门诊共济背景下职工基本医疗保险个人账户改革方案设计与释放资金测算  

Design and Financial Release Estimation for the Individual Accounts Reform Plan of Basic Medical Insurance for Employees in the Context of Outpatient +Co-payment Reform

作　　者：鲁志鸿[1] 吴敏 穆晓敏 韩志琰 Lu Zhihong;Wu Min;Mu Xiaomin(Shandong University of Traditional Chinese Medicine,Jinan,Shandong,250035,China;不详)

机构地区：[1]山东中医药大学,山东济南250035 [2]山东第一医科大学,山东济南250000

出　　处：《中国卫生经济》2025年第2期46-49,共4页Chinese Health Economics

基　　金：山东省医疗保障局项目(2023-06);国家中医药管理局项目(YGZXKT2024265)。

摘　　要：基于国家改进职工基本医疗保险个人账户计入办法的政策导向,结合个人账户改革推行面临的阻力和基金可持续性的考量,设计了3种个人账户改革方案。以2022年山东省职工基本医疗保险数据为基准,模拟预测2024年个人账户改革全面实施后,各方案下个人账户改革资金总体释放规模及个人减计情况,并进行重点人群舆情风险预警分析。结果显示,方案一中个人账户释放资金总量最大(165.50亿元),但月人均减计额度最高(52.97元),从而增加了社会舆情风险。方案三最大程度地降低了个人账户改革推行的阻力,但个人账户释放资金总量最小(134.84亿元)。方案二则在个人账户释放资金总量(148.95亿元)、退休人员个人账户划拨(82.77亿元)及个人账户月人均减计(47.67元)间实现了较优平衡。研究进一步聚焦方案二,发现省直、油田等6个统筹区因退休人员减计比例最高(>90%),舆情风险最高;11个统筹区退休人员减计比例超过80%。本研究为政策制定者提供了关于职工基本医疗保险个人账户改革不同方案及其影响的实证依据,建议重点关注高风险区域,采取精细化、差异化的政策措施,以有效缓解社会舆情压力,确保改革平稳推进。Based on the national policy direction of improving the individual account crediting method for employees'basic medical insurance,it designed three individual account reform scenarios,considering the individual account reform and fund sustainability considerations.Based on the 2022 data of the basic medical insurance for employees in Shandong Province,simulations were conducted to predict the overall scale of individual account reform funds released and individual subtractions under each scenario after the full implementation of the individual account reform in 2024,as well as to conduct an early warning analysis of public opinion risks for key populations.The results indicated that Plan I had the largest total amount of released funds from individual accounts(16.55 billion yuan),but the highest per capita monthly reduction in credits(52.97 yuan),thereby increasing the risk of generating social public sentiment.Plan III minimized the resistance to the implementation of the individual account reform but has the smallest total amount of released funds from individual accounts(13.484 billion yuan).Plan II achieved areas such as the provincial government and oil fields have the highest public sentiment risk due to the highest reduction ratio for retirees(>90%);11 coordinated areas have a percentage of retiree subtraction of more than 80%.It provided empirical evidence for policymakers on different plans for the reform of individual accounts in the employee basic medical insurance and their impacts,and suggested that high-risk areas should be given special attention,adopting refined and differentiated policy measures to effectively alleviate social public sentiment pressure and ensure the smooth progress of the reform.

关 键 词：职工基本医疗保险 门诊共济 个人账户 资金释放 

分 类 号：R1-9[医药卫生—公共卫生与预防医学] F840.613[经济管理—保险]