我国异地就医统一结算平台的构建机制研究

发布时间：2018-06-20 02:53

本文选题：异地就医 + 异地就医结算　；参考：《吉林大学》2017年硕士论文

【摘要】：目前,我国基本医疗保险的参保人数已达全国总人数的99.07%,医疗保险的高覆盖率很好地满足了社会保障“广覆盖”的基本要求,体现了我国医疗保险发展的近年来取得的成就。然而,在基本医疗保险取得辉煌成绩的同时,应该警惕的是,有一部分人虽然履行着缴费的义务,却因异地就医而无法享受到正常的医疗保险待遇。我国自2009年提出要大力推行异地就医结算服务以来,完善异地就医结算制度已成为医疗卫生体制改革的一项重点任务。当前我国的异地就医结算呈现“地区分割”的特征,即在各自的统筹区域内可实现异地就医直接结算。跨区域就医需要参保者先行垫费,回参保地报销。截止至2015年底,有29个省实现省内直接结算,跨省异地就医结算还处于省级合作的状态。近年来,随着人口流动的加快,人口老龄化程度的加深,异地就医需求也越来越大。当前“地区”分割下的异地就医结算具有很多的弊病,如申请异地就医程序繁琐,报销手续繁杂,监管易出漏洞,医疗费用报销难。这不仅损害了参保者自由选择医院就医的权利,限制了劳动力的流动,还阻碍了外地人员的城市融入。本文利用社会保障权理论、社会公平公正理论、人本主义理论、新制度经济学理论,论证“地区分割”下的异地就医结算的不合理性。从分析现实迫切性和必要性的角度,得出建立异地就医统一结算平台的论点。然而,异地就医统一结算平台的建立还面临这种种障碍。一是医保政策不一致、统筹层次低;二是参保地资金补偿难,发达地区医疗资源压力大;三是信息整合难,异地就医结算系统不健全;四是三大部门职能划分不明确。本文将以上问题概括为制度障碍、利益障碍、技术障碍、管理障碍,成为建立我国异地就医统一结算平台必须面对并解决的问题。为了获得异地就医问题解决的先进经验,本文阐述了欧盟社会保险卡在解决跨境就医上的运行机制,在分析可行性的基础上得到了建立异地就医统一结算平台的启示。如果说四大障碍的解决为异地就医统一结算平台铺平了道路,那么,全国异地就医统一结算系统的建立将为异地就医实现即时结算提供具体的操作手段。
[Abstract]:At present, the number of people participating in basic medical insurance in our country has reached 99.07% of the total number of people in the country. The high coverage rate of medical insurance meets the basic requirements of "wide coverage" of social security and reflects the achievements of the development of medical insurance in China in recent years. However, while the basic medical insurance has made brilliant achievements, we should be aware that, although some people are performing the obligation of paying fees, they are unable to enjoy the normal medical insurance treatment because of the medical treatment in different places. Since 2009, our country proposed to vigorously carry out the medical settlement service in different places, it has become a key task of the reform of medical and health system to perfect the settlement system of medical treatment in different places. At present, the settlement of medical treatment in different places in our country presents the characteristics of "regional division", that is, direct settlement of medical treatment in different places can be realized in their respective overall planning areas. Cross-regional medical needs to participate in the first cushion fee, back to the insurance reimbursement. By the end of 2015, 29 provinces had realized the direct settlement within the province, and the inter-provincial medical settlement was still in the state of provincial cooperation. In recent years, with the acceleration of population mobility and the deepening of population aging, the need for medical treatment in different places is increasing. At present, the settlement of medical treatment in different places under the division of "region" has many disadvantages, such as the complicated procedure of applying for medical treatment in different places, the complicated procedures of reimbursement, the vulnerability of supervision and the difficulty of reimbursement of medical expenses. This not only impairs the right of the insured to choose hospital care freely, restricts the movement of labor force, but also hinders the urban integration of non-residents. Based on the theory of the right to social security, the theory of social equity and justice, the theory of humanism and the theory of new institutional economics, this paper demonstrates the irrationality of the settlement of medical treatment in different places under "regional division". From the point of view of analyzing the urgency and necessity of reality, the thesis of establishing the unified settlement platform for medical treatment in different places is put forward. However, the establishment of a unified settlement platform for medical treatment in different places also faces these obstacles. One is the medical insurance policy is inconsistent, the overall planning level is low; the second is to participate in the insurance area fund to compensate, the developed area medical treatment resources pressure is big; three is the information conformity difficulty, the different place medical treatment settlement system is not perfect; the fourth is the three major departments function division is not clear. In this paper, the above problems are summarized as system obstacles, interest barriers, technical barriers, management obstacles, which must be faced and solved in the establishment of the unified settlement platform for medical treatment in different places in China. In order to obtain the advanced experience of solving medical problems in different places, this paper expounds the operation mechanism of EU social insurance card in solving the problem of cross-border medical treatment, and on the basis of analyzing the feasibility, it gets the inspiration of establishing the unified settlement platform for medical treatment in different places. If the solution of the four obstacles paves the way for the unified settlement platform of medical treatment in different places, then the establishment of the unified settlement system of medical treatment in different places will provide specific means of operation for the realization of instant settlement of medical treatment in different places.
【学位授予单位】：吉林大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R197.1;F842.684

【相似文献】