跨省异地就医直接结算数字监管问题及对策研究

Problems and Countermeasures of Digital Supervision of Direct Settlement of Cross-Province Medical Treat⁃ment

目的对跨省异地就医直接结算数字监管问题进行识别与分析,并提出对策建议。方法采用文献研究、专家访谈与问卷调查法,于2023年1月29日—2月13日选择H省各级医保局从事异地医保业务的管理人员、工作人员以及医保领域的学者为调查对象,采用主成分分析法对问题进行提取,基于提取结果,构建多元logistic回归模型,探究对跨省异地就医直接结算数字监管效果造成明显影响的问题。结果跨省异地就医直接结算数字监管问题分为7大类,累计方差贡献率为63.17%。其中数字监管系统的衔接、审核规则与预警问题,缺乏法律制度及界定的问题对监管效果有明显影响(P<0.05)。结论跨省异地就医就医地与参保地数字监管系统体系建设不完善,跨省异地就医直接结算数字监管法律制度保障不健全。因此,加强跨省异地就医直接结算数字监管系统的基础性建设、健全跨省异地就医直接结算数字监管法律制度对我国跨省异地就医直接结算数字监管有重要的指导意义。

Objective To identify and analyze the digital supervision issues of cross-province medical treatment in China,and propose countermeasures and suggestions.Methods Using literature research,expert interviews,and questionnaire surveys,from January 29,to February 132023,managers,staff from remote departments of medi⁃cal insurance bureau and scholar in the field of medical insurance in H province were selected.Principal component analysis was used to extract questions,and based on the extraction results,a multiple logistic regression model to explore that have a significant impact on the digital supervision of cross-province direct settlement of medical treat⁃ment.Results The problems of digital supervision of direct settlement for medical treatment across provinces and re⁃gions in China can be divided into 7 categories,with a cumulative variance contribution rate of 63.17%.The connec⁃tion of digital regulatory systems,audit rules and early warning issues,as well as the lack of legal systems and defi⁃nitions have a significant impact on regulatory effectiveness(P<0.05).Conclusion Incomplete construction of the digital supervision system between the place of insurance participation,and inadequate legal and institutional sateguards for the digital supervision of the direct settlement of cross-provincial cross-district medical consultations.Therefore,strengthening the basic construction of the digital supervision system for cross provincial and cross regional medical direct settlement,and improving the legal system for cross provincial and cross regional medical direct settle⁃ment digital supervision,have important guiding significance for the digital supervision of cross provincial and cross regional medical direct settlement in China.