省会城市三级医院医保管理调查及优化策略——基于济南市的实证研究

An Empirical Study on the Survey and Optimistic Strategies for Medical Insurance Management in Three-grade Hospitals in Provincial Capital Cities: Based on the Investigation of Jinan

目的分析济南市三级医院医保管理状况,为政府政策、医保部门和医院管理3方面共同加强医保管理提供优化策略。方法通过文献研究、专家咨询、实地调研等方式,设计电话调查问卷,对调查数据进行统计学分析。结果 2013年济南市有45.6%城镇职工医保病人在三级医院住院时因医院的医保管理缺陷而不能全面、全程享受医保福利;省部属的大型三级医院成为问题高发集中地;参保人对现行医保报销比例满意率为58.4%。结论深化医保政策改革应立足省会城市地域特殊性,合理均衡分布医疗资源,规范分级转诊就医秩序,完善支付机制,加强监管水平和保障力度。

Objective To Provide the optimistic strategies for the government policy, the medical insurance department and the hospital management by analyzing the medical insurance management of three-grade hospitals in Jnnan. Methods Using the method of the literature research, the expert consultation, the field survey and so on, researchers designed the telephone survey questionnaires, and analyzed the data by statistical methods. Results During their hospitalization in the three-grade hospitals, 45.6% Jinan urban workers medical insurance patients couldn＇t take full advantage of health insurance benefits, because of the flaws in the management in these hospitals. Large scale three-grade Provincial hospitals became the focus of the problem; Satisfaction of patients with medical insurance reimbursement was 58.4%. Conclusion Deepening medical insurance policy reform should be based on the regional particularity of the provincial capital cities, reasonable and balanced distribution of medical resources, standardized the classification of medical order, improved the payment mechanism, strengthened the supervision level and security.