为什么预防长期无法结算Why Prevention Has Been Hard to Settle

预防医疗面临一个根本性的商业悖论：预防成功的标志，是"什么都没有发生"。没有诊断，没有治疗，没有传统医疗结算体系所需要的任何触发点。Preventive medicine faces a fundamental commercial paradox: successful prevention means "nothing happened". No diagnosis, no treatment, no trigger point for traditional medical billing.

这个悖论造成了四个结构性障碍：This paradox creates four structural barriers:

障碍 01Barrier 01

没有标准化证明路径No Standardized Proof Path

传统医疗结算依赖ICD诊断码和明确收费项目。预防干预既无诊断码，也无可核实的"治疗行为"，支付方无框架可依。Traditional billing relies on ICD codes and defined charge items. Preventive interventions have neither, leaving payers with no framework to apply.

障碍 02Barrier 02

效果难以量化归因Effect Hard to Causally Attribute

即使能证明干预组比对照组健康，也无法排除"本来就更健康的人更倾向参与干预"的选择偏倚。没有因果证据，支付方不会买单。Even if the intervention group is healthier, selection bias cannot be ruled out. Without causal evidence, payers won't pay.

障碍 03Barrier 03

受益方与付费方错位Beneficiary-Payer Misalignment

企业为员工投入预防，但直接受益（降低赔付）的是保险公司。三方之间缺少可流通的证据货币。Employers pay for prevention, but insurers benefit from lower claims. No shared evidence currency exists between the three parties.

障碍 04Barrier 04

时间窗错位Time Window Mismatch

预防干预的效果需要数月至数年才能体现在医疗费用上，而支付方的预算周期通常以年度为单位，跨期结算机制缺失。Prevention effects take months to years to appear in medical costs, while payer budget cycles are annual. No cross-period settlement mechanism exists.

预防结算的标准定义Standard Definition of Prevention Settlement

一个完整的预防结算需要满足以下四个条件：A complete prevention settlement requires four conditions:

01

可量化的健康结果变化Quantifiable Health Outcome Change

干预前后存在可测量的健康指标变化（如心血管风险评分下降、住院率降低、医疗费用减少）。Measurable health metric changes before and after intervention (e.g., cardiovascular risk score reduction, lower hospitalization rates, reduced medical costs).

02

经过因果推断验证的干预效应Causally Verified Intervention Effect

通过PSM倾向评分匹配等方法，在排除混杂因素和选择偏倚后，确认健康结果改善在统计意义上可归因于干预本身。PSM propensity score matching confirms that health improvements are statistically attributable to the intervention itself after eliminating confounders and selection bias.

03

标准化的证据文件Standardized Evidence Documentation

生成符合真实世界证据（RWE）方法论标准的因果报告，包含ATT（平均处理效应）、置信区间、样本配对方法说明和数据来源。Generate causal reports compliant with RWE methodology standards, including ATT (Average Treatment Effect), confidence intervals, matching methodology, and data sources.

04

支付方正式认可并完成经济分配Payer Recognition and Economic Distribution

证据文件被医保、商业保险或企业雇主正式接受，并据此完成费用减免、保费优惠、绩效奖励等形式的经济分配。Evidence accepted by insurers, public health insurance, or employers, leading to economic distribution through cost reduction, premium discounts, or performance bonuses.

ReHealth Core 如何实现预防结算How ReHealth Core Enables Prevention Settlement

预测 → 干预 → 归因 → 结算 — 这不是四个独立的模块，而是一条因果链。去掉任何一环，链条断裂，预防结算无法完成。这是ReHealth Core区别于所有"止步于预测"的竞品的根本差异。This is not four independent modules but a causal chain. Remove any link and settlement fails. This is what fundamentally differentiates ReHealth Core from tools that stop at prediction.

各方在预防结算中的角色Stakeholder Roles in Prevention Settlement

🛡️

保险公司Insurance Companies

最直接的受益方。PSM证据可证明干预降低赔付，支持向企业客户提供保费优惠，推动险企从"被动赔付"转向"主动健康管理"商业模式。The most direct beneficiary. PSM evidence proves claims reduction, supporting premium discounts and the shift from passive payer to active health manager.

🏢

企业雇主Enterprise Employers

用因果证据证明健康投入的ROI，向保险方申请费率优惠，将健康福利从"员工关怀"转化为可量化的财务决策。Use causal evidence to prove health investment ROI, negotiate premium discounts, and convert health benefits from "employee care" to quantifiable financial decisions.

🏥

医疗机构Healthcare Institutions

向医保和商业保险证明预防科室的真实价值，为DRG/DIP体系之外的预防服务探索新的支付路径。Prove the real value of prevention departments to insurers and public health insurance, exploring new payment pathways outside DRG/DIP systems.

💊

药企Pharmaceutical Companies

利用带干预轨迹的真实世界数据支持新适应症申报、真实世界有效性研究，直接对接NMPA RWE注册路径。Use RWE with intervention trajectories for new indication submissions and real-world efficacy studies, directly aligning with NMPA RWE registration pathways.

常见问题Frequently Asked Questions

预防结算和传统医疗结算有什么不同？How is prevention settlement different from traditional medical billing?
传统医疗结算针对已发生的疾病治疗行为，有明确的诊断码（ICD）和收费项目。预防结算针对的是"尚未发生的疾病"的预防干预，需要通过可量化的因果证据向支付方证明干预确实降低了健康风险，从而获得支付认可。这是预防医疗商业化的核心挑战，也是ReHealth Core解决的核心问题。Traditional billing covers treatment of existing diseases with ICD codes and defined charges. Prevention settlement covers interventions for diseases that haven't occurred yet, requiring quantifiable causal evidence to prove to payers that the intervention actually reduced health risk.
为什么相关性不能用于结算？Why can't correlation be used for settlement?
因为参与健康管理项目的人本身就比不参与的人更健康（选择偏倚）。如果用简单相关性来证明干预效果，无法区分是干预本身有效，还是本来就更健康的人参与了干预。支付方需要因果证据——即在排除基线差异后，干预组相比对照组真实改善了多少。PSM倾向评分匹配是目前真实世界场景下最可行的因果推断方法。People who participate in health management programs are already healthier than those who don't (selection bias). Simple correlation cannot distinguish whether the intervention was effective or whether healthier people self-selected into the program. Payers need causal evidence — how much did the intervention group actually improve compared to matched controls after baseline differences are eliminated.
预防结算目前在中国有政策支持吗？Is prevention settlement supported by policy in China?
国家医保局已多次表态支持将预防干预纳入支付体系，NMPA也发布了真实世界证据（RWE）指南。但截至2026年，系统性的预防结算框架仍处于政策探索阶段。ReHealth Core的战略是先通过商业保险和企业雇主完成预防结算验证，再向公立医保体系渗透。China's National Healthcare Security Administration has repeatedly expressed support for incorporating preventive interventions into payment systems, and NMPA has issued RWE guidelines. As of 2026, a systematic prevention settlement framework is still in the policy exploration phase. ReHealth Core's strategy is to first validate prevention settlement through commercial insurance and employers, then penetrate the public insurance system.

相关概念Related Concepts

📄 什么是可结算证据 — 因果证据的生成标准What is Billable Evidence — Standards for Generating Causal Evidence→ ⚖️ PSM因果归因 — 倾向评分匹配的工作原理PSM Causal Attribution — How Propensity Score Matching Works→ 📚 为什么相关性不能用于结算Why Correlation Fails Settlement→