一、参保情况

（一）城乡居民医疗保险参保情况

2019年全年,我市城乡居民医疗保险参保人数为749631人，比去年减少18891人，同比下降2.5%。其中，在校学生115919人，占参保人数的15.5%。比去年减少4216人，下降3.5%；精准扶贫对象52635人，占参保人数的7.0%。比去年减少1263人，下降2.34%；重度残疾人员12966人，占参保人数的1.7%；低保对象13697人，占参保人数的1.8%。

（二）城镇职工医疗保险参保情况

2019年全年，我市职工医疗保险累计参保人数为177020人，比去年增加551人，增长0.003%。其中，在职人员132793人，占参保人数的75%；退休人员44227人，占参保人数的25%。

（三）生育保险参保情况

2019年全年，我市生育保险累计参保人数57526人，比去年增加3514人，增长6.5%。企业参保51721人，占参保人数的89.9%；事业单位参保5045人，占参保人数的8.7%；机关参保476人，占参保人数的0.8%；其他人员参保284人，占参保人数的0.6%。女性参加生育保险29849人，占参保人数的51.9%。

（四）工伤保险参保情况

2019年全年，我市工伤保险累计参保人数117649人，比去年增加2635人，增长2.3%。企业参保95863人，占参保人数的81.5%；事业单位参保13065人，占参保人数的11.1%；机关参保935人，占参保人数的0.8%；其他人员参保7786人，占参保人数的6.6%。

二、基金征缴情况

 （一）城乡居民医疗保险征缴情况

2019年，我市城乡居民医疗保险缴费标准220元/人，增长23%。财政补助比去年提高30元/人，同比增长7%。2019年全年，我市城乡居民医疗保险基金总收入为67678万元，比去年增加21360万元，增长46.12%。

    （二）城镇职工医疗保险征缴情况

     2019年全年，我市职工医保基金总收入为 80142万元，比去年减少3780万元，同比下降4.5%。

    （三）生育保险征缴情况

 2019年全年，我市生育保险基金收入3055万元，同比增长38.2%。

    （四）工伤保险征缴情况

 2019年全年，我市工伤保险基金收入2261万元，同比下降33.1%。

 三、基金支出情况

（一）基本医疗保险基金支出情况

1.门诊基金支出情况

2019年全年，我市享受城乡居民医疗保险门诊待遇共计1727142人次，比去年增加426431人次，同比增长33%；基金支出4283万元，比去年增加1075万元，同比增长34%。我市享受城镇职工医疗保险门诊待遇共计270744人次，比去年增加54085人次，同比增长25%；基金支出645万元，比去年增加149万元，同比增长30%。

2.重症慢性病基金支出情况

2019年全年，我市享受城乡居民医疗保险重慢病待遇共计30604人次，比去年增加5736人次，同比增长22%；基金支出2071万元，比去年增加1019万元，同比增长97%。我市享受城镇职工医疗保险重慢病待遇共计4781人次，比去年增加1984人次，同比增长71%；基金支出2077万元，比去年增加1112万元，同比增长115%。

  3.职工医保个人账户基金支出情况

2019年全年，我市职工医疗保险个人账户刷卡共计2224271人次，比去年增加75761人次，同比增长3.53%。基金支出24395万元，比去年增加1929万元，同比增长8.6%。

  4.住院基金支出情况

2019年全年，我市享受基本医疗保险住院待遇共计167034人次，比去年增加3092人次，同比增长1.89%；基金支出共计79670万元，比去年增加3565万元，同比增长4.68%。其中市内住院共计139306人次，比去年减少2028人次，同比下降1.43%；基金支出共计57591万元，比去年增加611万元，同比增长1.07%。市外住院共计27728人次，比去年增加5120人次，同比增长22.65%；基金支出共计22079万元，比去年增加2954万元，同比增长15.45%。市外住院中即时结算共计21393人次，占市外住院总人次的77.15%，比去年同期增加6409人次，增长42.77%。基金支出19653万元，比去年同期增加4461万元，增长29.36%。

5、精准扶贫基金支出情况

（1）门诊及慢性病基金支出

  2019年全年，我市精准扶贫对象享受门诊待遇共计142759人次，比去年增加28829人次，增长25.3%。医保基金支出366万元，比去年增加68万元，增长22.82%。享受门诊慢性病待遇共计13766人次，比去年增加5824人次，增长73.33%。医保基金支出2869万元，比去年增加2096万元，增长271.15%。

（2）住院基金支出 

 2019年全年，我市精准扶贫对象住院共计28161人次（含市外），比去年减少1745人次，下降5.83%。住院总费用14555万元，比去年增加74万元，增长0.51%。基本医疗支出10058万元，大病保险支出616万元，补充保险支出769万元，医疗救助支出909万元，兜底保障支出79万元，手工补偿53万元。精准扶贫对象住院报销合计12485万元，住院总费用平均报销比例为85.7%，目录内报销比例为92.5%。

（二）生育保险基金支出情况

2019年全年，我市生育保险基金待遇支出1907万元，同比增长15.4％。其中，享受生育保险待遇3626人次，同比增长3.7%。当期结余1148万元。

（三）工伤保险基金支出情况

 2019年全年，我市工伤保险基金支出2301万元，同比增长21.7%。其中，享受工伤待遇5334人次，同比下降5.8 %。当期结余-40万元，同比下降2.7%；

 四、基金运行态势分析

 （一）参保情况                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            

 2019年我市城乡居民参保人数与上年度比较下降了2.5个百分点，分析参保人数减少的原因：一是外出务工人数增加，据统计，我市2019年共采集有外出务工需求人员72920人，占全市总人口的6.7%；二是外出求学学生也是逐年增加趋势。工伤保险及生育保险参保人数增加的原因一是加强了工伤保险的政策宣传及征缴力度，二是农民工的社会保障问题纳入政府议事日程，推动了建筑业参加工伤保险的力度。生育保险参保人数增加的主要原因是二胎政策放开带来的效应。

（二）征缴情况

居民征缴收入增长的原因一是个人缴费标准由180元/人调至220元/人，二是财政补助标准由490元/人调至520元/人，三是2020年居民医保征缴收入纳入到2019年居民医疗保险收入内。

职工征缴收入减少的主要原因是2018年职工医保收入里根据市财政金库收入表补做了2017年收入8380万元。

生育保险征缴收入增长的主要原因缴费费率2018年7月由0.4%上调至0.8%以及参保人数较上年度增加了3514人。

虽然工伤保险参保人数增加了2635人，但是缴费费率下降了50%，导致基金收入有所下降。

（三）支出情况

我市享受城乡居民医疗保险门诊统筹待遇比去年同期增加426431人次，导致居民门诊统筹基金支出相应增加34%；享受职工医疗保险门诊统筹待遇比去年同期增加了270744人次，导致职工门诊统筹基金支出相应增加30%。

重慢病基金支出增长的原因一是每年都有新的重症慢性病人员增加；二是享受重慢病待遇人次增加了10517人次；三是57种新特药纳入重慢病报销，导致基金支出增加。

我市享受基本医保住院待遇基金支出比去年增加3565万元，增长的原因主要是总住院人次增加了3092人次。特别是市外住院人次较去年增加了5120人次，市外住院基金支出同比增长15.45%。

因生育保险享受待遇人次增加129人导致基金支出较去年同期有所增长。工伤定期待遇调整费率下降导致工伤基金支出相应增长。

（四）精准扶贫支出情况

根据《关于进一步调整完善全市农村贫困人口医疗保障政策的具体措施》（鄂州办发〔2019〕8号）文件规定，自2019年8月1日起，重症慢性病病种增加到24种，政策内报销比例达到80%。农村贫困人口在市域外就医，可享受城乡居民医保政策和医疗救助政策，不享受健康扶贫医保政策和医疗救助政策。

门诊基金支出增长22.82%的原因是享受待遇人次比去年增加142759。慢性病基金支出比去年增长271.15%，增长得原因一是享受待遇的人次比去年增加13766，二是57种新特药纳入重慢病报销，三是之前肾透析为手工报销，2019年之后纳入医保系统结算。 

五、下一步工作重点

（一）重视源头，狠抓扩面征缴。一是继续抓好扩面做到应保尽保。重点解决农民工、困难企业职工，外出打工人员、新生儿、少年儿童等参保工作。要深入基层、社区利用元旦及春节期间做好返乡农民工以及零星人员的参保工作，二是努力抓好基金征缴，做到应收尽收，并及时将医保基金上解到市财政专户确保扩面征缴数据准确。

    （二）加强对定点医疗机构的监管，控制就诊人次及医疗费用不合理增长

    1、门诊统筹。一是利用大数据分析对门诊人次增长过快的医疗机构进行重点监管，重点审核数据异常的村卫生室、社区卫生服务站门诊统筹相关资料，核对门诊处方和发票存根等内容，二是走访就医群众核实门诊统筹报销情况的真实性，重点查处套取医保资金、损害参保群众利益等违规违纪现象，三是要求医疗机构每月对门诊统筹报销情况进行公示，接受群众监督。 

    2、市内住院。2019年度市内住院基金情况总体运行平稳，随着智能稽查系统的上线以及持续开展打击欺诈骗保专项行动，各医疗机构挂床住院、诱导住院现象基本上得到遏制，2019年住院总人次较上年度下降了1.4分百分点，民营医疗机构住院人次下降最为明显，全市20家民营医疗机构有15家住院人次下降，个别医疗机构住院人次下降达52%，但少数乡镇卫生院住院率较上年度大幅度上升，有的乡镇卫生院住院人次与同期相比较上升了40.9%，下一步我们将对住院人次增长过快的医疗机构进行重点稽查，严厉打击挂床住院、无指征住院、降低住院标准的违规行为。

    （三）继续完善医保监管信息化的建设。2020年6月我们将对全市医疗机构上线医保智能稽查系统，并完善相关规则，充分利用大数据比对、人脸识别等技术加强对各医疗机构的监管，及时发现医疗服务监管漏洞保障医保基金安全运行。

    （四）开展打击欺诈骗取医保基金专项行动，严厉打击医保违法违规现象。2020年将继续开展打击欺诈骗取医保基金专项行动，决定在5月开展以“打击欺诈骗保 维护基金安全”为主题的宣传月活动，重点宣传打击欺诈、骗取医保基金行为及法律法规，并通报医保违规典型案例，形成高压态势，达到宣传法规，强化管理，净化环境，震慑犯罪的目的促进全市医疗机构守法经营、合法经营，确保基金安全运行。

附件1：2019年市内医疗机构住院情况对比表

                               2020年4月30日

 鄂州市医疗保障局