, some medical units appealed to the diagnosis of "wind and cold attack", which is unreasonable.Dont appeal about this diagnosis in the future.In fact, it is difficult to be considered a reasonable diagnosis that does not include "heat".
In the second category, the diagnosis of unreasonable western medicine disease.
According to the manual, Lanqi oral solution is a Chinese patent medicine for acute pharyngitis. Therefore, the diagnosis of "chronic pharyngitis" can be regarded as unreasonable; and "chronic pharyngitis acute seizures"This diagnosis can be regarded as reasonable.
Note that from the perspective of evidence, there are many clinical reports of Lanqi oral solution to treat "chronic pharyngitis", and there are corresponding META analysis.However, from the perspective of rationality, the bitterness -based heat -clearing and detoxifying Chinese medicine, which is dominated by Lan Bao oral solution, is the treatment of thermal poison syndromes (mainly sore, acute seizures), which is not mainly lung deficiency syndrome.Yin deficiency syndrome (dry throat, repeated attacks).
When conflicting with evidence and reasoning, we must use the theory of Chinese medicine as a higher level of judgment. This is the principle of traditional Chinese medicine research. This is the value of the "three -combined" evidence system.
Or, in the clinical evaluation of Chinese medicine, due to evidence, simply evidence is limited, and it is necessary to comprehensively decide according to the theory of traditional Chinese medicine.
So, the corresponding other chronic diseases, "chronic bronchitis", "chronic tonsillitis", "chronic obstructive pulmonary disease", etc., are not suitable for reasonable diagnosis.At the same time, "bronchitis" and "cough" and other diseases that need to relieve cough and phlegm and asthma to treat, or diseases that need to be treated with salty, sour and sour taste, and should not be used as a reasonable diagnosis of Lanpi oral solution.Essence
Evidence-based needs to combine the theory to find the best decision (Figure source network)
OK, lets talk about a Chinese medicine, 潞 Codonopsis oral solution.
The idea is still that idea.
According to the drug manual, the function of the Codonopotage Oral solution is "supplementing China to nourish qi, strengthen the spleen and lungs, nourish and strong, and enhance human immunity.Heart palpitations, eat less stools, and cough.
Take this Chinese medicine as an example, because the codonic medicine supplement medicine can be used too much, this can be seen from the manual.
How to judge this situation?
First of all, the name and disease name (Chinese medicine or western medicine, the same below) clearly identified in the pharmaceutical manual (Chinese medicine or western medicine, the same below) will not be screened as doubt.Therefore, in the diagnosis of "diarrhea", "anemia", and "chronic gastritis" diagnosis of "diarrhea", "anemia", and "chronic gastritis" will not occur, and "qi deficiency syndrome" and "lung and spleen deficiency" will occur.
The name (or symptoms) in the appeal diagnosis will appear, which are "palpitations", "heart rhythm", "fatigue", "spleen disease", etc.
The name of the appeal diagnosis will appear, it is "liver stagnation and spleen deficiency", "qi and yin deficiency", "heart and spleen deficiency", "heart qi deficiency", "qi", "qi qi", "qi qi"Blood insufficiency "," yang deficiency "," false labor "and so on.
How to determine these diagnosis?Yes, As long as the concept of the equivalent name or symptoms described by the manual should be regarded as reasonable. At the same time, according to the upper -level diagnosis and lower diagnosis of the previous article, as long as it contains the meaning of "qi deficiency" or "spleen deficiency", it should be regarded as reasonable.
So, in the above -mentioned doubt diagnosis, except for "yang deficiency" and "spleen disease", the rest are regarded as reasonable.
So, which diagnosis is unreasonable for Codonopsis oral liquid?Yes, it is simply a variety of cancer and tumor diagnosis, which should not be regarded as reasonable.Of course, if the diagnosis contains "chemotherapy" information, it is considered reasonable.
In fact, I found that there is a diagnosis that is especially suitable for patients with qi deficiency syndrome after tumor deficiency syndrome after tumor dewlogenic liquid, which is "tumor support treatment".I have passed all the similar diagnosis, which is deemed to be reasonable.
So, this job is both principled and flexible.It also tells us that the diagnosis of proprietary Chinese medicine is not that simple, and we need to work hard.
Principles and flexibility (Figure Source Network)
Okay,This is what I want to share with you today.
Finally, due to the rules of this review, each expert is formed independently under one basic principle.Therefore, the content of today is just the personal thoughts and practices of Teacher Jin , not necessarily all right .Other experts are not necessarily judged like this. Therefore, for reference only.
Of course, whether it is medical insurance review or pharmacy evaluation, the future development is definitely not literal to literal, not a knife, but a dialectical unity of principle and flexibility. It is a certain scale. It is a certain scale.Standardization and refinement below.This requires a lot of work, including the standardization of the rules of each review content, and the rules of each review of drugs are refined.Looking forward to this day coming as soon as possible.
