内控风险视角下医保监管系统规范公立医院医疗行为的有效性研究

Study on the effectiveness of medical insurance supervision system in regulating medical behavior in public hospitals from the perspective of internal control risk

目的构建医疗保险(以下简称“医保”)监管系统评价模型,评价医保监管系统规范公立医院医疗行为的有效性。方法基于扎根理论建立“五位一体”评价模型,以A公立医院集团为研究对象,对医保监管系统的应用效果进行全面评价。结果以临床诊疗规范规则库为核心的“五位一体”评价模型适用于医保监管系统评价,有效的医保监管系统有助于提升医护人员医保政策掌握水平、提高医护人员满意度,对于规范公立医院医疗行为、有效防范内部运营风险具有重要意义。结论对医保监管系统有效性开展全过程评价,能够有效提升医院治理能力和医保管理水平,保障医疗质量和医保基金安全。

Objective To construct the evaluation model of the supervision system of medical insurance and evaluate the effectiveness of the medical insurance supervision system in regulating the medical behavior in public hospitals.Method A“Five-in-one”evaluation model based on grounded theory was established and a public hospital group A was used as a pilot to comprehensively evaluate the application effect of the medical insurance supervision system.Results The“Five-in-one”evaluation model with a clinical diagnosis and treatment standard pool as the core was showed to be suitable for health care supervision system evaluation,and effective health supervision system helps to improve medical staff’s comprehension of health care policy,and their satisfaction.Further,this model is of great significance to regulate the medical behavior of public hospitals and effectively protect from internal operational risks.Conclusion The whole-process evaluation of the effectiveness of the medical insurance supervision system effectively improves the hospital governance capacity and the level of medical insurance management,and consequently ensures the quality of medical treatment and the safety of medical insurance fund.