非理性就医对医保费用质量管理挑战和应对策略

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1、非理性就医对医保费用质量管理挑战和应对策略　　【摘要】目的：分析非理性就医现象，探索应对策略，合理控制医疗费用增长。方法：结合本院参保患者就医情况和多年来医保管理体系、制度、措施，总结分析近年来各级医疗机构非理性就医现象、原因和结果，探索建立应对策略和规范化管理措施。结果：随着全民医保制度的实施和经济市场化，参保者对医疗服务提出了更高的需求，在就医过程中常常出现了许多非理性就医现象，主要形式有小病大医，无病要医或体检式检查，挂床住院，追求高值耗材、贵重药品等。这些行为给医保管理带来挑战，特别是影响了医保费用质量，助推了过度医疗和医疗费用不合理增长。结论：针对非

2、理性就医对医保费用质量管理的挑战，一是要进一步深化落实国家医药卫生体制改革精神，“保基本，强基层”；二要完善配套的医疗保险政策及相关规定，加强保基本医疗的政策宣传；三是以关键环节为重点，深化医院医保管理；四是把医保费用支付制度改革和临床路径管理相结合，特别是科学实行基本医疗付费总额控制办法，规范医疗服务行为，合理控制医疗费用增长，保障医保基金使用安全。【关键词】挑战；医保费用；非理性就医；策略TheChallengeandtheCopingStrategyofthe4IrrationalHospitalizedAccordingtotheMedicalInsu

3、ranceExpenseManagement/WANGAn-min，XIANYUJian-bo.//MedicalInnocationofChina，2013，10（20）：132-134【Abstract】Objective：Toanalyzethephenomenonoftheirrationalhospitalized，todiscussthecopingstrategy，andtocontroltheincreaseofthemedicalexpenserational.Method：Thisarticlecombinedtheconditionofp

4、atientswhowereenjoyedthemedicalinsurancehospitalizedwiththemanagementofthemedicalinsurance，summarizedandanalyzedthephenomenon，thecause，andtheresultoftheirrationalhospitalizedrecentyearsinseveralhospitals，andexploredthecopingstrategyandthenormativemanagement.Result：Thepeople’srequire

5、mentaccordingtothemedicalinsurancewashigheralongwiththecivilmedicalinsuranceandthemarketeconomy.Therewereseveralirrationalphenomenainthecourseofthehospitalized.Forexampledoctortreatedaminorillnessasaseriousdisease，treatedorexaminedapersonwhowasn’till.Peoplewasinhospitalbutwasn’tinth

6、e4hospital，selectedtheexpensivematerialandmedicine，andsoon.Thesephenomenainfluencedthequalityofthemedicalinsuranceexpense，andencouragedtheexcessmedicaltreatmentandtheirrationalincreasedofthemedicalexpense.Conclusion：Therearefourstepsaimedatthechallengewhattheirrationalhospitalizecau

7、sedtothemedicalinsuranceexpense.Firstlytoascertainthemedicalandhealthsystemreform，secondlytoperfectthemedicalinsurancepolicyandstrengthentopublicizethebasicmedical.Thirdlytopromotethemanagementofthemedicalinsuranceinthehospital.Fourthlytoconnectthemedicalinsurancereformandtheclinica

8、lpathwaymanagement，