打击医保欺诈成效及影响因素研究  

Research on the Effectiveness of Combating Medical Insurance Fraud and Its Influencing Factors:Taking Heilongjiang as an Example

作　　者：许峤 吴群红[1] 单凌寒[1] 焦明丽[1] 高力军[1] 张鑫 姜胜超 王可欣 陈佩雯 孟楠 XU Jiao;WU Qun-hong;SHAN Ling-han(School of Health Management,Harbin Medical University,Harbin,Heilongjiang,150081,China)

机构地区：[1]哈尔滨医科大学卫生管理学院,黑龙江哈尔滨150081

出　　处：《中国医院管理》2021年第11期25-29,共5页Chinese Hospital Management

基　　金：国家社会科学基金重点项目(19AZD013);国家自然科学基金面上项目(71874045);黑龙江省公共健康安全及医改策略高端智库研究项目。

摘　　要：目的通过对打击骗保成效及影响因素分析,为提升医保监管政策效果提供科学参考。方法对从事医保经办与医保相关行业的行政人员开展问卷调查,获有效问卷1933份,采用Spss22.0软件,运用二分类logistic回归分析探讨打击医保欺诈成效的影响因素。结果63%的被调查对象对打击骗保行为专项行动成效的总体评价较好。但仍存在着诸如:查处违规行动时机滞后,特别地方医保信息系统标准不统一、医保治理体系尚未建立等问题制约着整体效果的提升。此外,医保系统的信息化、智能化程度(OR=5.570)、医保支付改革成效(0R=3.620)、医保治理的体系化建设程度(OR=2.888)、医保信息系统的标准化(OR=2.007)、违规行为查处惩罚时机(OR=1.491)、骗保信息公开制度完善情况(OR=1.599)、医保局同其他医保监管相关部门协商能力(OR=1.332)等因素成为左右和影响我国打击骗保专项行动成效的关键因素。结论应通过推进医保系统信息化智能化建设,加快支付方式改革,探索建立医疗保障治理体系,保障医保基金的可持续发展。Objective It provided a scientific reference for improving the effectiveness of medical insurance regulatory policies by analyzing the effectiveness and influencing factors of combating fraudulent insurance.Methods A questionnaire survey was conducted among administrative staff engaged in medical insurance management and medical insurance-related industries,and 1933 valid questionnaires were obtained.SPSS 22.0 Software was used and binary logistic regression was used to analyze the influencing factors of the effectiveness of combating medical insurance fraud.Results 63%of the respondents gave a good overall evaluation of the effectiveness of the special action against fraudulent insurance.However,there are still problems such as the time to investigate and deal with violations is lagging,in particular,local medical insurance information system standards are not uniform,and medical insurance governance systems have not yet been established,which restrict the improvement of the overall effect.In addition,the degree of informatization and intelligence of the medical insurance system(OR=5.570),the effectiveness of medical insurance payment reform(0 R=3.620),the degree of systematic construction of medical insurance governance(OR=2.888),the standardization of medical insurance information systems(OR=2.007),the timing of investigation and punishment of violations(OR=1.491),the improvement of the information disclosure system of fraudulent insurance(OR=1.599),the ability of the Medical Insurance Bureau to negotiate with other medical insurance regulatory authorities(OR=1.332)and other factors have influenced and affected China’s crackdown on fraudulent insurance Key factors for the effectiveness of special actions.Conclusion It needs top romotes the informatization and intelligent construction of the medical insurance system,accelerate the reform of payment methods,explore the establishment of a medical insurance governance system,and ensure the sustainable development of medical insurance funds.

关 键 词：医疗保障基金 骗保 打击成效 影响因素 

分 类 号：R197.1[医药卫生—卫生事业管理]