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The author:(作者)qqpublished in(发表于) 2013/11/23 17:22:04 Medicare offsite claims little trouble， national network of settlement is difficult
With the increase of floating population, offsite have received more and more attention to the issue of Medicare reimbursement. Families especially those suffering from serious illness, chronic disease, offsite reimbursement of health care has become a broken heart. Recently, the CPC Central Committee on several major issues of comprehensive reform decision made, "settled in fully integrating farmers into urban social security system in town", "the perfect social insurance relationship transfer and renewal policy". Organization of the work in accordance with the health care reform, this year in some provinces have started to pilot the inter-provincial offsite medical clearing facility.
Why so tangled hearts offsite health care reimbursement? What is to keep health insurance in place? Achieving national interoperability still has a long way to go? Journalists and research.
To a foreign doctor, claims little trouble
China's floating population of nearly 300 million, while non-insured medical reimbursement level differences, or simply not reported
Ever since over a year ago found daughter with cerebral palsy, in Shenzhen, Guangdong Province kuen do express services, began with the kids every day to do the rehabilitation. High cost of rehabilitation, to spend tens of thousands of dollars each month. Kuen in Shaoguan, Guangdong province's rural areas, are part of new-style rural cooperative, so she went home to her to pay the costs of participating, sent medical documents to back home each month aunt aunt make claims on their behalf. Claims not much, at most, only 20%, waiting time is very long. "If Shenzhen Shenzhen claims it would be nice to see a doctor. ”
Jiangsu Xuzhou in Grandpa suffering from uremia, because the county can't do dialysis, he follows his son living in Beijing, and prescribes a drug to hospitals on a regular basis, review. Spent seven thousand or eight thousand Yuan a month, his wife, tends to lay up to twenty thousand or thirty thousand Yuan to send money home. In Uncle are part of urban residents on health care, according to the rules, leaving the County doctor belongs to register for medical treatment, while in the big cities of Beijing, is across the province to register for medical treatment, only hospital reimbursement. In Uncle waiting for a reimbursement back home can play back, but often have to wait for about half a year, to get some 20% expense.
As the floating population increases, more and more people have similar experiences. Statistics show that floating population in China has reached nearly 300 million, these include migrant workers and their children, elderly people living with their children or to a foreign pension, there are many who treat people in uncle had to go to the big city.
Today, the new rural cooperative medical care, basic medical insurance for urban residents, basic medical insurance for urban workers basic medical insurance system for the three, has covered more than 95% of urban and rural residents, up to 1.3 billion. Compared to 10 years ago, the concept can claim to see a doctor, have been involved.
But people notice, insurance and the participants to see the doctor, handy expense ratio is relatively high. And non-insured, even closer to home in the County, city, reimbursement levels vary, even the doctor in the clinic cannot be reimbursed, on health care won't be using it. Many young migrant workers, to see a doctor or go to the big city of participants who simply are not reported, usually to see a doctor as little. For many families with major diseases, chronic diseases, Medicare reimbursement issues in different places has become a broken heart.
Treatment of regional disparity to be the biggest obstacle
Enter as much of the population in developed areas, high levels of health care treatment, fearing that immigrants raises funds for reimbursement on the ground risk
Why different reimbursement levels so different? When do as the locals do so much?
Tongji Medical College, Huazhong University of Professor Yao Lan explained that Medicare imposed territorial management and regional institution-building in terms of groups, rural/urban area, and urban workers ' medical insurance introduction combines social pool and personal accounts of financing methods, residents ' medical insurance and new rural cooperative medical financing of local financial benefits and personal contributions. Medicare, ncms levels commensurate with the level of local social development, Central, provincial and municipal finance on insurance, benefits the participants who, in General, means much more developed regions make up some, less of the Midwest. Different geographical different, means different, causing around medical security levels vary considerably. Based on premium income, set their own list of claims, capping pay line, line and proportion of the reimbursement classification.
Residents of workers ' health insurance, health insurance in order to coordinate efforts at the municipal level, ncms in most parts of the County are planning regional, leaving co-ordinating City doctor, issues related to offsite health care claims.
"If all of off-site medical treatment costs reimbursed by the inflow, even developed areas can hardly afford. So, every region, every insurance through careful calculation, avoid the risk of cost overruns, guarantee funds are running well. "Yao Lan said.
Executive Ma Jin, President of Shanghai Jiao Tong University School of public health, said: "the wide differences and imbalances between regions, such as the level of economic development, levels of health, diseases, cause movements of health care difficulties. Taking Shanghai for example, Shanghai's higher funding levels, lower levels of foreign financing, relatively speaking, people abroad for medical treatment back to Shanghai-Shanghai claims it is easy, but to outsiders is the opposite. ”
Research Centre Director Zheng Gongcheng of Renmin University of China's social security considered offsite enable offsite settlement lies at the heart of Medicare and gradual realization of medical insurance, medical care and treatment. The current imbalance between urban and rural economic development, a time still not eliminate the differences of the three types of health care treatment and co-ordination between regional gap. "Unrealized uniform universal health care system, the need to explore the improvement of the basic medical insurance system insurance relationship transfer and renewal measures to accommodate population movements and workers ' professional identity conversion. ”
Looking forward to the national network "schedule"
Roaming in some provinces have completed the province, introducing settlement network in regional differences between the big cities became the biggest challenge
In September this year, laian County in Anhui Province, 70, half Tower residents of Chiang's duties, due to risk of coronary heart disease came to county-level city in tianchang city people's Hospital, not far from home. Due to the experiences of new rural cooperative medical offsite instant knot settlement agreements were signed, Jiang Shouli pay only co-payments of 14,000 yuan, and prior to that, he needs a full advance medical total cost of 37843.08 Yuan.
Tianchang introduced new rural cooperative medical management Center Director Zhu Zongzhi, tianchang city and neighbouring counties to register not only settled on a real-time basis, and also close to 3 hospitals in Nanjing city, Jiangsu Province signed a settlement agreement, this 3 hospitals agreements, according to tianchang reimbursement list, cost requirements for reimbursement.
From the departments concerned, according to new farm 90% County (city, district), as well as workers and urban residents healthcare in 8 provinces (cities) has been achieved within the domain of the province to register at the doctor settled on a real-time basis. In respect of inter-provincial offsite medical clearing now ncms are Unicom, Beijing, Inner Mongolia, Jilin and other 9 platforms and 29 large medical institutions at the provincial level.
Workers and urban residents ' health care 4 municipalities and Hainan, Tibet has adopted the provincial co-ordinating, achieving regional unity and the immediate benefits of total settlement. 4 municipalities and 4 provinces of Fujian, Hainan, Yunnan and Xinjiang set up provincial medical insurance information management system to achieve network settled on a real-time basis within the province; another 15 provinces of informatization platform is under construction. In "Yangtze River Delta", "Pearl River Delta" regions through regional networking, and point to point, such as different forms of settlement, accessible and timely reimbursement of medical expenses.
Remote real time service in these provinces, is generally co-ordinating service levels in the region, development of information clearing platform and sign the settlement agreement and off-site in a similar form of intermediary services for off-site settlement. Like Shanghai, networking, delegate claims, claims for reimbursement 3 modes, and Zhejiang and Jiangsu provinces to enable offsite in real time.
"Twelve-Five" healthcare plan made it clear that by 2015 all planning regional and medical expenses in the province to register in real time. Starting this year in some provinces to explore the interprovincial long distance settlement trial. According to the current progress, offsite health care reimbursement has taken to be straightened out.
However, the national net settlement is difficult.
Ma Jin believes that regional differences in Medicare settlement in big city is a big challenge. Linkage only in relatively close personnel exchanges between, different insurance up to a certain size where pilot implementation. He suggested that the guidelines from the national level, from the top level design, exploring the clear cross-provincial and municipal health-care network settlement policies, operate the system of management, technical support and funding conditions, build capacity and expansion of the Medicare settlement trading platform, and ultimately settled off-site treatment nationwide health care network.
Zheng Gongcheng stressed, should as soon as possible to new rural cooperative medical insurance of urban residents and unification for unification of urban and rural residents in medical insurance, conditions are right then and the unification of basic medical insurance for the same universal health care. At the same time, improve basic health and manpower levels, the basic realization of provincial-level co-ordination, both improving the equity of health care needs, differential problem solving offsite health care, but also important condition for improving medical insurance relationship transfer and renewal mechanism.
Yao Lan we recommend, can be divided into 3 steps national network as soon as possible. "First, as far as possible people in the province for medical treatment and, secondly, concentration and massive outflow of personnel around hospital signed an agreement to settle; and, finally, for mobile personnel scattered, bridging the coverage gap, progress towards national coverage, to enable offsite health care services. "She thinks, you can start from the remote settlement within the province, gradually and neighbouring provinces to forge agreements, and finally form a national network.
(Edit: SN095)November 22, 2013 People's daily online-people's daily(医保异地报销又少又麻烦 全国联网结算尚有难度|异地|医保|报销_新闻资讯
随着流动人口增多，异地医保报销的问题越来越受到人们关注。特别是那些患大病、慢性病的家庭，在异地报销医保已成为一块心病。近日，《中共中央关于全面深化改革若干重大问题的决定》提出，“把进城落户农民完全纳入城镇社会保障体系”，“完善社会保险关系转移接续政策”。按照医改工作安排，今年起在部分省份开始试点跨省异地就医即时结算机制。
异地医保报销为何那么纠结人心？是什么把医保困在原地？实现全国互联互通还有多长的路要走？记者进行了调研。
■到外地看病，报销又少又麻烦
我国流动人口近3亿，在非参保地就医时，报销水平差异大，甚至根本报不了
自从一年多前发现女儿脑瘫，在广东深圳市做快递服务的阿娟，开始每天带孩子去做康复。做康复的费用很高，每个月要花费上万元钱。阿娟家在广东韶关的农村，参加的是新农合，于是，她特意回家给女儿也缴上参合的费用，每个月把看病单据寄给老家的舅妈，让舅妈代为报销。每次报销不多，顶多只有20%，等待的时间也很长。“要是能在深圳看病深圳报销就好了。”
江苏徐州的于大爷身患尿毒症，由于县城不能做透析，他跟随儿子在北京居住，并定期到医院开药、复查。每个月花费七八千元，他老伴往往攒到两三万元再寄回老家。于大爷参加的是城镇居民医保，按照规定，离开县城看病属于异地就医，而到北京这样的大城市，属于跨省异地就医，只有住院才能报销。于大爷天天盼着老家报销款能打回来，可是往往要等待半年左右，才能拿到约20%的报销费用。
随着流动人口的增加，有类似遭遇的人越来越多。统计数据显示，我国流动人口已达到近3亿，这些人包括外出打工的农民工及其子女、随子女居住或到外地养老的老人，还有不少跟于大爷一样只能去大城市治病的人。
如今，新型农村合作医疗、城镇居民基本医疗保险、城镇职工基本医疗保险三项基本医疗保险制度，已覆盖了我国95%以上的城乡居民，达到13亿。相比10年前，看病能报销的概念，已经深入人心。
但人们渐渐发现，在参保、参合地看病，很方便，报销比例也比较高。而到非参保地，即使是邻近的县城、地市，报销水平差别很大，甚至在门诊看病无法报销，医保根本用不上。很多年轻的农民工，或是到大城市看病的参合人，干脆都不报了，平时能不看病就不看。而对于很多患大病、慢性病的家庭来说，在异地的医保报销问题已成为一块心病。
■地区间待遇悬殊成最大障碍
人口输入地多为发达地区，医保待遇水平高，担心外来人口在当地报销会引发资金风险
为什么不同地方的报销水平差别那么大？什么时候才能像当地人一样报那么多？
华中科技大学同济医学院教授姚岚解释，我国医保实行属地管理，同时按人群、城乡、分区域建立制度，城镇职工医保实行社会统筹和个人账户相结合的筹资方法，居民医保和新农合实行地方财政补助与个人缴费的筹资方法。医保、新农合水平与当地社会发展水平相适应，中央、各省市财政对参保、参合人进行补助，一般来说，财力较发达地区补得多一些，中西部地区较少。身份不同，地域不同，财力不同，造成各地医疗保障水平差别较大。各地根据保费收入情况，确定各自的报销目录、起付线、封顶线以及分级分类的报销比例。
职工医保、居民医保以市级为统筹区域，大部分地区的新农合以县为统筹区域，离开统筹地市就医，就涉及异地医保的报销问题。
“如果异地就医费用全部由流入地报销，即使是发达地区也难以承受。所以每个地区、每个险种都要通过周密测算，避免超支风险，保证基金运行良好。”姚岚说。
上海交通大学公共卫生学院执行院长马进说：“地区间存在的巨大差异及不平衡，例如经济发展水平、医疗水平、疾病谱等，造成医保流动困难。以上海为例，上海的筹资水平较高，外地筹资水平较低，相对而言，上海人到外地就医回沪报销就容易，但外地人则相反。”
中国人民大学中国社会保障研究中心主任郑功成认为，异地医保的核心问题是实现异地结算，再逐步实现参保地、就医地待遇一致。当前我国城乡经济发展不平衡，一时间还没法消除三类医保待遇的差别，并统筹区域之间的差距。“在未实现一元化全民医疗保险制度前，需要探索完善基本医疗保险制度间医保关系转移接续办法，以适应人口流动和劳动者职业身份的转换。”
■期待全国联网有“时间表”
一些省份已实现省内漫游，在地区差异大的城市间实行结算联网成为最大挑战
今年9月，安徽来安县半塔镇70岁居民蒋守礼，因患冠心病来到离家不远的县级市天长市人民医院看病。由于该院与来安县新农合签订了异地即时结报结算协议，蒋守礼只需交纳个人自付部分14000元，而在这之前，他需要先行全额垫付医疗总费用37843.08元。
据天长市新农合管理中心主任朱宗智介绍，天长市不仅和相邻的县区开展异地即时结算，也和紧邻的江苏南京市3家医院签订了即时结算的协议，这3家医院受协议监管，按照天长市的报销目录、次均费用等规定进行报销。
来自有关部门数据显示，新农合90%的县(市、区)，以及职工和城镇居民医保在8个省(市)已经实现了省域内的异地就医即时结算。在跨省异地就医结算方面，目前新农合已联通北京、内蒙古、吉林等9个省级平台和29所大型医疗机构。
职工和城镇居民医保在4个直辖市和海南、西藏采取了省级统筹，实现了统筹区域内参保人员的待遇统一和即时结算。4个直辖市和福建、海南、云南、新疆4省份建立了省级医疗保险信息管理系统，实现省内联网即时结算；另有15个省份的信息化平台正在建设中。在“长三角”、“珠三角”等地区通过区域联网、点对点结算等不同形式，方便群众及时报销医药费用。
这些省份实行的异地即时结算服务，一般来说是先统筹本地区服务层次，再开发信息结算平台，然后和异地签订结算协议，以类似中介服务形式进行异地结算。比如上海，有代为报销、委托报销、联网报销3种模式，和浙江、江苏多地市实现异地即时结算。
“十二五”医改规划明确提出，到2015年全面实现统筹区域内和省内医疗费用异地即时结算。今年开始在部分省份探索跨省异地结算试点。按照当前各地的进度，异地医保报销问题已初步有了眉目。
不过，全国联网结算尚有难度。
马进认为，要在地区差异巨大的城市间实行医保结算是一个大挑战。联动只能在人员来往比较密切、异地参保人数达到一定规模的地方间试点推行。他提出，应从国家层面予以指导规范，从顶层设计着手，探索明确跨省市医保联网结算必备的制度政策、经办管理、技术支撑和资金投入等条件，搭建具有可容性和扩充性的医保结算交易平台，最终实现全国范围的医保异地就医联网结算。
郑功成强调，应尽快将城镇居民医疗保险与新农合并轨为统一的城乡居民医疗保险，条件成熟后再与职工基本医疗保险并轨为一元化的全民医疗保险。同时，提高基本医保的统筹层次，基本实现省级统筹，这既是提高医保公平性的需要，解决异地医保的差别性问题，更是完善医保关系转移接续机制的重要条件。
姚岚则建议，可以分3步来尽快实现全国联网。“首先，尽可能引导人们在省内就医；其次，各地和大量流出人员集中地医院签订协议，进行结算；最后，对于零散的流动人员，要缩小各地保障水平差距，逐步实现全国一样的保障水平，才能实现异地医保服务。”她认为，可以先从省内异地结算做起，逐步和邻近省份形成协议，最后形成全国联网。
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