定点医疗机构信用管理在医保基金监管中的重要性与实现策略  

The importance of credit management and its realization strategy among designated medical institutions in the supervision of medical insurance fund

作　　者：刘孟嘉 张金穗 陈文[1] 李建梅 龚忆纯 胡敏[1] LIU Meng-jia;ZHANG Jin-sui;CHEN Wen;LI Jian-mei;GONG Yi-chun;HU Min(School of Public Health,Fudan University,Shanghai 200032,China;Shanghai Medical Insurance Association,Shanghai 200051,China)

机构地区：[1]复旦大学公共卫生学院,上海200032 [2]上海市医疗保险协会,上海200051

出　　处：《中国卫生政策研究》2020年第11期32-36,共5页Chinese Journal of Health Policy

基　　金：国家社科基金(20ZDA072)。

摘　　要：我国医保基金安全面临重大挑战,而当前的医保基金监管体系存在局限性,对此,我国提出将信用管理引入医保基金监管。信用管理可对现有医保基金监管体系形成有效补充,能够拓展医保监管内容,引导医疗机构合理使用医保基金;延伸医保监管时效,保证基金监管力度;补充医保监管手段,引导医疗机构自觉约束服务行为。为最大化实现信用管理的目标,需构建起一套适用于定点医疗机构的信用评分指标体系,以及综合多指标来源的信用监测及评价体系,并在此基础上明确信用结果在医疗机构监管中的作用和流程,使信用管理起到守信激励和失信惩戒的效力,最终形成完善的医保信用管理制度体系,保障信用管理体系对定点医疗机构发挥最大作用。In China,the safety of medical insurance fund(MIF in this research)is faced with multi-facetedchallenges,and the current medical insurance fund supervision system(MIFSS)has some limitations linked to the system structure and to the emerging development.For this cause,it is proposed to introduce credit management into the supervision of MIF.In case it is introduced and implemented,the mechanism and function of credit management can form an effective supplement to the existing MIFSS,which can expand the content of medical insurance supervision and enhancemedical institutions to make rational use of their already received MIF,reduce the limitations and extend the flexibility of medical insurance supervision to ensure effective management of the funds,supplement medical insurance supervision means and guide medical institutions to voluntarily elaborate guidelines and restrictions related to the service behaviors.To make the credit management objective easily achievable,it is necessary to construct a set of credit score index system that may be applied into the designated medical institutions and a comprehensive credit monitoring and evaluation system based on multiple indicators.On this basis,the role and process of credit management informationin the actual supervision of medical institutions should be clarified,in order to make credit management system realize its function as trust worthy incentive and dishonest punishment,and finally form a perfect MIFSS to ensure the credit management system plays the greatest role in medical insurance among the designated medical institutions.

关 键 词：医疗保险 医保基金监管 信用管理 社会信用体系 

分 类 号：R197[医药卫生—卫生事业管理]