基于故障树分析法的医保基金使用风险识别研究——以某市医保基金监管真实世界数据为例

Research on Risk Identification of Medical Insurance Fund Based on Fault Tree Analysis——Taking the Real-world Data of Medical Insurance Fund's Supervision in Shanghai

近年来,医疗保险基金使用中的违法违规行为愈演愈烈,且呈现出多种形式和特征,医疗保险基金监管面临挑战。本研究借助故障树分析法,从基金使用环节和基金使用中的常见违规行为两个角度建立医疗保险基金使用风险故障树,定性分析医疗保险基金使用风险基本事件,进而建立基本风险指标库,为进一步寻找影响医疗保险基金安全使用的风险因素、探讨精准监管策略奠定基础。

In recent years, illegal behavior of using medical insurance funds has intensifi ed and presented many forms and characteristics, and the supervision of medical insurance funds is facing great challenges. This study uses the Fault Tree Analysis method to establish a fault tree for the use of medical insurance funds from the perspective of the use process and the common violations. It lays the foundation for further fi nding the risk factors that aff ect the safe use of medical insurance funds and exploring the precise supervision strategy.