上海市医保定点医疗机构诚信制度探究.pdf

上海市医保定点医疗机构诚信制度研究 摘 要 社会医疗保险制度改革进入健全体系、完善管理、优化服务新阶段 后，随着社会与经济的发展，越来越多的诚信因素会给社会医疗保险基金 带来出险的可能。其中，定点医疗机构违规行为的存在会造成医疗费用难 以控制，社会医疗保险基金收支不平衡，会严重阻碍医疗保险制度的改革。 首先，本文通过研究上海市定点医疗机构医保违规现状，结合医保政 策监管的难点问题，探讨定点医疗机构的不诚信行为造成医疗费用上涨的 原因，为解决医疗保险基金收支不平衡问题，从博弈论的角度提出了解决 医保诚信问题的方法，即对定点医疗机构的诚信进行科学的评价。其次， 建立了定点医疗机构诚信的评价指标体系和模糊评价模型，得到诚信评价 的结果。最后，按诚信等级进行分级管理，形成较为有效的定点医疗机构 诚信监管与失信惩戒机制，引导医疗资源合理分配，促进医保改革在和谐 的诚信环境中可持续发展。 关键词： 定点医疗机构 诚信评价指标体系 模糊评价模型 I STUDY ON THE CREDIT EVALUATION OF THE CERTIFIED HOSPITALS IN SHANGHAI ABSTRACT Nowadays, social medical insurance system’s innovation has been entered “ameliorate system, improve management and customer services” the new stage. Along with the development of society and economy, there are more and more credit factors may cause some safety problems about the social medical insurance fund. Some certified hospitals violating the rule will not only cause the difficulty of control medical treatment fee and balance of the social medical insurance fund, but also result in cumber innovation of the social medical insurance fund system. This paper is research on the problems in some certified hospitals in ShangHai violating rules and also integrate the difficulty to manage the social medical insurance policy, thus, the article will explore that credit factors of the certified hospital may lead medical treatment fee i