山东居民医保普通门诊统筹待遇政策差异及推进省级统筹对策  

Policy differences in general outpatient coordinating treatment of Shandong residents’ medical insurance and countermeasures for promoting provincial unified financing

作　　者：吴敏 时涛[1] 韩志琰 牟燕 何有琴[1,2] 宋燕 宋奎勐[1,2] WU Min;SHI Tao;HAN Zhiyan;MOU Yan;HE Youqin;SONG Yan;SONG Kuimeng(Medical Security College,Shandong First Medical University&Shandong Academy of Medical Sciences,Jinan,Shandong 250117,China;Shandong Institute of Medicine and Health Information,Jinan,Shandong 250062,China)

机构地区：[1]山东第一医科大学(山东省医学科学院)医疗保障学院,山东济南250117 [2]山东省医药卫生科技信息研究所,山东济南250062

出　　处：《中国农村卫生事业管理》2022年第1期33-36,共4页Chinese Rural Health Service Administration

基　　金：山东第一医科大学学术提升计划项目(2019QL002);山东省医学科学院医药卫生科技创新工程项目;山东省医疗保障局委托课题。

摘　　要：基本医疗保险省级统筹是我国医疗保障工作的重点方向之一。文章以山东省为例,通过梳理16地市居民普通门诊统筹的起付标准、最高支付限额、支付比例等政策的差异,探讨基于普通门诊统筹视角的省级统筹政策建议。研究发现,山东省15市制定了普通门诊统筹待遇政策,各地政策间的差异主要集中在设置形式方面,待遇保障均处于相对较低的水平。建议在推进省级统筹过程中首先统一各地对普通门诊统筹保障功能定位和价值认知,其次在做好基金测算的基础上适度提高普通门诊统筹保障水平。随着经济社会发展和医保基金支付能力提升,建议逐步探索以费用保障为核心的普通门诊统筹和门诊慢性病融合发展的门诊保障模式。Provincial unified financing of basic medical insurance is one of the key parts of medical security work in China. This paper takes Shandong Province as an example to explore the provincial-level financing policy recommendations based on the perspective of general outpatient coordination by combing the differences in the minimum payment standards, maximum payment limits, and payment ratios of residents in 16 cities. The study found that 15 cities of Shandong Province had formulated general outpatient pooling policies, and the differences in policies among respective cities were mainly in the setting forms, and the benefits were at a relatively low level. It is suggested that in the process of promoting provincial-level unified financing, the functional orientation and value cognition of general outpatient coordination should be unified first, and then the level of general outpatient coordination capacity should be moderately improved on the basis of good funding calculation. With the economic and social development and the improvement in fund payment capacity of medical insurance, it is also suggested to gradually explore the outpatient support mode of integrating general outpatient coordination and outpatient chronic disease treatment with expense guarantee as the core.

关 键 词：居民 基本医保 省级统筹 普通门诊统筹 待遇保障 

分 类 号：R1-9[医药卫生—公共卫生与预防医学] F840.684[经济管理—保险]