山西省城镇职工基本医疗保险异地就医结算运行研究

发布时间：2018-05-15 09:59

本文选题：山西省 + 城镇职工　；参考：《山西财经大学》2017年硕士论文

【摘要】：我国城镇职工基本医疗保险制度的覆盖率逐年提升,但是由于制度遵循属地化管理原则,且现阶段基本医疗保险统筹层次较低,造成异地就医参保人报销困难、经办机构管理不便。在面对人员流动增多、异地就医需求增大的情况下,异地就医结算问题凸显。“十三五”规划建议指出,要健全医疗保险制度,完善异地就医结算管理,重点解决异地安置的退休人员的就医需求。职工医疗保险是对参保人患病后医疗费用损失进行一定补偿的保险。异地就医结算是根据相关规定对医疗保险参保人跨统筹区就医发生的医疗费用给予报销结算。实现异地就医直接结算,减轻参保人垫付负担重、报销难的问题是现阶段异地就医结算工作的目的。山西省在完成基本医疗保险市级统筹的基础上,选择异地联网直接结算模式,统一社会保障卡,搭建异地就医系统平台。到2014年底,全面实现省内11个市级统筹地区异地就医直接结算,实现全省完全意义上的“省级联动、互联互通”,减轻了参保人员报销负担,方便了经办机构审核管理。截止2016年底,山西省省内异地就医直接结算超过32万人次,总费用金额超过11亿元。在取得相应成绩的基础上,山西省城镇职工异地就医结算也存在经办机构业务协调效率较低、系统平台建设不完善、异地就医结算发展不均衡、部分地区医保基金风险较大、影响分级诊疗制度实施的一系列问题。具体表现在经办机构专业人员少但工作复杂不易协调、系统兼容性差且资金不足、各地异地就医结算运行效果差异较大、部分地区医保基金外流风险加大、结算便利增加大医院就医人数从而不利于分级诊疗。提高统筹层次、选择异地联网直接结算模式、做到“业务宣传到位”和“技术改造全面”、坚持“分层次推进”原则是山西省异地就医结算得出的启示。山西省城镇职工异地就医结算还需要进一步完善,主要从完善异地就医结算管理制度、提高异地就医结算管理效率、与分级诊疗制度有效衔接给出相应建议。
[Abstract]:The coverage rate of the basic medical insurance system for urban workers in China has been increasing year by year, but because the system follows the principle of localized management and the overall level of basic medical insurance is relatively low at this stage, it is difficult for the insured to get medical treatment in different places. The management of the agency is inconvenient. In the face of increased staff flow and increased demand for medical treatment in different places, the problem of settlement of medical treatment in different places is prominent. It is pointed out in the 13th Five-Year Plan that it is necessary to improve the medical insurance system, improve the settlement management of medical treatment in different places, and focus on solving the need for medical treatment for retirees who have been resettled in different places. Worker medical treatment insurance is the insurance that carries on certain compensation to insurance of medical treatment cost loss after insurance-holder falls ill. The settlement of medical treatment in different places is to reimburse and settle the medical expenses incurred by medical insurance participants in cross-planning areas according to the relevant regulations. To realize the direct settlement of medical treatment in different places, to lighten the burden on the insured, and to make reimbursement difficult is the purpose of the settlement of medical treatment in different places at the present stage. On the basis of the basic medical insurance planning, Shanxi Province chooses the direct settlement model of different places, unifies the social security card, and sets up the system platform of medical treatment in different places. By the end of 2014, the direct settlement of medical treatment in 11 cities and regions in the province will be realized in an all-round way, and the "provincial linkage and interconnection" will be realized in the whole province, which will lighten the burden of reimbursement to the insured and facilitate the auditing and management of the agencies. By the end of 2016, more than 320000 medical visits had been made in Shanxi Province, with a total cost of more than 1.1 billion yuan. On the basis of the corresponding achievements, there are also some problems in the settlement of medical treatment for urban workers in Shanxi Province, such as the low efficiency of business coordination of agencies, the imperfect construction of system platform, the uneven development of medical settlement in different places, and the risk of medical insurance fund in some areas. A series of problems affecting the implementation of the classified diagnosis and treatment system. This is manifested in the fact that the agencies have fewer professionals but less complex and uncoordinated work, poor system compatibility and insufficient funds, greater differences in the operation results of medical settlement in different places, and increased risk of outflow of medical insurance funds in some regions. Settlement facilities increase the number of patients in large hospitals, which is not conducive to hierarchical diagnosis and treatment. To improve the overall planning level, select the direct settlement mode of different places network, achieve "business propaganda in place" and "comprehensive technical transformation", adhere to the principle of "hierarchical promotion" is the inspiration of Shanxi Province from different places of medical settlement. It is necessary to further improve the settlement of medical treatment for urban workers in Shanxi Province, mainly from perfecting the management system of medical settlement in different places, improving the efficiency of the management of medical settlement in different places, and giving corresponding suggestions to effectively link up with the system of classified diagnosis and treatment.
【学位授予单位】：山西财经大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R197.1;F842.684

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