Objective:This study aims to offer insights for enhancing the outpatient security mechanism for employees,by summarizing and analyzing the current situation of general outpatient coordination benefits design and examining the changes in employees'medical services utilization after the implementation of the outpatient mutual aid reform.Methods:By searching for policy documents on the official websites of healthcare security administration,this study systematically reviewed and analyzed the deductible,cap,and reimbursement rate of general outpatient coordination across all coordinated regions.Additionally,outpatient data from employees'medical insurance in Nanjing City were used to assess changes in outpatient medical services utilization before and after the policy implementation.Results:The design of general outpatient coordination benefits and the guarantee level for employees varied across regions.After the implementation of the policy,there was a noticeable increase in outpatient visits,medical expenses and the expenditure of the pooling fund in Nanjing City,with more pronounced increases in the number of patients in the elder group,the number of high-cost segments and year-end costs.Conclusion:It is necessary to further optimize the design of general outpatient coordination benefits,strengthen the guidance for primary care visits,enhance the supervision of the outpatient medical services system,in order to achieve fairness and sustainability in the outpatient guarantee mechanism for employees as well as to promote the construction of a hierarchical medical system.
关键词
职工医保/门诊共济/医疗服务利用/统筹待遇设计
Key words
employees'medical insurance/outpatient mutual aid security/medical service utilization/design of coordination benefits
维普
万方数据