2023 年第 1 期 第 18 卷

跨省异地就医门诊直接结算现状分析与解决方案探究

Analysis of the current situation and exploration of solutions of direct settlement of outpatient services in cross-province medical treatment

作者：王成思焦卫平

英文作者：Wang Chengsi Jiao Weiping

单位：首都医科大学宣武医院医疗保险管理办公室，北京100053

英文单位：Medical Insurance Management Office Xuanwu Hospital Capital Medical University Beijing 100053 China

关键词：异地就医；直接结算；医疗保险

英文关键词：Off-sitemedicaltreatment;Directsettlement;Medicalinsurance

• 摘要：

• 目的  分析跨省异地就医门诊直接结算患者数据，结合国家基本医疗保险管理工作中遇到的问题，提出相应的政策建议。方法提取北京某三甲医院2020年11月3日接入国家异地就医结算系统至2021年12月的门诊结算数据。通过以时间为维度的系统随机抽样，筛查分析异地就医门诊直接结算现状。包括直接结算总体情况、不同统筹地区直接结算情况、门诊费用结构、跨省异地就医直接结算人群年龄构成及问题咨询情况。结果  2021年12月共完成1 587笔异地持卡就医挂号费用实时结算工作，相较于同年1月份的114笔，同比增长了1 292.1%，月均增长率达到了34.8%。抽样范围内共涉及7 118笔跨省异地就医国家基本医疗保险直接结算，按统筹地区分析，医院共接收了来自27个不同省份的患者，排名前5的共4 733人次，包括河北省、天津市等，直接结算涉及普通门诊交易共5 045笔、急诊交易共2 073笔。7 118笔跨省异地就医直接结算涉及患者3 108例，年龄>55岁的占比达到了68.9%（2 142例）。异地门诊持卡就医相关问题的咨询比例远高于住院持卡就医咨询。结论  跨省异地就医门诊直接结算业务和范围逐步扩大，全面推进需要进一步完善信息化建设，多角度加强异地就医政策宣传工作，加强跨部门及统筹地区协作交流。

• Objective  To analyze direct settlement of outpatient services data in cross-province medical treatment and to put forward corresponding policy suggestions based on problems encountered in the management of national basic medical insurance. Methods  The outpatient settlement data of a class 3 hospital in Beijing from November 3, 2020 to December 2021 were collected through the national off-site medical treatment settlement system. Through systematic random sampling based on time dimension, the current situation of direct settlement of outpatient services in different places was screened and analyzed, including the general situation of direct settlement, the situation of direct settlement in different planning areas, the structure of outpatient expenses, the age composition of patients with direct settlement of cross-province medical treatment and the situation of problem consultation. Results  In December 2021, a total of 1 587 off-site medical card registration fees were settled in real time, with an increase of 1 292.1% compared with 114 in January 2021 and an average monthly growth rate of 34.8%. There were 7 118 off-site national basic medical insurance direct settlements for medical treatment within the sampling range. Analysis by planning areas, patients admitted to the hospital came from 27 different provinces, and the top 5 areas had 4 733 person times, including Hebei Province, Tianjin and so on. The direct settlement involved 5 045 general outpatient transactions and 2 073 emergency transactions. There were 3 108 patients involved in 7 118 cases of direct settlement for cross-province medical treatment, and the proportion of those aged >55 years reached 68.9%(2 142 patients). The proportion of consultation on issues related to off-site card access of outpatient was much higher than that of inpatient. Conclusion  The business and scope of direct settlement of outpatient services in cross-province medical treatment expand gradually, and its comprehensive promotion needs to further improve the information construction, to strengthen the policy publicity from multiple perspectives, and to enhance cooperation and communication of cross department and planning areas.