CAJ | 학술논문

　　目的：探讨医院与医保经办机构之间良性互动关系的构建及其成效。方法：对医院与医保经办机构之间的良性互动及其成效分别进行案例分析和实证分析。结果：2010~2012年城镇职工医保出院患者次均费用增长趋势放缓，年均增长率为1.30%；医保拒付处于低水平，拒付金额从149548.83元下降到54372.21元，其占总费用比例从0.17%缩减到0.05%；出院患者投诉事件逐年下降，从22起下降到4起，减少了81.82%。结论：通过转变观念、规范医保管理以及建立有效的沟通机制等途径，医院与医保经办机构之间可以实现良性互动；良性互动关系的建立有助于医院争取医保政策支持、合理控制费用和减少医保拒付。
　　목적：탐토의원여의보경판궤구지간량성호동관계적구건급기성효。방법：대의원여의보경판궤구지간적량성호동급기성효분별진행안례분석화실증분석。결과：2010~2012년성진직공의보출원환자차균비용증장추세방완，년균증장솔위1.30%；의보거부처우저수평，거부금액종149548.83원하강도54372.21원，기점총비용비례종0.17%축감도0.05%；출원환자투소사건축년하강，종22기하강도4기，감소료81.82%。결론：통과전변관념、규범의보관리이급건립유효적구통궤제등도경，의원여의보경판궤구지간가이실현량성호동；량성호동관계적건립유조우의원쟁취의보정책지지、합리공제비용화감소의보거부。
Objectives:To investigate the construction and achievement of positive interaction between the hospital and health insurance management center. Methods: To analyze the interaction between the hospital and health insurance management center and its main achievements through case study and empirical study respectively. Results:During the period of 2010~2012,the growth of average medical expense per inpatient was slowed down, of which its average annual growth rate was only 1.3%. The payments refused by health insurance management center, was reduced from 149548.83 Yuan to 54372.21 Yuan, and the percentage of it to income was down from 0.17%to 0.05%. The patient complaint cases were decreased from 22 to 4, with an 81.82%cut. Conclusions:The positive interaction can be founded and it has brought benefits to health insurance management in the hospital, such as support coming from health insurance policy, willingness and action to control medical expenses and reduction in payment refused by health insurance management center.