医药医保政策改革下的江苏省医保基金运行绩效研究  

Study on the Operation Performance of Medical Insurance Funds in Jiangsu under the Medical and Drug Insurance Policy Reform

作　　者：万彬[1] 胡大洋 张蔚[3] 周夕鸣 周怡彤 冷明祥[4] WAN Bin;HU Da-yang;ZHANG Wei(The First Affiliated Hospital of Nanjing Medical University(Jiangsu Province Hospital),Nanjing,210029,China;不详)

机构地区：[1]南京医科大学第一附属医院(江苏省人民医院),南京210029 [2]江苏省医疗保险研究会,南京210000 [3]江苏省医疗保险基金管理中心,南京210000 [4]南京医科大学,南京210029

出　　处：《中国卫生经济》2020年第4期36-39,共4页Chinese Health Economics

基　　金：江苏省医疗保险研究会社会招标科研课题2019年(JSYB2018006)。

摘　　要：目的:评估江苏省医药医保关键改革政策前后,13城市医疗费用及医保基金运行情况,探讨改革对医保基金的影响。方法:采用文献复习法和专家访谈法相结合,建立医保基金运行绩效体系。基于评价体系,对改革前后江苏省13城市医保基金运行绩效评价。医疗费用及医保基金运行数据分别来源于卫生、医保部门统计数据。结果:在改革中,江苏各地因地区经济发展水平、医保支付方式、医疗保障水平、分级诊疗推进程度等不同,医保基金运行绩效有所差异。结论:通过加大医疗成本控制、探索科学医保支付,推进分级诊疗、发挥临床药师作用等方式,巩固医药医保相关改革成效、提升医保基金运行绩效。Objective:To evaluate the medical expenses and the operation of 13 cities’medical insurance funds before and after the related reform policies in Jiangsu Province and to analyze the impact of the reforms on medical insurance funds.Methods:The literature review and expert interview method are used to establish the evaluation system of medical insurance fund operation.Based on the evaluation system,it evaluates the 13 cities’medical insurance funds in Jiangsu Province before and after the reform.The data of the medical expenses and medical insurance fund operation come from the statistics of health and medical insurance departments.Results:During the reform process,the medical insurance fund operation is different in 13citiers due to different regional economic development levels,medical insurance payment,medical security levels and the advancement of hierarchical treatment.Conclusion:Increasing the control of medical costs and exploring scientific medical insurance payment are needed to promote hierarchical treatment,play the role of clinical pharmacists,consolidate the reforms and improve the performance of medical insurance funds.

关 键 词：医疗保险基金 基金运行绩效 医疗服务价格改革 江苏 

分 类 号：R1-9[医药卫生—公共卫生与预防医学] F840.613[经济管理—保险]