中国医学创新
中國醫學創新
중국의학창신
MEDICAL INNOVATION OF CHINA
2013年
20期
132-134
,共3页
挑战%医保费用%非理性就医%策略
挑戰%醫保費用%非理性就醫%策略
도전%의보비용%비이성취의%책략
Strategy%Challenge%Medical insurance expense%Irrational hospitalized
目的：分析非理性就医现象，探索应对策略，合理控制医疗费用增长。方法：结合本院参保患者就医情况和多年来医保管理体系、制度、措施，总结分析近年来各级医疗机构非理性就医现象、原因和结果，探索建立应对策略和规范化管理措施。结果：随着全民医保制度的实施和经济市场化，参保者对医疗服务提出了更高的需求，在就医过程中常常出现了许多非理性就医现象，主要形式有小病大医，无病要医或体检式检查，挂床住院，追求高值耗材、贵重药品等。这些行为给医保管理带来挑战，特别是影响了医保费用质量，助推了过度医疗和医疗费用不合理增长。结论：针对非理性就医对医保费用质量管理的挑战，一是要进一步深化落实国家医药卫生体制改革精神，“保基本，强基层”；二要完善配套的医疗保险政策及相关规定，加强保基本医疗的政策宣传；三是以关键环节为重点，深化医院医保管理；四是把医保费用支付制度改革和临床路径管理相结合，特别是科学实行基本医疗付费总额控制办法，规范医疗服务行为，合理控制医疗费用增长，保障医保基金使用安全。
目的：分析非理性就醫現象，探索應對策略，閤理控製醫療費用增長。方法：結閤本院參保患者就醫情況和多年來醫保管理體繫、製度、措施，總結分析近年來各級醫療機構非理性就醫現象、原因和結果，探索建立應對策略和規範化管理措施。結果：隨著全民醫保製度的實施和經濟市場化，參保者對醫療服務提齣瞭更高的需求，在就醫過程中常常齣現瞭許多非理性就醫現象，主要形式有小病大醫，無病要醫或體檢式檢查，掛床住院，追求高值耗材、貴重藥品等。這些行為給醫保管理帶來挑戰，特彆是影響瞭醫保費用質量，助推瞭過度醫療和醫療費用不閤理增長。結論：針對非理性就醫對醫保費用質量管理的挑戰，一是要進一步深化落實國傢醫藥衛生體製改革精神，“保基本，彊基層”；二要完善配套的醫療保險政策及相關規定，加彊保基本醫療的政策宣傳；三是以關鍵環節為重點，深化醫院醫保管理；四是把醫保費用支付製度改革和臨床路徑管理相結閤，特彆是科學實行基本醫療付費總額控製辦法，規範醫療服務行為，閤理控製醫療費用增長，保障醫保基金使用安全。
목적：분석비이성취의현상，탐색응대책략，합리공제의료비용증장。방법：결합본원삼보환자취의정황화다년래의보관리체계、제도、조시，총결분석근년래각급의료궤구비이성취의현상、원인화결과，탐색건립응대책략화규범화관리조시。결과：수착전민의보제도적실시화경제시장화，삼보자대의료복무제출료경고적수구，재취의과정중상상출현료허다비이성취의현상，주요형식유소병대의，무병요의혹체검식검사，괘상주원，추구고치모재、귀중약품등。저사행위급의보관리대래도전，특별시영향료의보비용질량，조추료과도의료화의료비용불합리증장。결론：침대비이성취의대의보비용질량관리적도전，일시요진일보심화락실국가의약위생체제개혁정신，“보기본，강기층”；이요완선배투적의료보험정책급상관규정，가강보기본의료적정책선전；삼시이관건배절위중점，심화의원의보관리；사시파의보비용지부제도개혁화림상로경관리상결합，특별시과학실행기본의료부비총액공제판법，규범의료복무행위，합리공제의료비용증장，보장의보기금사용안전。
Objective:To analyze the phenomenon of the irrational hospitalized,to discuss the coping strategy,and to control the increase of the medical expense rational. Method:This article combined the condition of patients who were enjoyed the medical insurance hospitalized with the management of the medical insurance,summarized and analyzed the phenomenon,the cause,and the result of the irrational hospitalized recent years in several hospitals,and explored the coping strategy and the normative management. Result:The people’s requirement according to the medical insurance was higher along with the civil medical insurance and the market economy. There were several irrational phenomena in the course of the hospitalized.For example doctor treated a minor illness as a serious disease,treated or examined a person who wasn’t ill. People was in hospital but wasn’t in the hospital,selected the expensive material and medicine,and so on. These phenomena influenced the quality of the medical insurance expense,and encouraged the excess medical treatment and the irrational increased of the medical expense. Conclusion:There are four steps aimed at the challenge what the irrational hospitalize caused to the medical insurance expense. Firstly to ascertain the medical and health system reform,secondly to perfect the medical insurance policy and strengthen to publicize the basic medical. Thirdly to promote the management of the medical insurance in the hospital. Fourthly to connect the medical insurance reform and the clinical pathway management,especially to control the amount of the basic medical insurance expense scientifically,to standard the medical,to control the increase of the medical expense reasonably,and to guarantee the safety of the insurance expense.
