[1]阮博宇,崔 斌,苏 岱.典型国家门诊服务和门诊药品的医保支付方式及启示[J].卫生经济研究,2026,43(03):23-28.
 RUAN Boyu,CUI Bin,SU Dai.Medical Insurance Payment Methods for Outpatient Services and Outpatient Drugs in Typical Countries and the Implications[J].Journal Press of Health Economics Research,2026,43(03):23-28.
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典型国家门诊服务和门诊药品的医保支付方式及启示

卫生经济研究[ISSN:1004-7778/CN:33-1056/F]

卷:
43
期数:
2026年03期
页码:
23-28
栏目:
医疗保障
出版日期:
2026-03-03

文章信息/Info

Title:
Medical Insurance Payment Methods for Outpatient Services and Outpatient Drugs in Typical Countries and the Implications
作者:
阮博宇1; 崔 斌2; 苏 岱1
1.首都医科大学公共卫生学院,北京 100069
2.北京大学公共卫生学院,北京 100191
Author(s):
RUAN Boyu;  CUI Bin;  SU Dai
School of Public Health, Capital Medical University, Beijing 100069, China
关键词:
门诊支付方式; 人头付费; 按病种分组; 医保支付方式改革
Keywords:
outpatient payment methods;  capitation payment;  diagnosis-related groups(DRG);  medical insurance payment reform
分类号:
R19
文献标志码:
A
摘要:
典型国家门诊服务的医保支付方式主要有“总额预算+点数计酬型”“人头付费+绩效激励型”“预算统筹+绩效分配型”及“多元整合型”,门诊药品的支付方式则呈现出“共付+目录管理”“统一补贴+定额共付”“商业主导+市场定价”等差异化路径。多数国家已建立起覆盖普通门诊与慢特病的双轨保障体系,形成了标准化路径管理、特病专项补助及绩效考核相结合的制度框架;在监管方面,呈现出集中式与多级协同并存的治理格局。我国应加强分层保障设计、提升基层服务能力、完善慢性病连续处方与特殊病支付机制,推进医保支付精细化改革与智能化监管,构建更加公平、高效与可持续的门诊保障体系。
Abstract:
Medical insurance payment methods for outpatient services in typical countries primarily include "global budgeting+point-based payment" "capitation payment+performance incentives" "budget coordination+performance-based distribution" and "multiple payment integration". Outpatient drug payment also presents differentiated paths such as "co-payment+catalog management" "unified subsidy+fixed co-payment" and "commercial dominance+market pricing". Most countries have established dual-track systems covering routine outpatient services and chronic/special diseases, forming institutional frameworks that integrate standardized pathway management, disease-specific subsidies, and performance evaluations. In terms of supervision, it presents a governance pattern of coexistence of centralized and multi-level collaboration. In China, it is necessary to strengthen the design of tiered security, improve primary service capabilities, improve the continuous prescription mechanism for chronic diseases and the payment mechanism for special diseases, and promote the refined reform of medical insurance payment and intelligent supervision, so as to build a more equitable, efficient, and sustainable outpatient security system.

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更新日期/Last Update: 2026-03-03