三明市三医联动改革效果分析——基于医保的视角

目的:分析三明市三医联动改革中医保制度改革的效果。方法:梳理2012年以来三明市医保制度改革的政策并描述分析2015—2018年三明市医保基金的运行数据。结果:三明职工医保和居民医保实施市级统筹后,收入较低的县区医保基金使用率和医疗服务利用率更低。2015—2018年三明医保患者次均住院费用下降,但自付次均住院费用增长;职工医保和居民医保患者住院实际补偿比分别约为60%和50%;职工医保患者利用三级医院和统筹区外住院服务的比例分别约为41%和21%,利用一级医院的比例不足7%;职工医保基金流向统筹区外的比例超过30%。居民医保患者和资金流向比职工医保合理。结论:三明医保门诊和住院的起付线不断调低、封顶线和补偿比例不断调高,但群众实际负担并未明显减轻;市级统筹存在穷帮富问题;职工医保个人账户比例过高,医保基金互助共济能力减弱;职工医保患者就医秩序有待改善。

Study of the outcome of tripartite system reform in Sanming city, Fujian province: An analysis based on the perspective of health insurance

Objectives:This paper aims to analyze the outcome of Sanming''stripartite system reform from the perspective of health insurance. Methods:Related health insurance system reform policies are exploredand the data of health insurance fund in Sanming from 2015 to 2017 are analyzed. Results:The study found that, after the implementationofhealth insurance policy on municipal level, counties with lower income use less fund and less health services; the fee per inpatient service has decreased, but the out-of-pocket fee per inpatient service increased; the actual reimbursement rate for inpatient service of employee medical insurance and resident medical insurance are about 60% and 50%, respectively; the proportion of patients covered by the employee medical insurancethat use tertiary hospital, hospitals outside of Sanming, and primary hospital are 41%,21% and 7%, respectively; 30% of the fund of the employee medical insurance flew to hospitals outside of Sanming. Conclusions:The deductible of health insurance in Sanming has decreased, while the cap line and reimbursement rate increased. Health insurance plans implementedatmunicipal level have brought the problem of where poor people are helping rich people. The proportion of personal account of the employee medical insurance istoo high. The use of inpatient servicefor patients covered by the employee medical insuranceis not rational and the burden of residents is not relieved.