异地就医与本地就医费用及其结构的差异:基于医保大数据的研究  

The Differentials in Medical Expenditures and Their Structure between Cross-Region and Local Medical Treatments:Based on the Research on the Social Medical Insurance Big Data

作　　者：陈昕欣 封进[2] 钱梦岑 CHEN Xin-xin;FENG Jin;QIAN Meng-cen

机构地区：[1]东北财经大学经济学院 [2]复旦大学经济学院 [3]复旦大学公共卫生学院

出　　处：《保险研究》2024年第9期105-116,共12页Insurance Studies

基　　金：国家自然科学基金(72334002)资助。

摘　　要：对异地就医行为的监管,一直是医疗保险管理经办的薄弱环节。本文利用中国西北部某地级市居民医保的住院赔付数据,比较异地就医和本地就医医疗费用的差异,以考察异地就医中是否存在基金使用不合理带来的费用增加。在控制了疾病种类、患者个人特征和医院机构等基本特征后发现,异地就医患者的医疗费用要比本地就医高出44%;从分项费用来看,药费是造成本地和异地住院费用差异的重要因素;实施单病种付费的疾病、治疗方案差异性越小的疾病,异地和本地医疗费用差距越小。本文的结果说明,异地就医中存在“基金管理缺位”带来的医疗支出增加,可为进一步完善异地就医直接结算政策、推进异地就医支付方式改革提供政策参考。The regulatory oversight of cross-region medical treatments remains a persistent vulnerable facet within the framework of the social medical insurance management.Leveraging on the hospitalization claims data from a specific prefecture-level city in northwestern China,this study rigorously investigates differentials in medical expenditures between cross-region and local medical treatments.The primary objective is to discern whether the observed escalation in costs associated with cross-region medical treat-ment is a consequence of irrational fund utilization.After controlling basic characteristics such as disease types,patient character-istics and hospital attributes,our empirical results reveal that medical expenses incurred by cross-region patients surpass those of their locally-treated counterparts by a notable 44%.In terms of itemized expenses,medicine costs are an important contributor to the observed disparity between local and cross-region inpatient expenses.Furthermore,the gap in medical expenditure is smaller for diseases subject to single-disease payment and with smaller differences in treatment methods.Our study suggests that the dis-cerned increase in medical outlays in the context of cross-region medical treatment is attributable to a"lacuna in fund manage-ment".In terms of practical implications,this paper provides policy insights,particularly for refining the direct settlement policy for cross-region medical treatment and promoting the payment method reform for cross-region medical practices.

关 键 词：异地就医 医疗费用 医保基金 

分 类 号：F840.684[经济管理—保险]