| 引用本文：黄蕊,罗力,张天天,等.区域医保目录协同路径研究：以浙江—上海为例[J].中国卫生政策研究,2025,18(10):19-23 |
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| 区域医保目录协同路径研究：以浙江—上海为例 |
| 投稿时间：2025-10-02 修订日期：2025-10-20 PDF全文浏览 HTML全文浏览 |
| 黄蕊1，罗力1,2，张天天2，毛澄2 |
| 1.复旦大学上海市重大传染病和生物安全研究院 上海 200032;2.复旦大学公共卫生学院 上海 200032 |
| 摘要:目的 在区域协调发展背景下，构建可推广的医保目录协同路径，为医保项目动态调整与基金影响测算提供方法学支撑，促进地区间目录趋同。方法 系统比对参保地与就医地医保目录，识别差异项目；基于国家医保信息业务编码，建立“就医地—国家—参保地”映射流程，实现诊疗项目标准化对应与就医人次精确统计；运用静态情景模拟法，结合真实结算数据，设计以异地就医人次为核心指标的多阈值纳入方案，并测算基金支出影响。结果 以浙江、上海为例，共识别差异项目344项，其中治疗类项目占主导。当异地就诊人次阈值由0上调至500时，纳入项目数由244降至36，新增医保支出由8.92亿元降至3.22亿元。结论 本研究构建的协同路径具有科学性与可操作性。建议各地区建立以需求为导向的目录动态调整机制，优先覆盖高频高需的治疗性项目，并完善多层次保障体系，以系统推进区域医保一体化进程。 |
| 关键词:异地就医 医保基金支出 区域协调发展 目录协同 |
| 基金项目:国家自然科学基金面上项目（72174041） |
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| Pathways to regional coordination of medical insurance catalogs： The case of Zhejiang and Shanghai |
| HUANG Rui1, LUO Li1,2, ZHANG Tian-tian2, MAO Cheng2 |
| 1.Shanghai Institute of Infectious Disease and Biosecurity， Fudan University， Shanghai 200032， China;2.School of Pubic Health， Fudan University， Shanghai 200032， China |
| Abstract:Objective Under the framework of regional coordinated development， this study aims to construct a generalizable pathway for the coordination of medical insurance catalogs， providing methodological support for dynamic adjustment and fund impact estimation， thereby promoting convergence among regional catalogs.Methods The medical insurance catalogs of the insured and treatment regions were systematically compared to identify discrepant items. Based on the National Healthcare Security Administration （NHSA） service coding system， a "treatment region-national-insured region" mapping process was established to standardize item correspondence and accurately calculate interregional service volumes. A static scenario simulation was then conducted， using the number of interregional hospitalizations as the core indicator to design multi-threshold inclusion schemes and estimate the resulting impacts on insurance fund expenditures.Results Using Zhejiang and Shanghai as a case study， 344 discrepant items were identified， with therapeutic services being predominant. When the inclusion threshold for interregional hospitalizations increased from 0 to 500 cases， the number of included items decreased from 244 to 36， while the additional insurance expenditure declined from 892 million to 322 million CNY.Conclusion The proposed coordination pathway demonstrates both scientific rigor and operational feasibility. It is recommended that regions establish a demand-oriented dynamic adjustment mechanism， prioritize the inclusion of high-frequency and high-demand therapeutic items， and improve multi-tier insurance systems to systematically advance the integration of regional medical insurance. |
| Key words:Cross-regional medical treatment Medical insurance fund expenditure Regional coordinated development Catalog coordination |
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