Research On Medical Insurance Credit Evaluation And Countermeasures Of Designated Medical Institutions

With the continuous expansion of medical insurance coverage in China,the safety of medical insurance fund is facing credit risk.In order to ensure the smooth operation of medical insurance fund,credit management is introduced into the medical insurance fund supervision process,and designated medical institutions,as the main party of medical insurance fund withdrawal,are bound to become the key object of medical insurance credit management.In order to optimize the medical insurance credit management effect of designated medical institutions,China proposes to carry out the construction of medical insurance fund supervision and credit system,and focuses on the construction of medical insurance credit evaluation of designated medical institutions.Based on this,this study aims to construct the medical insurance credit evaluation index system of designated medical institutions,select two designated medical institutions in Zhenjiang City,evaluate their medical insurance credit level by using the index system,find out the problems and put forward the corresponding countermeasures.First,this research explains the concepts and theories related to medical insurance credit in designated medical institutions.Secondly,follow the principles of operability and importance to initially construct an indicator system.Then through the expert consultation method to screen the indicators,use the analytic hierarchy process to determine the weight of the indicators,and finally build a four-level index consisting of basic management,medical management,cost management,and social evaluation,13second-level indicators,and 37 third-level indicators.The medical insurance credit evaluation index system of designated medical institutions.Finally,the indicator system is used to evaluate the medical insurance credit level of two designated medical institutions.The evaluation results show that the medical insurance credit level of the two designated medical institutions A and B is generally higher,and the medical insurance credit level of institution B is higher than that of institution A.Both institutions have violated regulations in the management of medical staff,mainly due to the registration of individual medical insurance doctors,overtime changes,and incomplete submissions.In terms of medication management,both institutions exceeded the national standard for the intensity of use of antibacterial drugs(DDDs);the proportion of prescriptions for essential medicines for outpatients decreased compared with last year;for essential medicines for inpatients The utilization rate of institution B has slightly decreased compared with last year.In terms of cost control,the total outpatient expenses of the two institutions have increased significantly compared with last year,especially the designated medical institution A,which has increased far beyond the standard value,and the average outpatient cost of institution A has also increased significantly compared with the previous year.In terms of social evaluation,the designated medical institution A needs to be further improved in terms of outpatient satisfaction.Based on the research results,from the perspectives of improving external supervision and strengthening internal management,the countermeasures to improve the medical insurance credit level of designated medical institutions are proposed.In terms of improving external supervision,the following countermeasures are proposed: first,improve the legal and regulatory system for medical insurance supervision;second,establish a departmental linkage and information sharing mechanism;third,improve the medical insurance intelligent monitoring system;fourth,introduce third-party supervision methods.In terms of strengthening internal management,the following countermeasures are put forward: First,improve the internal medical insurance management system of designated medical institutions;second,strengthen communication and collaboration among various departments and departments;third,expand the team of medical insurance management personnel;fourth,implement refined medical insurance management.