黑龙江省基本医疗保险跨省异地就医直接结算现状及靶点问题分析

Analysis on the Current Situation and Target Problem of Direct Settlement of Healthcare Medical Insurance in Heilongjiang Province

目的:分析黑龙江省基本医疗保险异地就医直接结算运行现状,找到靶点问题,并给出政策性建议。方法:采用SPSS 20.0软件对黑龙江省异地就医人次、统筹基金支付金额、实际报销比例及转外就医定点医院情况等进行描述性分析。结果:黑龙江省异地就医人次呈现直线上升趋势;作为参保省的统筹基金支付约是作为就医省的11.8(26.92/2.28)倍;实际报销比例差距较大,待遇差较严重;转外就医主要集中于京津的肿瘤专科医院与综合三级甲等医院。结论:基本医疗保险面临着严峻的基金外流问题挑战,亟需加快医疗卫生服务供给侧改革,实现医保与医疗服务的协同发展,同时将基本医疗保险异地就医直接结算政策嵌入黑龙江省特色发展战略,推动社会现代化发展。

Objective:To analyze the current situation of the direct settlement of basic medical insurance in Heilongjiang Province for medical treatment in other places,explore the target problem and give policy recommendations.Methods:Using SPSS 20.0 Software to conduct a descriptive analysis on the number of medical visits in different places in Heilongjiang Province,the payment amount of the overall fund,the actual reimbursement ratio,and the status of designated hospitals for medical treatment.Results:There is a linear upward trend in the number of remote medical treatments in Heilongjiang;the overall fund payment for the insured province is about 11.8 times of the medical province;the actual reimbursement rate gap is large,and the treatment difference is more serious;the transfer of medical treatment is mainly concentrated in cancer specialist hospitals and comprehensive tertiary first-class hospitals of Beijing and Tianjin.Conclusion:Basic medical insurance is facing a severe challenge of fund outflow.It is urgent to accelerate the reform of the supply side of medical and health services,and realize the coordinated development of medical insurance and medical services.The basic medical insurance direct settlement policy for medical treatment in different places should be embedded in the characteristic development strategy of Heilongjiang Province,to promote the development of social modernization.