“门诊共济”改革背景下南京市职工医保统筹基金的可持续性研究  

Research on the sustainability of the Nanjing City s employee medical insurance pool fund under the background of the outpatient pooling reform

作　　者：李爱芹[1] 赵宇[1] LI Ai-qin;ZHAO Yu(Schllo of Public Administration and Sociology,Jiangsu Normal University,Xuzhou Jiangsu 221116,China)

机构地区：[1]江苏师范大学公共管理与社会学院,江苏徐州221116

出　　处：《中国卫生政策研究》2024年第2期9-16,共8页Chinese Journal of Health Policy

基　　金：教育部人文社会科学研究规划基金项目(21YJA840009)。

摘　　要：以人口老龄化的南京市为例,通过构建保险精算模型的方法,预测并分析门诊共济保障机制改革对南京市2021—2035年期间职工医保统筹基金收支、结余的影响,模拟延迟退休和扩大筹资、支付方式改革等政策对提升医保基金可持续性的影响,基于此提出政策建议。研究发现:按现行门诊共济方案,到2032年,南京市职工医保统筹基金将发生穿底风险;与现行政策相比,实施男女同龄退休将使得累计结余亏空时间点推迟一年;实行扩大筹资政策,在职和退休职工个人均向统筹基金缴费后,统筹基金在中期内将消除亏损风险;实施支付方式改革政策,也能使统筹基金在中期内可持续发展。结论:在人口老龄化背景下实施的门诊共济改革可能导致统筹基金出现支付压力,长期来看需要组合多种配套政策,才能实现统筹基金的可持续发展。Taking the aging population of Nanjing as an example,through the method of constructing actuarial models,this paper predicts and analyzes the impact of the reform of outpatient mutual aid security mechanism on the income and expenditure of the overall planning funds of workers medical insurance in Nanjing during 2021—2035,and simulates the impact of policies such as delaying retirement,expanding financing and reforming payment methods on improving the sustainability of medical insurance funds.Based on this,it proposes policy suggestions.The study finds that under the current outpatient mutual aid security plan,by 2032,the overall planning funds of workers medical insurance in Nanjing will face the risk of running out;compared with the current policy,implementing the same retirement age for men and women will delay the time point of accumulated deficits by one year;implementing the policy of expanding financing,after both employed and retired workers pay contributions to the overall planning funds,the overall planning funds will eliminate the risk of deficits in the medium term;implementing the policy of reforming payment methods can also make the overall planning funds sustainable in the medium term.Therefore,it is concluded that the reform of outpatient mutual aid security implemented in the context of aging population may lead to payment pressure on the overall planning funds.In the long run,a combination of various supporting policies is needed to achieve sustainable development of the overall planning funds.

关 键 词：医保改革 门诊共济 保险精算 

分 类 号：R197[医药卫生—卫生事业管理]