异地就医下医保基金监管困境及应对策略的质性研究

Quality Research on the Dilemma of Supervision of Medical Insurance Funds and Response Strategies un⁃der Differential Medical Care

目的对异地就医下医保基金监管困境进行分析,提出应对策略,为提升我国异地就医监管效率提供理论参考。方法系统检索异地就医下医保基金监管相关文献,检索时间为建库至2023年12月。采用NVivo 12 Plus软件对纳入的文献进行编码和分析。结果通过检索筛选,最终保留38篇文献纳入质性研究。提炼出53个初始概念、18个初始范畴及5个主范畴,得出异地就医基金监管在监管机制不健全、监管法律不完善、监管手段单一、监管主体能力不足以及监管对象道德风险5个维度的困境节点。结论异地就医下医保基金监管受多种因素制约:完善、健全的监管机制是其中最核心的问题,监管法律完备、有效是监管的重要依据,创新监管手段、促进监管效力提升则是异地就医下医保基金监管的重要手段,制约就医地机构和参保人员的道德风险则是监管过程的关键环节。

Objective To analyze the dilemma of medical insurance fund regulation under cross-location medical treatment in China,and put forward coping strategies to provide theoretical reference and reference for enhancing the efficiency of cross-location medical treatment regulation in China.Methods A systematic search was conducted to retrieve the literature related to the regulation of health insurance funds under off-site medical care from the time of database construction to December 2023 NVivo 12 Plus software was used to code and analyse the included litera⁃ture.Results 38 Articles were finally retained for qualitative research through searching and screening.Fifty-three ini⁃tial concepts,18 initial categories and 5 main categories were extracted,and the dilemma nodes of the supervision of cross-district medical fund in the dimensions of incomplete supervision mechanism,imperfect supervision law,single supervision means,insufficient capacity of supervision subject and moral risk of supervision object and moral risk of supervision object were obtained,insufficient capacity of the regulatory body and moral risk of the regulatory object.Conclusion The supervision of medical insurance fund under the cross-location medical care is constrained by many factors,and the soundness of the supervision mechanism is the core issue;the completeness and effectiveness of the supervision law is the important basis for supervision;the innovation of the supervision means and the promotion of the improvement of the effectiveness of the supervision are the important means of the supervision of the medical insurance fund under the cross-location medical care;and the restriction of the moral hazards of the institutions in the place of medical care and of the insured persons is the key link of the super⁃vision process.