跨省异地医保直接结算现状分析:基于上海某三甲医院数据
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摘要
目的基于医院HIS数据,分析异地医保直接结算现状和特点,为进一步推进跨省异地医保直接结算提供依据。方法数据来源于2017年8月—2018年8月1 842例异地医保结算数据,统计描述基本信息、医保基金支付、费用和病种等。结果异地医保患者主要来源于浙江省和江苏省,73.96%为职工基本医疗保险,平均年龄为46岁,71.17%的患者就诊于妇科,平均住院天数为5.1天,平均住院费用为13 414元,总体医保统筹基金支付比例为46.50%,恶性肿瘤患者占比为47.47%。结论异地医保报销待遇有待进一步提高,建议统一全国医保三大目录编码,加快长三角地区分级诊疗体系建设,引导有序就医。
OBJECTIVE Based on Hospital HIS data,to analyze the direct settlement status and characteristics of remote medical insurance,so as to provide evidence for further promotion of medical insurance in different provinces across provinces. METHODS Medical insurance cases of hospital from August 2017 to August 2018 was used. Statistical description was conducted from basic information,health care fund payments,fees,and disease types. RESULTS The patients were mainly from Zhejiang Province and Jiangsu Province.73.96% were basic medical insurance for employees,the average age was 46 years old. 71.17% of the patients were treated in the Gynecology Department. The average hospital stay was 5.1 days. The average hospitalization cost was 13 414 yuan. The payment proportion of the medical insurance pool fund was 46.50%,and the proportion of patients with malignant tumors was 47.47%. CONCLUSION The reimbursement of medical insurance in different places needed to be further improved. It was recommended to unify the three major catalogues of national medical insurance,speed up the construction of hierarchical diagnosis system in the Yangtze River Delta,and guide patients to seek medical care in an orderly manner.
OBJECTIVE Based on Hospital HIS data,to analyze the direct settlement status and characteristics of remote medical insurance,so as to provide evidence for further promotion of medical insurance in different provinces across provinces. METHODS Medical insurance cases of hospital from August 2017 to August 2018 was used. Statistical description was conducted from basic information,health care fund payments,fees,and disease types. RESULTS The patients were mainly from Zhejiang Province and Jiangsu Province.73.96% were basic medical insurance for employees,the average age was 46 years old. 71.17% of the patients were treated in the Gynecology Department. The average hospital stay was 5.1 days. The average hospitalization cost was 13 414 yuan. The payment proportion of the medical insurance pool fund was 46.50%,and the proportion of patients with malignant tumors was 47.47%. CONCLUSION The reimbursement of medical insurance in different places needed to be further improved. It was recommended to unify the three major catalogues of national medical insurance,speed up the construction of hierarchical diagnosis system in the Yangtze River Delta,and guide patients to seek medical care in an orderly manner.
引文
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[3]朱荣峰.只传费用大类,结算数据的准确性、合理性将不确定[J].中国社会保障,2017,274(5):81.
[4]何佳莹.上海市基本医疗保险异地就医费用结算现状及对策研究[D].上海:上海工程技术大学,2012.
[5]李志建,方秉华.异地就医即时结算现状及问题探讨[J].中国医院管理,2015,35(7):67-68.
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