医保预付制改革的初步实践

Preliminary study on the reform of prepaid medical insurance system

目的:研究医院在医保总量资金"预付制"的前提下,如何在内部各临床科室之间合理地分配预付总量,实现医保总量资金最有效的使用。方法:采取代数方法计算各科室总量,将上海交通大学附属仁济医院(以下简称仁济医院)2009年和2008年的医保完成情况进行比较分析。结果:仁济医院2009年完成医保总量61549万元,与全年总量指标61799万元相比较,累计节余250万元。医保门急诊服务人次和住院服务人次与2008年同期相比分别上升7.6%和7.7%。结论:仁济医院通过加强内部管理、提升内涵质量、调整费用结构、调动医务人员积极性,来实现医保资金的有效使用,最终达到医保预付制改革试点成功。

Objectives: To analyze the medical insurance funds allocation among internal hospital department and achieve the maximum utilization of total medical insurance funds in the context of globe budget. Methods: Algebra was used to calculate the amount of medical insurance funds in every department. The amount of medical insurance funds in 2008 and 2009 is compared. Results: In 2009,the medical insurance fund distributed to Renji Hospital is 617.99 million yuan, the actual amount was 615.49 million yuan and the balance was about 2.5 million yuan. Outpatient and emergency service and hospital admission of medical insurance respectively had 7.6% and 7.7% ascents over the same period in 2008. Conclusions: Renji Hospital achieved effective use of total medical insurance fund by strengthening internal management, improving the quality of content, adjusting expense structure and promoting the motivation of staff. It successfully implemented the pilot reform of medical insurance prepaid system.