DIP改革背景下负向医疗行为成因及治理策略分析  

Analysis of the Causes and Governance Strategies of Negative Medical Behaviors under the Background of DIP Reform

作　　者：侯慧玉[1] 张少华 田溢卿[1] 王建斌[1] 李景涛[1] 王亚珍[1] HOU Huiyu;ZHANG Shaohua;TIAN Yiqing;WANG Jianbin;LI Jingtao;WANG Yazhen(Medical Insurance Management Office,Hebei General Hospital,Shijiazhuang 050051,China;Medical Affairs Office,Eighth People's Hospital of Hebei Province,Shijiazhuang 050011,China)

机构地区：[1]河北省人民医院公费医保办公室,河北石家庄050051 [2]河北省第八人民医院医务处,河北石家庄050011

出　　处：《医学与哲学》2024年第14期28-31,共4页Medicine and Philosophy

摘　　要：从医保管理部门、医疗机构和参保患者三个维度对医保支付方式改革背景下负向医疗行为的成因进行分析,发现以下问题:医保管理部门的法律制度不健全、部门联动缺失、双向沟通机制不完善,医疗机构的管理精细化程度不够、绩效考核体系落后、双向转诊落实不理想,部分参保患者存在负向就医行为。因此,避免负向医疗行为发生的治理策略包括:医保管理部门应健全法律制度体系、建立部门联动机制、拓展双向沟通渠道,医疗机构应推进管理精细化程度、调整绩效考核体系、建立分级诊疗秩序,参保患者应提高道德感使命感,共同维护医保基金安全。This study analyzes the causes of negative medical behaviors under the context of medical insurance payment method reforms from three perspectives:healthcare management departments,medical institutions,and insured patients.The findings indicate the following issues:inadequate legal systems,lack of inter-departmental coordination,and imperfect bidirectional communication mechanisms within healthcare management departments;insufficient refinement in management,outdated performance evaluation systems,and suboptimal implementation of bidirectional referrals within medical institutions;and negative healthcare-seeking behaviors among some insured patients.To prevent negative medical behaviors,the governance strategies should include:establishing a comprehensive legal system,developing inter-departmental coordination mechanisms,and expanding bidirectional communication channels within healthcare management departments;enhancing the management refinement,adjusting the performance evaluation systems,and establishing a tiered diagnosis and treatment order within medical institutions;and fostering a sense of moral responsibility among insured patients to collectively safeguard the medical insurance fund.

关 键 词：医疗保险 按病种分值付费 医疗费用控制 负向医疗行为 

分 类 号：R-05[医药卫生]