中国医科大学附属第一医院医疗保险管理体系构建研究

发布时间：2018-10-20 17:31

【摘要】：加快我国医药卫生体制改革，完善社会保障制度，是国家保障广大人民群众的医疗需求是社会经济发展的客观要求和改革目标，是构建和谐社会，共享改革成果的具体体现。医疗保险制度的建立和完善又会进一步促进社会的进步和生产的发展。一方面医疗保险解除了劳动者的后顾之忧，使其安心工作，从而可以提高劳动生产率，促进生产的发展；另一方面也保证了劳动者的身心健康，保证了劳动力正常再生产。中国医科大学附属第一医院作为一所大型综合性医院，管理好医疗保险和医保基金是确保医院稳定运行的基础。医保定点医疗机构的医疗保险管理工作是医院整体管理的重要组成部分。它起到了参谋助手，效益管理和监督职能的作用。做好新形势下定点医疗机构医疗保险管理工作，对提高医院整体管理水平和经济效益，增强医院的生命力和凝聚力具有十分重要的意义。中国医大一院面对越来越多的参保患者，在执行国家医疗保险政策过程中，应该在医院内部研究并制定出相应的医疗保险管理体系，从而既让参保患者获得充分的医疗服务，又能使医院在保证医疗服务质量的前提下控制医疗保险费用的不合理增长。目前，医院在医疗保险管理工作中仍存在着医保患者对医疗服务质量不满意；医院在控制医疗费用方面存在极端化；医保患者对于医保政策的理解存在不理解、医务工作者对待医保工作和医保患者存在消极态度等诸多问题，如何解决这些难题，是作为医院在医疗保险管理工作中所要面临和思考的课题。本文就中国医大一院如何完善医疗保险管理工作为核心，以大型综合性医院的视角来阐述如何加强医疗保险管理，并根据实际需求制定相应的管理体系。详细阐述了从建设医院医疗保险管理体系，加强医疗保险管理；完善医疗保险信息系统（HIS），利用科学手段介入日常医保管理中，提高工作效率；针对各类医疗保险就医制定有效的管理措施，层层细化，把医疗保险政策落到实处；医院应当合理控制医疗保险费用，重视医保超支将会给医院带来的直接影响，完善数字化管理模式，，科学、合理地研究对策；建立医院内部奖惩机制，对医护人员的医疗行为作出合理的评价，从而督促医护人员规范自己的医疗行为，提高医保管理意识；医院还应该制定合理的医疗保险结算方式，使大型综合性医院在获得良好经济效益和社会效益的同时让政府满意，让参保患者满意，实现“医、保、患”三方共赢。
[Abstract]:Speeding up the reform of Chinese medical and health system and perfecting the social security system are the objective requirements and reform goals of social and economic development, and the concrete embodiment of building a harmonious society and sharing the results of reform. The establishment and perfection of medical insurance system will further promote the progress of society and the development of production. On the one hand, the medical insurance relieves the laborer's worries, makes him work at ease, thus can improve the labor productivity and promote the development of production; on the other hand, it also guarantees the physical and mental health of the laborer and the normal reproduction of the labor force. As a large general hospital, the first affiliated Hospital of China Medical University manages the medical insurance and medical insurance fund well, which is the basis to ensure the stable operation of the hospital. Medical insurance management of designated medical institutions is an important part of overall hospital management. It acts as a staff assistant, benefit management and supervisory function. It is of great significance to do a good job in the management of medical insurance in designated medical institutions under the new situation to improve the overall management level and economic efficiency of the hospital and to enhance the vitality and cohesion of the hospital. In the face of more and more insured patients, the first Hospital of the Chinese Medical University should study and formulate a corresponding medical insurance management system within the hospital in the course of implementing the national medical insurance policy, so that the insured patients can obtain adequate medical services. The hospital can control the unreasonable increase of medical insurance cost under the premise of ensuring the quality of medical service. At present, there are still medical insurance patients dissatisfied with the quality of medical service in the management of medical insurance, hospitals have extremes in controlling medical expenses, medical insurance patients do not understand the medical insurance policy, Medical workers have many problems such as negative attitude towards medical insurance and medical insurance patients. How to solve these problems is a subject that hospitals face and think about in the management of medical insurance. This paper focuses on how to improve the management of medical insurance in the first Hospital of Chinese Medical University, expounds how to strengthen the management of medical insurance from the perspective of large general hospital, and formulates the corresponding management system according to the actual demand. This paper expounds in detail the construction of hospital medical insurance management system, the strengthening of medical insurance management, the improvement of medical insurance information system (HIS), the use of scientific means to intervene in the daily medical insurance management, and the improvement of working efficiency. To formulate effective management measures for all kinds of medical insurance, to refine the medical insurance policy, to implement the medical insurance policy, the hospital should reasonably control the medical insurance expenses, and pay attention to the direct impact of overspending on medical insurance on the hospital. Perfect the digital management mode, scientifically and reasonably study the countermeasure, establish the internal reward and punishment mechanism of the hospital, make the reasonable appraisal to the medical treatment behavior of the medical staff, thus urge the medical staff to standardize their own medical behavior, improve the management consciousness of the medical insurance; The hospital should also formulate reasonable medical insurance settlement method so that the large general hospital can obtain good economic and social benefits and make the government satisfied and the insured patients satisfied so as to realize the "doctor, insurance, patient" tripartite win-win.
【学位授予单位】：吉林大学
【学位级别】：硕士
【学位授予年份】：2013
【分类号】：R197.323;F842.684

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