乌海市医疗保险付费方式改革问题研究

发布时间：2018-05-26 05:16

本文选题：医疗保险 + 付费方式改革　；参考：《内蒙古大学》2017年硕士论文

【摘要】：医疗保险的基本问题在于,医疗保险服务方对医保资金的要求无限增长,为满足患者的医疗需求,增加成本和利益收入,医疗保险支付方要在有限的医保资金的情况下,满足服务方的要求,还不能降低对患者的服务要求。付费方式作为医疗保险管理的手段,是平衡参保人员、医疗机构利益关系的关键性政策,是调节医疗服务行为的经济杠杆;提高医疗保险基金的拨付和使用,使患者可以享受医疗保险服务,体现政府治理的积极作用,是实现医疗保险制度可持续发展的重要支点,也是医保管理机构的天然使命。本研究首先详细介绍了医疗保险付费方式和改革相关的概念和改革的必要性分析,乌海市医疗保险付费方式改革进程以及对存在的问题分析,从而提出,促进乌海市医疗保险付费方式改革对策建议,主要包括加强政府主导与部门协作关系、完善经办管理的支付方式、加强付费方式改革的机制建设、加强基金预算管理、加强协议管理、发挥信息系统建设的基础支撑作用等。不同的付费方式会引导产生不同的医疗服务行为,没有哪一种付费方式是万能的,在选择了一种付费方式的优势时,同时也要面对这种付费方式的弊端。医疗保险管理者要充分了解各种付费方式的特征,预见其可能产生的后果,并采取相应的有针对性的管理措施,才能充分发挥付费方式引导医疗服务行为和控制医疗费用的积极作用,避免或减轻不利影响。从而保证经办管理的严格,比如协议管理、医保医师管理、医疗监控管理等措施相结合,形成一个系统工程,达到医保基金收支平衡的要求。
[Abstract]:The basic problem of medical insurance is that the demand for medical insurance funds by medical insurance providers is increasing indefinitely. In order to meet patients' medical needs, increase costs and benefit income, medical insurance payers should have limited medical insurance funds. To meet the requirements of the service side, can not reduce the service requirements for patients. As a means of medical insurance management, payment method is a key policy to balance the interests of insured personnel and medical institutions, is to regulate the economic leverage of medical service behavior, and to improve the allocation and use of medical insurance funds. It is an important fulcrum to realize the sustainable development of medical insurance system to make patients enjoy medical insurance service and reflect the positive role of government governance. It is also the natural mission of medical insurance management organization. This study firstly introduces the concept and necessity of medical insurance payment mode and reform, the reform process of Wuhai medical insurance payment system and the analysis of the existing problems. The countermeasures and suggestions to promote the reform of medical insurance payment mode in Wuhai City mainly include strengthening the relationship between the government leading and the departments, perfecting the payment mode of the administrative management, strengthening the mechanism construction of the reform of the payment mode, and strengthening the fund budget management. Strengthen the agreement management, give play to the basic supporting role of the information system construction and so on. Different payment methods will lead to different medical service behavior, no payment is omnipotent, in the choice of the advantages of a payment method, but also to face the drawbacks of this way of payment. Medical insurance administrators should fully understand the characteristics of various payment methods, foresee the possible consequences, and take appropriate targeted management measures. Only in order to give full play to the positive role of paying way to guide medical service behavior and control medical expenses, to avoid or mitigate the adverse effects. In order to ensure strict management, such as agreement management, medical care physician management, medical monitoring management and other measures combined to form a system engineering, to meet the requirements of health insurance fund income and expenditure balance.
【学位授予单位】：内蒙古大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R197.1;F842.684

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