目的:系统剖析上海市医保信用监管体系建设面临的实践困境,以及破解医保信用监管困境的原则和实施机制。方法:在系统梳理医保信用监管相关政策法规、指标体系研究与地方实践的基础上,结合上海市医保信用监管实践的案例分析,识别现行监管的突出问题。结果:上海市医保信用监管存在指标设计复杂、震慑力度有限、信用管理落地难等实践困境。在此基础上,本文提出以风险管控优先、审慎可行、过罚相当为原则,以闭环映射的信息归集机制、科学动态的信用评价机制、激励约束并重的评价结果应用机制、程序闭环的救济修复机制为核心的信用监管框架。结论:所构建的医保信用监管体系以失信约束为先导、聚焦基金安全、兼具操作可行性与制度延展性,可系统回应“引导机构自律、优化资源配置、推动社会共治”的信用监管目标。

Objective:This study aims to systematically analyze the practical dilemmas in the construction of Shanghai City's medical insurance credit supervision system, and to explore the principles and implementation mechanisms for addressing these dilemmas. Methods:Based on a systematic review of relevant policies and regulations, indicator system research, and local practices in the field of medical insurance credit supervision, combined with case studies of credit supervision practices in Shanghai City, this paper identifies the prominent problems in current regulatory operations. Results:The study finds that medical insurance credit supervision in Shanghai City faces practical dilemmas such as complex indicator design, limited deterrent effect, and difficulties in implementation. In response, this paper proposes a credit supervision framework guided by the principles of risk control first, prudence and feasibility, and penalties commensurate with offenses. The framework consists of four core mechanisms: a closed-loop information collection mechanism based on mapping, a scientific and dynamic credit evaluation mechanism, an application mechanism for evaluation results that balances incentives and constraints, and a procedurally complete relief and repair mechanism. Conclusions:The proposed medical insurance credit supervision system, which prioritizes dishonesty deterrence, focuses on fund security, and balances operational feasibility with institutional extensibility, can systematically address the credit supervision goals of guiding institutional self-discipline, optimizing resource allocation, and promoting social co-governance.