| Background Since the exploration of the “Jiujiang and Zhenjiang”reform of the medical insurance system in 1995,under the system of group design by population and the management practice according to administrative divisions,cross-regional medical care has always existed.As the urbanization process accelerates,the population is aging,increased mobility of personnel,in addition,the allocation of medical and health service resources is “high in the east and low in the west”,and “urban-rural differences” are prominent.In particular,since the basic medical insurance system for employees and the medical insurance system for urban and rural residents as the main body,the universal medical insurance system has been gradually established.The problem of inter-provincial medical care has become more and more prominent.It becomes a policy issue that needs to be resolved urgently:in the current policy arrangements for inter-provincial medical care,medical insurance catalogue refers to the management of medical treatment places,cost compensation level refers to the place of participation,which made hospitalization expenses differences between direct settlement on the platform and manual reimbursement settlement is more prominent.So,to figure out the causes for this difference is very urgent and important for solving the problem and guaranteeing the fairness of the treatment of the insured.Purpose This study intends to analyze the literature,documents and implementation plans for inter-provincial medical care data sampling surveys and typical cases on the direct settlement platform for hospitalization expenses for inter-provincial medical care,to analyze the operation of the policy and the treatment of the insured.For the problem of hospitalization expenses differences,to analyze the causes,suggest improved strategies to improve,optimize and improve medical policy and management,so as to improve the fairness,efficiency,convenience and sustainability of the medical insurance system.Methods 1.literature Research Consult the literature,to collect relevant theoretical works,research results on the medical treatment system and the direct settlement management of expenses in different places at home and abroad.Collect relevant policies and regulations on inter-provincial medical treatment in China.Establish the theoretical foundation,and evaluate the design of direct settlement policies.2.Data sampling analysis(1)Data from 10,000 cases of inter-provincial direct settlement from January 2017 to April 2018 were randomly selected from the national platform.And organize and analyze,describe the current basic status.(2)A total of 1344 cases of 10,000 cases with manual settlement fees and details were analyzed for the difference in treatment between direct settlement and manual settlement.3.Typical case analysis According to the purpose of analysis,the case study of three typical cases(data from January 2017 to April 2018)was analyzed item by item,to find out the causes,and generate a fishbone diagram.Finally,for policy reasons,to make policy comparison and selection,which is combined with the supporting policies and management practices to optimize the countermeasures.Results 1.Evaluation of policy design The process of establishing the direct settlement platform follows the principles of convenient and standardized,step-by-step,orderly medical treatment,and unified management.The growth of the 4 key indicators is rapid(the number of designated medical institutions,the number of filings,the number of settlement persons,and the total settlement costs).2.Description and analysis of samples More males,the age is concentrated above 50 years old,mainly for remote referrals and placement of retirees in different places,the types of medical insurance are mainly based on basic medical insurance for urban employees.It mainly flows to tertiary hospitals in the eastern region and presents regional agglomeration: centering on Beijing,Shanghai,Guangdong,Jiangsu,Shaanxi,and Sichuan provinces.3.Cost situation of direct settlement The median total hospitalization cost was 13560.9 yuan,with a mean value of 2,6303.2 yuan;the median of the actual compensation ratio was 68.6%,with an average of 66.3%.The current policy has better solved the economic burden of the insured.4.Problem of the hospitalization expenses differences Most provinces have more cases of compensated more when direct settlement,and there are more cases in which the cost of medical insurance is high(the cost of category A is high and the cost of category B is low).It is speculated that the level of protection is higher in areas with higher economic and social levels.A small number of provinces have low direct settlement benefits and low expenses within the scope of medical insurance(lower category A fees and higher category B fees).For example,Xinjiang insured persons flow to Sichuan for medical treatment,Anhui provinces insured to Shanghai for medical treatment,and Jiangxi province insured to Beijing for medical treatment.It is speculated that some provinces have stricter management of medical insurance.,in particular,the scope of Category B is relatively narrow and the level of protection is low,so it is compensated less when directly settled.It may also be that some medical treatment items cannot be recognized as expenses within the scope of the medical insurance list when they are directly settled,so the expenses within the scope of reimbursement are reduced.The scope of the medical insurance catalog has a significant impact on the problem of the hospitalization expenses differences,but it is not absolute,but also affected by the level of insurance.For example,the catalogue B is also included in the category B catalogue,but the B-type prepayment ratios set in different provinces are different,while others set the maximum limit,so the expenses within the scope of medical insurance are different.Conclusion and Suggestions 1.Conclusion(1)There are two types of policy reasons for the hospitalization expenses differences problem : the scope of protection for medical places and participating areas is different(different medical insurance catalogues);the level of protection is different(the pre-pay ratios of Category B are different,and the price limits of consumables are different).More or less compensation is affected by the flow of the insured: when the insured person flows from a protected area with a narrow coverage and a low level of protection to a medical field with a wide coverage and a high level of protection,the direct settlement is higher;When the insured person flows from a protected area with a wide coverage and a high level of protection to a medical field with a narrow coverage and a low level of protection,the manual settlement is higher.(2)The management reasons for the hospitalization expenses differences problem include: fragmentation of medical insurance system,lack of uniform coding catalogue for charging items,and irregular management of medical personnel.2.Suggestions(1)According to the policy reasons for the hospitalization expenses differences problem,this study proposes that the national unified medical insurance reimbursement catalogue for hospitalization expenses in different provinces can be adopted,which means the national basic medical insurance catalogue is adopted.The scope of medical insurance covered by this method is moderate and the level of insurance is moderate.Therefore,the insured person’s personal burden is moderate and does not stimulate excessive medical care.(2)Supporting policies for reducing the hospitalization expenses differences: payment methods-promotion according to the type of disease;medical insurance system-improving the overall management level and gradually integrating the three basic medical insurance.(3)Proposing for optimization of management practice links for management reasons: Insured person’s medical management process optimization-clear criteria for defining the population,strengthening the record of the insured place,localized management;optimization of information transmission process-fine management of medical insurance catalogue,standardization of payment projects;optimization of fund clearing process-establishment of national accounts. |
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