黑龙江省跨省异地就医直接结算医保病人特征聚类分析研究  

Cluster Analysis on the Characteristics of Patients with the Direct Settlement of Medical Insurance for Trans-provincial Medical Treatment in Heilongjiang Province

作　　者：王海鑫 康正 梁秀坤 王欢 张博锴 张洪宇 张婷 石淇 刘剑 许金鹏 吴群红 WANG Haixin;KANG Zheng;LIANG Xiukun;WANG Huan;ZHANG Bokai;ZHANG Hongyu;ZHANG Ting;SHI Qi;LIU Jian;XU Jinpeng;WU Qunhong(Department of Social Medicine,School of Health Management,Harbin Medical University,Harbin,150081,China;不详)

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]黑龙江省医疗保障服务中心,黑龙江哈尔滨150008

出　　处：《中国社会医学杂志》2023年第6期729-733,共5页Chinese Journal of Social Medicine

基　　金：国家自然科学基金项目(72074064,71573068);中国博士后科学基金项目(2019M650068);中国博士后科学基金特别资助项目(2018T110319);国家社会科学基金重点项目(19AZD013)。

摘　　要：目的通过分析跨省异地就医直接结算医保病人聚类特征,为相关部门出台精细化异地就医医保政策,加强本地医疗卫生服务设施建设提供依据。方法运用SPSS 25.0对2020年黑龙江省作为参保地的跨省异地就医直接结算数据进行描述性分析和系统聚类分析。结果黑龙江省跨省异地就医病人流向前五名的省份分别是北京(20%)、山东(18%)、辽宁(3%)、上海(8%)和河北(8%),异地就医病种以恶性肿瘤(42%)、冠心病(22%)、脑梗死(16%)、老年慢性疾病(高血压、糖尿病)(14%)为主。以就医地作为分层因素,黑龙江省跨省异地就医医保病人可被分为特征明显的五类,分别是山东省、东部地区、西部地区、东部沿海地带和其他地区。结论跨省异地典型流出省份要结合跨省异地就医的流向、病种及人群聚类特征,制定针对异地安置退休人员和异地转诊人员的精细化医保政策,加快推进跨省门诊慢性病及特殊疾病直接结算,加强本地专科及基层医疗卫生服务设施建设,促进异地就医人员合理流动。Objective By analyzing the clustering characteristics of medical insurance patients,this paper will provide a basis for strengthening the construction of local health service facilities and delicacy medical insurance policies for trans-provincial medical treatment.Methods SPSS 25.0 software was used to conduct descriptive analysis and hierarchical clustering analysis on the medical insurance data of Heilongjiang Province's direct settlement of trans-provincial medical treatment in 2020.Results In Heilongjiang Province,trans-provincial medical treatment patients mainly flew to Beijing(20%),Shandong(18%),Liaoning(3%),Shanghai(8%),Hebei(8%).The diseases of trans-provincial medical treatment patients were mainly malignant tumor(42%),coronary heart disease(22%),brain infarction(16%),diabetes and hypertension(14%).Taking the location of medical treatment as the stratification factor,trans-provincial medical treatment of Heilongjiang Province can be divided into five categories,which were Shandong,the eastern region,the western region,the eastern coastal zone and other regions.Conclusion It is necessary to combine the flow,disease,and clustering characteristics of trans-provincial medical treatment,formulate elaborate medical insurance policies for relocation of retirees and referrals,accelerate the direct settlement of chronic diseases and special diseases in inter-provincial outpatient services,and strengthen the construction of basic-level medical service facilities,which will promote the rational flow of trans-provincial medical treatment for the typical outflow provinces.

关 键 词：基本医疗保险 异地就医 直接结算 人群特征 聚类分析 

分 类 号：R197.1[医药卫生—卫生事业管理]