异地就医住院费用即时结算工作的实践与反思——以北京市某三甲医院为例被引量：7

Current Situation,Problems and Countermeasures of Real-time Settlement of Medical Expenses in Different Places——Taking a Third Class Hospital in Beijing as an Example

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摘要异地就医即时结算是减轻流动人口办理医疗事务负担的重要举措。近些年,北京市积极推进异地就医住院费用即时结算工作,取得了积极成效。但在实践中也存在一些问题,主要包括:参保人对异地就医结算政策知晓率较低;医保属地化管理导致“待遇差”引发的公平性问题;医保基金监管难度加大,医院结算管理压力增加;结算平台性能不稳定,信息系统兼容性较差;参保地与就医地之间的协调机制不健全。其主要原因为:各统筹区域医保政策的碎片化;异地就医直接结算系统平台接入标准不一;优质医疗资源配置分布不均衡;缺乏全国联网、信息共享的管理平台。在未来发展中,国家需要加强政府部门、经办机构、医疗机构的合作,从信息系统、协调机制、统筹层次、管理服务等方面继续完善异地就医费用即时结算工作。 This study analyzes the implementation effect and main problems of the policy of direct settlement of medical treatment in other places,and puts forward relevant suggestions.The main problems include:the insured’s low awareness of the settlement policy of medical treatment in other places,the fairness problems caused by“poor treatment”of the localization management of medical insurance,the increased difficulty of medical insurance fund supervision,the increased pressure on hospital settlement management,the unstable performance of the settlement platform,the poor compatibility of information system,and the imperfect coordination mechanism between the insured place and the medical treatment place.The main reasons include:the fragmentation of medical insurance policies in each overall planning region,different access standards of remote medical treatment direct settlement system platform,uneven distribution of high-quality medical resources,and lack of national networking and information sharing management platform.Relevant suggestions are put forward from the government level,agency level and medical institution level.

作者龙玉其杜会征 LONG Yuqi;DU Huizheng

机构地区首都师范大学管理学院首都医科大学宣武医院医保办

出处《北华大学学报（社会科学版）》 2022年第1期103-110,154,共9页 Journal of Beihua University(Social Sciences)

基金北京市社科基金项目“北京市基本养老服务均等化现状评估与实现路径”(19SRC022)的阶段性研究成果。

关键词异地就医住院费用即时结算医保政策 real-time settlement of hospitalization expenses in different places hospital expenses instant settlement health care policy

分类号 C913.7 [经济管理] R197.1 [医药卫生—卫生事业管理]

作者简介龙玉其,首都师范大学管理学院副教授,博士,主要从事社会保障与社会政策研究(北京100089);杜会征,首都医科大学宣武医院医保办助理研究员,管理学硕士,主要从事医疗保障理论与政策研究(北京100053)。