医保基金信用监管体系评价研究——基于济南市2023年定点医疗机构信用评价数据  

Research on the Evaluation of the Credit Supervision System for Medical Insurance Fund--Based on the Credit Evaluation Data of Designated Medical Institutions in Jinan City in 2023

作　　者：王思冉 张志烁 李倩 曹养栋 王晴云 时涛 

机构地区：[1]山东第一医科大学(山东省医学科学院)医疗保障学院,济南250117

出　　处：《中国医疗保险》2024年第12期65-73,共9页China Health Insurance

基　　金：2024年度教育部人文社会科学研究项目“面向新质生产力发展的高素质技术技能人才培养体系重塑探究”(24YJA880042);山东省社科联2024年人文社会科学课题卫生健康专项“山东省医疗卫生服务体系新质生产力的新评价与优化提升策略研究”[24H063(Z)];济南市哲学社会科学规划重点课题“海外社交媒体的济南城市国际形象呈现与提升策略研究”(JNSK2025B034)。

摘　　要：医保基金信用监管体系(以下简称医保信用体系)建设是保障医保基金安全、促进医保事业健康发展及营造全社会诚信守法良好氛围的重要举措。济南市积极探索建立以全主体参与、全过程覆盖为支撑的标准化、一体化及精细化医保信用体系,通过构建多维度信用评价体系对定点医药机构进行综合评价。本研究从医保信用评价理论基础出发,以2023年度定点医疗机构评价结果的截面数据为研究样本,结合济南市医保信用评价指标体系的构建及实践情况,对现行体系中显现的问题进行系统梳理与深入剖析。最终从医保信用体系的优化、形成社会共治的监管合力两个角度出发提出可行性建议。The construction of the credit supervision system for medical insurance fund(hereinafter referred to as medical insurance credit system)is an important measure to ensure the safety of medical insurance funds,promote the healthy development of the medical insurance undertaking,and create a favorable atmosphere of integrity and law-abiding in the society.Jinan City has actively explored the establishment of a standardized,integrated and refined medical insurance credit system supported by full coverage of all subjects and the whole process,and conducted comprehensive evaluations of designated medical and pharmaceutical institutions through the construction of a multi-dimensional credit evaluation system.Starting from the theoretical basis of medical insurance credit evaluation,this study takes the cross-sectional data of the evaluation results of designated medical institutions in 2023 as the sample,and combines the construction and practice of Jinan's medical insurance credit evaluation index system to systematically analyze the problems manifested in the current system.Finally,feasible suggestions are proposed from the two perspectives of optimizing the medical insurance credit supervision system and forming the joint force for social co-governance.

关 键 词：医疗保障基金 信用监管体系 信用评价指标体系 信用等级 

分 类 号：F840.684[经济管理—保险] C913.7[社会学]