医疗保险院端日常审核中的问题及对策

基本医疗保险审核结算慢、结算难成为参保人员和医院反映强烈的突出问题。为找出症结所在,笔者分析总结了我院2009年上半年1967份出院医保费用清单审核中的问题,以求进一步提高和完善医保结算工作。     

军队医院DRG付费试点实践与体会

目的 构建与医保DRG付费相适应的信息流程和组织流程,实现与医保DRG付费系统的全面对接。方法 建立标准的编码数据库和病案首页填报系统并及时更新,加强医务人员培训,改进军队医院病案首页填报质量和填报效率,实施临床路径管理,新增病案交互功能设置,引入DRG智能软件,制订相关数质量分析评价考核机制。结果 解放军总医院第四医学中心被遴选为执行DRG实际付费的首家驻京军队医疗机构,历经三年多模拟运行实践,病历组合指数（case mix index,CMI）从试运行初期的0.96跃升为1.22,病种入组率从95%升至99%。结论 信息和组织两个流程的构建和优化是推行DRG付费的前提和基础,二者相互补充,缺一不可,此举为军队医院DRG付费从试点到实际应用积累了经验。     

“医保患者费用监控系统”在医院的应用

随着国家医疗制度改革的不断深入,医疗保险政策的覆盖面越来越大,来院就诊人员中参保患者所占的比例在逐年增加,各类医保管理部门每年对定点医院进行检查、排名,执行制度和规定不严格的医院要除名,直接影响医院的社会效益和经济效益.如何在保障患者享受合理的医疗服务的前提下落实医保政策的相关规定,适度控制参保人员的医疗费用,协调之间的矛盾使管控机制形成良性循环成为了医院医保管理工作的难点.针对此问题我院开发使用了"医保患者费用监控系统",该系统以患者医嘱为源头进行实时监控[¨,将医保管控模式前移,在政策范围内更好地为广大患者服务.     

影响医院医保管理绩效的因素与对策

目的：探讨影响医院医保管理绩效的相关因素,不断提升医院医保管理绩效水平。方法：采用回顾性研究的方法,分析2007～2008年,本院医保管理绩效资料,对组织管理、规章制度、政策宣传、知识学习、审核监督、奖罚机制共6个层面作分类描述。结果：组织管理、规章制度、政策宣传工作基本到位;参加集中学习的人数中护士最多,共316人,占护士总人数30.90%,医生较少,共132人,占医生总人数16.28%;在审核和监督中共计403人（次）有违规事件;奖罚机制中奖少罚多,共1人受到奖励,355人受到罚款。结论：医保管理绩效受多种因素影响,只有加强内部管理、重视医保知识宣传和学习、启动激励机制、加强对外联络,才能保证医院医保管理工作的准确、合理的高效率运转。     

加强医保管理降低医疗费用

当前，涉及人民群众切身利益的“看病难、看病贵”问题已引起社会的广泛关注和国家领导人的高度重视。2005年贵阳市各大医院超控制线较严重，我院也在其中；2006年省市医保工作重点是控制医疗费用，医院为此积极整改，加强组织机构，制定和完善各项管理规定，对病历实行双审制，网上时时监控不合理费用，对超出医保中心结算标准的费用实行医院与相关科室分担机制，今年第一季度已见成效，医保住院病人人均费用较去年明显降低。现将转们的骷法轺告加下．     

医院物资管理系统的应用体会

医院物资种类繁杂,规格多样,传统管理方法已无法适应当今医院发展,为提高医院物资管理效率,我们通过搭建网络信息化平台,实现医院物资的采购、入库、出库、结算的动态信息化管理,达到物资管理的快速、明确、规范,实现利益最大     

《公共管理教学案例解析》出版:新形势下的医院医保管理分析北大核心CSCD

根据《公共管理教学案例解析》表明目前医保存在管理混乱的问题,相关制度管理落实不到位,管理制度不健全、不严密、常态化自查自纠不深入,导致医保管理仍存在缺口,需要进一步改进。建立和完善医院医保管理,加强内控机制建设,规范医疗保障服务行为,是医院医保管理的重要组成部分。好的医保管理需要做到为民服务,而不是职业行业垄断,真正是站在百姓的角度以人为本治病救人的宗旨,来订立制度,而不是为了权利和利益来确定使用范围,为民服务,为民造福来制定医保制度。     

《中国医疗保障发展报告》出版:大数据分析在医院医保管理中的应用研究北大核心CSCD

《中国医疗保障发展报告》数据显示我国已经构建起了世界上最大的医疗保障体系,惠及了13亿多中国人民,然而随着对医院医保管理的高质量要求,各医院越来越重视建立健全院内医保质量管理体系,医保管理质量考核,规范医疗服务质量,新时期面临的新挑战日益严峻。在建设有中国特色医疗保障制度走向成熟、定型的时期,其改革与发展值得追踪研究,推进医院医保的管理成为医保工作的主要方向。医保管理帮助充分调动医务人员贯彻执行医保政策的自觉性,推动了医院医保管理向高品质、规范化发展。大数据分析能够给医保管理提供借鉴,使得管理具有科学性,以此提升自身的医保管理水平,对医保管理工作的认识和重视,对医保管理的主动性,实现医院的高质量发展。     

医院医保管理中会计档案信息化的作用分析

医院会计档案作为医院医保工作的重要信息来源,可以研究、分析和判断医保政策的运行,医保资金的投入和控制,医院管理状况的好坏等基本情况,关系到医患双方的切身利益,医院的现代化建设以及医保工作的稳定发展。因此,应当高度重视医院会计档案的工作,不断提高其信息化水平,充分发挥会计档案在医院医保管理中的地位和作用。     

浅析医保窗口服务存在的问题及对策

我国的基本医疗保险制度和医保工作是新时期国家公共政策的重要组成部分,与国计民生息息相关[1]。而医保窗口服务工作与民生联系最紧密,直接关系到参保患者就医问题。本文通过分析影响医保窗口服务质量的因素,进一步规范医保窗口管理及服务流程,提高服务质量,更好地为参保     

The computer in radiology--medical letter generation and practice management with COMRAD

One year after introduction of the COMRAD EDP system of text processing to the radiological practice of the author, the advantages resulting for the physician and medical staff as well as for the transferring physician and their patients are presented and the economic efficiency is determined. The high capacity of COMRAD including the automatic text processing for a complete computer aided administration of medical practice and the accounting department, is based on the advanced technological development of microelectronics and combined with a user specific software. The hardware equipment enables multiprogram processing, data processing in on-line operation as well as short access-time of stored data, due to the rapid tracertechnology of the computer. The software equipment, with text processing and a medical practice administration system, permits the regular workload to be handled efficiently and reliable. The main issue is text processing using a text rail. An integrated part of the result output is the performance capacity enabling automatic settlement of accounts with health insurance agencies and privately insured patients. Statistical evaluation, for instance the daily performance efficiency of the practice can be recalled any time. An accounting system accounts receivable, accounts payable, payroll and general accounting supplements the software package enabling a computer aided handling of all administrative tasks required in a radiological practice.     

美国空军的医疗保障体系

借鉴与学习美国空军医疗保障体系与先进理念,以及稳定航空军医队伍的有效手段.主要引用美国空军两个网络资料,文献4篇,军标1个.这些资料表明,美国空军高层已形成共识——良好的医疗服务是飞行安全与战斗力的重要保障.因此,每年预算庞大的经费,以维持75个医疗中心、医院、诊所或医疗站的专一而高效地运转.而军事人员通用医疗保险制度(TRICARE)使三军人员就近就诊,大幅节省费用.全球搜救、空运医疗服务系统和分级健康维护与治疗,构成完备的医疗保障体系.航空军医则是保障空军全体官兵健康的重要前哨,通过分级培训与较高待遇,使航空军医在专业与生活水平两方面均能不断提升,有效地稳定了这支队伍.美国TRICARE制度可以借鉴,稳定航空军医队伍的手段值得学习.     

Experience of an Italian Hospital Claims Management Committee: A tool for extrajudicial litigations resolution

Litigation related to medical liability has a great impact on Italian healthcare expenditure. Recently, many Italian Regions have adopted a “self-insurance system” and, in Sicilian Hospitals, were established the Claims Management Committees (CMC) to provide the direct management of claims.Here the experience of a Sicilian University Hospital CMC was described to analyze the claims features and their outcomes providing evidence on CMC usefulness. The analysis involved claims for compensation received during 4 years, using data obtained by a retrospective analysis of claims database created by Forensic Medicine Service. Claims data, obtained from the insurance broker, were used to perform the statistical comparison. During the examined period a total of 377 claims were received by CMC, respectively 63.6% for professional liability and 36.4% for other causes (damages not related to medical malpractice). The prevalence of complaints about malpractice regarded surgery. The CMC had expressed an opinion on 120 claims related to malpractice with the percentages of admission or rejection of liability respectively of 55% and 45%. The statistical analysis revealed a greater number of lawsuits in the Insurance system and, moreover, the CMC higher probability to reach the amicable settlement of litigations.CMC provides specific data on claims trend and economic expenditure, demonstrating its usefulness for analysis and monitoring the causes of patients/people damage. It is a tool for medical malpractice risk assessment and prevention. It can encourage the amicable settlement and prevention of civil action. It seems to be an efficient system to reduce the health liability costs.     

海南省2013年医疗机构医疗废物管理处置调查

 目的 调查海南省2013年各级医疗机构的医疗废物管理处置情况,为制定医疗废物管理措施提供依据。方法 采用横断面调查,研究内容包括医疗废物的组织管理、分类收集、暂时贮存和处置。检查医疗机构1830家(三级医疗机构5家,二级医疗机构18家,一级医疗机构235家,一级以下医疗机构1572家)。结果 95.03%制定管理制度和应急方案,89.00%开展工作人员培训,89.78%配备工作人员个人防护,85.79%建立交接登记,76.23%交接登记内容完整,75.90%分类收集,84.97%盛放容器符合要求,68.03%暂存地点符合要求,78.09%暂存时间符合要求,59.95%运送工具清洁消毒符合要求,80.60%采取集中处置;二级以上医疗机构的医疗废物管理处置工作基本符合要求,一级医疗机构存在一定问题,一级以下医疗机构存在问题(组织管理、收集运送、贮存、处置)明显,三者之间有统计学差异(P＜0.05)。结论 医疗机构的级别越低,医疗废物处理的合格程度越低,尤其一级以下医疗卫生机构。此类机构数量最多、不合格项目最多,而且与大众接触的密切程度也最高,应引起高度重视;管理制度建设比较完善,但后续的收集、存储、运送和处理逐渐递减,这可能是卫生监督的关键控制点。另外,探讨应用《医疗废物管理评价计分表》对医疗机构进行量化分级监督,增加后续指标权重的分级量化管理,值得后续深入研究。
     

医疗安全风险预警机制系统的设计与实现

目的：本研究旨在建立医疗安全风险预警机制信息化平台模型。方法：通过文献复习、调研学习、专家咨询及借鉴软件系统开发相关的原理确定预警系统模型。结果：开发了医疗安全风险预警系统,实现了机制运行的信息化。结论：医疗安全风险预警机制的信息化提高了机制运行的准确性与效率性。     

Evaluation of the third-party mediation mechanism for medical disputes in China

Medical disputes have been increasing in recent years in China, which cause growing tension between doctors and patients. In many locations, it has started as a practice of exploring diversified dispute settlement methods. Great importance has been attached to the non-lawsuit model through third-party mediation, which might have been led by professional organizations, insurance companies, People's Mediation Committees, or three-level governmental authorities. Those have contributed to a rapid effective resolution of medical disputes. However, there are some deficiencies that need to be addressed and fixed up, thus calling for improvement, such as the lack of a sustainable supporting mechanism, unclear legal status of the mediation institutions and mediation agreements, patching up a quarrel by only compensation.     

美国国民警卫队卫勤保障体制研究

 目的 探讨美国国民警卫队卫勤保障体制.方法 通过对美国陆军、空军及预备役部队卫勤编制体制及卫勤组织实施进行对比分析研究,探讨美国国民警卫队卫勤保障体制及组织实施过程.结果 美国国民警卫队卫勤保障系统由分队级、师级、军级和战区地幅级组成并以分队级、师级、军级三级卫勤保障体系组织实施.结论 美国国民警卫队卫勤保障是按作战情况及伤病员分级处理、治疗和后送需要制定和实施.     

Medical support of peace keeping forces in the Georgian-Abkhazian armed conflict zone

Since 1994 in the settlement of Georgian-and-Abkhazian armed conflict together with wide spectrum of means of political, diplomatic and economical character the Russian peace-making forces effectively use the operation for peace support. Taking into account the number of peace-making forces, the problems the solve and conditions of activity the staff of military medical service was presented by the head of medical service of united headquarters for peace support; by the medical platoons of battalions strengthened by physician, sanitary and medical equipment, additional medical things; by the medical station with infirmary (15 permanent beds); by the reanimation mobile group; by the emergency medical service group. The quality of medical support and successful solution of peace-making problems depend first of all on the management effectiveness, quality of medical specialist selection, discipline and professional training. It allows to work out the proposals for improvement of peace-making contingent's medical support in the zone of Georgian-and-Abkhazian armed conflict.     

精益管理在门诊流程改善中的应用

目的 优化门诊流程,充分提高医院门诊医疗资源利用效率.方法 运用精益思想,建立门诊精益管理体系:合理布局门诊就医环境、门诊"银医一卡通"支付模式、多元化预约挂号服务、分诊与排队叫号系统、检查(检验)申请电子集成、门诊药房自助收费系统.有效利用医疗资源,实现门诊人流、物流、信息流的同步并行.结果 完善了门诊就医流程,降低了运营成本,门诊整体运作效率显著提高.结论 精益管理实现门诊流程标准化、管理规范化,有利于提升门诊管理效率.