The Irregularities And Supervision Research Of Designated Medical Institutions Of Nanning's Urban Basic Medical Insurance

Objective Sorting out and analyzing the unreasonable medical behavior of the designated medical institution and the way of supervision and management.To know the status of regulation of designated medical institutions.And analyze the problems and difficulties existing in supervision, put forward counter measures and suggestions for further strengthening supervision of designated medical institutions.Methods Investigating the agency of Nanning social insurance, making questionnaire to collect quantitative data about supervision, and doing statistics analysis of these data.The qualitative interviews should be taken to talk with the head of relevant departments of Nanning social insurance agency, administrators of targeted at all levels of medical institutions, medical workers and the insured patient to understand the supervision status and existing problems of designated medical institutions.The case study method is used to analyze and discuss the supervision of designated medical institutions in Nanning City, which provides empirical support for this paper.Result1. From 2012 to 2014, the average annual growth rate for collective fund incomings of employee health insurance is 19.39% ,and the outgoings is 16.95%,income growth slightly larger than spending growth rate, but relatively close to the absolute value. From 2012 to 2014, the average annual growth rate for collective fund incomings of residents health insurance is 8.61% ,and the outgoings is40.36%,spending growth rate greater than income growth. The average annual growth rate of total hospitalization expenditures is 14.44% and 22.03% respectively.2. There is no difference between different insurance participants, different designated medical institution and different nature designated medical institution about the medical records violations rate,all at around 50% (P>0. 05) . On the irregularities fees of designated medical institutions, unreasonable drugs and unreasonable costs is 39% and 38% respectively,which is the the highest.There is a proportion of 63.64% which medical institutions exist unreasonable fees and unreasonable drug use behavior,31.82% existing unreasonable therapy.63.64%of the medical institutions exist 1-2 kinds of irregularities and 22.73% of the medical institutions exist 3-4 kinds of irregularities.3. From 2013 to 2015, the agreement rate of medical service between Nanning social security agency and designated medical institution is all 100%.Auditing the designated medical institutions from 2013 to 2015 is 307 times, 236 times and 285 times respectively , illegal fees amount is 2.8705 million yuan , 12.8759 million yuan and 9.5431 million yuan respectively,the fees violation rate is 3%, 12% and 5.2% respectively. There are 13274 health care physician in Nanning, including 9095 in third grade fixed-point medical institution and 2004 in secondary grade fixed-point medical institution ,which accounted for 83.61% of total health care physicians. Among the general control indicators of employee health insurance , third grade fixed-point medical institution, secondary grade fixed-point medical institution and first grade fixed-point medical institution is 73.57%? 21.91% and 4.52%, actual excessive proportion were 7.38%, -5.90% and 4.05%. Among the general control indicators of residence health insurance , third grade fixed-point medical institution, secondary grade fixed-point medical institution and first grade fixed-point medical institution is 53.32%, 40.04% and 6.64%, actual excessive proportion were 8.89% , -0.38% and 11.00%.Up to 2014, there are three fixed-point medical institutions identified as AAA, which are large comprehensive hospitals and armour hospital in Guangxi.4. At present, the social security department has canceled the administrative approval of the designated medical institutions .Nanning social security department specially set point to supervise the designated medical institutions,including signing the service agreement, auditing and checking,carrying out health care physicians, total pay and hierarchical management.Conclusion At present, the urban medical insurance fund expenditureand medical costs are rising rapidly, the designated medical institutions's unreasonable medical behavior is also obvious.It is urgent to strengthen supervision. There exist some problems such as lack of supervision system,supervision professionals and lack of incentive mechanism and so on.Social security agency should establish and perfect the supervision and management mechanism of designated medical institutions by constructing linkage supervision mechanism, perfecting the supervision system,talent team construction, exploringthe third party supervision mechanism and establishing incentive mechanism and its like.