【作者】 黄磊；

【导师】 李士雪；

【作者基本信息】 山东大学 ， 社会医学与卫生事业管理， 2011， 硕士

【摘要】 新型农村合作医疗(以下简称“新农合”)制度与新农合定点医疗机构相互支持、相互依存。新农合支付能力的逐步提高促进了定点医疗机构的发展。而新农合定点医疗机构能否为参合农民提供优质规范、收费合理、价格适宜的医疗服务,是确保新农合基金安全有效使用和制度平稳运行的基础。所以对新农合定点医疗机构的有效监管是保证新农合制度持续健康运行的关键。各级卫生行政部门在这个方面出台了相关政策,有关专家也对新农合定点医疗机构的监管开展了基础研究和应用研究工作,为定点医疗机构的监管工作提供了基本的理论依据和政策参考。各地在相关政策和前期研究成果的引导下,结合本地实际卓有成效地开展了新农合定点医疗机构监管的研究和实践工作,形成了一些行之有效的监管策略、机制和方法。本研究基于新农合发展的新要求,采用文献复习、现场调查和典型案例分析相结合的研究方法,分析了山东省菏泽市牡丹区、单县、潍坊市青州市、泰安市岱岳区、济宁市汶上县、嘉祥县以及枣庄市中区等样本地区目前新农合运行现状,管理经办体系和制度建设,定点医疗机构在服务提供、费用控制、制度执行等方面的情况,总结样本地区新农合制度对定点医疗机构有效监管的经验和做法,提炼出可供借鉴的普遍规律,发现存在的主要问题,提出解决问题的可能途径和方法,为进一步完善新农合定点医疗机构监管机制提供政策建议。研究的主要内容包括各级新农合管理机构建设情况,新农合监管体系的组织与建立,新农合经办机构的设置和建设情况；新农合经办机构制度建设,尤其是对定点医疗机构的管理办法、监管制度和措施,对定点医疗机构的合同管理,准入退出制度,奖罚制度；定点医疗机构自身建设；民主监督情况；支付方式对新农合监管的影响；对定点医疗机构的监管审核如药品使用、不合理化验与仪器检查、不合理住院、复诊率和重复住院率的变化、病历和处方的规范管理、重复分解收费、乱计费、不提供收费公示清单等。通过对研究结果的分析和样本地区监管效果的评价,本研究提出了完善新农合定点医疗机构监管机制的建议：建立健全各级新农合管理机构和监督机构,构建分工明确、功能合理、统一高效的新农合管理体系；建立健全制度完善、岗位设置合理、责任明确、职能到位、管理有序、有编制、有经费、有场所的新农合管理经办机构；培养和建设一支责任心强、业务熟练、懂政策、善管理、能服务的专业化、职业化管理经办队伍；制定定点医疗机构的基本标准和要求,实施合同管理,完善规章制度,强化机构自律意识,严格执行定点医疗机构的准入和退出机制；建立完善的审核组织、制度和流程,包括费用审核组织及责任、内容与方式、资料及要求、重点环节及方法等；加强信息化与网络建设；完善社会监督机制,加大惩治力度等。更多还原

【Abstract】 The New rural cooperative medical scheme (abbreviated to NCMS)and certified medical institutions are interdependent and mutually supportive. The gradually increase of payment capacity of NCMS promotes the development of certified medical institutions. Whether or not the certified medical institutions of NCMS can provide qualified and reasonably charged medical service for concerned peasants matters the foundations of not only the safety and effectiveness of fund but also the stable operation of this system. So the effective supervision of the certified medical institutions is the key factor for ensuring the sustained and healthy operation of the NCMS.Various relevant policies in this respect promulgated by health administration departments of all levels and experts’basic and applied researches on supervision of the certified medical institutions have provided theoretical basis and references for policies. A lot of available strategies, mechanisms and methods of supervision are coming into being inasmuch as the relevant polices and early researches have been effectively applied to the concrete practices and works throughout the country. Based on the new requirements of NCMS’s development,the method of literature review,field survey and typical case study are adopted together to analyze the samples consisting of several regions of Shandong province.including the Mudan District and Shanxian County of Heze City, Daiyue District of Taian City,Wenshangxian County and Jiaxiangxian County of Jining City,Shizhongqu District of Zaozhuang City and Qingzhou City which is a county-level city of Weifang City. Through analyzing the present operation status of NCMS.the management system and system construction,the implementation of service provision and charge control,summing up the experience of effective supervision of certified medical institutions provided by NCMS, subtracting quotable universal laws, discovering the main problems,more and more available solving approaches and methods are emerging to provide policy suggestions for further improve on NCMS’s supervision of certified medical institutions. This paper covers the main contents as follows:the construction of NCMS’s administration of all levels,the organization and establishment of NCMS’s regulatory system,the setup and construction of NCMS’s organization of agency;the system construction of NCMS’s organization of agency especially on the NCMS’s management methods,regulatory systems and measures,contract management systems and admittance and quitting systems,a system of rewards and penalties; the self construction of certified medical institutions; the condition of democratic supervision; the influence of different methods of payment to NCMS’s supervision;The auditing and regulation for certified medical institutions with respect to aspects such as the usage of medicine,the absurd test and equipment inspection, abnormal rate changes in hospitalization, re-hospitalization and re-examination,the normative management of the case history and prescription, repetitive decomposition of fees, arbitrary charges and not providing the notes of charges etc.According to the analysis of research findings and evaluation of the effectiveness of supervision for the sample regions, this study suggests a lot on how to improve the supervision mechanism of the certified medical institutions. Specific as follows:establishing and improving the administration and supervision departments of all levels to construct a unified,highly efficient system with clear-cut division and reasonable function establish and improve the NCMS’s organization of agency, targeting on making these organizations have complete system Reasonable post setting, clear responsibility, full-fledged function, orderly management authorized personnel, sufficient funds and fixed premises. Train a group of high-quality professional talents with strong responsibility sense, full awareness of policies,skillful operational and administrative capability formulate basic standards and requests for the certified medical institutions,implement contract administration;perfect the rules and regulations; strengthen the organization self-discipline; strictly execute the access and withdrawal mechanism of the certified medical institutions;establish perfect auditing organizations, institutions and procedures, as well as the charge auditing organizations, definitely specify their responsibilities,work contents and patterns, required materials, key links and methods etc. strengthen the construction of informationization and networking;perfect the social supervision mechanism and enhance the punishment measures etc.更多还原