| 引用本文：冯逸佳,张璐莹,李骄阳,等.协同发展视角下长三角职工医保门诊统筹政策差异分析[J].中国卫生政策研究,2025,18(4):18-24 |
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| 协同发展视角下长三角职工医保门诊统筹政策差异分析 |
| 投稿时间：2025-04-01 PDF全文浏览 HTML全文浏览 |
| 冯逸佳1,2,张璐莹1,2,李骄阳1,2,张森伟1,2,陈文1,2 |
| 1.复旦大学公共卫生学院 上海 200032 ;2.复旦大学长三角医疗保障研究中心 上海 200032 |
| 摘要:目的:梳理长三角职工医保门诊统筹政策差异,从协同发展视角提出政策建议。方法:收集2024年8月以前长三角省级和部分经济发达城市职工医保普通门诊费用统筹、门诊慢特病和零售药店纳入门诊统筹三个方面的政策进行内容分析,并选取典型案例详细介绍。结果:长三角门诊共济保障水平整体较高,个人账户支付场景向商业保险、长护险、家庭医生签约费拓展；门诊慢特病数量从上海3类门诊大病到安徽83类省级门诊慢特病不等；零售药店政策在准入条件、待遇保障等方面差异较小,电子处方快速推进,苏州积极探索零售药店总额预算管理。结论:在“差异化协同”原则下优化长三角门诊统筹保障待遇；推动门诊慢特病由“病种保障”向“费用保障”转变；加强门诊统筹零售药店管理,完善长三角异地门诊和购药费用直接结算协同监管机制。 |
| 关键词:门诊统筹 门诊共济 长三角协同发展 零售药店 门诊慢特病 |
| 基金项目:国家自然科学基金(72374049) |
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| Policy analysis on general outpatient fund pooling of employee basic medical insurance from the perspective of coordinated development of Yangtze River Delta Region |
| FENG Yi-jia1,2, ZHANG Lu-ying1,2 ,LI Jiao-yang1,2, ZHANG Sen-wei1,2, CHEN Wen1,2 |
| 1.School of Public Health, Fudan University, Shanghai 200032, China;2.Yangtze Delta Institute of Health Insurance Research, Fudan University, Shanghai 200032, China |
| Abstract:Objective:To analyze policy differences in general outpatient fund pooling of employee basic medical insurance in Yangtze River Delta Region and raise suggestions from the perspective of coordinated development. Methods:The study analyzed policy documents on general outpatients financing, outpatient chronic and special diseases, and inclusion of retail pharmacies into risk pooling at provincial level and in some economically developed cities before August, 2024. Typical cases were selected for detailed introduction. Results:General outpatient coverage of employee medical insurance in Yangtze River Delta Region is high, with individual account payment scenarios expanding to commercial health insurance, Long Term Care Insurance and family physician contracted service fees. Number of outpatient chronic and special diseases ranges from 3 to 83. Retail pharmacy policies differ less in access conditions and treatment and e-prescription is advancing rapidly. Suzhou is actively exploring total budget management of retail pharmacies. Conclusions:Outpatient fund pooling policies should be gradually promoted under the principle of “differentiated coordination”. It is necessary to transform outpatient chronic and special diseases from “disease coverage” to “cost coverage”; strengthen the management of retail pharmacies under the outpatient fund pooling scheme, and improve the coordinated regulatory mechanism for direct settlement of outpatient and medication expenses incurred in other places in the Yangtze River Delta. |
| Key words:Outpatient fund pooling Outpatient co-payment Yangtze River Delta co-development Retail pharmacy Outpatient chronic and special diseases |
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