关于我国医疗保险机构构建定点医疗机构管理体系的研究

发布时间：2018-05-02 00:13

本文选题：基本保险制度 + 医保机构　；参考：《西南财经大学》2014年硕士论文

【摘要】：在我国经济发展水平取得大幅提高之后,人们更加关注自身的健康状况。健康作为社会中每一位社会成员的基本权利,对于公民的生活幸福与否具有决定性作用。我国在进行医疗卫生体制改革以前,医疗保险制度的只是覆盖到了城市中的部分职工,广大的城市居民医疗服务需求无法满足,覆盖更广大的农村居民的老农合也失去发挥作用的基石,大部分人们的健康权利被忽视,而看病难、看病贵的问题则把这种矛盾外化并推向顶峰,政府作出决心来解决好这个关系重大的民生问题。我国医疗保险制度开始时实施的是“双轨制”,即政府事业单位独享的免费医疗保险制度和由企业内部自行负担的职工医疗保险制度。伴随着经济的市场化,我国医疗保险制度的市场化改革也自1997年启动,以劳保医疗保险制度的改革为起点,城镇职工医疗保险制度的覆盖人群得到进一步扩大。随后,通过顶层制度的设计完善与全面铺开的试点运行之后,将我国的社会医疗保险制度的覆盖面扩展到全体居民。人们的健康权利从制度覆盖层面得到初步维护。从当前实际来看,我国医疗保险制度的改革取得了可喜的成绩,但是从长远的视角来看,制度设计层面的完善只是初级阶段,更为重要的是在运行过程中合理解决实践中出现的管理问题,这才能真正使参保人的健康权利得到真正保障。参保患者健康权利的实现和医疗服务需求的满足取决于定点医疗机构。而定点医疗机构有自身的角度与考虑,可能与参保人的利益产生矛盾,而人们的弱势地位和定点医疗机构的优势地位则促使后者牺牲前者的利益来扩大自身的利益。此时,医保机构,作为参保人员的代理人,将就定点医疗保险机构提供的医疗服务质量、服务态度和服务价格进行管理,以使参保患者的医疗服务需求得到最大满足。我国医保机构对定点医疗机构进行管理的目标是使参保患者得到及时高效优质的医疗服务,提高他们对我国社会医疗保险制度的满意度。定点医疗机构作为我国参保人的医疗服务的专属提供方,直接影响参保人对医疗保险制度的直观感受、也决定参保人自身的健康水平,更是关系到我国社会和经济的稳定发展。可是,医保机构在对定点医疗机构的管理实践中可借助的手段还比较少。因此,笔者基于建立有效的管理体系的目的,首先从我国自身管理实践发现的问题进行分析和总结,再通过梳理国外发达国家在其不同的制度模式下主要建立的体系和实践措施,同时,对于国内其它发达地区在对定点医疗机构进行的管理探索实施追踪,期以得到构建我国定点医疗机构管理体系的启示。为增加本文的现实意义,笔者对成都温江区实施的综合管理办法进行分析,对比和总结不同经济发展情况下我国医保机构的管理体系的建立和完善,最后还提出为保障我国医保制度长期发展对定点医疗机构进行管理时重点要解决的问题。本文的主要写作思路与逻辑框架如下所示：第一章,笔者首先对研究背景和研究对象进行阐述,从医保机构与定点医疗机构的利益和关系特点的角度指出两者之间的有共同发展的可能性,注重分析了探索建立有效的定点医疗机构管理体系的意义。然后,再通过文献综述逐个回顾了国外的英国、德国、新加坡、美国的四种不同医疗保障模式中保险机构建构的医疗服务提供方管理体系。再结合国内学者对定点医疗机构管理的的探讨,提出此命题还有研究价值与空间。第二章,从医保机构、参保人、定点医疗机构的利益需求出发,分析与归纳我国医保机构对定点医疗机构管理实践中存在的问题。同时,笔者也从深层次分析导致这些问题出现的原因。第三章,尽管英国、德国、美国建立的医疗保险模式不同、基础也相差较大,但是通过研究发现它们在管理实践中存在有一些类似的机制。笔者通过对它们的经验进行总结,其一,对医院及其设备的准入都有严格规划,同时还对医护人员的从业资质和行为规范都有规定。其二,细分并确定政府、行业组织与自治机构在医疗服务市场中的作用。其三,各国都重视患者就医的直观感受和反馈,并通过独立的专业第三方对医疗服务进行质量管理。其四,主张通过市场的作用对医疗服务价格进行调节,引入社会和个人资金,以供需情况来确定医疗服务价格。第四章,笔者主要介绍和分析国内的定点医疗机构管理实践。在对本行政区的基本医疗保险制度进行完善以后,北京和上海也意识到了医保机构对医疗服务质量管理的重要性,因此,它们也探索建立起了一套独特的管理体系。北京医保机构不仅重视准入和退出管理,还在日常管理中加入不同级别医院实施医疗费用指标的管理,并根据日常考核和年度考核来实现分为A级、B级两级管理。除了细化考核管理制度之外,上海创造性实施总额预付制,并对定点医疗机构中的科室医师予以重视,积极推行信用制,强化个人行为的自觉性,从医疗机构和医务人员层面直接确保医疗服务质量。第五章,主要阐述在借鉴国内外经验之后成都温江区建立和实施的一套全面的、综合的管理体系。尽管温江处于西南地区,经济发展较北京和上海落后,在医保管理的实践和创造没有这么强烈,但是为了参保人的医疗利益的出发点是一样的,通过不断的经验学习,自身的管理制度设计,温江区医保机构对区域内的定点医疗机构也实施了一系统完整的管理措施。笔者对此进行了详细的实证分析,为西南等欠发达区的医保管理机制提出一些新的观点和带来了新的实践借鉴。第六章,在对国内外医疗服务供方管理实践进行经验总结之后,笔者也为我国定点医疗机构管理体系的构建提出了建议。同时以系统的观点看待我国的医疗卫生体制的改革,笔者提出我国医保机构对定点医疗机构建立管理体系时,在重点关注医疗服务质量的同时,还需要关注和解决医疗服务市场内相关问题,如定点医疗机构、医生的生存和发展以及医疗费用转移的问题。本文研究的主要贡献： 1.以系统论为理论基础,提出要实施全面的措施来构建定点医疗机构管理体系,以期实现我国医疗保险制度的保证医疗质量和控制医疗费用的目的。 2.对成都温江区定点医疗机构管理体系试点进行实证跟踪,并总结了中西部医保机构构建定点医疗机构管理体系的相关经验,也强调了对医疗卫生服务市场中其它相关问题进行思考和解决。本文的不足之处在于：由于时间和获取资源的方式等原因,笔者只是进行了定性分析,没能以数据的形式呈现医保机构构建的定点医疗机构管理体系的成效。
[Abstract]:After a large increase in the level of economic development in China, people pay more attention to their own health. As the basic rights of every social member of the society, health is decisive for the well-being of the citizens. Before the reform of the medical and health system in China, the medical insurance system was only covered in the city. The medical service demand of the majority of the urban residents can not be satisfied. The old farmers' cooperation which covers the larger rural residents has lost the cornerstone of their function. Most people's health rights are ignored. The problems of seeing a doctor are difficult and the problems of seeing a doctor are externalized and pushed to the peak. The government has made up the mind to solve the relationship. A big problem of the people's livelihood.
At the beginning of the medical insurance system in China, the "double track system" was implemented, that is, the free medical insurance system of the government institutions and the medical insurance system of the workers and workers within the enterprise. With the economic marketization, the market-oriented reform of the medical insurance system in China started in 1997, with the reform of the insurance system of labor insurance. As a starting point, the coverage of the medical insurance system for urban workers has been further expanded. After that, the coverage of the social medical insurance system in China is extended to all residents after the design of the top level system is perfected and fully opened, and the health rights of the people are initially maintained from the system coverage level.
From the current reality, the reform of China's medical insurance system has made gratifying achievements, but from a long-term perspective, the improvement of the system design level is only the primary stage, and the more important thing is to solve the management problems in practice in the process of operation, which can truly guarantee the health rights of the insured.
The realization of the health rights of the insured and the satisfaction of the medical service demand depend on the fixed-point medical institutions. The fixed-point medical institutions have their own angles and considerations, which may have a contradiction with the interests of the insured, and the disadvantaged position of the people and the dominant position of the designated medical institutions encourage the latter to sacrifice the interests of the former to expand their own benefits. At this time, the medical insurance agency, as the agent of the insured personnel, will manage the medical service quality, service attitude and service price provided by the fixed-point medical insurance institution, so that the medical service needs of the insured patients can be met to the maximum.
The goal of medical insurance institutions to manage designated medical institutions in China is to make the insured patients get timely, efficient and high-quality medical services and improve their satisfaction with the social medical insurance system in our country. The designated medical institution, as a special provider of medical service for the insured persons, directly affects the direct medical insurance system of the insured. It is also related to the stable development of our society and economy. However, the means of medical insurance institutions in the management practice of fixed-point medical institutions are still relatively small. Therefore, the author, based on the objective of establishing an effective management system, first found the problems found in the practice of our own management. To analyze and summarize the system and practice measures of foreign developed countries in the different system mode, and to follow up the management exploration of the other developed areas in the designated medical institutions in China, in order to get the inspiration for the construction of the management system of the designated medical institutions in China. In practical significance, the author analyzes the comprehensive management measures implemented in Wenjiang District of Chengdu, compares and summarizes the establishment and improvement of the management system of medical insurance institutions in China under different economic development conditions. Finally, it also puts forward the key problems to be solved in order to ensure the long-term development of the medical insurance system to the management of designated medical institutions.
The main writing ideas and logical framework are as follows:
In the first chapter, the author first expounds the research background and research object, points out the possibility of common development between the medical insurance institutions and the designated medical institutions, and pays more attention to the significance of exploring and establishing an effective management system for designated medical institutions. Then, the literature review is reviewed. The management system of medical service providers constructed by insurance agencies in four different medical security models of Britain, Germany, Singapore and the United States of the United States. And then, combining the domestic scholars' discussion on the management of designated medical institutions, this paper also puts forward the proposition and the research value and space.
The second chapter, from the medical insurance institution, the insured person, the interest demand of the designated medical institutions, analyzes and summarizes the problems existing in the management practice of the medical insurance institutions of our country to the fixed-point medical institutions. At the same time, the author also analyzes the causes of these problems from the deep analysis.
The third chapter, although Britain, Germany, the United States established medical insurance models are different, the basis is also different, but through the study found that there are some similar mechanisms in the management practice. Second, subdivide and determine the role of the government, industry organizations and autonomous institutions in the medical service market. Thirdly, all countries attach importance to the intuition and feedback of the patient's medical treatment, and carry out the quality management of medical services through independent professional third parties. Fourthly, it advocates the role of the market to medical care. Service prices are regulated, social and personal funds are introduced to determine the price of medical services based on supply and demand.
The fourth chapter, the author mainly introduces and analyzes the management practice of domestic fixed-point medical institutions. After perfecting the basic medical insurance system in the administrative area, Beijing and Shanghai also realize the importance of medical insurance institutions to the management of medical service quality. Therefore, they also explore and establish a unique set of management system. Beijing medical insurance system. The organization not only attaches importance to admittance and exit management, but also joins the management of medical expenses in different levels of hospitals in daily management, and according to the daily assessment and annual assessment, it can be divided into class A and class B two level management. In addition to refining the assessment management system, Shanghai's creative total amount prepayment system and the Department of designated medical institutions are also included. The physicians should pay attention to it, actively implement the credit system, strengthen the consciousness of individual behavior, and directly ensure the quality of medical service from the level of medical institutions and medical personnel.
The fifth chapter mainly expounds a set of comprehensive and comprehensive management system established and implemented in Wenjiang District of Chengdu after learning from domestic and foreign experience. Although Wenjiang is in the southwest region, the economic development is behind Beijing and Shanghai, the practice and creation of medical insurance management is not so strong, but the starting point for the health care of the people is a starting point. Through continuous experience learning and the design of its own management system, the medical insurance agency of Wenjiang district has also carried out a systematic and complete management measure to the designated medical institutions in the region. The author has carried out a detailed and empirical analysis to put forward some new ideas and new practice for the medical insurance management system in the less developed areas in the southwest and other areas. Learn from.
In the sixth chapter, after summarizing the experience of the management practice of the domestic and foreign medical service providers, the author also puts forward some suggestions for the construction of the management system of the designated medical institutions in China. At the same time, the author views the reform of the medical and health system in our country with a systematic view. The author puts forward that the medical insurance system in China has established a management system for the designated medical institutions. While paying attention to the quality of medical services, it is necessary to pay attention to and solve the related problems in the medical service market, such as the fixed-point medical institutions, the survival and development of doctors, and the transfer of medical expenses.
The main contributions of this study are:
1. based on the theory of system theory, it is proposed to implement comprehensive measures to construct the management system of designated medical institutions in order to realize the purpose of ensuring medical quality and controlling medical expenses in the medical insurance system of China.
2. to carry out an empirical study on the management system of the designated medical institutions in Wenjiang District of Chengdu, and summarize the relevant experiences of the establishment of the management system of the designated medical institutions in the central and Western medical insurance institutions, and also emphasize the consideration and solution of other related problems in the medical and health service market.
The inadequacies of this paper are: due to the reason of time and access to resources, the author only conducts a qualitative analysis, and can not show the effectiveness of the fixed medical institution management system built by the medical insurance institution in the form of data.

【学位授予单位】：西南财经大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：F842.684;R197.1

【参考文献】