| [Background]Since the establishment of China’s medical insurance system, the medical insurance industry in China has been greatly developed, which plays the major roles in protecting the health of urban and rural residents, reducing the economic burden of disease, and guaranteeing the medical needs of the urban and rural residents. However, with the expansion of health insurance coverage and the higher compensation proportion, China’s total health expenditure also will be the rapidly grow, and the medical insurance fund is facing great challenges.Fund management is an important aspect of health insurance management, the balance of payments of medical insurance fund is the prerequisite and guarantee for the medical insurance system’s sustainable development. Since the implementation of China’s social medical insurance system, on the whole it maintained a balance of fund payments, protected the medical needs of the majority. However, the medical insurance fund in China is also faced with the challenges posed by the medical insurance cost increasing. As in the health insurance market there is itself information asymmetry, coupled with the post-paid system, therefore, in addition to strengthening the reform of the Medicare payment system, the medical insurance regulation is also necessary for medical services and medical expenses.Because of the great amount of health insurance data and real-time requirements, the professional medical audit information system will greatly reduce the labor intensity of health insurance management, simplify aspects of the work, improve management quality and service efficiency, control and correct the irrational growth of medical costs and unreasonable medical practices.In order to improve the capacity and efficiency of professional auditing and supervision of social health insurance and fill the blank of domestic professional medical review information systems, this study aimed at the social health insurance institutions for research and practice base, to explore and build the health insurance professional medical review information systems audit model, and then we use the system for experimental audit to provide a reference for further exploration and the establishment of social health insurance.[Objectives]The purpose of this study is that through risk factors research and expert consultation, combined with the disease clinical path and the actual diagnostic and treatment practices, determining the disease medical audit indicator system and its weight, then build disease medical audit model, and use the model to experimental review. At last reach the goal of improving the capacity and efficiency of medical audit and supervision of social health insurance. Specific sub-objectives are:①Construction of medical audit evaluation index system;②Design the audit model of medical quality and expensives;③Run the evaluation model.The content of the following five aspects:①Screening the diseases of the audit of the medical research;②Determine the expensives and quality indicators of disease, and build up the index system;③Make sure the weight of index;④Design disease expensives and quality of the assessment model;⑤Run the evaluation model and evaluate the effect of the operation.[Methodology]Data sources1.The choice of the sample hospitalsIn this study, we analysis all three-level public hospitals in Zhuhai City, exclude specialist hospital---Zhuhai Maternal and Child Health Hospital, and chose the remaining three three-level public hospitals (Zhuhai First People’s Hospital, Zhongshan University’s Fifth Affiliated Hospital and Zhuhai Second People’s Hospital), after consultation, to study a sample of hospitals.2.Survey methodology and data collection methodsIn2010we carry out two data collection. The first was the health insurance database from Human Resources and Social Security Bureau in Zhuhai City in September2010, which gets access to disease information; The other one was collecting indicators of quality and cost data to build medical audit model.(1)Secondary data collection methodIn order to understand the disease’s cost and quality of the base case of Zhuhai City, this study extracted all insured persons of the hospital in2009type2diabetes in the Medicare database information from Zhuhai medical insurance management department, analyzing its costs and quality of medical services.(2)Sample survey methodIn this study sample, according to the mechanical sampling method, each hospital survey50cases of Medicare patients,30cases of non-Medicare patients, if dissatisfied with the50/30cases, full extraction. Then analyze and determine the cost and quality of service evaluation and audit indicators.(3)Depth interviewsTo further complete the medical services indicators of type2diabetes, we design the questionnaire based on related issues. Through in-depth interviews with senior experts of the endocrinology department of the First People’s Hospital, we understand the influencing factors of the costs and key joints.(4)Questionnaire methodThrough literature review, clinical path as well as interviews with experts, as a framework of the structure-process-the results of quality assessment theoretical framework to determine the cost and quality indicators, we developed the questionnaire, and carry on the sample survey.(5)Expert consultationWe determine the weight of each index from expert consultation---the "Delphi Method". In the study, the experts are composed by19people, including14endocrinology experts,5medical insurance regulatory agencies responsible for audit monitoring and information systems business.Analysis Methods1. Literature induction methodThis study mainly collected the literature of three aspects:First, international and domestic literature on the practical experience of professional medical review of health insurance information systems; Second, the literature of the disease costs and quality evaluation; Third, policy documents about social medical insurance system in Zhuhai, especially the payment system policy file. Through the collection and reading of international and domestic academic papers, web pages and policy documents, know the condition of the medical insurance audit.2. The "structure-process-results " analytical frameworkThrough the "structure-process-results" analytical framework, we designed the questionnaire for quality and cost indicators of type2diabetes as the model framework as the medical audit model.3. Analysis toolsWe collected data of the patient’s quality and cost indicators through designing the questionnaire to three three-level hospitals with type2diabetes, input data using Epidata3.1, analyzed data by SPSS11.5.[Results]The key findings of this study are as follows:(1)Medical audit theory and practice analysis in the health insurance industryWe found in the health insurance industry, the management of quality and costs are mainly related to three theories:"Total quality management","clinical pathways", and "Structure-process-results" assessment methods. These three theories all see medical services as a whole, not only including the description of medical services’results, also attaching great importance to the medical service process management, and they are all based on process in control of the result. The necessity and appropriateness of the service process, not only will affect the quality of medical services, also affect medical costs, so, medical quality and cost are closely linked. This study considered the quality and cost indicators that can affect the medical audit results, designed medical audit model framework, and ultimately built the audit model.(2)Inpatient evaluation index systemIn this study, we build the medical audit model by quality and cost index system of type2diabetes. First, based on the clinical path and the views of clinical experts, we preliminary screened the indicators of health care quality and cost; Secondly, according to the preliminary screening indicators, we designed quality and cost indicators questionnaire (hospitalization), got access to inpatient quality and cost information; analyzed the questionnaire, took into account risk factors, combined with the requirements of the clinical pathway and expert advice, and built the medical audit indicators system. The indicator system included36indicators, which contained3diagnostic indicators,6treatment indicators,18check/laboratory indicators,1hospital day index,2discharged indicators, and6cost indicators.(3)The research of the medical audit index weightsThis study adopts the Delphi expert consultation to determine the weight of each indicator. The results show that:the selected experts are more evenly distributed, involving hospitals, health departments and social security departments, with long years of work and more experienced; there are better coordination between two expert consultations, and the coordination coefficient in the second round is greater than the first round; In this study, we increase, decrease and modify some of indicators in the first round of expert consultation to make more scientific and reasonable evaluation index system. After normalized scores on the basis of the importance, operability and sensitivity, we obtained composite score for each indicator, divided each indicator score by the total score for all indicators, and derived weights of each index. (4) Build the medical audit model and carry out empirical researchCombined with medical audit evaluation index system and expert consultation weightings, we build the medical audit model. By the scores of indicators, we got the final score. According to the final score, we determine whether the medical service was licensed. Through the empirical run on the model of medical audit, we found that the professional audit model can well grasp the current medical audit priorities and standards, and the model was effective. |
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