我国职工医保门诊共济保障改革的进展与思考

Progress and Reflection on the Reform of Outpatient Coordinated Guarantee Mechanism of Employee Medical Insur⁃ance in China

目的:系统梳理和归纳我国各省职工医保门诊共济保障改革政策进展,为推进和完善改革提供参考。方法:采用内容分析法,在各省级政府网站收集职工医保门诊共济保障改革政策文件,从个人账户计入与使用范围、普通门诊统筹待遇、慢特病统筹待遇和零售药店统筹待遇4个方面,分析各地的主要做法和差异。结果:我国各省个人账户计入办法分为按定额计入和按比例计入,少数省份个人账户支付范围拓宽至商业医疗保险缴费;普通门诊起付线在0元至1800元,支付比例在50%至90%,封顶线在1200元至不设封顶线,待遇政策向退休人员和基层医疗机构倾斜;4省正逐步探索全省统一的门诊慢特病病种和保障待遇;8省已明确零售药店门诊统筹待遇。结论:各省职工医保普通门诊统筹待遇差异较大,少数省份已探索省级门诊慢特病待遇统一和零售药店门诊统筹,改革需注意普通门诊保障与住院保障衔接,并加强与家庭医生签约、医共体等改革的联动。

Objective:To systematically summarize the reform measures for outpatient coordinated guarantee mechanism of employee medical insurance in provinces of China,as a reference for the promotion and improvement of the reform.Methods:The content analysis method was adopted to collect policy documents related to the reform from provincial government websites.Based on four aspects,including individual account distribution and usage scope,general outpatient treatment,chronic and special illness treatment for outpatient,and retail pharmacy treatment,the main practices and differences in each province were summarized.Results:In terms of personal account contribution,some provinces adopted a fixed amount while others utilized a proportion-based approach,with a few provinces expanding the scope of personal account payment to include commercial medical insurance premiums.The general outpatient treatment deductible ranged from 0 to 1800 yuan,with a reimbursement rate between 50%and 90%,and a cap ranging from 1200 yuan to no cap,with preferential policies being extended to retirees and grassroots workers.4 provinces are gradually exploring a unified list of outpatient chronic and special illnesses and their corresponding medical treatment standards,and 8 provinces have defined retail pharmacy treatment policies.Conclusion:There are significant differences in the general outpatient treatment of employee medical insurance policy among provinces of China,and a few provinces have explored the unification of outpatient chronic disease treatment policies and developed retail pharmacy treatment policies.The reform should emphasize the connection between general outpatient and inpatient coverage,strengthen policy coordination and cooperation with the family doctor contract services and the medical community.