基本医疗保险异地就医结算研究

发布时间：2018-05-29 07:32

本文选题：基本医疗保险 + 异地就医　；参考：《山西大学》2017年硕士论文

【摘要】：由于我国基本医疗保险属地化管理、各地统筹层级不同、医保政策不同、各地筹资保障水平不同,导致异地就医即时结算问题日益突出。各地在探索基本医疗保险异地就医结算方面做了很大努力,制定了符合本地区发展水平的政策,但是国家层面的统一政策还有待出台。对基本医疗保险异地就医结算进行研究,可以提高参保人员就医自主选择性,特别是重症患者越来越多地享受到优质的医疗资源与医疗服务,提高参保人员的医疗保障水平,解决参保人员异地就医后费用垫付多、报销程序繁琐、经济负担重的问题,也可提高医保经办机构的工作效率,是一项便民工程。目前,我国各省已经完成省内基本医疗保险异地就医即时结算工作,各省也积极开展省外医保异地就医结算模式的探索,海南、上海等地区为全国各省做出很好的示范作用。但是,各地医保异地就医结算面临政策差异大衔接困难、大病医保异地就医直接结算政策缺位、经办与政策上衔接的问题较多、信息系统互不相容、信息资源不能共享、异地就医结算经办不规范,监管及核实查处困难、个人负担重垫付压力大等各方面问题。放眼国际典型国家和地区解决异地就医结算的方式,欧盟、美国、日本等国家,尤其是欧盟在法律、公共信息平台、跨境医疗管理机制、医疗政策建设等方面为我国的顶层设计提供了有益的启示。从我国实际出发,通过对国内外异地就医即时结算管理模式和经验的借鉴,对优化异地就医政策提出新的政策性思考。政府、经办机构、参保人三个层面通盘考虑先行规划,从异地就医服务管理体系、信息系统软硬件建设、经费管理和运营等各个环节,为这项工作的开展做好必要准备。
[Abstract]:Because of the localization management of the basic medical insurance in our country, the different levels of overall planning, the different medical insurance policy and the different level of financing guarantee, the problem of immediate settlement of medical treatment in different places is increasingly prominent. All localities have made great efforts in exploring the settlement of medical treatment in different places of basic medical insurance, and formulated policies in line with the level of development of the region, but the unified policy at the national level has yet to be issued. A study on the settlement of medical treatment in different places of the basic medical insurance can improve the independent selection of the insured, especially the more and more serious patients enjoy quality medical resources and medical services, and improve the medical security level of the insured. It is a convenient project to solve the problem that the insured can pay more expenses in different places, the reimbursement procedure is cumbersome, and the economic burden is heavy. It can also improve the working efficiency of medical insurance agencies. At present, the provinces of our country have already completed the work of settling accounts for medical treatment in different places of basic medical insurance in the province, and the provinces have also actively carried out the exploration of the settlement mode of medical insurance in different places outside the province. Hainan, Shanghai and other regions have made a good demonstration role for the provinces of the whole country. However, local medical insurance accounts in different places face great difficulties in policy convergence, the direct settlement policy of medical insurance in different places is absent, there are many problems in connection between operation and policy, information systems are incompatible, and information resources cannot be shared. The medical settlement in different places is not standardized, the supervision and verification is difficult, the personal burden is heavy and the pressure is great. Looking at the way in which international typical countries and regions resolve the settlement of medical treatment in different places, the European Union, the United States, Japan, and other countries, especially the European Union, in its laws, public information platforms, and cross-border medical management mechanisms, The medical policy construction and so on has provided the beneficial enlightenment for our country top-level design. Starting from the reality of our country, this paper puts forward new policy thinking on optimizing the policy of seeking medical treatment in different places by drawing lessons from the management mode and experience of instant settlement of medical treatment in different places at home and abroad. The government, the agency and the insured have all considered the plan in advance, making necessary preparations for the development of the work from the aspects of the management system of medical service in different places, the construction of software and hardware of information system, the management of funds and the operation of the system.
【学位授予单位】：山西大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R197.1;F842.684

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