精神专科医疗机构医保基金使用违法违规问题剖析与治理对策  

Analysis and Countermeasures of Illegal Use of Medical Insurance Fund in Psychiatric Medical Institutions

作　　者：王奕婷 王运柏 黄圣平 周秀兰 汪健健[3] 肖卫 林翕 

机构地区：[1]湖南财政经济学院,长沙410000 [2]湖南省医疗保障局,长沙410002 [3]中南大学湘雅二医院精神病学科,长沙410011 [4]湖南泰阳科技信息有限公司,长沙410114

出　　处：《中国医疗保险》2023年第1期23-29,共7页China Health Insurance

摘　　要：目的:实证分析湖南省精神专科医疗机构医保基金使用存在的违法违规问题,探索治理对策,促进精神专科医疗机构医保基金使用合法合规,提升重性精神病患者的社会保障效益。方法:摸底调查湖南省精神专科医疗机构基本情况、既往专科医保违法违规使用医保基金问题查处情况,通过大数据分析、个案解剖等方式深入分析成因。结果:当前精神专科医疗机构存在较多医保违法违规问题,形成原因复杂,包括疾病特殊性因素(家庭社会因素)、经费保障机制不健全、民营专科机构逐利倾向明显、专科技术人才严重缺乏、诊疗规范缺乏、部门联动机制不健全等多方面因素。建议:严格规范专科医疗服务,严格监管虚构医疗服务项目、服务不足、过度医疗等医保违法违规问题;建立部门联合监督管理工作机制,推进相关体制机制改革等。Objective: The paper attempts to empirically analyze the illegal use of medical insurance funds in psychiatric medical institutions in Hunan Province, explore the countermeasures, promote the legal compliance of the use of medical insurance funds in psychiatric medical institutions, and enhance the social security benefits of patients with severe mental illness. Methods: We investigates the basic situation of psychiatric medical institutions in Hunan Province, and the investigation and punishment of the illegal use of medical insurance funds by specialized medical insurance in the past. Through big data analysis, case anatomy and other ways, we conducts in-depth analysis of the causes. Results: At present, there are many medical insurance violations in psychiatric specialist medical institutions, and the causes are complex, including the unique features of disease(family and social factors),imperfect fund guarantee mechanism, obvious profit-seeking impulse of private specialist institutions, serious shortage of specialist technical talents, lack of diagnosis and treatment norms, imperfect linkage mechanism among departments and so on. Suggestions: We should strictly regulate the specialized medical services and supervise the illegal problems in health insurance, such as false medical service items, insufficient services and excessive medical treatment, etc. Meanwhile, we should establish a united management mechanisms among department and push forward the reform for relevant mechanisms and systems.

关 键 词：精神专科医疗机构 重性精神病 医保 基金监管 

分 类 号：F840.684[经济管理—保险] C913.7[社会学]