【作者】 陈烨；

【导师】 章伟；

【作者基本信息】 上海交通大学 ， 公共管理（MPA）（专业学位）， 2020， 硕士

【摘要】 长期以来,国内医疗保障实行属地化管理和医保定点管理的制度,“异地报销难”是患者就医的一大难题。我国依据2009年《中共中央国务院关于深化医药卫生体制改革的意见》要求以异地安置的退休人员为重点改进异地就医结算服务,开始了异地就医结算机制的探索,直至2017年9月底,国家异地就医结算系统全面启动,才标志着异地医保联网即时结算政策开始执行。为进一步做好该项工作,2019年两会报告上,李克强总理再次强调要“抓紧落实和完善跨省异地就医直接结算政策”。异地医保联网直接结算政策很好的满足了异地就医需求,有效缓解垫付费用、报销费用的困难,但存在诸多问题如政策知晓率低、统筹水平低、结算待遇差、信息不对称、监管压力大等仍影响着政策的执行效果。笔者在上海市某公立医院工作,掌握大量异地医保患者就诊与结算数据资料和诊疗情况,对异地医保直接结算政策与执行状况有直接体会与感受。整体性治理理论是以公民需求为导向,以协调、整合、责任为治理机制,以信息技术为手段,对治理的层级、功能以及信息系统的碎片化问题进行协调整合,提供无缝隙的整体型服务的治理理论模式。本文在整体性治理理论的指导下,采用文献研究法、实证研究法、规范研究法等对结果进行统计分析,总结当前异地医保政策执行现状与问题,分析原因制定对策。笔者首先阐述异地医保政策执行现状研究目的与意义,归纳评价国内外研究现状后,对异地医保相关概念进行界定,对整体性治理理论从理论要义、分析框架、与异地医保政策研究适用性进行分析,再对上海市公立医院异地医保、联网报销政策进行阐述。最后通过案例--上海市CH医院和异地医保问卷调查的分析,摆清数据,在此基础上梳理政策执行的现状,发现当前政策执行过程中存在的困境主要是政策知晓率低、各地政策不统一、信息不对称、备案手续复杂、监管压力大,进而分析出原因为政策重视及宣传不够、统筹水平低、缺乏统一的信息标准与平台、备案手续不够简化等,基于整体性治理理论提出以服务公民为导向加大政策宣传力度、通过自上而下的决策整合提升统筹水平、基于跨地区横向协调与整合逐步实现异地医保政策的标准化、基于全国统一数据库构建异地就医信息共享体系、通过流程再造简化异地就医的备案程序和就诊环节、构建整合的监管与支持体系等建议。本研究希望能进一步改善异地医保政策执行现状中存在的问题,优化执行路径,服务于改善政策实行效果和丰富政府公共服务理论,方便公民就医,使异地医保政策真正解决民生难题,使合情合理的异地结算问题不再成为群众的痛点。更多还原

【Abstract】 For a long time,domestic medical security has implemented localized management and designated medical insurance management system,and "difficulty in reimbursement from other places" is a major problem for patients seeking medical treatment.Basis in our country in 2009 "the central committee of the communist party of the opinions of the state council on deepening the reform of medical health system" requirements to relocated the retiree with emphasis on the improvement of different ground settlement services,started to explore different ground treatment and settlement mechanism,until the end of September 2017,national long-distance medical billing systems,to mark the different health care network instant settlement policy officially launched.In order to further improve the work,Premier Li Keqiang once again stressed the need to "promptly implement and improve the policy of direct settlement of medical expenses across provinces and cities" in the report of the two sessions in 2019.The policy of network direct settlement of medical insurance in different places well meets the demand for medical treatment in different places,and effectively alleviates the difficulties of advance payment and expense reimbursement.However,there are still many problems,such as low policy awareness rate,information asymmetry,low overall planning level,poor settlement treatment and great regulatory pressure,which still affect the implementation effect of the policy.Working in a public hospital in Shanghai,I have mastered a large number of first-hand data and understood the policies and conditions of medical insurance in different places.Holistic governance theory is a theory that focuses on the integration and coordination of organizations with the concept of citizen demandoriented governance and the realistic appeal of solving fragmented and intractable problems.Based on the theoretical basis of holistic governance,this study adopts literature research method,empirical research method,normative research method and case study method to conduct statistical analysis of the results,summarize the current implementation status and problems of medical insurance policies in other places,analyze the reasons and formulate countermeasures.This paper expounds the status quo of the research purpose and meaning,medical insurance policy in different inductive evaluation research status at home and abroad,defining the relevant concepts,on a long-distance medical treatment from a theoretical point of holistic governance theory,analysis framework,applicability and different health policy research is analyzed,and the health care and public hospital in Shanghai instant reimbursement policy.Finally through the analysis of the questionnaire and the case of long distance medical care-CH hospitals in Shanghai,set data,on the basis of analyzing the status quo of the policy implementation,found that the current difficulties mainly exist in the process of policy execution policies across low awareness,not unified,information asymmetry,put on record formalities complex,regulatory pressure is big,then analysis the reasons for the low level of policy attention and publicity,as a whole,lack of unified information standard and platform and put on record formalities simplified enough,Based on the theory of holistic governance,Suggestions are put forward,such as increasing policy publicity and expanding coverage,gradually improving the overall planning level,standardizing and unifying the information system for medical treatment in different places,simplifying the procedures for recording medical treatment in different places,and increasing financial support and supervision.This study hopes to further improve the current situation of the implementation of the medical insurance policy in different places,optimize the implementation path,serve to improve the implementation effect of the policy,enrich the theory of government public service,facilitate citizens to seek medical care,make the medical insurance policy in different places truly solve the problems of people’s livelihood,and make the reasonable settlement of different places no longer a pain point for the masses.更多还原