关键词: 临床预测模型; 医疗保险; 风险调剂; 风险平准

Abstract: Advancing the reform of medical insurance payment methods is not only a necessity for the high-quality development of medical insurance, but also a requirement for alleviating the burden of people’s medical expenses and enhancing their well-being. In recent years, China has made positive progress in the reform of diversified and composite medical insurance payment methods, which has also raised higher requirements for the management of medical insurance funds and medical institutions. Against the backdrop of health big data, clinical prediction models have been maturely applied in areas such as drug trials, demonstrating good capabilities in quantitatively assessing the risk level of patients’ diseases and the intensity of medical resource consumption. This paper aims to draw lessons from international experiences in medical insurance risk adjustment mechanisms and risk prediction models, explore the feasibility of applying clinical prediction models to diagnosis related groups and medical insurance reimbursement risk adjustment under the reform of medical insurance payment methods, and provide corresponding references for further improving the quality of medical institution services and enhancing the efficiency of medical insurance fund utilization.

Key words: Clinical prediction model; Medical insurance; Risk adjustment; Risk equalization