基于政策网络理论的黑龙江省异地就医直接结算政策执行问题诊断研究  

Research on the Problem Diagnosis of Direct Settlement of Cross-Regional Medical Treatment in Heilongjiang Province Based on the Policy Network Theory

作　　者：王海鑫 康正 郑岩 吴群红 田国梅[2] 张博锴 李远雷 张洪宇 张婷 WANG Haixin(Department of Social Medicine,School of Health Management,Harbin Medical University,Harbin,Heilongjiang,150081,China)

机构地区：[1]哈尔滨医科大学卫生管理学院社会医学教研室,黑龙江哈尔滨150081 [2]哈尔滨医科大学附属第四医院核医学科,黑龙江哈尔滨150000

出　　处：《医学与社会》2022年第9期105-109,144,共6页Medicine and Society

基　　金：国家自然科学基金资助项目,编号为72074064;首都医科大学国家医疗保障研究院开放性课题项目,编号为YB2019B05;中国博士后科学基金第11批特别资助项目,编号为2018T110319;中国博士后科学基金面上项目,编号为2019M650068;2017年度黑龙江省政府博士后资助经费项目,编号为LBH-Z17102。

摘　　要：目的:分析与评价黑龙江省异地就医直接结算政策执行问题,为拓宽异地就医直接结算政策覆盖范围,增强政策执行有效性提供参考依据。方法:运用政策网络理论分析异地就医直接结算政策执行相关主体,通过文献研究法和德尔菲法形成异地就医直接结算政策执行问题集,最后运用TOPSIS综合评价法探究影响异地就医直接结算政策执行的关键靶点问题。结果:异地就医直接结算政策执行分为政策社群、府际网络、专业网络、生产者网络及议题网络共五大行动主体,黑龙江省异地就医直接结算政策执行主体问题严重性排名前三位的分别是生产者网络,专业网络,政策社群。影响政策执行的前五位关键靶点问题分别为各级医保机构工作人员不足,不同医疗机构的信息专业人员缺少,医保基金审核方式不合理,省级与省级之间直接结算的报销目录不一致导致的待遇差问题严重和信息系统软件人员与地市医保经办之间没有合理的沟通渠道。结论:要将加强信息系统智能化建设、医保治理能力专业化建设及提升协同治理能力多元化作为优化黑龙江省异地就医直接结算政策执行的重要手段,促进异地就医直接结算政策更好地推进落实。Objective:To analyze and evaluate the policy implementation problems existing in the direct settlement of cross-regional medical treatment in Heilongjiang province,so as to provide a reference to expand the coverage of policy and enhance the effectiveness of policy implementation.Methods:The policy network theory was used to analyze the relevant subjects of the policy implementation of direct settlement of cross-regional medical treatment,and the problems set of policy implementation of direct settlement of cross-regional medical treatment was formed through the literature research method and the Delphi method.Finally,TOPSIS method was used to explore the key target issues affecting the policy implementation.Results:The policy implementation of direct settlement of cross-regional medical treatment was divided into 5 major actors,which include policy community,local government network,professional network,producer network and issue network.In Heilongjiang province,the top three major issues in the implementation of direct settlement of cross-regional medical treatment were the producer network,professional network,and policy community.In addition,the top 5 key target issues that affect policy implementation were the insufficient staff of medical insurance institutions at all levels,the lack of information personnel in different medical institutions,the unreasonable method of reviewing medical insurance funds,the inconsistency of the reimbursement catalog for direct settlement between the provincial and provincial levels and an unreasonable communication channel between the information personnel of the medical institution and the medical insurance agency.Conclusion:It is necessary to strengthen the intelligent construction of information systems,the professional construction of medical insurance governance capabilities,and improve the diversified capabilities of collaborative governance as important means to optimize the implementation of direct settlement policy,so as to promote the implementation of direct settle

关 键 词：异地就医 直接结算 政策执行 政策网络理论 

分 类 号：R197.1[医药卫生—卫生事业管理]