城乡居民医保普通门诊统筹政策分析  

Analysis of General Outpatient Fund Pooling Policies of Basic Medical Insurance for Urban and Rural Residents

作　　者：张加敏 朱晓丽[2,3] 代涛[3] 

机构地区：[1]北京协和医学院,北京100730 [2]中国医学科学院医学信息研究所,北京100020 [3]中国医学科学院卫生政策与管理研究中心,北京100020

出　　处：《中国医疗保险》2025年第3期13-18,共6页China Health Insurance

基　　金：首都医科大学国家医疗保障研究院开放性课题“基于国内外实践的医保统筹层次研究”(YB2023B05)。

摘　　要：随着城乡居民门诊就医需求的快速增长,门诊统筹制度应运而生。本研究通过对全国31个省份部分地区的政策文件进行分析,系统归纳总结了门诊统筹的筹资机制、保障水平和医疗服务管理制度等方面的特点。结果显示,筹资方式主要分为是否单独筹资和不同的基金管理方式,保障水平在起付标准、报销比例及最高支付限额等方面存在地区差异。尽管部分地区已取消单次限额,提高了居民的医疗可及性,但总体保障水平仍较低,地区间差异较大。此外,门诊统筹以基层为重点的政策设计有待明晰,各地在服务管理上缺乏有效衔接。鉴于此,为有效提升城乡居民医保门诊保障水平,建议加强政策间的衔接、优化医疗资源配置,并鼓励基层医疗服务发展,以改善参保居民的就医体验。With the rapid growth of outpatient medical demands among urban and rural residents,the outpatient fund pooling system has been gradually established.This study analyzes policy documents from selected areas in 31 provincial administrative regions nationwide,systematically examining the characteristics of the outpatient pooling system in terms of financing mechanisms,security levels,and medical service management systems.The results show that financing methods are primarily categorized by whether funds are raised separately and different fund management approaches.Regional disparities exist in security levels,including deductible standards,reimbursement ratios,and maximum payment limits.Although some regions have eliminated single-visit limits to enhance residents'healthcare accessibility,the overall benefit levels remain relatively low,with significant differences among regions.Furthermore,the policy design emphasizing primary care institutions requires to be clarified,and there is a lack of effective coordination in service management across regions.In view of this,it is recommended to strengthen the connection between policies,optimize the allocation of medical resources,and encourage the development of primary medical services to improve the medical experience of insured residents to effectively improve the outpatient security level of urban and rural residents'medical insurance.

关 键 词：城乡居民基本医保 门诊政策 门诊统筹 

分 类 号：F840.684[经济管理—保险] C913.7[社会学]