安徽省异地就医直接结算的实践探索  

Practical Exploration of Direct Settlement for Off-site Medical Treatment in Anhui Province

作　　者：张文钰 赵允伍 蒋心梅[2] 王珩[2,1] ZHANG Wenyu;ZHAO Yunwu;JIANG Xinmei;WANG Heng(School of Health Service Management,Anhui Medical University,Hefei Anhui 230032,China;不详)

机构地区：[1]安徽医科大学卫生管理学院,安徽合肥230032 [2]安徽医科大学第一附属医院,安徽合肥230022

出　　处：《卫生经济研究》2024年第8期58-60,64,共4页

基　　金：国家自然科学基金项目“DRG支付方式下的医保-医疗协同机制研究”(72374004);国家重点研发计划“主动健康和老龄化科技应对”(2020YFC2006500、2020YFC2006502)。

摘　　要：当前,安徽省医保异地就医直接结算在完善待遇政策、提升服务质量、强化信息支撑等方面取得了一定成效,但也存在医保基金不合理流失、跨省异地基金监管难度大、直接结算与手工报销存在待遇差以及跨区域医疗机构虹吸效应较大等问题。对此,建议运用大数据挖掘,深入分析医保数据,探索开展区域间协同联查合作,持续推进长三角医保一体化,建立待遇补差业务协同规范;通过优质医疗资源扩容和下沉,发挥分级诊疗作用,推动形成有序的异地就医格局,不断优化异地就医直接结算制度。At present,the direct settlement for off-site medical treatment in health insurance in Anhui Province has achieved certain results in improving treatment policies,improving service quality,and strengthening information support.However,there are also serious problems such as unreasonable loss of health insurance fund,great difficulty in supervision of cross-provincial health insurance fund,treatment difference between direct settlement and manual reimbursement,and large siphoning effect of cross-regional medical institutions.In this regard,it is recommended to use big data mining to analyze health insurance data in depth,explore inter-regional collaborative and joint investigation cooperation,continue to promote the integration of health insurance in the Yangtze River Delta,and establish collaborative norms for the treatment difference business.Through the expansion and sinking of high-quality medical resources,we can play the role of hierarchical diagnosis and treatment,promote the formation of orderly pattern of off-site medical treatment,and continuously optimize the direct settlement system for off-site medical treatment.

关 键 词：异地就医直接结算 医疗保险 分级诊疗 

分 类 号：F840.684[经济管理—保险]