论医疗保险对医疗服务的制衡与监管

On the Restriction and Supervision of Medical Insurance for Medical Service

随着全民医保的实现,作为参保人代表的医疗保险机构已成为医疗服务市场的主要"购买者"。由于医疗服务市场的特殊性,医疗保险作为第三方购买者,应该具备制衡与监管医疗服务的作用。尤其是面对当前我国医疗保险机构、医疗机构及患者间错综复杂的利益关系,医保制衡与监管功能的发挥显得更为迫切和需要。从事前的谈判机制、事中的结算机制及事后的评价机制等几方面着手,探讨如何加强医保对医疗服务的制衡与监管。

With the implementation of national health insurance, medical insurance institutions on the behalf of the insured person are the main buyers of the medical service market. Because of the particularity of medical service market, as the third party purchaser, medical insurance should have the restriction and supervision of medical service role. Espe- ciaUy there are perlexing relations between the current medical insurance institutions, medical institutions and patients, It is urgent and neccessary to play the functions of restriction and supervision of medical insurance. From several aspects of prior negotiation mechanism, settlement mechanism, past evaluation mechanism and so on, this paper discussed how to strengthen the balance and supervision of medical insurance for medical service.