泰州市城乡居民医保整合实施效果分析——以泰州市某三级甲等综合医院为例  

Implementation effect of medical insurance integration for Taizhou urban and rural residents:a case study of a tertiary class A general hospital in Taizhou City

作　　者：黄秀芹[1] 周杰华[1] 孔旭辉[1] 杜佩玉 郭素萍[1] 李凌[1] 纪门 HUANG Xiu-qin;ZHOU Jie-hua;KONG Xu-hui;DU Pei-yu;GUO Su-ping;LI Ling;JI Men(Office of Medical Insurance,the People′s Hospital of Taizhou,Taizhou 225300,China)

机构地区：[1]江苏省泰州市人民医院医疗保险办公室,泰州市225300

出　　处：《广西医学》2021年第1期96-99,共4页Guangxi Medical Journal

摘　　要：目的以泰州市某三级甲等综合医院为例,探讨泰州市城乡居民医保整合的实施效果。方法收集泰州市城乡居民医保整合前后,城乡居民医保住院患者医保费用数据和泰州市某三级甲等综合医院的运行数据,评价城乡居民医保整合实施效果。结果城乡居民医保整合后,居民医保筹资标准和待遇水平进一步提高,样本医院住院人次增长显著,实际住院报销比例较整合前明显提高,但基金结付率过低,且逐年下降,由2016年97.67%下降到2019年40.35%;样本医院医保费用药占比虽下降明显,但次均费用却未见明显降低。结论城乡居民医保整合在保持适度筹资标准和保障水平的同时,应提高城乡居民医保基金的统筹层次,加强基金管理;继续推进支付方式改革,推动形成合理的医保支付标准,引导定点医疗机构规范服务行为,控制医疗费用不合理增长。Objective To investigate the implementation effect of medical insurance integration for Taizhou urban and rural residents by a case study of a tertiary class A general hospital in Taizhou City.Methods The inpatients expenses data of medical insurance of urban and rural residents as well as the data of running a tertiary class A general hospital in Taizhou City were collected before and after the implementation of medical insurance integration for Taizhou urban and rural residents,and the implementation effect of medical insurance integration for urban and rural residents was assessed.Results After the integration of medical insurance for urban and rural residents,the standards of financing for residents′medical insurance and their treatment levels were further improved,the number of hospitalized cases in the sample hospital increased significantly,the proportion of actual hospitalization reimbursement was significantly higher than that before the integration,however,the funds that were used for payment and account settlement were quite low and decreased year by year from 97.67%in 2016 to 40.35%in 2019.Although the percentage of drug expenditures to medical insurance expenses in the sample hospital decreased remarkably,the average expenditures per case did not show a notable decline.Conclusion While maintaining appropriate fundraising standards and funding level in the integration of medical insurance for urban and rural residents,the government should improve the level of coordinating medical insurance funds for urban and rural residents,enhance funds management,continue to advance payment approach reform,promote the development of reasonable medical insurance payment standards,encourage designated medical institutions to regulate their services,and control unreasonable medical expenses growth.

关 键 词：城乡居民医保 整合 泰州市 

分 类 号：R197.1[医药卫生—卫生事业管理]