非理性就医对医保费用质量管理的挑战及应对策略

摘要

目的：分析非理性就医现象，探索应对策略，合理控制医疗费用增长。方法：结合本院参保患者就医情况和多年来医保管理体系、制度、措施，总结分析近年来各级医疗机构非理性就医现象、原因和结果，探索建立应对策略和规范化管理措施。结果：随着全民医保制度的实施和经济市场化，参保者对医疗服务提出了更高的需求，在就医过程中常常出现了许多非理性就医现象，主要形式有小病大医，无病要医或体检式检查，挂床住院，追求高值耗材、贵重药品等。这些行为给医保管理带来挑战，特别是影响了医保费用质量，助推了过度医疗和医疗费用不合理增长。结论：针对非理性就医对医保费用质量管理的挑战，一是要进一步深化落实国家医药卫生体制改革精神，“保基本，强基层”；二要完善配套的医疗保险政策及相关规定，加强保基本医疗的政策宣传；三是以关键环节为重点，深化医院医保管理；四是把医保费用支付制度改革和临床路径管理相结合，特别是科学实行基本医疗付费总额控制办法，规范医疗服务行为，合理控制医疗费用增长，保障医保基金使用安全。%Objective:To analyze the phenomenon of the irrational hospitalized,to discuss the coping strategy,and to control the increase of the medical expense rational. Method:This article combined the condition of patients who were enjoyed the medical insurance hospitalized with the management of the medical insurance,summarized and analyzed the phenomenon,the cause,and the result of the irrational hospitalized recent years in several hospitals,and explored the coping strategy and the normative management. Result:The people’s requirement according to the medical insurance was higher along with the civil medical insurance and the market economy. There were several irrational phenomena in the course of the hospitalized.For example doctor treated a minor illness as a serious disease,treated or examined a person who wasn’t ill. People was in hospital but wasn’t in the hospital,selected the expensive material and medicine,and so on. These phenomena influenced the quality of the medical insurance expense,and encouraged the excess medical treatment and the irrational increased of the medical expense. Conclusion:There are four steps aimed at the challenge what the irrational hospitalize caused to the medical insurance expense. Firstly to ascertain the medical and health system reform,secondly to perfect the medical insurance policy and strengthen to publicize the basic medical. Thirdly to promote the management of the medical insurance in the hospital. Fourthly to connect the medical insurance reform and the clinical pathway management,especially to control the amount of the basic medical insurance expense scientifically,to standard the medical,to control the increase of the medical expense reasonably,and to guarantee the safety of the insurance expense.