[1]高奇隆,朱佳英,朱立明,等.职工医保普通门诊统筹政策的省际比较研究[J].卫生经济研究,2025,42(01):43-47.
　GAO Qilong,ZHU Jiaying,ZHU Liming,et al.An Inter-provincial Comparative Study on General Outpatient Coordination Policies of Employee Health Insurance in China[J].Journal Press of Health Economics Research,2025,42(01):43-47.
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职工医保普通门诊统筹政策的省际比较研究
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卫生经济研究[ISSN:1004-7778/CN:33-1056/F]

卷:
42
期数:
2025年01期
页码:
43-47
栏目:
改革探索
出版日期:
2025-01-07

文章信息/Info

Title:
An Inter-provincial Comparative Study on General Outpatient Coordination Policies of Employee Health Insurance in China
作者:
高奇隆1; 朱佳英1; 朱立明1; 董恒进2
1.浙江省人民医院（附属人民医院），杭州医学院，浙江 杭州 310014
2.浙江大学医学院公共卫生学院卫生政策学研究中心与浙江大学医学院附属第四医院，浙江 杭州 310058
Author(s):
GAO Qilong;  ZHU Jiaying;  ZHU Liming;  DONG Hengjin
Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou Zhejiang 310014, China
关键词:
职工医保; 门诊统筹; 门诊共济; 医保待遇; 省际比较
Keywords:
employee health insurance;  outpatient coordination;  outpatient mutual-aid;  medical insurance benefits;  inter-provincial comparison
分类号:
R840.684
文献标志码:
A
摘要:
目的：梳理我国省级层面职工医保普通门诊统筹政策，为完善门诊统筹政策提供参考。方法：收集1998年12月至2024年2月省级层面发布的职工医保门诊统筹政策，从筹资机制、起付标准、报销比例、支付限额四个维度进行对比分析。结果：截至2022年，我国已形成职工医保门诊统筹政策布局，绝大多数省份基于“弱化个人账户、增强统筹基金”的思路建立和完善门诊统筹制度，设置较高的报销比例，但在起付标准和支付限额上差异较大，门诊统筹待遇可分为探索型、保守型、福利型、兼顾型、灵活型5种模式。结论：职工医保门诊统筹成为保障职工门诊费用的主要制度安排，对患者、医保、医院、医药多方产生影响；亟需做好门诊统筹与个人账户等政策的衔接，推进门诊支付改革，加强基金监管，进一步优化职工医保门诊统筹政策。
Abstract:
Objective To sort out the general out-patient coordination policies of basic health insurance for employee(BHIE) at the provincial level in China, and to provide references for further improving the out-patient coordination policies. Methods The policy documents of out-patient coordination of BHIE issued by departments of provincial administrative regions in China from December 1998 to February 2024 were collected and analyzed from four dimensions of financing mechanism, deductible line, reimbursement ratio and capping line. Results By 2022, China had formed a nationwide layout of outpatient coordination policies and the vast majority of provinces had established and improved the outpatient coordination mechanism based on the way of "weakening individual health insurance accounts and strengthening pooling funds". The provinces had set a higher reimbursement ratio, but there were major differences in the deductible line and capping line. The benefit model could be divided into five types: exploration type, conservative type, welfare type, balanced type and flexible type. Conclusion The outpatient coordination policy has become the main method to guarantee the outpatient expenses of employee, which have multiple impacts on patients, health insurance department, hospitals and medicine. There is an urgent need to ensure the connection between outpatient coordination and personal account policies, promote the reform of the outpatient payment, strengthen the fund supervision, and further optimize the policy of the outpatient coordination of employee health insurance.

参考文献/References:

[1] 王东进.与时偕行的中国医疗保障制度（上）[J].中国医疗保险，2019（08）：1-5.
[2] 王宗凡.《完善医疗保障制度与管理》[M].北京：中国言实出版社，2015：5-12.
[3] 倪沪平.实事求是考量个人账户的前世今生[J].中国医疗保险，2015（09）：23.
[4] 廖藏宜，杨峰，杨燕绥.职工医保基金的结构性失衡问题研究：基于Ａ市数据的精算分析[J]．江淮论坛，2021（04）：156-161.
[5] 王超群，李珍．中国医疗保险个人账户的制度性缺陷与改革路径[J]．华中农业大学学报（社会科学版），2019（02）：27-37.
[6] 杨松，钟艳红，彭美华，等.职工门诊统筹制度的理论依据、关键机制与潜在风险[J].卫生经济研究，2024，41（07）：36-40.
[7] 林坚.职工基本医疗保险门诊统筹研究综述[J].中国医疗保险，2014（01）：29-32.
[8] 杨芊，於梦菲，唐吉，等.四川省定向免费医学生政策的实践与探索[J].中国卫生政策研究，2018，11（12）：62-67.
[9] 房鑫，郝艳华，吴群红，等.基于Delphi法的完善全民医保制度要素设计专家意见分析[J].中国卫生经济，2016，35（02）：29-31.
[10] 李娟，王宗凡.职工医保门诊共济保障机制改革的现状分析和对策建议[J].兰州学刊，2023（01）：75-87.
[11] 侯宜坦，毛宗福.职工医保门诊共济保障政策分析与优化[J].中州学刊，2023（12）：91-95.
[12] 黄薇，朱晓丽.我国职工医保门诊共济保障政策分析及优化[J].卫生经济研究，2023，40（01）：49-52.
[13] 吴敏，时涛，韩志琰，等.山东居民医保普通门诊统筹待遇政策差异及推进省级统筹对策[J].中国农村卫生事业管理，2022，（01）：33-36.
[14] 熊先军.调整个人账户政策须系统设计[J].中国社会保障，2014（07）：86.
[15] 赵斌.个人账户需要渐进式改革[J].中国社会保障，2016（01）：79-80.
[16] 冯毅，姚岚.典型发达国家和地区门诊保障政策比较及经验启示[J].中国卫生政策研究，2016，9（07）：46-52.
[17] 曹清华，宋海伦.城镇职工医保门诊统筹的政策效应分析——基于CHARLS数据的实证检验[J].社会保障研究，2022（04）：23-32.
[18] 鲁蓓，王舒瑶，张丞，等.门诊共济保障机制下医保基金使用风险识别研究——以北京市某三甲医院为例[J].中国医疗保险，2023（06）：106-112.
[19] 傅卫，赵东辉.职工医保门诊共济保障改革与分级诊疗制度建设[J].中国医疗保险，2020（12）：17-22.
[20] 胡婉慈，杨钰婷，左根永.我国零售药店纳入门诊统筹政策省际比较研究[J].中国卫生政策研究，2023，16（10）：56-63.

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更新日期/Last Update: 2025-01-07