Study On The Refined Medical Insurance Management Model In Public Hospitals

[Purpose]The purpose of this study is to analyze the current situation of refined medical insurance management in public hospitals and build a theoretical framework of its management model,analyze the current status of internal medical insurance management operations in public hospitals around the key components of the management model,and establish a set of fine medical insurance in public hospitals and provide a basis for selecting typical case studies for effect testing;explore the impact of the refined management model of internal medical insurance in public hospitals on the four core stakeholders of medical insurance,hospitals,medical personnel,and patients,and to evaluate the effectiveness of the refined management model in public hospitals;analyze the problems in the construction of the refined management model of medical insurance in public hospitals and propose optimization strategies.[Methods]1.Bibliometric analysis methodBased on the co-word analysis,cluster analysis,and visual analysis of related literature and gray literature at home and abroad,the connotation of the refined medical insurance management model in public hospitals is defined to build a theoretical analysis platform and framework for this research.2.Empirical research method（1）Typical case study.Based on literature research,expert consultation and field surveys,28 typical hospitals with refined management of medical insurance from gray literature were collected and 17 public hospitals in Guangzhou City,Sanming City,Wuhan City,Zhijiang City,Jingmen City,and Nanchong City were conducted to surveys.Their relevant institutional documents,fine-grained management measures,medical insurance operation data,intelligent audit data,patient costs data and so on were collected to analyze the operation status of medical insurance refined management in public hospitals.（2）Questionnaire survey method.A questionnaire survey was conducted on 75 medical insurance staff and 1,242 medical staff on their perceptions of the refined medical insurance management model and job satisfaction.（3）Key insider interviews.The interview outline was determined through literature research,topic selection group discussions,expert consultation,etc.,interviewed a total of56 senior managers of 17 public hospitals,56 heads of medical insurance departments and related functional departments,and medical insurance liaison officers,covering the their feeling about the construction of medical insurance management mode in hospitals,understanding of refined management of medical insurance,management effectiveness and suggestions.3.Expert consultation methodA total of 30 expert inclouded scholars and leaders of medical insurance departments,health administration departments,and hospital who have extensive experience in hospital medical insurance management are invited to provide expert opinions and score.4.Analysis methodUsing literature measurement analysis and content analysis method to construct research theoretical framework,define the connotation of fine management model of hospital medical insurance.Based on the rooted theory of multi-case analysis,in-depth interviews,questionnaires and results analysis management and operation status.Based on the multi-criteria fuzzy evaluation method,an evaluation model for the refined management model of public hospitals’medical insurance was constructed.Through the longitudinal comparison of typical samples and the horizontal comparison of the typical samples with the control group,the effect of implementation of the refined management of medical insurance in public hospitals was demonstrated.[Results]1.It defined the connotation of the refined medical insurance management model in public hospitals,which is a internal medical insurance management system of the public hospital constructed under the guidance of the refined management concept,and is composed of the medical insurance management function positioning,organizational structure,medical insurance management process,medical insurance management system,medical insurance management tools in line with the new situation,with stable internal structure and good operation,with a mechanism to achieve the goal of refined medical insurance management with high standards,high effects and high quality;and builded a management model theory with key management elements and logical relationships frame.2.The study found that some public hospitals across the country have carried out certain medical insurance fine-grained management practice exploration.The practice exploration of various hospitals in organizational structure,process transformation,management system construction,and application of refined management tools provided a basis for the model evaluation and model optimization.However,their respective focuses and directions were different,and a systematic and refined management model of hospital medical insurance has not been established.3.A set of evaluation tools for the refined management mode of medical insurance in public hospitals was constructed.The evaluation model explained that for the refined management mode of medical insurance in public hospitals,the management philosophy,management objectives,and management personnel can be regarded as causal factors or motivational factors（R₁=0.963;R₄=0.502;R₂=0.418）;the organizational structure,management process,management system,management tools,and operating mechanism can be regarded as the result factors of the refined medical insurance management model（R₅=-0.823;R₃=-0.532;R₇=0.207;R₈=0.198;R₆=0.124）;In terms of the centrality of the factors,management theory,management goals and management personnel are the three most important factors in the refined management mode of hospital medical insurance（P₄=24.039;P₁=23.443;P₂=22.619）.4.The model evaluation shows that with the implementation of refined medical insurance management,the overall probability of the occurrence of the medical insurance fund risk in the hospital and the actual deduction of the medical insurance fund from January2015 to July 2019 showed a downward trend,and the risk probability decreased from 30%to 7%.The actual deduction amount of the medical insurance fund decreased from an average of RMB 18.671 million in 2015 to RMB 771,100 in 2018;the number of DRGs in the hospital increased from 580 to 689,and the number of cases with a weight greater than 1 in the DRGs group continued to rise,with the weight less The number of cases decreased from 0.5,the CMI value increased from 0.83 to 0.99,the time consumption index decreased from 1.1 to0.94,the cost consumption index decreased from 1.05 to 0.87,and the low-risk mortality rate decreased from 0.31%to 0.1%;medical staff’s management of medical insurance The comprehensiveness of recognition and the improvement of recognition（P<0.05）;it is conducive to improving the level of patients’benefits and the satisfaction of patients（P<0.05）.[Conclusions]1.The connotation of the refined medical insurance management model in public hospitals is a internal medical insurance management system of the public hospital constructed under the guidance of the refined management concept,and is composed of the medical insurance management function positioning,organizational structure,medical insurance management process,medical insurance management system,medical insurance management tools in line with the new situation,with stable internal structure and good operation,with a mechanism to achieve the goal of refined medical insurance management with high standards,high effects and high quality2.Faced with the complex new situation,the hospital medical insurance management needs to clarify its functional positioning,as the communication link between the hospitals,insurance and patients,the guardian of the medical insurance fund and the baton of hospital development.Only by establishing a refined management model can we better promote our strengths and avoid weaknesses,and meet the opportunities and challenges of the new situation.3.At present,some hospitals have carried out explorations on the practice of refined medical insurance management,which has laid the foundation for the establishment of a systematic in-hospital medical insurance refined management model and measurement evaluation.4.In the constructed evaluation tools and model factor relationship models of refined medical insurance management models in public hospitals,the refined medical insurance management concepts,management objectives,and management personnel can be regarded as motivating factors,of which the management philosophy factors have the greatest impact on other factors,followed by Management staff,management goals;organizational structure,management process,management system,management tools and operating mechanism can be regarded as the result factors,of which management process factors are most affected by other factors,followed by organizational structure,management tools;from the center of the factors In terms of degree,management theory,management objectives and management personnel are the three crucial factors in the refined management model of hospital medical insurance.5.The refined medical insurance management model can promote the risk prevention and control of hospital medical insurance funds,but the flexibility and adaptability of the medical insurance policy system still need to be strengthened;the refined medical insurance management model can promote the development of hospital discipline capabilities;and it can further standardize The behavior of doctors,but further reform of the operating mechanism is needed to win doctors’recognition and increase satisfaction;and it can further protect the rights and interests of patients and reduce the economic burden on patients.6.In the current construction of a refined management model for internal medical insurance in public hospitals,there are still problems such as neglecting the concept of refined management,lack of refined management goals and functional positioning,the need to further optimize the organizational structure and communication between departments,and lack of refined management of the entire process.[Innovation and Deficiency]1.InnovationInnovation from a research perspective:This research starts from the perspective of management model construction and optimization,and focuses on the development of a system model in which public medical insurance management in public hospitals faces a complex situation,opportunities and challenges coexist,and meets practical needs and supported by scientific theory.From the perspective of the key components of the refined management model,an optimization strategy for the refined management mode of medical insurance in public hospitals is proposed.Innovation of research ideas:Based on classic theories such as refined management theory,incentive compatibility theory,internal control theory,stakeholder theory,and modern organization theory,this paper builds a refined management model for internal medical insurance in public hospitals on the basis of connotation definition The theoretical framework provides theoretical basis for carrying out empirical research,and provides support for the determination of research content and methods.Methodological innovation:This study uses bibliometrics,text analysis,and qualitative research methods to analyze expert consultations,interview results with key insiders,and scientifically define the connotation of the refined medical insurance management model,build a theoretical framework,summarize the current operating status,and scientific discovery practices.The problem.Use a combination of quantitative and qualitative methods to build an evaluation model and management effectiveness analysis.Applied innovation:This study sorts out and analyzes the current practice of the internal medical insurance management model in public hospitals,builds a new internal medical insurance management model in public hospitals that adapts to the new situation,and provides guidance for China’s public hospitals to build a refined internal medical insurance management model.2.DeficienciesIn terms of the collection of empirical data,there may be differences in the comparison of some hospitals in the study,because of the influence of different medical insurance policies,payment methods,and local financial actualities in various regions,the medical insurance policies,medical insurance risks and supporting information level implemented by each hospital different.In terms of the content of the research data,the quantitative analysis of medical insurance data is based on identifiable risks,and some"invisible"risks hidden deep cannot be identified and analyzed.The questionnaire survey and on-site interview as the analysis evidence of this study is a subjective perception and judgment,and the objectivity of the data may have certain limitations.In addition,due to the impact of the new coronavirus pneumonia（COVID-19）epidemic,the sample scope and field investigation content of the field survey of public hospitals in this study were restricted.Although this adverse factor has been circumvented by big data,this study hopes to continue the investigation to improve the representativeness and comprehensiveness of the research results after the end of the epidemic.