| 引用本文：王日珍, 吴群红, 单凌寒, 覃英华, 李嘉程, 郭朋飞, 马云霞, 高珊珊.我国门诊慢病医保经办精细化管理服务典型模式——基于医保管理增效案例的分析[J].中国卫生政策研究,2022,15(3):16-21 |
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| 我国门诊慢病医保经办精细化管理服务典型模式——基于医保管理增效案例的分析 |
| 投稿时间：2022-02-08 修订日期：2022-03-10 PDF全文浏览 HTML全文浏览 |
| 王日珍, 吴群红, 单凌寒, 覃英华, 李嘉程, 郭朋飞, 马云霞, 高珊珊 |
| 哈尔滨医科大学卫生管理学院 黑龙江哈尔滨 150081 |
| 摘要:目的：我国门诊慢病医保经办管理服务尚未形成统一规范，研究基于各地实践案例运用程序化扎根理论编码技术探索其典型模式，为其他地区乃至全国范围内的优化方向提供参考。方法：以国家医保局官网“向改革要红利、向管理要效益”平台所发布的有关门诊慢病医保管理增效案例为研究文本，采用三级编码逐级进行归纳、整理和分析。结果：提炼出29个初始范畴、11个主范畴和3个核心范畴，最终形成精准宣传、简化认定流程，保障就医购药服务、加强支付监管和“互联网诊疗+慢病医保”三种门诊慢病医保经办精细化管理服务的典型模式。结论：目前各地主要在政策宣传、申报认定、就医管理、用药保障以及互联网诊疗方面创新经办服务，未来我国应结合各地实践经验，进一步拓宽病种目录，推动认定标准统一，调动医药机构参与慢病管理积极性，促进互联网诊疗医保服务平台完善。 |
| 关键词:门诊慢病 医保经办服务 精细化管理 |
| 基金项目:国家社会科学基金项目(19AZD013) |
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| A typical model of refined management service of outpatient chronic disease health insurance in china: Based on cases of health insurance management efficiency improvement released by the National Health Security Administration |
| WANG Ri-zhen, WU Qun-hong, SHAN Ling-han, QIN Ying-hua, LI Jia-cheng, GUO Peng-fei, MA Yun-xia, GAO Shan-shan |
| School of Health Management, Harbin Medical University, Harbin Heilongjiang 150081, China |
| Abstract:Objective: To explore the typical model based on the practice cases in various places using the programmed grounded theory coding technology as outpatient chronic disease health insurance management services have not yet formed a unified standard in China, so as to improve the reference for the optimization direction in other regions and even all over China. Method: Taking the relevant outpatient chronic disease health insurance management efficiency improvement cases published on the official website of the National Healthcare Security Administration “requires dividends from reform and benefits from management” as the research text, the three-level coding is used to summarize, sort and analyze level by level. Results: 29 initial categories, 11 main categories and 3 core categories were refined, resulting in a typical model of refined outpatient chronic disease health insurance management services with three dimensions: precise promotion, simplification of the recognition process, protection of access to medicine, strengthening of payment supervision and “Internet diagnosis and treatment + chronic disease health insurance”. Conclusions: At present, various localities mainly innovate handling services in policy publicity, declaration and certification, medical treatment management, drug protection and Internet diagnosis and treatment. In the future, we should combine the practical experience of different regions, further broaden the catalog of disease types, promote the unification of recognition criteria, mobilize the enthusiasm of medical institutions to participate in the management of chronic diseases, and promote the improvement of the health insurance service platform for the Internet. |
| Key words:Outpatient chronic disease Medical insurance agency Refined management |
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