我国基本医保门诊慢特病政策分析——基于内容分析法

Policy analysis of basic health insurance chronic disease and special critical diseases security in China:Based on content analysis

目的:从保障病种、保障模式和患者认定三个方面回溯全国31个省、自治区、直辖市基本医疗保险门诊慢特病政策。方法:系统收集与梳理各地区城镇职工和城乡居民基本医保门诊慢特病相关政策文件,基于内容分析法提炼各地门诊慢特病病种的共性特点,总结保障模式,分析患者认定流程等。结果:各地纳入保障范围较多的疾病可总结为重度精神障碍、疾病负担较重的传染病、恶性肿瘤、器官移植术后治疗、神经系统疾病、需要长期治疗的血液病、慢性心脑血管疾病等11个病种大类。各地门诊慢特病保障病种因统计口径不同导致数量差异大,且缺乏认定的规范标准。结论:我国基本医保门诊慢特病政策仍处于探索改革创新阶段,尚缺乏国家顶层设计,各省份门诊慢特病政策共性和差异性并存。建议:(1)加强顶层设计,探索中央到地方"由粗到细"的病种目录;(2)引入卫生技术评估和医保精算,建立病种准入和调整机制;(3)确定公平合理的慢特病保障模式和病种保障限额;(4)科学制定慢特病认定标准,规范患者资格认证。

Objective:To review the outpatient policy for chronic and special diseases in the basic medical insurance of 31 provinces,municipalities and autonomous regions in China from the following three aspects:insured disease types,insurance model and patient identification.Methods:This work systemically collected and organized the relevant outpatient policy documents for chronic and special critical diseases in the basic medical insurance of urban employees and residents from all studied regions.Based on the content analysis method,this work summarized the common features of and the insurance models for chronic and special critical diseases in these regions’clinics,and analyzed the defects in the current patient identification procedure.Results:The diseases commonly covered by the insurance of different regions could be summarized into 11 categories including severe mental disorders,infectious diseases with a relatively heavy disease burden,malignant tumor treatment,treatment after organ transplantation,neurological diseases,hematological diseases that require long-term treatment and chronic cardiovascular and cerebrovascular diseases.Due to differences in statistical calibers among different regions,the number of types of insured chronic and special critical diseases in various regions varied greatly,and there was a lack of normative standards for identification of patients with chronic and special critical diseases.Conclusions:The outpatient policy for chronic and special critical diseases in China’s basic medical insurance is still in the stage of exploration,reform and innovation at the provincial and city levels,which is in lack of a national top-level design.Commonalities and differences both exist in the outpatient policy of different provinces for chronic and special critical diseases.We suggested that the government should(1)strengthen the top-level design and explore the establishment of a central-to-local“coarse-to-fine”disease type catalog;(2)bring in the health technology assessment and medical insurance actuarial science,and establish a disease inclusion and adjustment mechanism;(3)develop a fair and reasonable insurance model and disease type-based reimbursement limit rules for chronic and special critical diseases;(4)establish identification standards for chronic and special critical diseases in a scientific manner,and standardize patient qualification identification procedure.