《保险研究》20240808-《城乡居民基本医疗保险门诊统筹对慢性病患者健康水平的影响机制分析》（李乐乐、王曦）

［摘   要］门诊统筹是我国医疗保险制度的重要组成部分。实行城乡居民医保门诊统筹，能降低城乡居民的门诊就医负担，提高城乡居民门诊医疗服务可及性。本研究采用“中国健康与养老追踪调查”(CHARLS)2015、2018年两期数据，建立Probit模型，实证检验城乡居民医保门诊统筹对慢性病患者健康水平的影响机制。研究发现：城乡居民医保门诊统筹政策的实施能显著提高慢性病患者的健康水平，城乡居民医保门诊统筹政策存在“健康效应”；城乡居民医保门诊统筹政策的实施提高了门诊保障水平，显著提高了慢性病患者及时到门诊就医的概率，降低了住院就医的概率，避免“小病拖成大病”；但“分流效应”统计学意义上并不显著，城乡居民医保门诊统筹政策的实施并没有起到预期分流患者的作用。因此，建议适当提高基层医疗机构的门诊保障水平、提升基层医疗机构服务能力，以推进城乡居民医保门诊统筹制度的改革进程。

［关键词］城乡居民基本医疗保险；门诊统筹；慢性病；健康效应

［基金项目］国家自然科学基金项目“标尺竞争机制、DRG/DIP支付方式改革与医疗服务定价”(72204251)。

［作者简介］李乐乐，中国人民大学劳动人事学院副教授，研究方向：社会保障、医疗卫生政策；王曦(通讯作者)，中国人民大学劳动人事学院学生，研究方向：社会保障、医疗卫生政策。

An Analysis of the Influencing Mechanism of Outpatient Fund Pooling of Basic Medical Insurance for Urban and Rural Residents on the Health of Patients with Chronic Diseases

LI Le-le,WANG Xi

Abstract：Outpatient fund pooling is an important part of the social medical insurance system in China.The outpatient fund pooling of the basic medical insurance for urban and rural residents can help to reduce the burden of outpatient expenses for insured personnel,and enhance their access to the outpatient medical services.The Probit model is established based on the data of China Health and Pension Tracking Survey (CHARLS) in 2015 and 2018 to empirically test the influencing mechanism of the fund pooling on the health of patients with chronic diseases.The results show that:the implementation of the policy can significantly improve the health level of patients with chronic diseases,and the policy has a health effect.Furthermore,the implementation of the pooling policy has improved on outpatient service security,and can significantly increase the probability of patients with chronic diseases seeking outpatient services in time to avoid “minor illnesses turning into major diseases”,which helps to reduce the probability of hospitalization.However,the triage effect is not statistically significant.The implementation of the pooling policy has not played the expected role of the triage of patients.According to the research results,this paper puts forward suggestions to appropriately improve the level of outpatient security in primary medical institutions,improve their quality of service,and further promote the reform process of the outpatient fund pooling system of the social medical insurance for urban and rural residents.

Key words：basic medical insurance for urban and rural residents;outpatient fund pooling;chronic disease;health effect