门诊共济机制下提高职工医保个人账户使用效率探讨

Utilization improvement of individual accounts of medical insurance after the establishment of outpatient co-ordination service

据测算职工医保门诊共济保障机制实行后,每年仍然有超过6 000亿资金流入个人账户,如何转变个人账户使用方式、提升资金使用效率依然值得关注。从控费和提升个人账户资金使用效率两方面进行分析,发现设置一定免赔额能发挥个人账户控费的作用,增强个人账户归属性能降低中低风险群体不合理门诊与药品支出。建议合理设置免赔额,并增强个人账户的个人归属性。其次,考虑到我国个人账户资金存量主要积累在中低年龄群体,建议引导个人账户资金进入统筹共济和健康管理领域,利用个人账户实现家庭参保,解决部分断保和未参保的问题,引导个人账户资金投保定制型补充商业健康保险,通过商业健康保险提供健康管理服务,促进疾病的早期防控和筛查。

It is estimated that after the implementation of outpatient co-ordination service for urban workers and residents, still more than 600 billion funds flow into personal accounts every year. Thus, how to change the way to use individual accounts and to improve the efficiency of personal account fund utilization is still worthy of attention. By analyzing from medical expense control and efficiency improvement of personal account utilization, we came to the conclusions that individual accounts with higher deductibles and higher attribution could reduce the irrational outpatient and drug expenditures among the low-and middle-risk population. It is suggested to set reasonable deductibles and enhance the personal attribution of individual accounts. Furthermore, considering that the capital stock of individual accounts was mainly accumulated in middle and low age groups, it is recommended to guide individual account funds into the field of insurance co-ordination service and health management. On the one hand, individual accounts were used to implement insurance as a family unit and solve the problems of insurance interruption and non-insured participation. On the other hand, individual accounts were suggested to insure supplementary commercial health insurance, and provide health management services through commercial health insurance to promote early disease prevention, control and screening.