基于“行政MDT”管理模式构建医院医保基金长效管理体系

Construction of Long-term Management System of Hospital Medical Insurance Fund Based on Administrative MDT Model

目的:通过医院“行政MDT”管理模式,有效降低医保基金拒付率,确保医保基金高效使用。方法:比较“行政MDT”模式实施前(2019年)与实施后(2021年)上海市某二级医院医保扣款数据和医保出院患者相关运营及质量数据。结果:实施“行政MDT”管理模式后,医保违规项目发生扣款次数减少,服务人次增加,次均费用下降,医院CMI提升。结论:“行政MDT”管理模式增强职能部门间的配合度,减少医保基金违规行为,提高医院医保基金使用效率。

Objective: The paper attempts to reduce the refusal rate of medical insurance fund and ensure the efficient use of medical insurance fund by the "administrative MDT" management mode of hospital. Methods: After the implementation of the "administrative MDT" model(2021) and before the implementation(2019), the medical insurance reimbursement data, and the operation and quality data of discharged insured patients in a Level Ⅱ hospital in Shanghai were compared. Results: After the implementation of "administrative MDT" mode, the number of reimbursement items of medical insurance fund decreased significantly, the number of service person-time increased,the average cost per time decreased and the CMI of the hospital increased. Conclusion: The "administrative MDT" model enhances the coordination between functional departments, reduces the violation of medical insurance fund,and improves the operation efficiency of medical insurance fund.