天津市异地就医直接结算现状及优化策略质性研究OA

Objective To improve the level of settlement services and to ensure the safety and rational use of national medical insurance funds through a qualitative study on the current situation and optimization strate-gies of cross-provincial direct settlement of medical expenses in Tianjin.Methods The purpose sampling method was adopted.Patients eligible for direct cross-region settlement,their family members,relevant practitioners in five provinces,and national medical insurance practitioners and Tianjin medical insurance practitioners were se-lected as interviewees(n=50)for a semi-structured interview.The subject content analysis was performed in combination with Atlas.ti 8.3 software for encoding and analysis.Results At present,direct settlement of inter-provincial medical expenses in Tianjin was guaranteed by comprehensive work system,practical policies and processes,and superb information technology.However,there were still some problems:First,the filing process was complicated,and there was a lack of training;second,policies varied from place to place,making consistent management difficult;third,there was a big gap in the level of network infrastructure across different regions;fourth,there was a lack of direct and effective monitoring mechanism;fifth,the hierarchical medical service sys-tems were not coordinated.Conclusions The optimization strategies for cross-provincial direct settlement of medi-cal expenses are to change the settlement management mechanism and redefine business responsibilities.