异地就医直接结算政策执行的利益相关者分析

Stakeholder Analysis on the Implementation of Immediate Settlement Policy for Out-of-town Medical Treatment

本文根据现场调研和访谈资料,分析异地就医直接结算政策执行过程中的利益相关者行为。直接结算政策执行的主要推动者和支持者是各级医保管理部门和参保人;商业保险机构由于拥有充足的资金和较高的经办水平,有可能在政策执行中起到推动作用。就医地医疗机构和就医地经办机构如遇到工作量或资金垫付风险增加等问题,可能采取政策回避、抗拒或执行偏离等抵触行动;参保地经办机构在政策执行中持中立态度,在保障基金安全的前提下,能够发挥推动作用,否则可能出现执行偏离;参保人因待遇差的存在可能自由选择结算方式,因而可能阻碍政策执行。建立异地就医政策执行的激励约束和利益平衡机制的核心在于合理布局异地定点医疗机构及建立有效的监管机制。

Based on field research and interview,the stakeholders'behavior in the implementation of the immediate settlement policy for out-of-town medical treatment are analyzed.The main promoters and supporters of the implementation of the policy are the medical insurance management departments at all levels and the insured.Commercial insurance institutions might play a role in promoting the policy due to their sufficient funds and high handling level.If the local hospitals and the local medical insurance agencies encounter problems such as increased workload or risk of capital advance,they may take conflicting actions such as policy avoidance,resistance or deviation from implementation.The agencies of the insured places hold a neutral attitude in the policy implementation,and can play a promoting role on the premise of ensuring the security of the fund,otherwise the implementation deviation may occur.Due to the existence of different reimbursements,the patients could choose the settlement freely,which can be a hindrance.The core of promoting the implementation of the policy lies in the rational distribution of designated medical institutions and the establishment of effective supervision mechanism.