跨省就医农村患者直接结算可及性及影响因素分析

Accessibility of immediate reimbursement for cross-provincial healthcare and its influencing factors for rural residents: a nationwide cross-sectional survey

目的 研究跨省就医农村患者直接结算的可及性,并从宏观和微观2个层面分析其影响因素,为有针对性地完善相关政策提供依据。方法 于2019年9月—2020年9月选取跨省就医直接结算量排名前100家定点医疗机构,以外省农村地区患者为调查对象,通过简单随机抽样选取上一年度有过跨省住院经历的2 363例农村患者进行问卷调查,利用分层模型从宏观和微观2个层面对跨省就医农村患者直接结算可及性进行分析。结果 跨省就医直接结算比例为19.2%(454/2 363),大病转诊[31.7%(152/480)]和三级医疗机构跨省就医[21.0%(351/1 674)]的农村患者直接结算比例最大。长期在外居住和工作的农村患者直接结算概率仅为大病转诊人群的25.4%和54.5%。二级医院就诊的直接结算概率约为三级医院的64.4%。跨省就医直接结算定点医疗机构占区域医疗机构比例每增加1%,农村患者跨省就医直接结算的可能性就会增加36.8%。结论 农村患者跨省就医需求与直接结算网络的差异以及流动身份的制约造成了其直接结算可及性不足。应结合农村患者就医特点进一步扩展跨省就医直接结算服务网络在基层医疗机构以及门诊服务的覆盖面,加强就医地的分级诊疗制度建设,并建立适应其流动特点的宣传和备案方式,以进一步提升农村患者的直接结算可及性。

Objective To examine the status and influencing factors of accessibility to immediate reimbursement for cross-provincial healthcare among rural residents and to provide evidence for improving related policies. Methods With simple random sampling, a nationwide online questionnaire survey was conducted among 2 497 rural residents having crossprovincial hospitalization during past one year in 100 designated hospitals providing healthcare service to non-local residents and with leading amount of immediate reimbursement for the services from September 2019 through September 2020.Macro-and micro-factors affecting the accessibility of immediate reimbursement for cross-provincial healthcare of rural residents were analyzed using hierarchical model. Results Of the 2 363 participants with valid responses, only 19.2%(n=454) received cross-provincial immediate reimbursement for their out-of-pocket medical costs;the ratio of receiving crossprovincial immediate reimbursement was the highest among the participants with severe disease referrals(31.7% [152/480])and cross-provincial medication in tertiary hospitals(21.0% [351/1 674]). For the participants with long-term living/working in non-home provinces, the probability of receiving immediate reimbursement for cross-provincial healthcare was only25.4%/54.5% of that for the participants with severe disease referrals;for the participants having the cross-provincial healthcare in secondary hospitals, the probability was 64.4% of that for the participants having the healthcare in tertiary hospitals. Each 1% increase in the proportion of designated hospitals with immediate reimbursement for cross-provincial healthcare against all hospitals in a region is associated with a 36.8% increase in the probability of immediate reimbursement for cross-provincial healthcare among rural residents. Conclusion The accessibility to immediate reimbursement for crossprovincial healthcare among rural residents is poor probably due to the gap between cross-provincial healthcare and the coverage of immediate reimbursement network and due to the restriction of the rural residents’ migration. The results suggest that targeted strategies need to be developed to increase the accessibility.