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[目的]对广东医科大学附属医院异地就医人次前20位病种的医疗保险异地结算现状进行分析总结。为进一步推进医保付费方式改革、公立医院职能改革、合理配置医疗资源、提升医疗效率以及顺利推进跨省异地医保即时结算提供依据。[方法]采用统计描述的方法比较不同参保患者群体(省内异地、海南异地、南宁铁路职工)异地医保结算的主要病种构成和自付比例,分析目前异地医保结算存在的问题。[结果]截至2017年7月,累计办理异地医保出院结算3399人次,其中海南职工医保、南宁铁路职工医保和省内异地医保结算分别为609人次、1012人次和1778人次;异地结算的前20位病种中,海南医保和南宁铁路职工医保主要以慢性病为主,省内异地主要以大病、重病为主,海南职工医保、南宁铁路职工医保和省内异地医保结算自付比例分别为:26.82%、12.25%和45.12%。[结论]大型公立医院医疗保险异地就医即时结算需要进一步改革,加强统筹,缩小不同参保群体的差距,充分利用公立医院医疗资源,提升医疗效率。
[Objective] To analyze and summarize the status quo of the medical insurance in different places in the top 20 medical patients in Guangdong Medical University Affiliated Hospital. This will provide the basis for further promoting the reform of medical insurance payment system, reform of public hospital functions, rational allocation of medical resources, improvement of medical efficiency and smooth promotion of inter-provincial medical insurance in different provinces. [Method] The statistical methods were used to compare the composition of major diseases and the proportion of out-of-pocket payment of medical insurance in different places among different groups of insured patients (off-site in different provinces, different places in Hainan Province and workers in Nanning Railway), and to analyze the existing problems in current medical insurance settlement in different places. [Results] As of July 2017, a total of 3399 medical insurance settlement in different places had been handled, of which 609 were medical insurance for staff and workers of Hainan and Nanning Railway, and 1078 and 1778 for medical insurance in different places within the province respectively; the top 20 in different places Among the disease types, Hainan Medicare and Nanning Railway staff mainly provided chronic diseases, mainly in serious diseases and serious diseases. Hainan Medical Insurance for Employees, Medical Insurance for Employees in Nanning Railway and Medical Insurance in Other Cities in the Province were 26.82% , 12.25% and 45.12% respectively. [Conclusion] The immediate settlement of medical insurance in large-scale public hospital needs further reform in medical treatment in different places. It needs to further improve co-ordination, narrow the gap between different groups and make full use of public hospital medical resources to enhance medical efficiency.