医保病人门诊大病就诊费用统筹支付的分析与探讨

分析了江苏省南通市2001--2003年纳入统筹基金支付的7种门诊大病的患病、就诊、费用与补偿情况，发现慢性痛的门诊就诊次均费用一般不高，但年累计就诊费用要占个人年工资的30.00％以上，按“板块式”基金管理方式，个人账户一般无法承担如此高额的费用、由统筹基金支付较好地解决了慢性病高额费用负担问题：可以减少参保者为了获得统筹支付而住院的比例，对提高基金使用效率、缓解慢性病人费用负担均有较好的作用。建议采取有效措施，加强监管与诊断审查，控制非支付范围内的疾病冒用统筹基金.

Analysis on Specific Diseases Covered by Risk--Pooling Fund for Keceiving Outpatient Services in the Urban Medical Insurance Scheme

The article analyzed sickness suffering, service seeking, expenses and reimbursement of 7 specific chronic diseases covered by risk-pooling fund in the urban medical insurance scheme in Nantong 2001-2003. Authors find that the average expense per visit is no thigh generally, but the cumulative yearly costs in some groups take up to 30.00% of individual salary. Based on the policy of separate payment system for outpatient and inpatient services, individual account could not afford such a high expenditure. So, the policy of risk-pooling fund paying for outpatient services of some specific chronic diseases resolves this problem well. And it reduces the number of inpatient services by those who want to get risk-pooling fund reimbursement for chronic diseases, which works well for improving insurance fund efficiency and release economic burden of participants with chronie disease. The meidical insurance fund center should take some effective policies of enhancing supervision and diagnosis audit to control risk-pooling fund reimbursing services out of the range.