医保异地即时结算会否推高异地三级医院就医人次?——基于广东省肇庆市A区的分析  

Does immediate payment policy increase the number of medical treatments in tertiary hospital outside Zhaoqing city: Based on the data of health insurance in A district of Zhaoqing, Guangdong province

作　　者：钟玉英[1] 梁婷 ZHONG Yu-ying;LIANG Ting(School of Public Adiministration,South China University of Technology,Guangzhou Guangdong 510640,China)

机构地区：[1]华南理工大学公共管理学院

出　　处：《中国卫生政策研究》2019年第6期35-40,共6页Chinese Journal of Health Policy

基　　金：广州市哲学社会科学“十三五”规划2018年度课题(2018GZYB15);华南理工大学中央高校基本科研业务费专项课题(x2ggD2153020)

摘　　要：新医改以来,分级诊疗、异地就医联网结算等新政层出不穷,研究这些政策之间可能存在的交互效应,对后续医改政策设计与调整具有重要意义。广东省肇庆市于2016年实现了省内的异地联网结算。本文采集了肇庆市A区异地联网结算政策实施前(2015年)和实施后(2017年)城乡居民医保结算数据,对城乡居民异地就医人次和费用,以及前往异地三级医院住院就医人次和费用作频数统计、卡方检验和方差分析,发现异地联网即时结算政策一定程度上推高了异地三级医院的就医人次,对就医地分级诊疗造成负面影响。建议调整异地就医报销比例和报销范围,完善异地就医转诊制度,调整三级医院诊疗服务范围和服务量等。Since the new medical reform,new policies including hierarchical medical system involving grading diagnosis and treatment,immediate settlement policy for out-of-city (OOC) medical treatment and so on have been put in practice in and endless streak.It is of great significance to study the possible interaction effects between these policies for the design and adjustment of follow-up of medical reform policies.Located in Guangdong Province,Zhaoqing City realized the immediate settlement policy for OOC or remote networks' medical treatment within the province in the midst of 2016.Based on medical insurance settlement data of urban and rural residents before and after the implementation (2015 and 2017) of immediate settlement policy for OOC medical treatment in A District of Zhaoqing City,this paper analyzed statistically the number of medical treatments and expenses of urban and rural residents,as well as the number of medical treatments and expenses of tertiary remote hospitals,with statistical analysis including frequency distribution,ANOVA and chi-square test.The results found that the number of medical treatments in tertiary hospitals outside Zhaoqing City,described as remote hospitals,have been pushed up to a certain extent after the implementation of the settlement policy;which has a negative impact on the establishment of Hierarchical Medical System.It is suggested that to adjust the OOC proportion and its reimbursement scope,improve the referral system for medical treatment in different places,adjust the scope and quantity of outpatient service in those remote tertiary hospitals,and etc.

关 键 词：城乡居民医保 异地就医 分级诊疗 

分 类 号：R197[医药卫生—卫生事业管理]