摘要
网上自主备案是我国智慧医保领域服务创新的一大亮点,但即便流程再简化,也会增加患者的时间成本,并且备案后差异化的报销待遇和复杂的结算手续仍影响异地就医的公平和效率,如何推动医保共建共享成为老百姓关注的热点话题。基于利益相关者理论、整体智治理论,构建异地就医直接结算的整体智治逻辑框架,并对京津冀地区异地就医“视同备案”的创新实践进行分析。研究发现,若要实现“一码通行”的便捷就医模式,推动异地就医服务的“同城化”进程,将会面临医保结算效率低下、医保基金收不抵支、超级医院虹吸效应以及医保监管权利责不对称等现实难题。为应对这些挑战,可从加强平台结算、基金支配、异地监管、基层诊疗智慧化入手,推进医保基金使用更加科学安全,异地就医更加公平高效。
Online self-registration is a significant highlight of service innovation in the smart medical insurance field of China.However,even if the process has been simplified,it still increases the time cost for patients.Moreover,the differentiated reimbursement benefits and complex settlement procedures after registration also affect the fairness and efficiency of cross-regional medical treatment.How to promote the co-construction and sharing of medical insurance has become a hot topic of concern for the public.Based on the stakeholder theory and the theory of holistic smart governance,a holistic smart governance logic framework for direct settlement of crossregional medical treatment is constructed.Through the analysis of the innovative practice of“deemed registration”for cross-regional medical treatment in the Beijing-Tianjin-Hebei region,it is found that to achieve the convenient medical treatment model of“one code for all”and to promote the“urban integration”process of cross-regional medical treatment services,the following practical problems will be faced:low efficiency of medical insurance settlement,insufficient medical insurance funds,the super hospital suction effect,and the asymmetry of rights and responsibilities in medical insurance supervision.To address these challenges,efforts can be made to strengthen platform settlement,fund allocation,cross-regional supervision,and the intelligentization of primary medical treatment,to promote the more scientific and safer use of medical insurance funds and to make cross-regional medical treatment fairer and more efficient.
作者
唐丽萍
李旋
TANG Liping;LI Xuan(School of Humanities,Donghua University,Shanghai 200051,China;不详)
出处
《中国农村卫生事业管理》
2025年第10期723-729,共7页
Chinese Rural Health Service Administration
关键词
智慧医保
整体智治
医保基金
跨省结算
异地就医直接结算
免备案
Smart healthcare insurance
Holistic smart governance
Medical insurance fund
Cross-provincial settlement
Direct settlement for cross-regional medical treatment
Exemption from filing
