新疆某二级医院住院医保定额管理模式探讨

Discussion of One Secondary Hospital Medical Insurance Quota Management Mode in Xinjiang

目的研究定点医院如何科学、合理地用足用好各社保局分配的住院医保定额。方法通过自身前后对比法和德尔菲法,对新疆某二级甲等综合性医院2011—2014年给各临床科室二次分配和实际使用的住院医疗保险基金的额度进行对比,对医院住院医保定额管理与控制进行相关分析和评价。结果定点医院通过对住院医保定额的二次分配,13%的临床科室超出核定的额度,87%的临床科室完成的额度控制在合理的区间。结论在定点医院推广住院医保定额管理模式有效控制了住院医疗保险定额的超支比例,提高了医保基金的总额预算和总控成效,避免了定点医院因住院医保定额超支导致医疗保险基金分担的经济风险。

Objectives To find a way of using the allocation of medical insurance from Social Security Bureau scientifically and rationally.Methods By Delphi method and the comparison method of past and present,the secondary distribution to practical use of hospitalization insurance fund amount to clinical departments were compared in a second level grade a comprehensive hospital in Xinjiang during 2011-2014,and relative analysis and evaluation were made about hospitalization medical insurance quota management and control.Results Through the secondary allocation of hospital medical insurance quota,13% clinical departments exceeded the quota of the allocation and 87% of them controlled the allocation in a reasonable interval.Conclusions In designated hospital,the promotion of medical insurance quota management mode can effectively control the overspending proportion of hospitalization insurance,improve the effect of total budget and control,and greatly reduce the economic risk of the designated hospital for overspending medical insurance quota.