刘蓉

[摘要] 目的 在医院医保管理中通过PDCA循环模式进行管理，对其应用价值进行评价。方法 随机从该院在2018年1月—2019年1月这一期间中收治的患者中挑选出60例患者，进行随机分组，30例患者不通过任何管理模式进行管理，作为对照组， 30例患者通过PDCA循环管理，作为观察组，分别对两组患者的次均住院费用（职工医保每次住院费用，居民医保每次住院费用）、报销比例（职工医保报销比例（%），居民医保报销比例（%）以及两组患者的管理满意度进行比较。结果 观察组患者的住院费用低于对照组患者，观察组患者的职工医保每次住院费用为（6 749±30.8）元，居民医保每次住院费用为（4 419±21.9）元，满意度高于对照组患者，观察组患者的管理总满意度为90.0%（27/30），报销比例明显高于对照组，观察组患者的职工医保报销比例（%）为88.46%，居民医保报销比例（%）为76.78%。组间差异有统计学意义（P<0.05）。结论 在医保管理中，通过PDCA循环进行管理，可以明显降低住院费用、提升报销比例、提高患者的满意度，值得在临床中推广以及应用。

[关键词] PDCA循环;医院医保管理;应用研究

[Abstract] Objective To evaluate the value of its application in the management of hospital medical insurance through the PDCA cycle model. Methods 60 patients were randomly selected from the patients admitted in the hospital during the period from January 2018 to January 2019 and randomly divided into two groups. 30 patients were managed without any management mode as a control group， 30 patients were managed through the PDCA cycle as an observation group， the average inpatient expenses for each group of patients （Employee Medicare inpatient expenses， Resident Medicare each inpatient expenses）， Reimbursement ratio （Employee Medicare reimbursement ratio （%）， Resident Medicare Reimbursement ratio （%） and management satisfaction of the two groups were compared. Results The hospitalization expenses of patients in the observation group were lower than those in the control group. The employee medical insurance costs per hospitalization in the observation group were（6 749±30.8）yuan， and the residents medical insurance costs were（4 419±21.9）yuan. The satisfaction rate was higher than that in the control group. The observation group of the patient's total management satisfaction was 90.0%（27/30）， and the reimbursement ratio was significantly higher than that of the control group. The employee medical insurance reimbursement ratio （%） in the observation group was 88.46%， and the resident medical insurance reimbursement ratio （%） was 76.78%. The difference between the groups was statistically significant（P<0.05）. Conclusion In the medical insurance management， the management through the PDCA cycle can significantly reduce the hospitalization expenses， increase the reimbursement ratio， and improve patient satisfaction. It is worth promoting and applying in the clinic.

[Key words] PDCA cycle; Hospital medical insurance management; Applied research

隨着我国经济的逐渐发展，民生事业逐渐强大。医疗事业更是逐渐改革，医疗保险的覆盖面积也是越来越宽，越来越广。其中，医疗保险的质量管理关系医疗机构的生存发展及患者的生活质量。管理者运用现代化管理工具提高医疗质量及医保报销比例，提升患者满意度。减少医疗费用，减轻就医压力，让患者有获得感，促进医院发展。如何在有限的医保经济体系下，运用现代医疗工具解决患者病痛，同时减轻患者经济负担，达到国家、医院、患者“三赢”的目的是管理者必须思考的问题。……