【摘要】：加快我國醫(yī)藥衛(wèi)生體制改革，完善社會保障制度，是國家保障廣大人民群眾的醫(yī)療需求是社會經(jīng)濟(jì)發(fā)展的客觀要求和改革目標(biāo)，是構(gòu)建和諧社會，共享改革成果的具體體現(xiàn)。醫(yī)療保險制度的建立和完善又會進(jìn)一步促進(jìn)社會的進(jìn)步和生產(chǎn)的發(fā)展。一方面醫(yī)療保險解除了勞動者的后顧之憂，使其安心工作，從而可以提高勞動生產(chǎn)率，促進(jìn)生產(chǎn)的發(fā)展；另一方面也保證了勞動者的身心健康，保證了勞動力正常再生產(chǎn)。中國醫(yī)科大學(xué)附屬第一醫(yī)院作為一所大型綜合性醫(yī)院，管理好醫(yī)療保險和醫(yī)�；鹗谴_保醫(yī)院穩(wěn)定運行的基礎(chǔ)。醫(yī)保定點醫(yī)療機(jī)構(gòu)的醫(yī)療保險管理工作是醫(yī)院整體管理的重要組成部分。它起到了參謀助手，效益管理和監(jiān)督職能的作用。做好新形勢下定點醫(yī)療機(jī)構(gòu)醫(yī)療保險管理工作，對提高醫(yī)院整體管理水平和經(jīng)濟(jì)效益，增強(qiáng)醫(yī)院的生命力和凝聚力具有十分重要的意義。中國醫(yī)大一院面對越來越多的參保患者，在執(zhí)行國家醫(yī)療保險政策過程中，應(yīng)該在醫(yī)院內(nèi)部研究并制定出相應(yīng)的醫(yī)療保險管理體系，從而既讓參�；颊攉@得充分的醫(yī)療服務(wù)，又能使醫(yī)院在保證醫(yī)療服務(wù)質(zhì)量的前提下控制醫(yī)療保險費用的不合理增長。目前，醫(yī)院在醫(yī)療保險管理工作中仍存在著醫(yī)保患者對醫(yī)療服務(wù)質(zhì)量不滿意；醫(yī)院在控制醫(yī)療費用方面存在極端化；醫(yī)�；颊邔τ卺t(yī)保政策的理解存在不理解、醫(yī)務(wù)工作者對待醫(yī)保工作和醫(yī)�；颊叽嬖谙麡O態(tài)度等諸多問題，如何解決這些難題，是作為醫(yī)院在醫(yī)療保險管理工作中所要面臨和思考的課題。 本文就中國醫(yī)大一院如何完善醫(yī)療保險管理工作為核心，以大型綜合性醫(yī)院的視角來闡述如何加強(qiáng)醫(yī)療保險管理，并根據(jù)實際需求制定相應(yīng)的管理體系。詳細(xì)闡述了從建設(shè)醫(yī)院醫(yī)療保險管理體系，加強(qiáng)醫(yī)療保險管理；完善醫(yī)療保險信息系統(tǒng)（HIS），利用科學(xué)手段介入日常醫(yī)保管理中，提高工作效率；針對各類醫(yī)療保險就醫(yī)制定有效的管理措施，層層細(xì)化，把醫(yī)療保險政策落到實處；醫(yī)院應(yīng)當(dāng)合理控制醫(yī)療保險費用，重視醫(yī)保超支將會給醫(yī)院帶來的直接影響，完善數(shù)字化管理模式，，科學(xué)、合理地研究對策；建立醫(yī)院內(nèi)部獎懲機(jī)制，對醫(yī)護(hù)人員的醫(yī)療行為作出合理的評價，從而督促醫(yī)護(hù)人員規(guī)范自己的醫(yī)療行為，提高醫(yī)保管理意識；醫(yī)院還應(yīng)該制定合理的醫(yī)療保險結(jié)算方式，使大型綜合性醫(yī)院在獲得良好經(jīng)濟(jì)效益和社會效益的同時讓政府滿意，讓參保患者滿意，實現(xiàn)“醫(yī)、保、患”三方共贏。
[Abstract]:Speeding up the reform of Chinese medical and health system and perfecting the social security system are the objective requirements and reform goals of social and economic development, and the concrete embodiment of building a harmonious society and sharing the results of reform. The establishment and perfection of medical insurance system will further promote the progress of society and the development of production. On the one hand, the medical insurance relieves the laborer's worries, makes him work at ease, thus can improve the labor productivity and promote the development of production; on the other hand, it also guarantees the physical and mental health of the laborer and the normal reproduction of the labor force. As a large general hospital, the first affiliated Hospital of China Medical University manages the medical insurance and medical insurance fund well, which is the basis to ensure the stable operation of the hospital. Medical insurance management of designated medical institutions is an important part of overall hospital management. It acts as a staff assistant, benefit management and supervisory function. It is of great significance to do a good job in the management of medical insurance in designated medical institutions under the new situation to improve the overall management level and economic efficiency of the hospital and to enhance the vitality and cohesion of the hospital. In the face of more and more insured patients, the first Hospital of the Chinese Medical University should study and formulate a corresponding medical insurance management system within the hospital in the course of implementing the national medical insurance policy, so that the insured patients can obtain adequate medical services. The hospital can control the unreasonable increase of medical insurance cost under the premise of ensuring the quality of medical service. At present, there are still medical insurance patients dissatisfied with the quality of medical service in the management of medical insurance, hospitals have extremes in controlling medical expenses, medical insurance patients do not understand the medical insurance policy, Medical workers have many problems such as negative attitude towards medical insurance and medical insurance patients. How to solve these problems is a subject that hospitals face and think about in the management of medical insurance. This paper focuses on how to improve the management of medical insurance in the first Hospital of Chinese Medical University, expounds how to strengthen the management of medical insurance from the perspective of large general hospital, and formulates the corresponding management system according to the actual demand. This paper expounds in detail the construction of hospital medical insurance management system, the strengthening of medical insurance management, the improvement of medical insurance information system (HIS), the use of scientific means to intervene in the daily medical insurance management, and the improvement of working efficiency. To formulate effective management measures for all kinds of medical insurance, to refine the medical insurance policy, to implement the medical insurance policy, the hospital should reasonably control the medical insurance expenses, and pay attention to the direct impact of overspending on medical insurance on the hospital. Perfect the digital management mode, scientifically and reasonably study the countermeasure, establish the internal reward and punishment mechanism of the hospital, make the reasonable appraisal to the medical treatment behavior of the medical staff, thus urge the medical staff to standardize their own medical behavior, improve the management consciousness of the medical insurance; The hospital should also formulate reasonable medical insurance settlement method so that the large general hospital can obtain good economic and social benefits and make the government satisfied and the insured patients satisfied so as to realize the "doctor, insurance, patient" tripartite win-win.
【學(xué)位授予單位】：吉林大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2013
【分類號】：R197.323;F842.684

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