新疆医科大学学报

目的 通过对某市实施城镇职工门诊统筹政策前后效果的比较分析，为下一步门诊共济保障政策的调整提供参考。方法 以该市医疗保障事业发展中心提供的数据(2015-2018年)为基础，对该市2 597家不同级别医疗机构、5 471 096例城镇职工在门诊统筹政策实施前(2015-2016年)和政策实施后(2017-2018年)的门诊及住院人次、费用和结构变化情况进行分析。结果 2017年门诊统筹政策实施后，该市参加城镇职工医保的患者就诊次数明显增加，普通门诊和住院的增幅程度分别为22.14%及3.52%;随着年龄的增加增幅程度越明显，普通门诊的就诊人次随着年龄的增加，增幅程度逐渐升高，住院人次随着年龄的增加增幅降低；普通门诊患者在政策实施前，2015-2016年两年的总费用、化验费、检查费及药品费用的中位数均低于政策实施后的两年(2017-2018年);2017年1月政策实施后，普通门诊及住院患者2017-2018年各年龄段的均次费用相对于2015-2016年均有所增加，≤40岁增加幅度均大于其他年龄组。结论 门诊统筹政策的实施可以引导患者改变就医习惯，在一定程度上降低住院人次，有效缓解住院压力，减轻患者个人负担医疗费用，但保障力度还不充分，需要调整起付线和限额，政策更需要适度向老年参保患者倾斜。

Objective Through the comparative analysis of the effect before and after the implementation of the urban employee outpatient coordination policy in a city, to provide reference for the next step of the adjustment of mutual assistance policy in outpatient. Methods Based on the data provided by the city′s Medical Security Development Center(2015-2018), the number of outpatient and inpatient visits, expenses and structure changes of 2 597 medical institutions of different levels and 5 471 096 urban employees were analyzed before the implementation of the outpatient coordination policy(2015-2016) and after the implementation of the policy(2017-2018). Results After the implementation of outpatient coordination policy in 2017, the number of the patients participating in urban employee medical insurance in the city were increased significantly, the increase degree of general outpatient and inpatient was 22.14% and 3.52%, respectively. With the increase of age, the increase degree of general outpatient visits were gradually increased with the increase of age, while the increase degree of inpatient visits were decreased with the increase of age. Before the implementation of the policy, the median total costs, laboratory fees, examination fees and drug costs of general outpatients in 2015-2016 were all lower than those in the two years after the implementation of the policy(2017-2018). After the implementation of the policy in January 2017, the average cost of general outpatient and inpatient patients of all ages were increased in 2017-2018 compared with 2015-2016, and the increase rate of ≤40 years old was greater than that of other age groups. Conclusion The outpatient pooling policy can indeed guide patients to change their medical habits, reduce the number of inpatients to a certain extent, effectively relieve the pressure of hospitalization, and reduce patients′ personal medical expenses. However, the guarantee is not enough, and the minimum payment line and limit should be adjusted, and the policy should be moderately tilted to the elderly insured patients.