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随着社会医疗保险事业的发展,社会医疗保险基金的运行风险不断加大,来自定点医疗机构的风险是其主要风险之一。根据风险管理的方法,分析社会医疗保险目前存在的主要风险因素,如管理风险、诱导性需求、过度性供给和医疗欺诈行为等,并有针对性的制定风险控制方法,整合、建立和发展更为有效的风险管理模式,通过加强监管队伍建设、完善计算机信息系统和强化对定点医疗机构的监督管理等各种措施,降低医疗保险基金支出风险,保障社会医疗保险基金的安全运行。根据我们的初步实践,实施风险管理后,年住院总人次、人均住院费用增幅、每人每年使用统筹基金数等均各类重点指标有所降低,其中一级医院人均住院费用降低10.17%,二级医院的人均住院费用虽有所增高,但增幅仅为3.41%。
With the development of social medical insurance, the running risk of social medical insurance fund is constantly increasing. The risk from the designated medical institutions is one of the major risks. According to the methods of risk management, this paper analyzes the main existing risk factors of social medical insurance, such as management risk, induced demand, excessive supply and medical fraud, etc., and makes targeted risk control methods to integrate, establish and develop more As an effective risk management model, we can reduce the risk of medical insurance fund expenditure and ensure the safe operation of social medical insurance fund by strengthening the construction of regulatory team, perfecting computer information system and strengthening the supervision and management of designated medical institutions. According to our initial practice, after implementation of risk management, the key indicators such as the total number of inpatient visits per person, the increase in per capita hospitalization expenses, and the use of unified funds per person per annum decreased. Among them, the per capita hospitalization expenses of hospitals in primary hospitals decreased by 10.17% Although the per capita hospitalization costs have increased, but only an increase of 3.41%.