利益相关者视角下职工医保门诊统筹保障模式对比研究

Comparative study on guarantee mode of employee medical insurance outpatient overall planning under the perspective of stakeholders

[目的]提出适合我国国情的职工医保门诊统筹实施路径。[方法]基于利益相关者理论,从患者和医保两个主要利益相关者角度对比门诊慢特病保障和普通门诊统筹两种主流模式。[结果]从患者角度,门慢/门特保障范围较为有限但待遇水平较高,而普门保障范围较广但待遇水平较低;从医保角度,前者对基金需求程度较小且医保管理难度小,后者则与之相反。[结论]两种保障模式对提高门诊待遇水平均有积极作用但各有优劣,各地应根据基金水平和管理能力选择适合的门诊统筹待遇保障模式。

Objective To propose implementation path of employee medical insurance outpatient overall planning that suits for the situation of China.Methods Based on the stakeholder theory,it compared two mainstream modes of guarantee for special and chronic disease and general outpatient from perspective of the two main stakeholders of patients and medical insurance.Results From the view of patients,the scope of insurance coverage for special and chronic disease outpatient is limited but with high reimbursement level,while the scope of insurance coverage for general outpatient is wider but with low reimbursement level.From the view of medical insurance,the guarantee for special and chronic disease outpatient which needs less fund and easily management,while the guarantee for general outpatient is on the contrary.Conclusions Both of the two modes have positive effects on improving the outpatient reimbursement level,but each has its own advantages and disadvantages.Local governments should choose the appropriate guarantee mode according to the fund level and management ability.