跨省门诊慢特病直接结算存在问题与对策研究——以苏州市S医院为例

Research on the problems and countermeasures of direct settlement for chronic and special critical diseases in cross provincial outpatient service——taking suzhou S hospital as an example

目的探究跨省门慢特直接结算政策实施现状及存在问题,提出改进对策和建议,为进一步完善跨省门慢特直接结算政策提供参考,提升患者就医满意度和便捷性,共同维护医保基金安全。方法提取S医院跨省门慢特结算数据和医保服务平台数据,收集并梳理日常结算中遇到的困难,分析政策实施存在的问题及原因。结果跨省门慢特直接结算给患者带来了便利,结算人次日益增多,但仍存在结算流程繁琐、结算人次不高、部分病种无法结算、患者不清楚结算政策、开通医疗机构数量不多及结算数据不准确等问题。结论各级医保部门和医疗机构需共同努力,制定统一门慢特目录、扩大试点病种和医疗机构覆盖范围、优化结算流程、加强信息化建设、加强政策宣传和人员培训力度、建立异地门慢特结算监管机制。

Objective To explore the current implementation status and existing problems of direct settlement for chronic and special critical diseases in cross provincial outpatient service policies,propose improvement strategies and suggestions,provide reference for further improving direct settlement for chronic and special critical diseases in cross provincial outpatient service policies,enhance patient satisfaction and convenience in seeking medical treatment,and jointly maintain the safety of medical insurance funds.Methods Extract settlement data from chronic and special critical diseases in cross provincial outpatient service and medical insurance service platform data from S Hospital,collect and sort out the difficulties encountered in daily settlement,and analyze the problems and reasons in the implementation of settlement policies.Results Direct settlement for chronic and special critical diseases in cross provincial outpatient service has brought convenience to patients,with an increasing number of settlement personnel.However,there are still problems such as cumbersome settlement processes,low settlement personnel,inability to settle certain diseases,unclear settlement policies for patients,limited number of medical institutions opened,and inaccurate settlement data.Conclusion Medical insurance departments and institutions at all levels need to work together to develop a unified list of outpatient treatment for chronic and special critical diseases,expand the scope of pilot diseases and medical institutions,optimize settlement processes,strengthen information construction,strengthen policy promotion and personnel training,establish a regulatory mechanism of outpatient treatment for chronic and special critical diseases in remote locations.