城乡居民“两病”门诊用药保障政策设定现状分析  

Analysis on the current status of outpatient benefit policies for patients with hypertension and diabetes in urban and rural residents

作　　者：吴佩林 梁晶 苗艳青 田东华 WU Pei-lin;LIANG Jing;MIAO Yan-qing;TIAN Dong-hua(School of Government,Beijing Normal University,Beijing 100875,China;School of Public Health,Tianjin Medical University,Tianjin 300070,China;China National Health Development Research Center,Beijing 100191,China;School of Sociology,Beijing Normal University,Beijing 100875,China)

机构地区：[1]北京师范大学政府管理学院,北京100875 [2]天津医科大学公共卫生学院,北京300070 [3]国家卫生健康委卫生发展研究中心,北京100191 [4]北京师范大学社会学院,北京100875

出　　处：《中国卫生政策研究》2025年第2期24-29,共6页Chinese Journal of Health Policy

基　　金：国家医保局项目(2209444)。

摘　　要：目的:分析全国城乡居民“两病”患者的门诊用药保障政策设定现状,为深化“两病”门诊用药保障机制提供参考。方法:采用问卷调查,获取普通门诊统筹、“两病”门诊用药保障机制(“两病”专项)和门诊“慢特病”有关起付线、政策范围内报销比和封顶线的基本情况,并进行描述性统计分析。结果:在334个统筹区中,同时设定了三项政策的统筹区有253个,占全部统筹区的75.75%。分地区看,普通门诊统筹和“两病”专项的报销比在东中西部间有显著差异(P<0.001),西部明显高于东中部,门诊“慢特病”的报销比在东中西部间没有显著差异(P>0.05);普通门诊统筹的起付线在东中西部没有显著差异(P>0.05),但“两病”专项和门诊“慢特病”的起付线在东中西部有显著差异(P<0.05),三项政策的封顶线在东中西部间有显著差异(P<0.001)。结论:全国城乡居民“两病”门诊用药保障政策已经实现了应保尽保,但保障水平有待进一步提高,区域间均等化水平有待进一步改善。建议加强数据信息反馈,推进医保省级统筹。Objective:To analyze the current policy design of outpatient benefit policies for patients with hypertension and diabetes(H&D)in urban and rural residents in China,and to provide references for optimizing the outpatient benefit mechanism for patients with H&D.Methods:A questionnaire survey was conducted to collect data on the basic features of General Outpatient Benefit(GOB),Outpatient Medication Guarantee Mechanisms for Hypertension and Diabetes(OMGM-H&D)and Outpatient Benefit for Patient with Chronic and Special Diseases(OB-C&S),focusing on deductibles,policy reimbursement ratios,and maximum payment limits.Descriptive statistical analysis was performed on the data.Results:A total of 334 regions were surveyed,of which 253 regions(75.34%)had implemented all three policies.Regional analysis revealed significant differences(P<0.001)in reimbursement ratios for GOB and the OMGM-H&D between the eastern,central,and western regions,with the western region having notably higher ratios than the eastern and central regions.However,no significant difference(P>0.05)was observed in the reimbursement ratios for OB-C&S across regions.Regarding deductibles,no significant regional difference(P>0.05)was found for GOB,but significant differences(P<0.05)existed for the OMGM-H&D and OB-C&S.Additionally,the annual maximum payment limits for all three policies showed significant regional variations(P<0.001).Conclusions:The outpatient benefits policy for patients with H&D have achieved full coverage nationwide among urban and rural residents in China,but regional equity in benefit levels requires improvement.It is recommended to strengthen data feedback mechanisms and promote provincial-level pooling of medical insurance.

关 键 词：高血压 糖尿病 门诊用药保障 政策设定 

分 类 号：R197[医药卫生—卫生事业管理]