【作者】 张文杰；

【导师】 张晓；

【作者基本信息】 东南大学 ， 社会保障， 2016， 硕士

【摘要】 目的：目前的门诊医疗保险政策主要由普通门诊、门诊慢性病、门诊特定项目等组成,这种多账户多层次的保障模式在提高参保者保障水平的同时也增加了医保部门经办管理的难度和基金运行的风险。本研究的目的在于分析目前门诊医疗保险政策的运行效果,总结政策运行过程中出现的问题,对门诊医疗保险政策的调整和完善提供建议方法：本研究采用理论研究与实证分析相结合的方法,总结了门诊医疗保险制度设计的理论基础,同时以南京市的城镇职工基本医疗保险门诊保障政策实践为例,对门诊医疗保险政策运行情况进行描述性统计,并采用数据包络分析的方法,对门诊医疗保险政策的运行效率进行分析。结果：(1)人口老龄化影响门诊医疗保险政策的可持续性；(2)门诊慢性病、门诊统筹政策医保基金支出上涨；(3)参保者就诊倾向三级医疗机构；(4)门诊医疗保险政策项目间的边界不够清晰；(5)门诊医疗保险政策设计缺乏系统性；(6)门诊医疗保险政策对控制住院作用有限；(6)门诊医疗保险政策的效率呈现递减趋势。结论：(1)门诊医疗保险政策的整合,具体的细节包括扩大门诊统筹、门诊统筹单独筹资和整合后的待遇水平的确定,在管理方式上继续实施定点管理。(2)门诊支付政策的调整,针对不同级别的医疗机构构建复合式的支付方式。(3)门诊医疗保险政策效率的提高方法。更多还原

【Abstract】 Objective:Current outpatient medical insurance policy mainly consists of general out-patient, outpatient chronic disease, specific outpatient projects, etc., this multi-account multi-level security model improves the participants’security level, but also increases the difficulty of health care sector’s management and the venture of fund operation. The purpose of this study is to analyze current operating results of outpatient medical insurance policy, summarize the policy issues during the operation, and provide advice on the adjustment and improvement of outpatient medical insurance policy.Methods:This study adopted theoretical research combined with empirical analysis method. It summarized the theoretical foundation of outpatient medical insurance system design, and took outpatient security polices of basic medical insurance for urban workers in Nanjing as an example, conducted descriptive statistics of outpatient medical insurance policy operation, and adopted data envelopment analysis (DEA) to analyze the efficiency of outpatient medical insurance policy.Results:(1)population aging affects the sustainability of outpatient medical insurance policy; (2) fund expenditure of outpatient chronic disease and outpatient co-ordination medical insurance is increasing; (3) the insured tends to seek treatment in tertiary care institutions; (4) the boundary among the projects of outpatient medical insurance policy is not clear; (5) the design of outpatient health insurance policy is unsystematic; (6) the effect of outpatient medical insurance policy controlling hospitalization is limited; (6) the efficiency of outpatient medical insurance policy shows a decreasing trend.Conclusions:(1) the integration of outpatient medical insurance policy, specifically including the expansion of outpatient co-ordination, financing outpatient co-ordination alone and the determination of consolidated pay levels, and continuing to implement fixed administration in the aspect of management style. (2) the adjustment of outpatient payment policies, namely establishing compound pattens of payment for medical institutions of different levels. (3) the methods of improving the efficiency of outpatient medical insurance policy.更多还原