摘要
目的:分析A市定点医疗机构非合规使用医保基金行为的总体态势、结构特征与高风险项目分布,揭示其在不同机构属性间的异质性,为建立精准化、差异化的医保分类监管体系提供依据。方法:采用分层抽样法,选取A市17所不同级别(二、三级)、性质(公立、民营)与类别(综合、专科)的定点医疗机构作为研究对象。综合运用描述性分析、Mann-Whitney U检验和Kruskal-Wallis H检验等非参数检验及卡方检验,从宏观、中观、微观3个层面对2024年非合规使用医保基金行为数据进行系统分析。结果:宏观上,样本机构非合规行为发生频次较多、涉及非合规的金额差异显著,提示区域医保基金使用存在普遍风险。中观上,三级医院非合规行为规模高于二级医院,其高额非合规行为以“过度检查”“支付范围外费用纳入结算”为主,二级医院则以“过度检查”“超标准收费”为主;两类医院高频次非合规行为均集中于“过度检查”与“重复收费”。公立医院非合规行为以“过度检查”为主;民营医院高频次非合规行为多为“重复收费”,高额非合规行为则为“过度检查”与“超标准收费”。综合医院集中于“过度检查”;专科医院则呈现专科相关性,“串换项目”为其特有高额非合规行为类型。微观层面,识别出以实验室检验类和药品类为主的10大高额、高风险非合规行为项目。结论:非合规使用医保基金行为存在显著机构间差异,需实施三维精准治理:宏观层面推动建立价值医疗导向的控费机制;中观层面开展机构属性差异化监管;微观层面聚焦高风险非合规行为项目,促进临床指南与医保政策协同,以全面提升基金使用效率与监管效能。
Objective:To analyze the overall trends,structural characteristics,and distribution of high-risk items associated with noncompliant medical insurance fund utilization among designated medical institutions in City A,to reveal heterogeneity across different institutional attributes,and to provide evidence for establishing a precise and differentiated medical insurance classification supervision system.Methods:Using stratified sampling,17 designated medical institutions in City A were selected as study subjects,covering different levels(secondary and tertiary),ownership types(public and private),and categories(general and specialty).Descriptive analysis,nonparametric tests including the Mann–Whitney U test and Kruskal–Wallis H test,as well as chi-square tests were comprehensively applied to systematically analyze non-compliant medical insurance fund utilization behaviors in 2024 from macro,meso,and micro perspectives.Results:At the macro level,non-compliant behaviors occurred frequently across sample institutions,with significant differences in the amounts involved,indicating widespread risks in regional medical insurance fund utilization.At the meso level,the scale of noncompliant behaviors was higher in tertiary hospitals than in secondary hospitals.High-amount non-compliant behaviors in tertiary hospitals were mainly“overuse of examinations”and“including out-of-scope expenses in settlement,”while secondary hospitals were mainly characterized by“overuse of examinations”and“charging above standard.”High-frequency non-compliant behaviors in both hospital levels were concentrated in“overuse of examinations”and“duplicate charging.”In public hospitals,non-compliant behaviors were predominantly“overuse of examinations,”whereas in private hospitals,high-frequency non-compliance mainly involved“duplicate charging,”and highamount non-compliance involved“overuse of examinations”and“charging above standard.”General hospitals were concentrated in“overuse of examinations,”while specialty hospitals showed specialty-related characteristics,with“item substitution”identified as a distinctive type of high-amount non-compliance.At the micro level,ten high-amount and high-risk non-compliant items were identified,mainly involving laboratory tests and pharmaceuticals.Conclusion:Significant inter-institutional differences exist in non-compliant medical insurance fund utilization behaviors.A three-dimensional precision governance approach is required:at the macro level,promoting value-based cost containment mechanisms;at the meso level,implementing differentiated supervision based on institutional attributes;and at the micro level,focusing on high-risk non-compliant items to enhance coordination between clinical guidelines and medical insurance policies,thereby comprehensively improving fund utilization efficiency and regulatory effectiveness.
作者
黄靖懿
汤子健
朱平华
HUANG Jingyi;TANG Zijian;ZHU Pinghua(School of Humanities and Social Sciences,Guangxi Medical University,Nanning,Guangxi Zhuang Autonomous Region,530021,PRC)
出处
《中国医院》
北大核心
2026年第3期16-19,共4页
Chinese Hospitals
基金
国家社会科学基金项目(18XZZ013)
广西卫生健康委员会委托课题(22TKC01)。
关键词
医保基金
医保监管
医保违规
基金监管
medical insurance funds
medical insurance supervision
medical insurance violations
fund supervision
