医保信用等级制度的框架、预期效应与内容  

Theory Frame,Anticipated Effect and Content of Medical Insurance Credit Rank System

作　　者：王鸿勇[1] 王黎勇[1] 王晓屏 彭涛 王军 崔爱庆[3] 

机构地区：[1]山东省潍坊市卫生局,山东潍坊261061 [2]山东省临沂市医疗保险事业处,山东临沂276000 [3]山东大学齐鲁医院,济南250012

出　　处：《中国卫生经济》2010年第11期11-13,共3页Chinese Health Economics

摘　　要：由于原有的医疗保险管理中存在费用支付方式不合理、管理机制单一及管理措施执行不力等因素,对医疗费用控制没有实现预期目标,不能为患者提供制度性保护,不断提高的筹资率加重了企业的负担。通过研究,改革医疗保险管理机制,要从增强对供方的制约作用入手。文章提出了信用等级制度的理论框架,即在考核评价的基础上,确定定点医院的信用等级,向社会公布信用等级,以引导患者合理就医。实施信用等级制度,通过扩大影响范围、增加作用机制和拓展管理手段等,增强对定点医院的约束,有效控制医疗费用,但也存在医院通过转移费用等方式来弥补损失。文章还对实施信用等级制度的考核评价的指标体系和主要内容进行了介绍。Due to the unreasonable original medical insurance management fee payment,simple management method,lack of effective measures in control of medical expenses,the medical care cost control targets are unable to be achieved,rapid growth of medical expenses increace the burden of enterprises.Through the research,reform of medical insurance management mechanism needs to strengthen the restriction role.The theoretical framework of credit rank system is propesed.Namely,on the basis of evaluation,the credit rating of the hospital should be determined,and be announced to the society to guide the rational medical patients.Implementing credit rank system,by expanding influence,increasing the action mechanism and expanding management mechanism,etc,can strengthen the restriction of hospital,effectively control medical expenses,but hospital may compensate for the loss trough fee transfer.The assessing criterion and main content of credit rank system which implemented in a certain city are introduced.

关 键 词：医疗保险 医院 信用等级制度 医疗服务管理 费用控制 

分 类 号：F842.684[经济管理—保险]