韩国医疗保险监管组织体系和管理能力及其启示  

Organizational system and management capability of medical insurance supervision in South Korea and its implications to China

作　　者：郭莺[1] 茅雯辉 向浩[3] 汤胜蓝[2] GUO Ying;MAO Wen-hui;XIANG Hao;TANG Sheng-lan(Zhongshan Hospital, Fudan University, Shanghai 200032, China;Duke Global Health Institute, Duke University, 27710, USA;Global Health Institute, Wuhan University, Wuhan Hubei 430071, China)

机构地区：[1]复旦大学附属中山医院,上海200032 [2]杜克大学全球健康研究所,美国27710 [3]武汉大学全球健康研究中心,湖北武汉430071

出　　处：《中国卫生政策研究》2020年第3期1-5,共5页Chinese Journal of Health Policy

基　　金：中国医疗保障体系完善项目(OPP1199760)。

摘　　要：医疗保险监管具有确保医疗服务质量、控制医疗保险基金风险以及促进医疗服务合理利用的重要职能。本文通过研究韩国医疗保险监管组织体系发现,韩国医疗保险监管具有完善的组织构架、专业化水平较高的监管人员和对医疗机构有较强的约束力等方面的特点,在此基础上,梳理和总结韩国医疗保险监管组织体系和管理能力方面的成熟经验,结合我国国情,为完善我国医疗保险监管组织体系和提升管理能力,建议明确医疗保险监管机构架构及其职能、采用监管核心与分散职能部门相结合的模式以及提升医疗保险监管队伍的能力。Health insurance supervision has core roles in medical service quality assurance,mitigation of potential risks on health insurance funds and promotion of proper medical service provision and rational use.Considering South Korea’s medical insurance regulatory system,this paper analyzed the institutional setting and management ability of health insurance supervision agencies and found that South Korea has perfect and strong organizational structure,highly specialized regulatory personnel and strong influential power on healthcare service providers.Therefore,combing and summarizing the mature experiences of South Korea's medical insurance organization system and management ability,and combining with China's national conditions,policy recommendations are put forward for China to improve the health insurance supervisory and enhance the management ability in the likes of defining the structure and functions of insurance supervision agencies,using the combination of core and decentralized functional departments,and building the capacity of medical insurance regulatory personnel.

关 键 词：医疗保险监管 费用审核 质量评估 

分 类 号：R197[医药卫生—卫生事业管理]