Zhongnan Hospital Of The Basic Medical Insurance For Hospitalization Cost Control Methods

Under the system of the quota settlement of the hospitalization fees in the basic medical insurance, the institute of medical insurance transfers the price risk of the balance of the insurance funds to the assigned hospitals. In order to realize the reasonable profit, the assigned hospitals must solute the risk and maximize the quota index.Central South Hospital took the way of settlement according to practical fees with its clinical departments before. The limitation of this way were: collusion between the clinical departments and patients, the earning of project less than the cost, and the goal of the maximum of the quota index can't lasts long. Furthermore, post-auditing of settlement according to practical fees may worsen the conflicts between the hospital and the clinical departments, such as the dispute on the definition of the reasonable medical treatment and the risk of rejection of the medical insurance transferred to the clinical departments finally. So the settlement according to practical fees is hard to be applied. Its practical shortcoming concentred on the serious overspend of the quote index.In order to conquer such conflicts between the hospital and its clinical departments, Central South Hospital is taking the way of the quota settlement divided into section offices now. This settlement way has the quota index established by the institute of medical insurance decomposed into secondary quota indexes of clinical departments. The hospital will settle the medical fees of insuraned patients with the secondary quota indexes but not the practical fees. When the practical fees exceed the secondary quota indexes, the part of over-fee will be borned by the section offices; in the opposition result, the balance will dominate by the clinical departments itself. This kind of settlement way is a good system designed to control medical fees, which make the practical fees approach closely to the secondary quota indexes with the advantage of calculous principle and the two bodies(control body and obligation body) gathered together, mobilize the clinical departments' activities and initiatives to control medical fees. We analyses the data specifically produced by quota settlement divided into clinical departments practiced in Central South Hospital. It is found that: in the aspect of macro ways, the earning of the hospital increase greatly, the degree of the satisfaction of patients ranks number one in years in the whole province, the performance of the work of the medical insurance is remarkable, and the rejection fees was the least continually in years in the whole province. In the micro aspect, the real medical fees of different clinical departments has approched year by year to the quota index of 7200, it shows that clinical departments realize the goal of maximize of the quota index.