CAJ | 학술논문

医疗机构与商业健康保险机构开展直付服务合作，是国际通用的商业健康保险理赔方式。本文通过分析武汉市某医院开展直付服务的实践，探讨当前医疗机构开展直付服务受限的原因：商业健康保险规模过小；医院成本控制总结运行中遇到的问题，即存在医疗费用拒付和过度医疗的风险、增加医疗机构成本、有违医疗服务均等化原则，并就医院开展直付服务提出建议：加强风险管控、参与“大数据”健康管理、联合商保机构改造HIS系统、调整直付服务价格体系。
의료궤구여상업건강보험궤구개전직부복무합작，시국제통용적상업건강보험리배방식。본문통과분석무한시모의원개전직부복무적실천，탐토당전의료궤구개전직부복무수한적원인：상업건강보험규모과소；의원성본공제총결운행중우도적문제，즉존재의료비용거부화과도의료적풍험、증가의료궤구성본、유위의료복무균등화원칙，병취의원개전직부복무제출건의：가강풍험관공、삼여“대수거”건강관리、연합상보궤구개조HIS계통、조정직부복무개격체계。
Commercial health insurance institutions cooperating with medical institutions to carry out the "direct-billing service"is an in-ternational method for commercial health insurance claims.This article analyzed the practice of a certain hospital in Wuhan carrying out the "di-rect-billing service"as an example, discussed the causes of restriction in medical institutions'execution of "direct-billing service", which are small-scale commercial health insurance and hospital cost control.Problems occurred while attempting to carry out the service are summarized. For instance, the insurance company refused to pay medical expenses, the medical risk is excessive, the hospital cost increased, it violates the e-qualization of essential healthcare services.This paper proposes some suggestions on medical institutions'execution of "direct-billing service", such as reinforcing risk control, participating in the management of"big data"in the healthcare industry, reforming hospital HIS system with com-mercial insurance institutions, and adjusting the price system of "direct-billing service".