京津冀地区参保农民跨省就医即时结报的利益相关者分析

发布时间：2018-09-08 18:44

【摘要】：研究目的本研究旨在了解京津冀地区参保农民跨省就医即时结报的基本情况,进而分析即时结报过程中涉及的主要利益相关者,探究主要利益相关者与京津冀地区参保农民跨省就医即时结报之间的影响,从而为京津冀地区跨省就医即时结报工作提供建议。研究内容1.梳理异地就医即时结报、利益相关者的相关概念、内涵、理论和国内外研究现状、实践经验。2.分析京津冀地区参保农民跨省就医即时结报的政策制度、信息技术、业务流程和结算方式,并归纳所面临的主要问题。3.利用利益相关者分析方法,分析京津冀地区参保农民跨省就医即时结报的主要利益相关者的关联程度、执行意愿和政策影响力。4.探讨主要利益相关者与京津冀地区参保农民跨省就医即时结报之间的影响,结合即时结报存在问题与利益相关者分析结果,提出相应的建议。研究方法1.资料来源:(1)文献研究:通过在中外文献数据库以及政府门户网站检索与研究主题相关的文献资料,系统梳理相关理论和国内外实践;(2)现场调查:通过问卷调查及半结构式访谈,了解京津冀地区参保农民跨省就医即时结报的政策制定及实施状况。2.研究方法:(1)利益相关者分析法:确定京津冀地区参保农民跨省就医即时结报工作中涉及的主要利益相关者,并利用分析指标,借助问卷调查和深入访谈,了解各主要利益相关者的特征;(2)专家咨询法:先后在设计调查问卷、确定利益相关者、确定主要利益相关者及确定分析指标阶段咨询专家学者;(3)描述性统计分析法:对问卷调查、深入访谈和专家咨询中收集的定性、定量资料运用常用的统计学方法处理分析。结果1.京津冀地区参保农民跨省就医即时结报的基本情况政策制度方面,京津冀三地的统筹补偿政策、报销政策呈现差异化,均强调转诊制度。信息化建设方面,京津冀三地的管理信息系统建设、医疗机构联网结报、结算平台建立以及配套信息系统建设存在差异。业务流程方面,京津冀地区按照就医管理、登记备案、预付金管理、医疗费用结算、医疗费用清算的五个步骤进行。试点应用方面,京津冀地区目前尚未针对参保农民的跨省就医即时结报进行即时结报试点,但其他领域已设计出“面对面”结报模式。存在问题方面,京津冀地区在开展即时结报工作中面临着城乡居民医保的统筹层次低且不一、即时结报的信息化建设参差不齐以及欠缺系统规划等主要问题。2.京津冀地区参保农民跨省就医即时结报的利益相关者分析京津冀地区参保农民跨省就医即时结报的主要利益相关者分别为人社部门、卫生行政部门、医保经办机构、就医地医疗机构、参保地医疗机构和参保农民。主要利益相关者的角色定位、利益、立场、联盟、资源、权力和领导能力的不同程度影响了相关者的关联程度、执行意愿和政策影响力。人社部门具有高关联程度、高政策影响力,持支持态度;卫生行政部门具有低关联程度、中等政策影响力,持支持态度;医保经办机构具有高关联程度、较高政策影响力,持较支持态度;就医地医疗机构具有高关联程度、较高政策影响力,持中立态度;参保地医疗机构具有低关联程度、较低政策影响力,持中立态度;参保农民具有高关联程度、较低政策影响力,是最大利益受益者,持支持态度。结论1.人社部门、医保经办机构和就医地医疗机构与京津冀地区即时结报工作关联程度高,具有较强的政策影响力,需加强三个部门(机构)在京津冀地区即时结报工作中的执行意愿。对于人社部门,需调动人员的工作积极性以及加强统筹规划与协调能力;对于医保经办机构,需调动人员的工作积极性以及规避医保资金风险问题;对于就医地医疗机构,需确保医保报销费用在规定时限内回款。尽管参保农民的政策影响力小,但是作为最大利益受益者,需考虑不同类型参保农民的跨省就医需求,因人制宜。2.主要利益相关者对京津冀地区参保农民跨省就医即时结报的系统规划、统筹层次和信息化建设产生影响,而京津冀地区参保农民跨省就医即时结报为主要利益相关者带来了风险监管和激励约束的问题。建议1.协调即时结报工作中主要利益相关者的利益关系;2.逐步提高京津冀地区基本医保制度统筹层次;3.加快信息化建设,为跨省就医即时结报夯实基础;4.加强风险控制,实施有效监管;5.建立考核机制和激励约束机制;6.树立整体观,通过系统规划形成制度合力。
[Abstract]:Objective The purpose of this study is to understand the basic situation of the instant report of the insured peasants'cross-provincial medical treatment in Beijing-Tianjin-Hebei region, and then analyze the main stakeholders involved in the process of the instant report, and explore the influence between the main stakeholders and the instant report of the insured peasants' cross-provincial medical treatment in Beijing-Tianjin-Hebei region, so as to make the cross-provincial medical treatment in Beijing-Tianjin- Research contents 1. Combine the related concepts, connotations, theories and research status at home and abroad, practical experience. 2. Analyze the policy system, information technology, business processes and settlement methods of the instant report of the insured peasants in Beijing-Tianjin-Hebei region, and summarize the main problems faced. Key issues. 3. Using stakeholder analysis method, this paper analyzes the correlation degree, willingness to implement and policy influence of the main stakeholders in the instant report of the insured peasants'cross-provincial medical treatment in Beijing-Tianjin-Hebei region. 4. Discusses the influence between the main stakeholders and the instant report of the insured peasants' cross-provincial medical treatment in Beijing-Tianjin-Hebei region. Data sources: (1) Literature research: Systematically combing the relevant theories and practices at home and abroad by searching and researching relevant literature materials in Chinese and foreign literature databases and government portals; (2) Field survey: through questionnaire survey and semi-structured interviews, Methods: (1) Stakeholder analysis: Determine the main stakeholders involved in the work of instant medical report of the insured peasants in Beijing-Tianjin-Hebei region, and use the analysis indicators, with the help of questionnaires and in-depth interviews, to understand the main stakeholders. Characteristics of stakeholders; (2) Expert consultation method: the design of questionnaires to identify stakeholders, identify major stakeholders and determine the stage of analysis indicators consultation experts and scholars; (3) Descriptive statistical analysis: questionnaire survey, in-depth interviews and expert consultation collected in qualitative, quantitative data using commonly used statistical methods Result 1. The basic situation and policy system of the instant medical report of the insured peasants in Beijing-Tianjin-Hebei region, the overall compensation policy and the reimbursement policy in Beijing-Tianjin-Hebei region are different, all of which emphasize the referral system. In the aspect of business process, Beijing-Tianjin-Hebei region has not carried out the real-time settlement test for the cross-provincial medical treatment report of the insured peasants. However, other areas have designed a "face-to-face" reporting model. The existing problems, Beijing-Tianjin-Hebei region in the implementation of immediate reporting work is faced with the low and different levels of urban and rural residents'medical insurance, the information construction of immediate reporting is uneven and the lack of systematic planning and other major issues. 2. Beijing-Tianjin-Hebei region insured farmers cross-province. Stakeholder analysis of medical immediate report in Beijing-Tianjin-Hebei region People's and social sectors have high degree of association, high policy influence and supportive attitude; health administrative departments have low degree of association, medium policy influence and supportive attitude; medical insurance agencies have high degree of association and higher political power. Policy influence and relatively supportive attitude; local medical institutions have high degree of association, higher policy influence and neutral attitude; medical institutions in the insured areas have low degree of association, lower policy influence and neutral attitude; farmers in the insured areas have high degree of association, lower policy influence, and are the biggest beneficiaries of support attitude. Conclusion 1. People's and social departments, medical insurance agencies and local medical institutions have a high degree of correlation with the work of immediate reporting in Beijing-Tianjin-Hebei region, and have a strong policy influence. It is necessary to strengthen the willingness of the three departments (institutions) to implement the work of immediate reporting in Beijing-Tianjin-Hebei region. For medical insurance agencies, it is necessary to mobilize the enthusiasm of staff and avoid the risk of medical insurance funds; for local medical institutions, it is necessary to ensure that the reimbursement fees of medical insurance are paid back within the prescribed time limit. The main stakeholders have an impact on the system planning, overall planning level and information construction of the cross-provincial medical report of the insured peasants in Beijing-Tianjin-Hebei region, while the cross-provincial medical report of the insured peasants in Beijing-Tianjin-Hebei region has brought about the problems of risk supervision and incentive and constraint for the main stakeholders. To coordinate the interests of the major stakeholders in the immediate report; 2. to gradually improve the overall level of the basic medical insurance system in Beijing-Tianjin-Hebei region; 3. to speed up the construction of information technology to lay a solid foundation for the immediate report of inter-provincial medical treatment; 4. to strengthen risk control and implement effective supervision; 5. to establish an assessment mechanism and incentive and restraint mechanism; 6. to establish a holistic view and pass System planning creates a system of synergy.
【学位授予单位】：北京协和医学院
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R197.1;F842.684;F323.89

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