文献类型：期刊文献

中文题名：职工医保门诊共济制度对高血压患者医保费用影响的实证研究

英文题名：An Empirical Study on the Impact of Outpatient Mutual Assistance System of Employee Medical Insuranceon Medical Insurance Expenditures for Patients with Hypertension

作者：陈蒙恩[1,2,3];夏士霁[2];王昱涵[2];郁菁[2];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]北京中医药大学中医学院,北京102400;[2]北京中医药大学管理学院,北京102400;[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：北京中医药大学中医学院,北京102400

年份：2025

卷号：42

期号：7

起止页码：46

中文期刊名：卫生经济研究

收录：;北大核心:【北大核心2023】；

基金：国家中医药管理局项目“中医医疗服务质量监测评估指标信息标准研究”(GZY-FJS-2022-045);国家中医药管理局项目“已开展中医药DRG/DIP支付地区的操作方案梳理总结、实施前后评估、补偿模式研究”(ZYZB-2023-435)。

语种：中文

中文关键词：职工医保门诊共济;高血压;医保费用;中断时间序列分析

外文关键词：employee medical insurance outpatient mutual assistance;hypertension;medical insurance expenditures;interrupted time-series analysis

摘要：目的:分析职工医保门诊共济制度对高血压患者门诊医保费用支出的影响,为优化门诊保障制度提供实证依据。方法:从兰州市医保局获取2022—2023年城镇职工门诊医保费用相关数据,运用单因素分析与中断时间序列模型进行门诊共济制度改革前后对比研究。结果:职工医保门诊共济制度改革后,高血压患者次均统筹基金支出、个人支付金额、个人账户支出、符合范围金额、基金支付总额、基本医疗统筹支付比例均明显下降(P<0.05),但次均现金支付金额明显上升(P<0.05),次均全自费金额改革前后无统计学差异(P>0.05)。结论:职工医保门诊共济制度改革扩大了高血压人群的受益范围,但医保支付能力减弱;建议优化医保基金资源配置,完善门诊医保制度,逐步提高职工医保门诊待遇水平。
Objective To analyze the impact of the employee medical insurance outpatient mutual assistance system reform on medical insurance expenditures for hypertensive patients,and to provide empirical evidence for the optimization of outpatient support system.Methods The data related to outpatient medical insurance expenses for urban employees from Lanzhoul Healthcare Insurance Security Administration from 2022 to 2023 was collected.A comparative analysis of before and after the reform of outpatient mutual assistance system was conducted using univariate analysis and interrupted time-series models.Results After the reform of the outpatient mutual assistance system of employee medical insurance,there was a significant reduction in average per-visit pooling fund expenditure,individual payment,personal account expenditure,scope-compliant amount,total fund payment,and the proportion of basic medical pooling fund payment for hypertensive patients(P<0.05).However,the average per-visit cash payment amount increased significantly(P<0.05),and there was no statistically significant difference in average per-visit fully out-of-pocket payment amount before and after the reform(P>0.05).Conclusion The reform of the outpatient mutual assistance system of employee medical insurance has expanded coverage for hypertensive patients,but the ability of medical insurance to pay has weakened.It is recommended to optimize the resource allocation of the medial insurance fund,improve the outpatient medical insurance system,and gradually increase the level of outpatient treatment of employee health insurance.