职工医疗保险中医疗服务行为分析与监管对策研究

文章通过对江苏省南通市职工基本医疗保险2000￣2004年的运行数据分析,发现在职工基本医疗保险中,存在着诱导消费、过度提供服务等较为严重的不规范行为,这些不规范行为的存在,对医保基金和参保职工个人均会造成沉重的经济负担,不利于城镇职工基本医疗保险制度的可持续发展。笔者建议,利用计算机管理信息系统加强医疗服务监管,加大对不规范服务行为的处罚力度,同时通过探索新费用支付制度和医疗服务合理补偿政策,促进职工基本医疗保险的健康发展。

Analysis of Medical Service Behavior and Administration Policy in Health Insurance for Urban Workers

The article analyzed the data of Nantong health insurance for urban workers from 2000 to 2004,and found out that serious irregular behaviors,such as induced medical consumption and over-provision by the contract hospitals existed.These malpractices brang heavy economic burden to both the urban health insurance fund and urban workers,which was harmful to sustainable development of health insurance.This article suggests that the scheme administrators should emphasize medical service supervision by means of computer system,and heavily punish the malpractice providers,and meanwhile,explore new effective payment system and rational medical service reimbursement policies to improve the scheme development.