本文選題：山西省 + 城鎮(zhèn)職工��； 參考：《山西財(cái)經(jīng)大學(xué)》2017年碩士論文

【摘要】：我國(guó)城鎮(zhèn)職工基本醫(yī)療保險(xiǎn)制度的覆蓋率逐年提升,但是由于制度遵循屬地化管理原則,且現(xiàn)階段基本醫(yī)療保險(xiǎn)統(tǒng)籌層次較低,造成異地就醫(yī)參保人報(bào)銷困難、經(jīng)辦機(jī)構(gòu)管理不便。在面對(duì)人員流動(dòng)增多、異地就醫(yī)需求增大的情況下,異地就醫(yī)結(jié)算問題凸顯�！笆濉币�(guī)劃建議指出,要健全醫(yī)療保險(xiǎn)制度,完善異地就醫(yī)結(jié)算管理,重點(diǎn)解決異地安置的退休人員的就醫(yī)需求。職工醫(yī)療保險(xiǎn)是對(duì)參保人患病后醫(yī)療費(fèi)用損失進(jìn)行一定補(bǔ)償?shù)谋ｋU(xiǎn)。異地就醫(yī)結(jié)算是根據(jù)相關(guān)規(guī)定對(duì)醫(yī)療保險(xiǎn)參保人跨統(tǒng)籌區(qū)就醫(yī)發(fā)生的醫(yī)療費(fèi)用給予報(bào)銷結(jié)算。實(shí)現(xiàn)異地就醫(yī)直接結(jié)算,減輕參保人墊付負(fù)擔(dān)重、報(bào)銷難的問題是現(xiàn)階段異地就醫(yī)結(jié)算工作的目的。山西省在完成基本醫(yī)療保險(xiǎn)市級(jí)統(tǒng)籌的基礎(chǔ)上,選擇異地聯(lián)網(wǎng)直接結(jié)算模式,統(tǒng)一社會(huì)保障卡,搭建異地就醫(yī)系統(tǒng)平臺(tái)。到2014年底,全面實(shí)現(xiàn)省內(nèi)11個(gè)市級(jí)統(tǒng)籌地區(qū)異地就醫(yī)直接結(jié)算,實(shí)現(xiàn)全省完全意義上的“省級(jí)聯(lián)動(dòng)、互聯(lián)互通”,減輕了參保人員報(bào)銷負(fù)擔(dān),方便了經(jīng)辦機(jī)構(gòu)審核管理。截止2016年底,山西省省內(nèi)異地就醫(yī)直接結(jié)算超過32萬(wàn)人次,總費(fèi)用金額超過11億元。在取得相應(yīng)成績(jī)的基礎(chǔ)上,山西省城鎮(zhèn)職工異地就醫(yī)結(jié)算也存在經(jīng)辦機(jī)構(gòu)業(yè)務(wù)協(xié)調(diào)效率較低、系統(tǒng)平臺(tái)建設(shè)不完善、異地就醫(yī)結(jié)算發(fā)展不均衡、部分地區(qū)醫(yī)保基金風(fēng)險(xiǎn)較大、影響分級(jí)診療制度實(shí)施的一系列問題。具體表現(xiàn)在經(jīng)辦機(jī)構(gòu)專業(yè)人員少但工作復(fù)雜不易協(xié)調(diào)、系統(tǒng)兼容性差且資金不足、各地異地就醫(yī)結(jié)算運(yùn)行效果差異較大、部分地區(qū)醫(yī)�；鹜饬黠L(fēng)險(xiǎn)加大、結(jié)算便利增加大醫(yī)院就醫(yī)人數(shù)從而不利于分級(jí)診療。提高統(tǒng)籌層次、選擇異地聯(lián)網(wǎng)直接結(jié)算模式、做到“業(yè)務(wù)宣傳到位”和“技術(shù)改造全面”、堅(jiān)持“分層次推進(jìn)”原則是山西省異地就醫(yī)結(jié)算得出的啟示。山西省城鎮(zhèn)職工異地就醫(yī)結(jié)算還需要進(jìn)一步完善,主要從完善異地就醫(yī)結(jié)算管理制度、提高異地就醫(yī)結(jié)算管理效率、與分級(jí)診療制度有效銜接給出相應(yīng)建議。
[Abstract]:The coverage rate of the basic medical insurance system for urban workers in China has been increasing year by year, but because the system follows the principle of localized management and the overall level of basic medical insurance is relatively low at this stage, it is difficult for the insured to get medical treatment in different places. The management of the agency is inconvenient. In the face of increased staff flow and increased demand for medical treatment in different places, the problem of settlement of medical treatment in different places is prominent. It is pointed out in the 13th Five-Year Plan that it is necessary to improve the medical insurance system, improve the settlement management of medical treatment in different places, and focus on solving the need for medical treatment for retirees who have been resettled in different places. Worker medical treatment insurance is the insurance that carries on certain compensation to insurance of medical treatment cost loss after insurance-holder falls ill. The settlement of medical treatment in different places is to reimburse and settle the medical expenses incurred by medical insurance participants in cross-planning areas according to the relevant regulations. To realize the direct settlement of medical treatment in different places, to lighten the burden on the insured, and to make reimbursement difficult is the purpose of the settlement of medical treatment in different places at the present stage. On the basis of the basic medical insurance planning, Shanxi Province chooses the direct settlement model of different places, unifies the social security card, and sets up the system platform of medical treatment in different places. By the end of 2014, the direct settlement of medical treatment in 11 cities and regions in the province will be realized in an all-round way, and the "provincial linkage and interconnection" will be realized in the whole province, which will lighten the burden of reimbursement to the insured and facilitate the auditing and management of the agencies. By the end of 2016, more than 320000 medical visits had been made in Shanxi Province, with a total cost of more than 1.1 billion yuan. On the basis of the corresponding achievements, there are also some problems in the settlement of medical treatment for urban workers in Shanxi Province, such as the low efficiency of business coordination of agencies, the imperfect construction of system platform, the uneven development of medical settlement in different places, and the risk of medical insurance fund in some areas. A series of problems affecting the implementation of the classified diagnosis and treatment system. This is manifested in the fact that the agencies have fewer professionals but less complex and uncoordinated work, poor system compatibility and insufficient funds, greater differences in the operation results of medical settlement in different places, and increased risk of outflow of medical insurance funds in some regions. Settlement facilities increase the number of patients in large hospitals, which is not conducive to hierarchical diagnosis and treatment. To improve the overall planning level, select the direct settlement mode of different places network, achieve "business propaganda in place" and "comprehensive technical transformation", adhere to the principle of "hierarchical promotion" is the inspiration of Shanxi Province from different places of medical settlement. It is necessary to further improve the settlement of medical treatment for urban workers in Shanxi Province, mainly from perfecting the management system of medical settlement in different places, improving the efficiency of the management of medical settlement in different places, and giving corresponding suggestions to effectively link up with the system of classified diagnosis and treatment.
【學(xué)位授予單位】：山西財(cái)經(jīng)大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R197.1;F842.684

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本文編號(hào)：1892002