基本医保参保人门诊医疗服务利用、费用及风险分析

目的：分析45岁以上人群门诊服务利用、费用和风险。方法：基于CHARLS2018年数据，分别进行单因素分析和多元logit回归。结果：门诊服务利用率明显低于自行购药，门诊费用和自行购药费用月均1 000元以上组占比最高，门诊和购药费用获得医保报销的比例明显低于住院，报销比例亦是如此。门诊保障水平对门诊费用利用影响有统计学意义；门诊服务利用和自行购药都是引致灾难性卫生支出的重要影响因素；随着慢病患者患病种数的增加，未住院患者发生灾难性卫生支出的风险增加。建议：完善基本医保门诊报销政策，引导患者合理利用医疗服务，提高基金支出效率；重新认识门诊费用，重构医保待遇保障组合；提高慢病患者的门诊保障水平，减轻慢病患者门诊费用风险。

Utilization, cost and risk analysis of outpatient medical services among individuals with basic medical insurance

Objective: To analyze the utilization, cost and risk of outpatient services among people over 45 years old. Methods: Univariate analysis and multivariate logit regression were performed on CHARLS 2018 data. Results: The rate of utilizing outpatient services was significantly lower than that of medicine self-purchase. The group of individuals with an average monthly expense of more than 1,000 yuan on outpatient medical services and medicine self-purchase accounted for the highest proportion in the overall population. The proportion of the number of expenses on outpatient medical services and medicine self-purchase that got medical insurance reimbursement was significantly lower than that of hospitalization, and the reimbursement rate was also significantly lower. The insurance level of outpatient medical services has a statistically significant impact on the utilization of outpatient costs; utilization of outpatient medical services and self-purchasing of medicines are both important factors that lead to catastrophic health expenditure; with the increase in the number of types of chronic diseases, the risk of catastrophic health expenditure in unhospitalized patients also increased. Suggestions: The government should improve the outpatient reimbursement policy of basic medical insurance, guide patients to rationally use medical services and improve the efficiency of expenditure, re-understand outpatient costs, reconstruct the medical insurance benefit and protection combination, and enhance the outpatient insurance level of chronic disease patients to reduce their outpatient expense risks.