Study On The Direct Settlement Of Medical Treatment For Basic Medical Insurance For Urban Employees In Shanxi Province

In recent years,the state has continuously promoted the deepening of the reform of the medical and health system,and attaches great importance to the settlement of medical treatment in different places.The state has proposed the need to speed up the process of direct settlement of medical expenses for long distance medical treatment.The implementation of the direct settlement method of medical insurance for long distance medical treatment has provided convenience and saved time for the vast number of long distance medical personnel.This method saves the process of reimbursing medical expenses to place of residence and from medical place.This direct settlement method fundamentally protects the vital interests of the insured.Shanxi Province responded to the national call to continuously promote the process of direct settlement of medical treatment in different places.In 2012,Shanxi Province and the ten provinces and cities across the country achieved Settlement of medical expenses in different places.In 2014,Shanxi Province achieved direct settlement of medical treatment in different places within the province.In 2017,Shanxi Province and the country's long distance medical treatment direct settlement system are networked,Shanxi Province successfully completing cross-province long distance medical settlement.However,problems occurred after Shanxi Province achieved direct settlement of medical treatment in different places,like outpatient clinics cannot be settled directly,the direct settlement rate is not high.This exacerbates the strain on medical resources.Therefore,further research on direct settlement of medical treatment in different places is particularly important.Based on a review of the literature,Shanxi's urban employee basic medical insurance for direct medical settlement in different places has gone through three stages,reimbursement period,provincial intranet settlement period,promote national network settlement period.So far,Shanxi's urban employee basic medical insurance for direct medical settlement in different places in municipal level is local medical treatment,in provincial level is direct network settlement,in interprovincial level is avariety of settlement methods.This article has carried out a quantitative analysis of the data related to the direct settlement of long distance medical treatment for the basic medical insurance of urban employees in Shanxi Province,Concluded that there are large numbers of medical visits and expenses in different places,rapid growth,regional differences,overall stable operation and rising,and the proportion of major illness insurance is relatively low.This article comprehensively discusses the current situation of the operation of the direct settlement method for long distance medical treatment for the basic medical insurance for urban employees in Shanxi Province.After field investigation and analysis of actual data,the following problems existed in the direct settlement of long distance medical treatment for basic medical insurance for urban employees in Shanxi Province,The use of direct settlement at different places for medical treatment is inefficient,the unreasonable increase in the insured's medical treatment behavior,the unfair settlement caused by the difference in treatment,and the operating agency's work efficiency is low.The main reasons are: low level of informatization,irrational allocation of medical resources,insufficient supervision,inconsistent policies,and limited level of medical insurance agencies.Based on the analysis of problems and causes,this article proposes targeted recommendations as follows.First,raise the overall level and increase investment in technology.Shanxi Province needs to improve the overall planning level,and it is necessary to continuously increase technology input.Second,strengthen information construction and strengthen cost control.After the informatization construction is completed,the data of the settlement platform will be used to control medical expenses.Third,rationally allocate medical resources and promote hierarchical diagnosis and treatment.Shanxi needs to make use of the hierarchical diagnosis and treatment system to make up for the unreasonable allocation of medical resources.Fourth,improve policy content and strengthen business convergence.Fifth,improve supervision and management capabilities.Starting from the two aspects of the recipients and providers of medical services,improve supervision capabilities,optimize handling procedures,and scientifically allocate handling staff.Promote the development and improvement of the direct settlement method for long distance medical treatment forbasic medical insurance for urban employees in Shanxi Province from multiple sources.