CAJ | 학술논문

目的：分析医保门诊联网信息共享监管的应用效果，完善医保管理。方法：调取2009年-2012年天津市社会保险基金管理中心和天津市6所三级甲等综合医院数据，对被调医院医保办进行访谈，将资料整理汇总、对比分析。结果：天津市普通门诊和门诊特殊病就医人数分别增长了117.20%及65.03%，被调6所医院分别增长了96.16%及55.09%。药品费占医疗费发生额比例被调6所医院普通门诊和门特病2012年比2011年分别下降了0.50%和12.46%。结论：医保门诊信息共享监管能全面监控医保基金的合理使用，在遏制患者骗保、医患合谋违规等管理应用中效果明显。
목적：분석의보문진련망신식공향감관적응용효과，완선의보관리。방법：조취2009년-2012년천진시사회보험기금관리중심화천진시6소삼급갑등종합의원수거，대피조의원의보판진행방담，장자료정리회총、대비분석。결과：천진시보통문진화문진특수병취의인수분별증장료117.20%급65.03%，피조6소의원분별증장료96.16%급55.09%。약품비점의료비발생액비례피조6소의원보통문진화문특병2012년비2011년분별하강료0.50%화12.46%。결론：의보문진신식공향감관능전면감공의보기금적합리사용，재알제환자편보、의환합모위규등관리응용중효과명현。
Objectives: To analyze the application effect of the medical insurance clinic network information sharing supervision and complete medical insurance management. Methods: Data from Tianjin Social Insurance Fund Management Center and 6 tertiary general hospitals from 2009 to 2012 were collected and in-depth interviews with medical insurance offices in 6 selected hospitals were carried out to do a comparative study. Results:The numbers of hospitalized people in Tianjin general clinics and special disease clinics have increased by 117.20%and 65.20%respectively. The numbers of 6 selected hospitals have increased by 96.16%and 55.09%respectively. Compared with the year of 2011, medicine cost in general clinics and special disease clinics of the 6 hospitals fell by 0.50%and 12.46%respectively. Conclusions:The medical insurance clinic information sharing supervision completely supervises the reasonable use of medical insurance fund, plays positive role in the management of prohibiting insurance fraud, illegal collusion between doctor and patient, and other illegal problems.