职工医保门诊共济制度下定点零售药店监管问题研究——以保定市实践为例  

Research on the Supervision of Designated Retail Pharmacies Under the Outpatient Mutual Assistance System of Employees' Medical Insurance——Taking the Practice of Baoding City as an Example

作　　者：问瑜英 

机构地区：[1]河北省保定市医疗保障待遇审核中心,保定071000

出　　处：《中国医疗保险》2025年第2期77-83,共7页China Health Insurance

基　　金：河北省医疗保障研究课题“职工门诊共济制度下定点零售药店基金监管问题研究”(JYB240205)。

摘　　要：目的:通过分析保定市医保门诊共济制度改革现状和对定点零售药店的纳入及监管情况,探讨如何在充分保障参保职工门诊就医权益的同时,加强对门诊保障定点药店的监管,确保医保基金安全稳定运行。方法:检索2022年1月1日—2024年12月31日,保定市和河北省内其他地市出台的职工医保门诊共济(以下简称“职工门诊共济”)政策,将其职工门诊保障待遇水平作横向比较;梳理2022—2024年间保定市定点零售药店纳入门诊统筹的监管实践,归纳总结保定市对门诊保障定点药店的监管实践经验和其中存在的问题。结果:职工门诊共济制度改革后,保定市职工门诊统筹待遇水平在省内居中等偏上水平,门诊就医人数增长迅速,参保群众开始享受到这一制度改革的红利。保定市分批次择优将定点零售药店纳入门诊统筹,有利于更好地服务群众,减轻监管压力,但是在对药店的药品价格管理、医保支付等方面产生了一些负面影响。创造性运用远程视频监控系统起到了加强监管的作用,但是还应继续结合其他监管手段强化监管力度。结论:应继续加强和改进定点零售药店的药品价格管理,优化医保支付政策,完善门诊保障定点药店的监管手段,在充分满足群众门诊用药需求的同时保障医保基金安全。Objective:By analyzing the current situation of the medical insurance outpatient mutual aid system reform,and the inclusion and supervision of designated retail pharmacies in Baoding City,this paper explores how to strengthen the supervision of designated pharmacies for outpatient security while fully protecting the rights and interests of insured employees,ensuring the safe and stable operation of the medical insurance fund.Methods:The paper searches the outpatient mutual aid policies for employees of Baoding City and other cities in Hebei Province from January 1,2022 to December 31,2024,and compares the level of employee outpatient security benefits horizontally.Also,it analyzes the regulatory practice of Baoding City in incorporating designated retail pharmacies into outpatient security from 2022 to 2024,and summarizes the experience and problems.Results:After the reform of the employee outpatient mutual aid,the benefit level of employees' outpatient pooling in Baoding City is at medium to high level in Hebei Province.The number of outpatient patients has grown rapidly,and the insured people has begun to enjoy dividends of the reform.Baoding City includes the designated retail pharmacies to outpatient pooling in batches,which better serves the public and reduces regulatory pressure.However,it had some negative impacts on drug price management and medical insurance payments in pharmacies.The creative use of remote video surveillance systems has played a role in strengthening supervision,but we should continue to strengthen regulation by combining other regulatory measures.Conclusions:We should continue to strengthen and improve the drug price management of designated retail pharmacies,optimize medical insurance payment policies,improve the regulatory measures for outpatient security pharmacies,and ensure the safety of medical insurance funds while fully meeting the needs of the public for outpatient medication.

关 键 词：职工医保 门诊共济改革 定点零售药店 医保基金监管 

分 类 号：F840.684[经济管理—保险] C913.7[社会学]