南京市某三甲医院精神病门诊医保管理政策实施现状与思考  

Current situation and reflections on the implementation of medical insurance management policy for psychiatric outpatient clinics in a Grade III Level A hospital in Nanjing

作　　者：傅友[1] 朱晓舟 FU You;ZHU Xiaozhou(Nanjing Medical University,Nanjing,Jiangsu Province,211166,PRC)

机构地区：[1]南京医科大学,江苏省南京市211166 [2]南京医科大学附属脑科医院,江苏省南京市210029

出　　处：《中国医院》2023年第9期70-74,共5页Chinese Hospitals

基　　金：国家自然科学基金(我国基本药物目录覆盖疾病领域与疾病谱匹配度评价与提升研究-基于疾病优先性评价模型)(72274217)。

摘　　要：目的:调研南京市精神病门诊医保管理政策实施现状;完善相关配套措施,保障患者权益;优化精神病门诊医保基金的使用和监督。方法:根据南京市精神病门诊医保管理实践与实施成效发现制度现存问题。通过政策实施效果影响因素构建一套涉及政策设计、政策执行、政策效果3方面的指标体系,收集来自南京市某三甲医院及医保办各专家的相关数据资料对南京市精神病门诊医保政策进行定量评价。结果:南京市精神病门诊政策制定的正当性和确定性较为科学合理,医保投诉方式较为多样,门诊政策落实情况执行效率较高,信息化管理水平动态监管工作良好,但南京市精神病门诊异地就医制度和审核制度的完善性有待提高,政策设计有待进一步满足临床医师和医保工作者的工作需求。结论:建议按照门诊患者就医需求配置医疗资源,动态调整门诊结构;精细化设计精神病门诊医保政策,推进政策有效实施;针对精神病门诊医保支付管理制定相应奖惩措施;从技术层面对精神病门诊患者进行约束,形成医保方对精神病患者的约束,减少医患双方的冲突。Objective:To investigate the current status of implementation of outpatient psychiatric medical insurance management policy in Nanjing;to improve relevant supporting measures to protect patient's rights and interests;and to optimize the use and supervision of the psychiatric outpatient medical insurance fund.Methods:The existing problems of the system were found according to the management practice and implementation effect of the medical insurance system for psychiatric outpatients in Nanjing.In the empirical research part,a set of indicator systems involving policy design,policy implementation,and policy effect is constructed through the factors influencing the policy implementation effect,and first-hand data from experts of a Grade III Level A hospital in Nanjing and the medical insurance office are collected to quantitatively evaluate the medical insurance policy of Nanjing psychiatric outpatient service.Results:The legitimacy and certainty of the outpatient psychiatric policy formulation in Nanjing were more scientific and reasonable,the medical insurance complaints were more diverse,the implementation of outpatient policies was more efficient,and the dynamic supervision of the information management level was good.However,the improvement of the outpatient psychiatric policy and audit system in Nanjing needs to be improved,and the policy design needs to further meet the work needs of clinicians and medical insurance workers.Conclusion:It is recommended that medical resources be allocated according to the demand of outpatients,that the structure of outpatient services be dynamically adjusted;that the policy of outpatient medical insurance for psychiatric disorders is refined,and that its effective implementation be promoted;that appropriate incentives and penalties be formulated for the management of outpatient payment for psychiatric disorders;and that outpatient psychiatric disorders be restrained at the technical level,so that the medical insurance party can be restrained from the psychiatric disorders,and

关 键 词：精神病 门诊医保 医保管理 评价体系 

分 类 号：R197.3[医药卫生—卫生事业管理]