城乡居民医保普通门诊补偿:政策变迁与模式总结

The General Outpatient Compensation of Medical Insurance for Urban and Rural Resident:Policy Change and Model Summary

对城乡居民医保普通门诊补偿政策的总结能够为城乡居民医疗保险的一体化建设提供借鉴。通过分析各地城乡居民医保普通门诊补偿政策的演变过程,将政策变迁划分为三个阶段:家庭账户的建立及拓展阶段、由家庭账户向门诊统筹过渡阶段和门诊统筹方式主导下的多元化阶段。而当前城乡居民医保普通门诊补偿政策可划分为门诊统筹、医保统筹、"家庭账户+门诊统筹"和个人账户等4种模式。各地补偿政策普遍存在目标定位不明确、资金来源单一、保障水平低和支付方式不合理等问题,应该从推进门诊统筹、增加政府门诊补贴、合理设计报销方式并严格实行按人头付费等方面完善城乡居民医保普通门诊补偿政策。

The experience of general outpatient compensation policy could provide reterences tor the integration of medical insurance for urban and rural residents. It analyzed the evolution process of general outpatient compensation policy of the medical insurance for urban and rural residents, divided the policy change into three stages： the establishment and expansion of the new rural cooperative family accounts, the diversification of the transition from the family accounts to the outpatient pooling fund and the outpatient pooling fund. The current policy of general outpatient compensation of the medical insurance for urban and rural residents could be divided into four models： outpatient pooling fund, medical insurance pooling fund, ＂family accounts ＋ outpatient pooling fund ＂ and personal accounts. There were widespread problems in various places such as unequivocal target location, single source of funds, low level of protection and unreasonable payment methods. It should promote outpatient pooling fund, increase government outpatient subsidies, design more reasonable reimbursement and strict implementation of the head pay to perfect the general outpatient compensation poli- cy of the medical insurance urban and rural resident medical insurance.