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·药事管理·

美国基本医保委托经办管理制度研究及其对我国的启示 Δ

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朱梓荣 ，颜建周，邵 蓉（中国药科大学国家药物政策与医药产业经济研究中心，南京 211198）
中图分类号 R951 文献标志码 A 文章编号 1001-0408（2020）15-1793-06
DOI 10.6039/j.issn.1001-0408.2020.15.01

摘 要 目的：为完善我国医保委托经办管理制度提供参考。方法：通过分析我国医保委托经办管理模式的问题，并研究美国基
本医保委托经办管理中的承包商具体类型、职责分工及其特色，提出完善我国相应管理制度的建议。结果与结论：我国医保委托
经办管理存在公平经办竞争机制尚未建立、社保基金运行管理缺乏监管机制、政府角色不明确且缺乏经验、不完善的监管机制可
产生后续问题、委托经办管理制度是否提高医保管理效率仍然具有不确定性等问题。美国基本医保委托经办管理的方式是引入
第三方管理。美国医疗照顾与医疗救助服务中心雇佣的承包商主要包括医保管理承包商、区域方案廉政承包商、综合错误率测试
计划审查承包商与统计承包商、补充医学审查承包商、合格的独立承包商等，其中医保管理承包商居于核心地位。各承包商在处
理医疗索赔、预防医保欺诈、审查付款正确性、评估医疗记录、处理上诉申请方面有明确分工，各司其职。这种委托管理模式极大
程度地降低了政府工作压力、提高了医保管理运营效率、推动了整个制度不断完善。建议我国在医保管理工作中应扩大社会经办
管理范围、明确政府与社会资源责任、引入多种类型社会经办机构、构建全面有效的绩效监督管理体系，以提高我国医保治理现代
化水平。
关键词 医保委托经办管理；现状与问题；美国；承包商；启示

Study on Commission Management System of Basic Medical Insurance in the United States and Its
Enlightenment to China
ZHU Zirong，YAN Jianzhou，SHAO Rong（National Drug Policy and Medical Industry Economy Research
Center，China Pharmaceutical University，Nanjing 211198，China）

ABSTRACT OBJECTIVE：To provide reference for improving commission management system of medical insurance in China.
METHODS：By analyzing the problems of commission management system of medical insurance in China，studying the specific
types，responsibility division and its features of basic medical insurance contractors in the United States，the suggestions were put
forward for improving corresponding system in China. RESULTS & CONCLUSIONS：There are some problems in the entrusted
management of medical insurance in China，including that the fair competition mechanism has not been established；the operation
and management of social security fund lacks of supervision mechanism；the role of the government is unclear and inexperienced；
the imperfect supervision mechanism causes follow-up problems；it is still uncertain whether the entrusted management system can
improve the efficency of medical insurance management. In the United States，the way of entrusted management of medical
insurance was to introduce the third-party management. The contractors employed by the Centers for Medicare and Medicaid
Services in the United States mainly included medical insurance contractor，zone program integrity contractor，comprehensive error
rate test review contractor and statistical contractor，supplemental medical review contractor，qualified independent contractor and
so on，among which medical insurance contractor was in the core position. Each contractor had a clear division of labor in handling
medical claims，preventing medical fraud，reviewing the correctness of payments，evaluating medical records and handling appeals.
This mode greatly reduced the work pressure of the government，improved the efficiency of medical insurance management and
operation，and promoted the continuous improvement of the whole system. It is suggested that China should expand the scope of
social agency management，clarify the responsibilities of government and social resources，introduce various types of social
economic organizations and establish a complete and effective performance supervision and management system in order to improve
the modernization level of China’s medical insurance governance.
KEYWORDS Commission management of medical insurance； Situation and problems； The United States； Contractors；
Δ 基金项目：国家社会科学基金重大项目（No.15ZDB167）；中国 Enlightenment
药科大学“双一流”学科创新团队建设项目（No.CPU2018GY39）
＊ 硕 士 研 究 生 。 研 究 方 向 ：医 药 政 策 与 法 规 。 电 话 ：025-
医保经办管理体制是我国医保制度建设的重要内
86185084。E-mail：19850850622@163.com
容 。随着全民医保的不断推进，医保经办管理工作量
[1]
# 通信作者：教授，博士生导师，博士。研究方向：医药政策与法
[2]
规。电话：025-86185084。E-mail：shaorong118@163.com 日益增加 ，然而我国医保执行层面“重制度、轻管理”，
中国药房 2020年第31卷第15期 China Pharmacy 2020 Vol. 31 No. 15 ·1793 ·