医保参保人就医行为对基金管理的挑战与思考  

Challenges and Reflections on Fund Management Posed by the Medical Behavior of Insured Individuals

作　　者：侯慧玉[1] 张华星[1] 王建斌[1] 李景涛[1] 田溢卿[1] HOU Huiyu;ZHANG Huaxing;WANG Jianbin;LI Jingtao;TIAN Yiqing(Medical Insurance Management Office,Hebei General Hospital,Shijiazhuang 050051,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

出　　处：《医学与哲学》2025年第4期56-59,共4页Medicine and Philosophy

基　　金：2024年河北省医疗保障研究课题(JYB240306)。

摘　　要：通过分析参保人就医行为对医保基金管理产生挑战的原因,发现以下问题:不同地域不同参保身份医保待遇差别大、缺乏多部门多地区信息共享平台、医保基金监管能力有待提高、公众对医保政策及骗保行为认知不足、健康焦虑现象日趋严重。针对上述原因,提出以下对策:推进医保省级统筹、完善医保目录管理、加快医保信息化建设、提高基金监管能力、加大医保政策宣传力度、缓解公众健康焦虑现象,从而提高参保人维护医保基金安全的自觉性,与医保管理部门和医疗机构共同保障医保基金的可持续发展。Through analyzing the reasons why insured individuals'medical behavior poses challenges to the management of medical insurance fund,the following problems were found:significant differences in medical insurance benefits among different regions and insured identities,lack of information sharing platforms across multiple departments and regions,insufficient regulatory capacity of the medical insurance fund,limited public awareness of medical insurance policies and fraudulent behavior,and the increasingly serious phenomenon of health anxiety.In response to the above reasons,the following measures are proposed:promoting provincial-level coordination of medical insurance,improving the management of medical insurance catalog,accelerating the digitalization of medical insurance,enhancing the supervision ability of medical insurance fund,strengthening the promotion of insurance policies,and alleviating public health anxiety.These measures aim to increase insured individuals'awareness of protecting the medical insurance fund and foster collaboration between insurance management departments and medical institutions to ensure the fund's sustainable development.

关 键 词：参保人 就医行为 医保基金管理 欺诈骗保 

分 类 号：R-05[医药卫生]