Policy analysis on general outpatient fund pooling of employee basic medical insurance from the perspective of coordinated development of Yangtze River Delta Region
10.3969/j.issn.1674-2982.2025.04.003
- VernacularTitle:协同发展视角下长三角职工医保门诊统筹政策差异分析
- Author:
Yi-jia FENG
1
;
Lu-ying ZHANG
1
;
Jiao-yang LI
1
;
Sen-wei ZHANG
1
;
Wen CHEN
1
Author Information
1. 复旦大学公共卫生学院 上海 200032;复旦大学长三角医疗保障研究中心 上海 200032
- Publication Type:Journal Article
- Keywords:
Outpatient fund pooling;
Outpatient co-payment;
Yangtze River Delta co-development;
Retail pharmacy;
Outpatient chronic and special diseases
- From:
Chinese Journal of Health Policy
2025;18(4):18-24
- CountryChina
- Language:Chinese
-
Abstract:
Objective:To analyze policy differences in general outpatient fund pooling of employee basic medical insurance in Yangtze River Delta Region and raise suggestions from the perspective of coordinated development.Methods:The study analyzed policy documents on general outpatients financing,outpatient chronic and special diseases,and inclusion of retail pharmacies into risk pooling at provincial level and in some economically developed cities before August,2024.Typical cases were selected for detailed introduction.Results:General outpatient coverage of employee medical insurance in Yangtze River Delta Region is high,with individual account payment scenarios expanding to commercial health insurance,Long Term Care Insurance and family physician contracted service fees.Number of outpatient chronic and special diseases ranges from 3 to 83.Retail pharmacy policies differ less in access conditions and treatment and e-prescription is advancing rapidly.Suzhou is actively exploring total budget management of retail pharmacies.Conclusions:Outpatient fund pooling policies should be gradually promoted under the principle of"differentiated coordination".It is necessary to transform outpatient chronic and special diseases from"disease coverage"to"cost coverage";strengthen the management of retail pharmacies under the outpatient fund pooling scheme,and improve the coordinated regulatory mechanism for direct settlement of outpatient and medication expenses incurred in other places in the Yangtze River Delta.
