基于"先例-流程-结果"框架的医疗保险欺诈监督政策量化评估研究
Zixiao Zhang1, Shaoqun Ding2, Zitao Yang3
1School of Public Administration, Southwestern University of Finance and Economics, Chengdu, Sichuan, China.
PloS one
|January 6, 2025
概括
医疗保险欺诈威胁到基金的可持续性. 这项研究分析了中国的180起欺诈案件和18项政策,发现了对于高质量的医疗安全发展而言,普遍可以接受但无法改进的治理策略.
科学领域:
- 公共管理 公共管理
- 卫生政策 卫生政策
- 保险管理 保险管理
背景情况:
- 医疗保险欺诈对医疗保健基金的财务稳定性和可持续性构成重大威胁.
- 解决欺诈问题对于维持支付平衡和改革医疗保健支付系统至关重要.
研究的目的:
- 为了解和管理医疗保险欺诈,制定一个概念框架 ("先例-过程-结果").
- 评估旨在打击中国医疗保险欺诈的现有政策.
主要方法:
- 基于180起医疗保险欺诈案件的理论分析.
- 用政策管理周期 (PMC) 指数模型对18个选定的政策进行政策评估.
- 对政策属性,内容和影响进行比较分析.
主要成果:
- 评估政策的平均PMC指数为4.98,表明一般可接受的业绩.
- 在政策范围,监管链,指导和工具方面发现了缺陷.
- 分析显示,中国各地的欺诈监督政策存在相似之处和差异.
结论:
- 虽然目前的政策是广泛接受的,但有针对性的改进是必要的,以加强医疗保险基金治理.
- 提供了建议,以解决发现的政策缺陷,旨在高质量发展医疗安全系统.
- 这些发现为中国医疗安全框架的现代化提供了理论和实际见解.
相关概念视频
Types of Biopharmaceutical Studies: Controlled and Non-Controlled Approaches
101
Biopharmaceutical studies constitute a vital field aiming to enhance drug delivery methods and refine therapeutic approaches, drawing upon diverse interdisciplinary knowledge. In research methodologies, the choice between controlled and non-controlled studies significantly influences the study's reliability and accuracy.
Non-controlled studies, commonly employed for initial exploration, lack a control group, rendering them susceptible to biases and external influences. In contrast,...
Non-controlled studies, commonly employed for initial exploration, lack a control group, rendering them susceptible to biases and external influences. In contrast,...
101
Actuarial Approach
36
The actuarial approach, a statistical method originally developed for life insurance risk assessment, is widely used to calculate survival rates in clinical and population studies. This method accounts for participants lost to follow-up or those who die from causes unrelated to the study, ensuring a more accurate representation of survival probabilities.
Consider the example of a high-risk surgical procedure with significant early-stage mortality. A two-year clinical study is conducted,...
Consider the example of a high-risk surgical procedure with significant early-stage mortality. A two-year clinical study is conducted,...
36
Health Information Technology and Healthcare Information System
745
Health Information Technology (HIT)
Health Information Technology, commonly called HIT, integrates advanced information systems and technology in healthcare settings. Its primary functions include:
Health Information Technology, commonly called HIT, integrates advanced information systems and technology in healthcare settings. Its primary functions include:
745
Introduction to Epidemiology
538
Epidemiology, known as the cornerstone of public health, involves studying the distribution and determinants of health-related events in defined populations and applying these insights to control health issues. This is essential for understanding how diseases spread, identifying populations at greater risk, and implementing measures to control or prevent outbreaks. Epidemiology addresses not only infectious diseases but also non-communicable conditions like cancer and cardiovascular disease,...
538
Data Validation
4.7K
Data validation is an essential part of a comprehensive assessment. Validation is confirming or verifying and opening the door to gathering more assessment data as it clarifies vague or unclear data. The process of checking and verifying the collected information is called data validation. The primary purpose of data validation is to ensure data is as free from error, bias, and misinterpretation as possible.
Nursing assessment guides are generally based on holistic models rather than medical...
Nursing assessment guides are generally based on holistic models rather than medical...
4.7K
Strategies for Assessing and Addressing Confounding
62
Confounding is a critical issue in epidemiological studies, often leading to misleading conclusions about associations between exposures and outcomes. It occurs when the relationship between the exposure and the outcome is mixed with the effects of other factors that influence the outcome. Given that, addressing confounding is of high importance for drawing accurate inferences in research.
Confounding can be addressed at both the design phase of a study and through analytical methods after data...
Confounding can be addressed at both the design phase of a study and through analytical methods after data...
62


