我国医保基金监管创新实践现状研究  

Study on Current Status of Medical Insurance Fund Supervision Innovation Practice

作　　者：王佳慧 孟楠 陈佩雯 王日珍 姜胜超 张洪宇 张鑫 覃英华 周子力 吴群红[1] 郝艳华[1] 李叶[1] 高力军[1] WANG Jia-hui;MENG Nan;CHEN Pei-wen(School of Health Management,Harbin Medical University,Harbin,Heilongjiang,150081,China;不详)

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12期30-35,共6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：目的明确当前医疗保障基金监管创新方式实践现状与进程,总结全国各地先进做法与经验。方法通过搜寻政策、新闻资料等获取基金监管方式创新试点做法的相关信息,并运用政策文本分析方法、社会网络分析法对监管要素进行计量并可视化。结果社会网络分析中心度排名前5位的节点依次为引入第三方力量(239.000)、建立联动监管机制(224.000)、建立社会监督员制度(191.000)、建立信息披露制度(190.000)、建立举报奖励制度(182.000);措施网络图显示,在主体建设上,各地区主要开展引入第三方力量、组建专业监管队伍、建立联席会议制度等做法;制度方面,主要强化了事前预防以及事后溯源相关制度;机制方面,着重进行了联合监管机制建设;手段方面,着重进行了智能审核、视频监控等智能监管手段。结论在目前工作的基础上,未来还需要补足事中阶段控制与干预的相关制度、部门间衔接机制,完善线上线下多形式结合的监督检查手段,并通过加强民众对医保信息政策的宣教为全民参与监管的格局提供基础。Objective Clarify the current status and progress of medical security fund supervision practices and summarize advanced practices and experiences across the country.Methods It obtained relevant information on innovative pilots’practices of fund supervision methods by searching for policies and news materials,and used policy text analysis methods and social network analysis methods to measure and visualize regulatory elements.Results The results of social network analysis showed that the top five high centrality nodes are introducing third-party forces(239.000),establishing linkage supervision mechanism(224.000),establishing social supervisor system(191.000),information disclosure system(190.000)and reporting reward system.(182.000).The network measures chart showed that in terms of the construction of regulators,each region is mainly engaged in introducing third-party forces,establishing professional supervision teams,establishing the joint meeting system,and clarifying the powers and responsibilities;in terms of institution,it mainly strengthens the related systems of precautionary and post-tracing;in terms of mechanism;the construction of a joint supervision mechanism is focused;in terms of means,intelligent supervision such as intelligent auditing and video surveillance are focused.Conclusion On the basis of the current work,in the future it is necessary to improve the relevant systems for the stage of control and intervention and inter-departmental linkage mechanisms,perfecting online and offline monitoring and inspection methods,and strengthening the public’s publicity and education of medical insurance information policies to provide a basis for the pattern of public participation in supervision.

关 键 词：医疗保障基金 监管 创新实践 

分 类 号：R197.1[医药卫生—卫生事业管理]