重大疾病在城镇职工医疗保险实践操作中的界定

Defining the connotation of major diseases in the practice of basic medical insurance for urban employees

目的:从城镇职工基本医疗保险实践操作上明确界定重大疾病的内涵。方法:采用分层随机抽样法,从苏南、苏中和苏北各选择2个样本地区进行问卷调查,收集到各样本地区2011年门诊特殊疾病、门诊慢性疾病以及部分城镇职工住院费用的相关资料,使用Excel 2007对数据进行整理与分析。结果:将纳入统筹支付的15种门诊疾病界定为门诊重大疾病,将某地区灾难性卫生支出的起始点作为该地区的高额费用标准。结论:门诊重大疾病按病种界定,住院重大疾病按费用进行界定,并从省级层面乃至国家层面统一实施,可明确基本医疗保险的保障责任,同时有助于消除参保人员就医和待遇保障的不公平性。

Objective To clearly define the connotation of major diseases in the practice of basic medical insurance for urban employees. Methods Every two areas were chosen from southern, middle and northern Jiangsu with stratified random sampling method, and surveyed with questionnaire. Data of special diseases and chronic diseases in outpatient service and parts of hospitali- zation exponse in sampling areas in 2011 was collected and analyzed with software of Excel 2007. Results 15 kinds of outpatient major diseases involved in overall paying system were defined as major diseases in outpatient service. And the starting point of catastrophic health expenditure was defined as the high cost standard in this region. Conclusion It was suggested that outpatient major diseases can be defined by the kinds of diseases, and hospitalized major diseases by hospitalization costs ,which needs to be unified implemented in a province or nationwide. From which, the responsibility of basic medical insurance can be defined. And the equity of medical treatment and insurance for the insured can be ensured.