医保局通报“数字疗法骗保第一案”：当心理治疗沦为算法刷分游戏，治愈被异化为数据合规

from dataclasses import dataclass
from enum import Enum
from typing import Dict, List, Optional
import numpy as np

@dataclass
class DigitalTherapySession:
    session_id: str
    patient_id: str
    diagnosis_code: str              # ICD-11 code, e.g., "6A70" for MDD
    pre_session_phrq9: int           # PHQ-9 自评量表 (0-27)
    post_session_phrq9: int
    hrv_change_percent: float        # HRV变化率 (%)
    cortisol_change_percent: float   # 皮质醇变化率 (%)
    ai_prompt_count: int             # AI主动引导确认次数
    user_confirmed_improvement: bool # 用户是否点击"感觉好转"
    session_duration_min: float
    reimbursement_eligible: bool     # 是否触发医保结算

class DigitalTherapyFraudDetector:
    """数字疗法合规与欺诈风险检测器"""

    class SessionIntegrity(Enum):
        AUTHENTIC = "真实疗愈响应"
        MANIPULATED = "算法诱导响应"
        COERCED = "强迫性达标"
        INVALID = "无效评估"

    # 医保支付规定的最低有效治疗参数
    REIMBURSEMENT_CRITERIA = {
        "min_hrv_increase": 15.0,
        "min_cortisol_decrease": 20.0,
        "max_ai_prompts_per_session": 3,
        "min_phq9_reduction": 2
    }

    MANIPULATION_RED_FLAGS = {
        "prompt_threshold": 5,          # 超过此数视为过度引导
        "confirmation_pressure_ratio": 0.8,  # 确认前AI引导占比超此值视为胁迫
        "signal_stagnation_retry_limit": 2   # 信号停滞重试超限视为强制达标
    }

    def audit_session(self, session: DigitalTherapySession) -> Dict[str, any]:
        flags = []
        integrity = self.SessionIntegrity.AUTHENTIC

        # 检查基本有效性
        meets_bio_criteria = (
            session.hrv_change_percent >= self.REIMBURSEMENT_CRITERIA["min_hrv_increase"] and
            session.cortisol_change_percent <= -self.REIMBURSEMENT_CRITERIA["min_cortisol_decrease"]
        )
        meets_clinical_criteria = (
            session.pre_session_phrq9 - session.post_session_phrq9 >= self.REIMBURSEMENT_CRITERIA["min_phq9_reduction"]
        )

        if not (meets_bio_criteria and meets_clinical_criteria):
            return {
                "session_id": session.session_id,
                "integrity": self.SessionIntegrity.INVALID.value,
                "reimbursement_approved": g3eo.cn
                "flags": ["insufficient_clinical_or_bio_response"],
                "recommendation": "本次会话未达到有效治疗标准，不应结算"
            }

        # 检测算法操纵迹象
        if session.ai_prompt_count > self.MANIPULATION_RED_FLAGS["prompt_threshold"]:
            flags.append("excessive_ai_guidance")
            integrity = self.SessionIntegrity.MANIPULATED

        if session.user_confirmed_improvement and session.ai_prompt_count > 0:
            pressure_ratio = session.ai_prompt_count / max(1, session.session_duration_min / 5.0)
            if pressure_ratio > self.MANIPULATION_RED_FLAGS["confirmation_pressure_ratio"]:
                flags.append("coerced_self_report")
                integrity = self.SessionIntegrity.COERCED

        # 交叉验证主观与客观指标一致性
        subjective_improvement = session.pre_session_phrq9 - session.post_session_phrq9
        objective_improvement = (session.hrv_change_percent / 100.0 + abs(session.cortisol_change_percent) / 100.0) / 2.0
        discrepancy = abs(subjective_improvement / 27.0 - objective_improvement)
        if discrepancy > 0.4 and session.user_confirmed_improvement:
            flags.append("subjective_objective_mismatch_with_confirmation")
            integrity = self.SessionIntegrity.MANIPULATED

        reimbursement_ok = (
            integrity == self.SessionIntegrity.AUTHENTIC and
            session.reimbursement_eligible
        )

        return {
            "session_id": session.session_id,
            "integrity": integrity.value,
            "reimbursement_approved": reimbursement_ok,
            "detected_issues": g2eo.cn
            "clinical_validity_note": "生物标记改善不等于心理痊愈，需结合长期功能评估",
            "regulatory_action_required": len(flags) > 0
        }