总额控制下门诊特病管理效果探析

Analysis on the Management Effect of Special Diseases in Outpatient Department under Global Medical Insurance Budget

目的 :研究总额控制下医保门诊特病管理的可行性,为促进临床合理用药、降低医保基金运行风险以及控制药品费用不合理增长提供理论依据。方法 :制定门诊特病管理规定,采取规范门诊特病诊疗报销流程,完善医院医保药品目录,规范医保医师诊疗行为,加强医患沟通等措施,加强医保门诊特病管理。结果 :门诊特病患者医疗总费用、药品费用、个人负担、自付比例有效降低;违规资金率、医疗服务不规范发生率明显减少;患者满意度、临床医师处方合格率明显提高。结论 :总额控制下医保门诊特病管理是保障医保基金安全及合理使用的有效方法,既让患者得到规范的专业治疗,又保障了医保基金的合理有效使用。

PURPOSE The purpose of this study was to analyze the feasibility of the management of special diseases in outpatient department under Global Medial Insurance Budget, to provide a theoretical basis for promoting rational drug use, reducing operational risk of the health insurance fund and controlling the unreasonable growth of drug cost. METHODS We formulated administrative regulations for special disease in outpatient departments, standardized reimbursement process, improved medical insurance drug directories, standardized medical service behavior of physicians, strengthened doctor-patient communication, and intensified the management of special disease in outpatient departments. RESULTS The total cost of patients with special diseases, drug cost, personal costs, and the ratio of out-of pockets have been effectively reduced. The rates of illegal cost, and the occurrence of irregular medical service were significantly decreased, and patients＇ satisfaction and the qualification rate of clinical prescription have been apparently improved. CONCLUSIONS It is an effective way to protect medical insurance fund to be fairly and reasonably used by the management of special disease in outpatient departments, which not only allow patients to receive standardized professional treatment, but also protect the rational and efficient use of health care funds.