医保基金与医药企业直接结算风险防控探析

Analysis on Risk Prevention and Control in Direct Settlement Between Medical Insurance Fund and Pharmaceutical Enterprises

医保基金与医药企业直接结算有利于推进药品集中带量采购深入开展,也为控制医疗费用不合理上涨提供了新方法,但也可能给基金安全运行带来新的风险因素。本文在全面剖析结算方式变化的基础上,运用风险管理理论识别药品集中带量采购和直接结算业务的风险因素,分析风险成因,提出风险应对措施,建议提高医保业务程序化和标准化建设水平,稳步有序推进直接结算政策实施。

The direct settlement between medical insurance fund and pharmaceutical enterprises is beneficial to promoting the in-depth development of centralized volume-based drug procurement,and provides a new method to control the unreasonable rise of medical expenses as well.However,the adjustment of the routine settlement process also brings new risks to the safe operation of the fund.On the basis of a comprehensive analysis of the change of settlement methods,this paper uses the risk management theory to identify the risks of centralized volume-based drug procurement and direct settlement,analyzes the causes of risk,and puts forward the countermeasures.It is suggested improving the procedural and standardized construction level of medical insurance business,and promoting the implementation of the direct settlement policy in a steady and orderly manner.