文献类型：期刊文献

中文题名：职工医保门诊共济制度对糖尿病患者医保费用的影响研究

英文题名：A Study on the Impact of the Employee Medical Insurance Outpatient Mutual Assistance System on Medical Insurance Costs for Patients with Diabetes Mellitus

作者：陈蒙恩[1];张晓溪[1,2];袁有树[1];王焱[1];丛天珍[3];侯浩佳[3];杨敬宇[3];王志伟[4]

第一作者：陈蒙恩

机构：[1]北京中医药大学管理学院,北京102400;[2]中国中医科学院广安门医院,北京100053;[3]甘肃中医药大学卫生管理学院,甘肃兰州730000;[4]北京中医药大学国家中医药发展与战略研究院,北京102400

第一机构：北京中医药大学管理学院,北京102400

年份：2025

卷号：44

期号：10

起止页码：38

中文期刊名：中国卫生经济

外文期刊名：Chinese Health Economics

收录：;北大核心:【北大核心2023】；

基金：国家中医药管理局项目(ZYZB-2023-435、GZYFJS-2022-045)。

语种：中文

中文关键词：职工医保门诊共济;糖尿病;医保费用

外文关键词：employee medical insurance outpatient mutual assistance;diabetes mellitus;medical insurance costs

摘要：目的:分析职工医保门诊共济制度对糖尿病患者门诊医保费用的影响,为优化门诊保障制度和慢性病管理提供参考。方法:获取兰州市2022-2023年城镇职工糖尿病门诊费用结算数据,运用单因素分析与间断时间序列模型对职工医保门诊共济改革前后相关医保费用指标进行比较。结果:共纳入765 730条糖尿病患者门诊信息,男性占62.67%。职工医保门诊共济改革后患者次均统筹基金支出、次均个人支付金额、次均个人账户支出、次均符合范围金额、次均基金支付总额、次均基本医疗统筹支付比例的整体水平降低(P<0.05),且次均统筹基金支出、次均个人账户支出、次均现金支付金额、次均符合范围金额、次均基金支付总额、次均基本医疗统筹支付比例均呈现明显下降趋势(P<0.05),而次均全自费金额改革前后变化不明显(P>0.05)。结论:职工医保门诊共济改革缓解了糖尿病患者疾病经济负担,提升了医保基金使用效率,但降低了基本医疗统筹支付比例。建议持续完善职工门诊医保支付制度,加强医疗费用和服务质量监管,平衡患者利益与基金压力,以提升慢性病门诊待遇。
Objective:It aims to examine the effects of the employee medical insurance outpatient mutual assistance on medical insurance costs for patients with diabetes mellitus,offering insights for optimizing outpatient insurance policies and chronic disease management strategies.Methods:Outpatient cost settlement data of urban employees with diabetes mellitus in Lanzhou from 2022 to 2023 was collected.Univariate analysis and interrupted time-series models were used to compare relevant medical insurance cost indicators before and after the reform.Results:The inpatient data of 765730 diabetes mellitus patients were included in the study,and male patients account for 62.67%.After the reform,average per-visit pooling fund expenditure,average per-visit individual payment expenditures,average per-visit personal account expenditure,average per-visit eligible expense amount,average per-visit total fund payment,and the average per-visit proportion of basic medical pooling payments were decreased(P<0.05).Moreover,average per-visit pooling fund expenditure,average per-visit individual account expenditure,average per-visit cash payment,average per-visit eligible expense amount,average per-visit total fund payment,and the average per-visit proportion of basic medical pooling payments showed a notable declining trend post-reform(P<0.05).In contrast,the per-visit fully out-of-pocket expenditure exhibited no significant change before and after the reform(P>0.05).Conclusion:The reform of the employee medical insurance outpatient mutual assistance system has alleviated the economic burden of disease for diabetic patients and improved the efficiency of medical insurance fund utilization,but it reduced the proportion of basic medical pooling payments.It is recommended to continuously refine the outpatient medical insurance payment system,strengthen supervision of medical expenses and service quality,and balance patient benefits with fund pressure to enhance chronic disease outpatient benefits.