医保精细化监管系统的设计与应用

研究论著

RESEARCH WORK

引言

根据省市两级医保管理部门的规定，目前，我们医院的医保费用实行总额预付的方式进行管理[1]，市医保制定我院的年度医保统筹费用总额，每月按预先计划数额下拨，再由医院制定各科室医保统筹费用限额，各科室按照限额执行。医院的医保管理工作办公室和各科室在执行医保限额标准时，缺乏有效的实时监督管理手段，目前大部分医院的医保管理信息系统侧重于医保业务流程，缺少对住院患者医保费用的监管和预警功能，或功能较弱，针对医保费用的实时介入和监管手段欠缺[2-4]。

由于缺乏实时的超额预警和统计报告，医院、科室和

医生，这三个层级都无法及时对患者的医保统筹费用进行精细化管理[5]。医院每年需补贴大量医保超支费用；医生的医疗行为得不到规范，药占比、材料占比、自费项目占比居高不下，缺少了事前环节的控制；患者也无法了解每天的医保统筹支付费用情况，给医院的医保管理工作带来较多不便[6]。针对以上问题开发一套完整的医保精细化监管系统，通过信息化手段在医院、科室、医生这三个层级加强医保统筹费用的精细化管理，势在必行。

1 系统概述

1.1 开发技术

系统后台采用MySQL 数据库，提供标准化的API 接口，与医院的HIS 系统对接，无需改造现有的HIS 系统，只需

医保精细化监管系统的设计与应用

肖永平1，李中华2

1. 中国人民解放军联勤保障部队第九七〇医院 信息科，山东 烟台 264002；

2. 武警烟台特勤疗养中心 放射科，山东 烟台 264000

收稿日期：2018-07-25 修回日期：2018-08-13通讯作者：李中华，副主任医师，主要研究方向为影像信息。通讯作者邮箱：lizhonghua107@

[摘 要] 目的 开发医保精细化监管系统，对临床科室、医生和患者的医保统筹费用进行实时监管，规范医保统筹费的使用，提高医院的医保管理工作水平。方法 采用.NET 技术和MySQL 数据库，以接口方式与医院的HIS 系统对接，对重点医疗数据进行备份、提取和分析，形成监管数据和报告，医保管理人员实时查看报告并进行监管。结果 开发的系统具有患者医保费用监控、超额预警、控费分析和统计分析等功能，实现科室、医生、患者三级的医保统筹费用的精细化管理。结论 系统的部署规范了科室和医生的医疗行为，医院的药品、耗材、检验、检查等方面的诊疗工作更符合医保规定，节省了医保开支，医院的内涵质量建设更上一个台阶。

[关键词] 医保；统筹费用；精细化管理；监控分析；超额预警

Design and Implementation of Medical Insurance Fine Management System

XIAO Yongping 1, LI Zhonghua 2

1. Department of Information, 970 Hospital of the PLA JLSF, Yantai shandong 264002, China;

2. Department of Radiology, Yantai Special Service Sanatorium of Armed Police, Yantai shandong 264000, China

Abstract: Objective To supervise the medical insurance pooling expenses of clinical departments, doctors and patients in real time, standardize the use of medical insurance pooling fees, and improve the level of medical insurance management in hospitals based on developing a detailed supervision system of medical insurance. Methods The .NET technology and the MySQL database were used to interface with the HIS system in the hospital. The key medical data were backed up, extracted and analyzed, and the supervision data and reports were formed. The medical insurance managers checked the report and supervised the report in real time. Results The developed system had the functions of patient medical insurance cost monitoring, excess early warning, cost control analysis, and statistical analysis, so as to realize the fine management of the three level medical insurance overall cost of the department, the doctor and the patient. Conclusion The deployment of the system regulates the medical behavior of departments and doctors. The diagnosis and treatment work of drugs, consumables, inspection and inspection in the hospital is more in line with the provisions of medical insurance, which saves medical insurance expenses and brings the connotation and quality construction of the hospital to a higher level.

Key words: medical insurance; overall cost; meticulous management; monitoring analysis; excess warning [中图分类号] TP391.44 [文献标识码] A doi：10.3969/j.issn.1674-1633.2019.04.031 [文章编号] 1674-1633(2019)04-0119-04