异地就医联网结算背景下医药费用报销差异性及影响因素分析

Analysis on Differences and Influencing Factors of Medical Expense Reimbursement Under the Background of Remote Medical Online Settlement

目的通过研究异地就医联网结算政策下四川大学华西医院住院患者医保报销比例的差异性,探讨影响报销比例的因素,分析各类因素对报销比例的影响,为完善异地就医联网报销政策提供实证依据。方法采集2019年1月—2020年12月医保联网即时结算的参保患者报销费用相关指标。对参保患者的报销比例按不同保险类型、不同地区、不同病种进行因素分析。对各类参保患者分别采用随机森林模型建立其报销比例与影响因素之间的联系,并通过随机森林模型直观描述各因素以及因素间的相互作用对参保患者报销比例的影响。结果成都市本地的平均报销比例最高,其次为跨省异地的平均报销比例,省内异地平均的报销比例最低。影响报销比例的因素随不同地区的不同而不同。成都市中医保类型(即省部级、城镇职工以及城乡居民)对报销比例影响最大,其次是药品费用,再次是检查费用;省内异地中,对报销比例影响最大的为参保地政策,其次也是药品费用,再次是患者年龄;跨省异地中对报销比例影响最大的是参保地政策,其次是药品费用,再次是病种类型。另外,因素之间的相互作用也对报销比例产生影响。结论综合来看,就医地医保政策、患者药品费用、年龄及病种类型对于异地就医联网结算下各地参保患者报销比例影响较其他因素显著。应进一步完善异地就医政策,深化医保支付制度改革,实现医药费用的有效控制,降低患者的疾病负担。

Objective To provide practical support to improve the reimbursement policy of remote medical networks by investigating the heterogeneity of reimbursement rate of inpatients in West China hospital under the settlement policy of the remote medical network,identifying important factors that influence the reimbursement ratio,and analyzing the influence of factors on the reimbursement ratio.Methods Collect various indicators of reimbursement expenses of insured patients for medical insurance networking immediate payment from January 2019 to December 2020.Analysis factors are conducted on the reimbursement proportion of insured patients according to different types of insurance,regions,and diseases.Develop a random forest model for each class to explore the relationship between reimbursement ratio and various factors.Access the influence of factors and their interactions on the reimbursement ratio based on random forest models.Results The average reimbursement rate of Chengdu city is the highest,followed by the out-of-province regions,and the in-province cities except Chengdu city are the lowest.The important factors for reimbursement ratio vary with different regions.The type of insurance in Chengdu city(provincial and ministerial level,urban workers and rural residents)have the most significant impact on the reimbursement ratio,followed by drug costs and then inspection costs;As to the in-province cities,the local policy of the insured region has the most significant impact on the reimbursement ratio,followed by the drug costs,and then the patient's age;As to the out-of-province regions,the most significant impact on the reimbursement ratio is the local policy of the insured place,followed by drug costs,and disease types.In addition,interactions between factors also affect the reimbursement ratio.Conclusion In summary,the local medical insurance policy,drug cost,age,and disease type significantly influence on the reimbursement rate of insured patients within the remote network.It is necessary to improve the medical treatment policy further and deepen the reform of medical insurance payment system.Achieve the effective control of medical expenses and reduce the disease burden of patients.