职工门诊统筹制度的理论依据、关键机制与潜在风险

Theoretical Basis,Key Mechanism and Potential Risks of the Employee Outpatient Coordination System

职工医保面临个人账户资金积淀与门诊需求相冲突、需方与购买方责任错位、就医格局与医疗资源配置不合理的潜在矛盾,职工门诊统筹个人账户改革通过“腾空间、调结构”,激活职工医保沉淀资金,弥补了门诊医保制度的缺位,优化了医疗资源配置。梳理门诊统筹制度改革的理论依据与潜在风险,总结门诊统筹制度的双重效应、置换效应和替代效应,对健全医疗保障体系、探索门诊支付机制和完善医保基金监管具有重要意义。

In basic medical insurance system for employees,there are some problems,such as conflicts between the accumulation of funds in individual accounts and the demand for outpatient care,mismatched responsibilities between demanders and purchasers,and potential contradictions between the medical treatment pattern and the unreasonable allocation of medical resources.The reform of employee outpatient coordination in individual account can activate the funds deposited in basic medical insurance for employees,through the process of"vacating the space and adjusting the structure",which will fill the gap in the outpatient medical insurance system and optimize the allocation of medical resources.It is necessary to sort out the theoretical basis and potential risks of the reform of the outpatient coordination system,and summarize the double,replacement and substitution effects of the outpatient coordination system,which is important for improving the medical security system,exploring outpatient payment mechanisms,and improving the supervision of medical insurance funds.