江苏省社会医疗保险监管成效与困境研究

Research on the effect and dilemma of social medical insurance supervision in Jiangsu Province

目的:在当前国家对医保不合规行为保持严厉监管态势下,分析监管取得的成效及面临的困境。方法:通过访谈法和问卷调查法获得相关资料数据,随后进行描述性统计分析。结果:样本地区在监管流程、监管手段、监管重点以及追回资金等方面取得了较好的成效,但也面临着智能监控系统与临床实际衔接不畅、稽查依据标准不统一、部门联动动力不足、社会力量未能充分发挥作用等困境。结论:强化顶层设计、完善智能监控系统、建立激励与约束制度、营造良好氛围等可有效克服现实困境,从而提升医保监管效率和效果。

Objective:Under the current state that the country maintains strict supervision on medical insurance irregular behaviors,analyze the effectiveness of supervision and the difficulties faced by it.Methods:Relevant data were obtained through the interview method and questionnaire survey method,followed by descriptive statistical analysis.Results:The sample areas have achieved good results in terms of regulatory procedures,regulatory means,regulatory focus,and recovery of funds,but they also face difficulties such as the poor connection between the intelligent monitoring system and clinical practice,inconsistent inspection standards,insufficient linkage power of departments,and failure of social forces to give full play to their role.Conclusion:Strengthening the top-level design,improving the intelligent monitoring system,establishing an incentive and restraint system,and creating a good atmosphere can effectively overcome the real dilemma,thereby improving the efficiency and effectiveness of medical insurance supervision.