某地区医疗保险异地就医即时结算状况分析--以广东医科大学附属医院为例

Analysis of immediate settlement of off-site medical insurance in a certain area

[目的]对广东医科大学附属医院异地就医人次前20位病种的医疗保险异地结算现状进行分析总结。为进一步推进医保付费方式改革、公立医院职能改革、合理配置医疗资源、提升医疗效率以及顺利推进跨省异地医保即时结算提供依据。[方法]采用统计描述的方法比较不同参保患者群体(省内异地、海南异地、南宁铁路职工)异地医保结算的主要病种构成和自付比例,分析目前异地医保结算存在的问题。[结果]截至2017年7月,累计办理异地医保出院结算3399人次,其中海南职工医保、南宁铁路职工医保和省内异地医保结算分别为609人次、1012人次和1778人次;异地结算的前20位病种中,海南医保和南宁铁路职工医保主要以慢性病为主,省内异地主要以大病、重病为主,海南职工医保、南宁铁路职工医保和省内异地医保结算自付比例分别为:26.82%、12.25%和45.12%。[结论]大型公立医院医疗保险异地就医即时结算需要进一步改革,加强统筹,缩小不同参保群体的差距,充分利用公立医院医疗资源,提升医疗效率。

Objective To analyze and sum up current status of medical insurance intercity settlement of intercity see doctor in top20diseases which accepted medical treatment in affiliated hospital of Guangdong Medical University,so as to provide basis for further promoting medical insurance payment method reform,functions reform of public hospitals,allocating medical resources rationally,promoting medical efficiency,and also advancing immediate settlement of trans-provincial medical insurance favorably Methods It used statistical description method to compare main disease composition ratio and self-paid proportion in different insured patient groups Analyzed current problem of medical insurance intercity settlement Results Before July,2017,Accumulative total for dealing with medical insurance intercity settlement3399patients,(Hainan employee insurance,Nanning railway employee insurance and provincial intercity medical insurance was609,1012and1778respectively)In top20diseases,main disease of Hainan employee insurance,Nanning railway employee insurance was chronic disease,but main disease of provincial intercity was serious disease The self-paid ratio of Hainan employee insurance,Nanning railway employee insurance and provincial intercity medical insurance was2682%,1225%and4512%respectively Conclusions It needs to be reformed for medical insurance intercity settlement immediately Strengthen overall planning,shrink difference in different insured groups,make full use of public hospitals medical resources,promote medical efficiency.