住院补偿政策视角下山东省推进居民基本医保省级统筹的研究  

Promoting the unified schemes on Shandong resident basic medical insurance:from a perspective of inpatient compensation policy

作　　者：时涛 韩志琰 吴敏 苏君[2] Shi Tao;Han Zhiyan;Wu Min;Su Jun(School of Healthcare Security,Shandong First Medical University&Shandong Academy of Medical Sciences,Jinan 250117,Shandong Province,China;Medical Insurance Office,The Fourth People’s Hospital of Jinan,Jinan 250000,Shandong Province,China)

机构地区：[1]山东第一医科大学(山东省医学科学院)医疗保障学院,济南250117 [2]济南市第四人民医院医保办

出　　处：《中国医疗管理科学》2022年第5期19-23,共5页Chinese Journal Of Medical Management Sciences

基　　金：山东省医疗保障局委托课题“山东省医保省级统筹可行性研究”;济南市医保局委托课题“济南市医保大数据基金监管创新项目”。

摘　　要：目的对比梳理山东省16地市居民基本医疗保险住院待遇的起付标准、支付比例、最高支付限额等政策的差异,助推医保基金省级统筹。方法对2020年山东省16地市医疗保障局发布的居民基本医疗保险的政策文本采用政策文本分析和比较分析法进行分析。结果16地市居民医保的住院起付标准、支付比例存在设置过低或过高问题,不利于控制过度消费、降低道德风险及化解疾病经济风险作用的发挥;各地住院待遇保障水平具有较大差异。结论建议基于补偿理论强化住院待遇政策顶层设计,通过费用测算合理划定住院补偿起付标准,适当拉大不同等级定点医院的支付比例差距,增加向基层的倾斜,在科学测算的基础上拉平最高支付限额,通过三医联动改革赢得待遇调整空间。Objective To compare the differences in policies such as hospitalization payment threshold,payment ratio,and maximum payment quota under resident basic medical insurance in 16 cities in Shandong Province,so as to promote the provincial coordination of medical insurance funds.Methods The policy texts of resident basic medical insurance issued by the medical security bureaus of 16 cities in Shandong Province in 2020 were analyzed by the methods of policy text analysis and comparative analysis.Results The hospitalization payment threshold and payment ratio under basic resident medical insurance in 16 prefectures and cities were set too low or too high,which did not facilitate excessive consumption control,and reduction of moral risk and economic risks for disease treatment.There were significant differences in inpatient compensation among different regions.Conclusion We suggest to strengthen the top-level design of hospitalization expenditure policy based on compensation theory,reasonably delineate the payment threshold of hospitalization compensation through cost calculation,appropriately enlarge the payment ratio gap between designated hospitals of different levels with an inclination to the community level,and even up the highest limit for insurance expenditure on the basis of scientific calculation.Through coordinated medical service,medical insurance,and pharmaceutical reforms,we will gain space for adjustment of hospitalization cost.

关 键 词：居民基本医疗保险 省级统筹 住院补偿 山东省 

分 类 号：R1-9[医药卫生—公共卫生与预防医学] F840.684[经济管理—保险]