三级医院互联网医疗模式下医保管理的SWOT分析

SWOT Analysis of Medical Insurance Management in Tertiary Hospitals under Internet Medical Model

互联网医疗是互联网在医疗行业的新应用.医院的医保服务模式及医保管理内容都面临巨大变革。在互联网医疗模式下,医保管理涵盖了互联网医疗事前、事中、事后的全流程管理.通过使用更为先进的管理方法、手段以及信息系统,实现信息流、资金流、物流的全程可控。本文运用SWOT分析法.归纳了三级医院在互联网医疗模式下医保管理面临的慢性病患者复诊享受医保报销待遇更加方便快捷、医保基金过度支出、互联网就医模式引发的欺诈骗保行为等优势、劣势、机遇和威胁4个方面的问题。同时,提出注重培养复合型医保管理人才、加强医疗机构内部医保管理、调整医疗机构内部考核机制和互联网医保费用监管等管理措施。

Internet medical treatment is a new application of Internet in the medical industry. The medical insurance service mode and medical insurance management content of hospitals are facing great adjustment. In the Internet mode, medical insurance management covers the whole process management of Internet medical care,including before, during and after. By using more advanced management strategies, methods and information systems, the whole process of information flow, capital flow and logistics can be finally controlled. The paper employs SWOT analysis method and summarizes four problems of health care management functions under Internet medical model in the three levels of hospitals, which includes chronic diseases patients visit process, insurance reimbursement medical insurance fund overspending, Internet fraud insurance fraud behavior, as well as the strengths, weaknesses, opportunities and threats of the problem. At the same time, it puts forward control measures and suggestions from several aspects, such as paying attention to the cultivation of compound medical insurance management talents, strengthening the internal medical insurance management of medical institutions, adjusting the internal examination mechanism of medical institutions, and monitoring the medical insurance expenses on the Internet.