文献类型：期刊文献

中文题名：职工医保门诊共济制度改革对高血压慢病患者医疗费用的影响

英文题名：Impact of the Reform of The Employee Medical Insurance Outpatient Mutual Assistance System on Medical Costs for Patients with Hypertension

作者：陈蒙恩[1,2,3];郁菁[2];夏士霁[2];王昱涵[2];侯浩佳[3];丛天珍[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;[3]甘肃中医药大学卫生管理学院;[4]北京中医药大学国家中医药发展与战略研究院

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：756

中文期刊名：中国卫生事业管理

外文期刊名：Chinese Health Service Management

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;医保支付制度;医疗费用;间断时间序列分析

外文关键词：employee medical insurance outpatient mutual assistance;hypertension;health insurance payment system;medical costs;interrupted time-series analysis

摘要：目的:探究职工医保门诊共济制度改革对高血压慢病患者医疗费用的影响,为深化门诊医保支付改革和提升慢病医疗服务管理提供参考。方法:从兰州市医疗保障局获取兰州市2022年1月~2023年12月城镇职工门诊医疗费用结算表,提取患者基本信息和诊疗费用数据,分别采用单因素分析和间断时间序列分析来对比职工医保门诊共济改革前后患者就诊信息和医疗相关费用的变化。结果:共纳入688 510例高血压患者就诊信息,职工医保门诊共济改革前297 723例(43.24%),改革后390 787例(56.76%)。职工医保门诊共济制度改革前后高血压患者性别、民族分布不存在统计学差异(P>0.05),而患者年龄、支付地点类别、医疗机构等级分布改革前后存在明显差异(P<0.05),另次均医疗费总额、次均西药费、次均中成药费、次均医疗服务项目费改革后分别呈现平均每半月3.25元、1.87元、0.96元以及0.51元的明显下降趋势(P<0.05),而次均中草药费、次均医用耗材费改革后变化相对平缓(P>0.05),但其费用整体水平较改革前上升(P<0.05)。结论:职工医保门诊共济改革对于降低高血压患者医疗费用效果明显,能使共济者获得医保支持,并促进门诊医疗服务利用和调整医药费用结构,但仍需进一步深化门诊慢特病管理措施,完善定点零售药店的管理和服务规范,提高医保统筹资金使用效率,以提升高血压等慢病的门诊医保待遇和促进医保基金可持续发展。
Objective To examine the impact of the reform of the employee medical insurance outpatient mutual assistance sys-tem on medical costs for patients with hypertension,and provide references for advancing outpatient health insurance payment re-forms and enhancing healthcare services for chronic disease management.Methods Outpatient medical cost settlement tables for ur-ban employees in Lanzhou City from January 2022 to December 2023 were collected from the Lanzhou Municipal Medical Security Bureau to extract patient demographic and medical cost data.Univariate analysis and interrupted time-series analysis were ap-plied to assess the changes in patient visit patterns and medical-related costs before and after the reform of the employee medical insurance outpatient mutual assistance system.Results A total of 688,510 visited hypertension patients were included,with 297,733 cases(43.24%)prioring to the reform and 390,787 cases(56.76%)following the reform of the employee medical insur-ance outpatient mutual assistance system.No significant differences were found in gender or ethnic distribution of patients before and after the reform(P>0.05).However,significant differences were observed in patients'age,payment location categories,and medical institution levels(P<0.05).After the reform,there were notable reductions in the average total medical cost per visit,as well as the average costs for western medicines,proprietary Chinese medicines,and medical service items,with decrea-ses of 3.25,1.87,0.96,and 0.51 RMB per half-month,respectively(P<0.05).In contrast,the average costs for Chinese herbal medicine per visit and medical consumables per visit remained relatively stable(P>0.05),although their overall cost lev-els were higher compared to pre-reform(P<0.05).Conclusion The reform of the employee medical insurance outpatient mutual assistance system has significantly reduced medical costs for hypertension patients,which can provide participants with enhanced insurance coverage while promote outpatient service utilization and optimize medical expenditure structures.However,further ef-forts are needed to refine chronic and special disease management in outpatient care,improve the regulatory and service standards for designated retail pharmacies,and enhance the utilization efficiency of pooled insurance funds,thereby improving outpatient in-surance benefits for hypertension and other chronic diseases,and ensuring the sustainable development of medical insurance funds.