职工医保门诊支付方式改革研究——政策比较、问题挑战与优化路径  

Research on the Reform of Outpatient Payment Methods for Employees'Basic Medical Insurance——Policy Comparison,Problems,Challenges,and Optimization Path

作　　者：胡宏伟 邹光驰 陈一林 

机构地区：[1]中国人民大学公共管理学院,北京100872 [2]中国人民大学健康保障研究中心,北京100872 [3]新疆生产建设兵团医疗保障事业管理中心,乌鲁木齐830002

出　　处：《中国医疗保险》2025年第3期5-12,共8页China Health Insurance

基　　金：北京市社会科学基金项目重点项目“失能失智老人家庭照护社会支持体系优化研究”(24SRA006)。

摘　　要：本文基于我国地方门诊支付方式改革经验,系统比较各地相关政策,重点分析改革面临的问题和挑战,对如何完善改革提出政策建议。研究表明,我国各试点地区已形成由总额预算下的按项目付费、按人头付费、按分值付费和APG(门诊病例分组)4种门诊支付方式构成的多元复合付费机制,但仍面临人口老龄化与慢病趋势加剧、异地就医与医疗服务供需不平衡、“三医”协同和多主体管理矛盾等制度外部挑战,以及总额预算的粗放式管理风险、多元复合支付的精细化管理困境和门诊共济改革政策的整合化管理难题等内部制度问题。下一阶段,建议基于“人民至上”“健康中心”和“服务导向”的基本思路,持续革新门诊支付方式改革理念;结合家庭医生与按人头总额预付的主体功能,发挥新型支付方式在精细化管理上的制度优势,不断优化门诊支付方式改革措施;适应当前诊疗模式的转变,激励医疗机构提供高质量医疗服务,降低患者门诊医疗负担,引导资源合理配置,推动构建有序就医和诊疗的新格局,全面把握门诊支付方式改革演进趋势。Based on the experience of local outpatient payment method reform in China,the paper systematically compares the relevant policies in various regions,mainly analyzes the problems and challenges in the reform,and provides policy recommendations for improving the reform.The research shows that pilot regions in China have formed a diversified composite payment mechanism for outpatient services,including four types of payment methods under total budget:fee-for-service,capitation,value-based payment,and APG(Ambulatory Payment Group).However,there are still external challenges,including the aging population and worsening chronic disease trends,cross-region medical treatment and imbalance in the supply and demand of medical services,as well as conflicts between coordinated development and regulation of medical insurance,medical services,and pharmaceuticals and multi-party management.Internal institutional issues include the risks of extensive total budget management,the difficulties of refined management in diversified composite payments,and the difficulties in the integrated management of outpatient mutual aid reform policies.In the next phase,we should continue to innovate the concept of outpatient payment method reform based on the fundamental ideas of"people first""health-centered"and"service-oriented".Then the reform should combine the main functions of family doctors and capitation payment under total budget,leveraging the institutional advantages of new payment methods in refined management,and continuously optimize the reform measures of outpatient payment methods.Finally,the reform should adapt to the changes in current diagnosis and treatment models,incentivize medical institutions to provide high-quality medical services,reduce the burden of outpatient care on patients,guide the rational allocation of resources and promote the construction of a new orderly medical treatment and diagnosis system,comprehensively understanding the evolution trend of outpatient payment method reform.

关 键 词：门诊支付方式 按项目付费 按人头付费 APG 

分 类 号：F840.684[经济管理—保险] C913.7[社会学]