医保基金监管信用体系建设试点工作现况研究

Current Pilot Work of Credit Management of Medical Insurance Fund in China

目的:调研6个试点地区,公开收集相关文件,总结现行信用管理指标体系,各试点地区逐步探索出一套基本符合医保基金管理要求的信用管理办法。方法:采用文献分析、实地调研和专家、关键人访谈等方法,整理分析所有已落实医药机构信用体系建设的试点地区实施方案。结果:各地区对《医疗保障基金监管信用评价指标操作手册(定点医疗机构/A类)》指标采纳情况存在差异。现行试点地区存在评价指标建设情况不一、评价指标法律依据不足、地方系统平台协同不足的问题。结论:建议优化各项指标,引导各地区在管理方向和基本要素逐步趋同;加强顶层设计与法律依据;建设以省级为单位的信息化平台。

Objective:A total of 6 regions were selected as the pilot regions to collect relevant documents from public sources to analyze and summarize the current credit management indicator system.Since the pilot implementation,the pilot regions have gradual⁃ly explored a set of credit management methodsfor medical insurance fund.Methods:The results show variations in the adoption of the Operational Handbook for Medicare Fund Regulatory Credit Evaluation Indicators(Manual)indicators across regions.The current pilot districts suffer from inconsistencies in the construction of evaluation indicators,insufficient legal basis for evaluation indicators and insufficient synergies between local systems platforms.Results:The current pilot regions have the problems of inconsistent con⁃struction of evaluation indicators,differences in evaluation due to differences in hospital volume,insufficient legal basis for credit as⁃sessment indicators,and insufficient local information system platform construction and integrated collaboration.Conclusion:It is sug⁃gested to optimize the indicators in the handbook and guide regions to gradually converge in management directions and basic ele⁃ments,strengthen top-level design and legal basis and build a province-based informatics platform.