Research On Quality Evaluation Of Medical Insurance Management Within Public Hospitals

[Purpose]The medical insurance management quality of public hospitals is directly related to the survival and development of the hospital.This study explored the new situation of the medical insurance management of public hospitals in China,constructed a systematic,scientific,operational and multi-stakeholder medical insurance management quality evaluation system to provide theoretical support for hospital management.Through empirical research,demonstrate the feasibility of the index system,comprehensively evaluate the status of medical insurance management quality,and propose strategies to promote the quality of medical insurance management.[Methods](1)Literature research method: Fully search the Chinese and English database,check the official medical documents,medical insurance payment reform,public hospital medical insurance management,medical quality management,public hospital performance appraisal and other indicators system,establish a framework for the index system.(2)SWOT-PEST analysis: From the political,economic,social and technological aspects,analyze the internal advantages and disadvantages and external opportunities and threats of current public hospital medical insurance management.(3)Delphi expert consultation method: 12 experts were selected,including hospital medical insurance office directors,medical insurance research experts.Experts were asked to rate the importance of indicators at all levels(for the patients,hospital and insurance)and accessibility.After two rounds of consultation,the indicator system was determined.Use the product method to determine the combined weight of each level of indicators(4)Empirical research method: Two hospitals with similar service scale in Y City,Hubei Province were selected for on-site investigation.The institution questionnaire,the insured patient satisfaction questionnaire,the medical staff service ability questionnaire,and the medical insurance refusal payment questionnaire were adopted to collect the measured values of the evaluation indicators;Conduct in-depth interviews to understand the actual situation of hospital medical insurance management.(5)Weighted comprehensive index evaluation method: based on the measured values of the index obtained by empirical research,the national policy document standard,the provincial-level average level or the sample mean value was used as the reference value.After standardization of the measured values,the index of indicators and the comprehensive index of medical insurance management quality of the sample hospitals were calculated.Compare the management quality between two sample hospitals.[Results](1)The quality evaluation index system: The index system framework constructed by the literature method includes 5 first-level indicators,16 second-level indicators and 43 third-level indicators.The index system finalized through expert consultation includes 5 first-level indicators,13 second-level indicators,and 29 third-level indicators.The five primary indicators are medical insurance quality(226.2),cost control(223.8),patient experience(207.1),medical quality(173.8)and work efficiency(169.0).The consultation result has credibility.The positive coefficient of expert consultation is 100% and the authoritative coefficients of first-level indicators are above 0.7.The Kendall coordination coefficient tests show that the index evaluation results of importance and accessibility are consistent(p is less than 0.05),so the expert opinions are coordinated.(2)Comprehensive evaluation results: The comprehensive index of hospital A is 1.039,slightly higher than 0.956 of hospital B.The comprehensive index of medical quality,cost control and work efficiency of hospital A(0.336,0.186,0.171)is higher than that of hospital B(0.234,0.172,0.136).The standardized value of indicators such the clinical path management rate and completion rate,the annual growth rate of medical income,and the average hospitalization day and bed occupancy rate are significantly higher than that of hospital B;the quality of medical insurance and patient experience index of B hospital(0.207,0.207)is higher than that of hospital A(0.171,0.174),The standardized value of indicators such as awareness of the policy,patient satisfaction,proportion of patient complaints,and notification of medical insurance policies are higher.[Conclusions](1)The quality evaluation index system consists of 5 first-level indicators,13 second-level indicators and 29 third-level indicators.Combined with comprehensive evaluation methods,it can objectively evaluate the medical insurance management level of public hospitals.It takes the benefits of the hospital,insurance and patient into account,and can be used for the vertical comparison of internal medical insurance management quality in a single hospital in different periods and the horizontal comparison between multiple hospitals in a certain period.(2)Through the comprehensive evaluation of two public hospitals by using the index system,it can be judged that the quality of medical insurance management of hospital A is slightly better than that of hospital B,and the difference between two hospitals can be identified through specific indicators.Hospital A did better on clinical path management,medical expense growth rate control and hospital operation efficiency.In the meantime,medical insurance system construction,medical staff policy training,implementation of patient informed consent,reduction of patients' economic burden,and improvement of patient experience of hospital B were more in place.(3)Advices: Improve the quality management system and promote the collaborative collaboration among hospital departments by creating a hospital culture of friendship,communication and strong execution.Promote quality management from strengthening single disease management,service process management,quality evaluation and intelligent system construction.Strengthen the construction of professional multi-disciplinary talent team in medical insurance management.Strengthen negotiations and dialogue with medical insurance agencies,enhance the strength of negotiations and strengthen cooperation.