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Article(id=1228016567682789530, tenantId=1146029695717560320, journalId=1227665162245664772, issueId=1228016566646801206, articleNumber=null, orderNo=null, doi=10.20043/j.cnki.MPM.202505099, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=null, receivedDate=1746720000000, receivedDateStr=2025-05-09, revisedDate=null, revisedDateStr=null, acceptedDate=null, acceptedDateStr=null, onlineDate=1770711565180, onlineDateStr=2026-02-10, pubDate=1758729600000, pubDateStr=2025-09-25, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1770711565180, onlineIssueDateStr=2026-02-10, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1770711565180, creator=13701087609, updateTime=1770711565180, updator=13701087609, issue=Issue{id=1228016566646801206, tenantId=1146029695717560320, journalId=1227665162245664772, year='2025', volume='52', issue='18', pageStart='3265', pageEnd='3456', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=null, createTime=1770711564932, creator=13701087609, updateTime=1770711815039, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1228017615784833769, tenantId=1146029695717560320, journalId=1227665162245664772, issueId=1228016566646801206, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1228017615784833770, tenantId=1146029695717560320, journalId=1227665162245664772, issueId=1228016566646801206, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=3353, endPage=3359, ext={EN=ArticleExt(id=1228016567947030686, articleId=1228016567682789530, tenantId=1146029695717560320, journalId=1227665162245664772, language=EN, title=An empirical study on the impact of the employee medical insurance outpatient mutual assistance reform on outpatient costs for patients with hypertension in medical and pharmaceutical institutions, columnId=1228016567846367388, journalTitle=Modern Preventive Medicine, columnName=Health Policy and Management, runingTitle=null, highlight=null, articleAbstract=
Objective

To analyze the impact of the outpatient mutual assistance reform of employee medical insurance on outpatient costs in medical and pharmaceutical institutions, offering valuable insights for deepening outpatient medical system reforms and optimizing chronic disease management.

Methods

Outpatient cost indicators for hypertensive patients in City L from January 2022 to December 2023 were collected. Univariate analysis and a two-group interrupted time-series model were employed to compare changes in cost indicators before and after the reform.

Results

A total of 688 510 valid cases were included, with 158 474 (23.02%) from pharmacies, and 530 036 (76.98%) from hospitals. The overall outpatient costs in medical and pharmaceutical institutions showed statistically significant differences before and after the reform (Z/t= -3.486/6.972, P<0.05), with post-reform data showing reduced total expenditures. However, the reform also led to a decline in the average reimbursement rate per visit, with a more pronounced effect observed in retail pharmacies than in medical institutions. Furthermore, the reform was associated with increased utilization of Chinese herbal medicines, accompanied by a significant rise in related expenditures (Z/t= -4.229/-4.285, P<0.05).

Conclusion

The outpatient mutual assistance reform of employee medical insurance has alleviated the financial burden of hypertension patients in medical and pharmaceutical institutions, though the payment capacity of health insurance slightly declined in the early stages of reform. It is essential to coordinate the outpatient mutual assistance reform with other policies, establish a comprehensive tripartite linkage system involving medical management, insurance payment, and drug supply, and optimize outpatient management strategies for chronic diseases.

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目的

分析职工医保门诊共济改革对医药机构门诊费用的影响，为深化门诊医疗制度和优化慢性病管理提供参考。

方法

收集L市2022年1月—2023年12月高血压患者门诊费用指标，运用单因素分析和双组间断时间序列模型比较改革前后费用指标的变化。

结果

共纳入688 510条有效病例信息，其中药店158 474例（23.02%），医院530 036例（76.98%）。职工医保门诊共济制度改革前后医药机构的门诊费用整体水平，差异具有统计学意义（Z/t= -3.486/6.972，P<0.05），改革后的整体费用水平更低，但改革降低次均医保报销支付力度，且药店较医疗机构更甚；另改革促进医药机构中草药利用，其费用水平上升（Z/t= -4.229/-4.285，P<0.05）。

结论

职工医保门诊共济制度缓解了医药机构高血压患者门诊疾病经济负担，但医保支付保障能力在改革初期略下降。要做好职工门诊共济改革与相关政策衔接工作，建立完善的医疗管理、医保支付、医药供应三方联动制度，并优化慢性病门诊管理方案。

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王志伟，E-mail:
, copyrightStatement=本刊刊出的所有文章不代表中华预防医学会和本刊编委会的观点，除非特别声明。, copyrightOwner=中华预防医学会和四川大学华西公共卫生学院, extLink=null, articleAbsUrl=null, sourceXml=wnlwRk2DylWyQ58DpnD0Pg==, magXml=YadHEkBLCJvBdpeLkZj0Qw==, pdfUrl=null, pdf=Kh2/WUw2sE/KfNE8Zx83tg==, pdfFileSize=921933, pdfExtLink=null, richHtmlUrl=null, mobilePdfUrl=null, reviewReport=null, pdfFirstPage=null, abstractGraph=D3rado8ZrCwoOjH6USU4+A==, abstractGraphContent=null, abstractVideo=null, citation=null, cebUrl=null, magXmlContent=hsWhcCaePCTnZhWgpe5sEg==, mapNumber=null, authorCompany=null, fund=null, authors=

陈蒙恩（1996—），男，博士在读，研究方向：卫生政策与医疗保障

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陈蒙恩（1996—），男，博士在读，研究方向：卫生政策与医疗保障

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陈蒙恩（1996—），男，博士在读，研究方向：卫生政策与医疗保障

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Modern Preventive Medicine, 2025, 52(11): 2040-2045.(In Chinese), articleTitle=An empirical study on DIP payment for rehabilitation patients based on interrupted time series analysis, refAbstract=null), Reference(id=1228016579959518041, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1228016567682789530, doi=null, pmid=null, pmcid=null, year=2025, volume=44, issue=3, pageStart=18, pageEnd=24, url=null, language=null, rfNumber=[11], rfOrder=19, authorNames=陈蒙恩, 袁有树, 王焱, journalName=中国卫生经济, refType=null, unstructuredReference=陈蒙恩，袁有树，王焱，等．DRG支付方式改革对中医医院住院费用及结构的影响[J].中国卫生经济，2025, 44(3): 18-24., articleTitle=DRG支付方式改革对中医医院住院费用及结构的影响, refAbstract=null), Reference(id=1228016580093735775, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1228016567682789530, doi=null, pmid=null, pmcid=null, year=2025, volume=44, issue=3, pageStart=18, pageEnd=24, url=null, language=null, rfNumber=[11], rfOrder=20, authorNames=Chen ME, Yuan YS, Wang Y, journalName=Chinese Health Economics, refType=null, unstructuredReference=Chen ME, Yuan YS, Wang Y, et al. 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[2025-07-25]. https://ideas.repec.org/c/boc/bocode/s457668.html., articleTitle=ACTEST: stata module to perform Cumby–Huizinga general test for autocorrelation in time series, refAbstract=null)], funds=[Fund(id=1228016577249997447, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1228016567682789530, awardId=ZYZB-2023-435; GZY-FJS-2022-045, language=CN, fundingSource=国家中医药管理局资助项目(ZYZB-2023-435; GZY-FJS-2022-045), fundOrder=null, country=null)], companyList=[AuthorCompany(id=1228016569184350382, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1228016567682789530, xref=1．, ext=[AuthorCompanyExt(id=1228016569188544687, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1228016567682789530, companyId=1228016569184350382, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing 102400, China), AuthorCompanyExt(id=1228016569201127600, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1228016567682789530, companyId=1228016569184350382, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1．北京中医药大学中医学院，北京　102400)]), AuthorCompany(id=1228016570019016881, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1228016567682789530, xref=2．, ext=[AuthorCompanyExt(id=1228016570027405490, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1228016567682789530, companyId=1228016570019016881, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=2．北京中医药大学管理学院)]), AuthorCompany(id=1228016570111291573, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1228016567682789530, xref=3．, ext=[AuthorCompanyExt(id=1228016570123874487, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1228016567682789530, companyId=1228016570111291573, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=3．甘肃中医药大学卫生管理学院)]), AuthorCompany(id=1228016570220343481, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1228016567682789530, xref=4．, ext=[AuthorCompanyExt(id=1228016570224537786, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1228016567682789530, companyId=1228016570220343481, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=4．北京中医药大学国家中医药发展与战略研究院)])], figs=[ArticleFig(id=1228016575190594022, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1228016567682789530, language=EN, label=Fig.1, caption=Schematic diagram of the two-group interrupted time series model, figureFileSmall=7kqEWCJJ50G9ux4wYkaTWw==, figureFileBig=D3rado8ZrCwoOjH6USU4+A==, tableContent=null), ArticleFig(id=1228016575421280759, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1228016567682789530, language=CN, label=图1, caption=双组间断时间序列模型示意图, figureFileSmall=7kqEWCJJ50G9ux4wYkaTWw==, figureFileBig=D3rado8ZrCwoOjH6USU4+A==, tableContent=null), ArticleFig(id=1228016576159478299, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1228016567682789530, language=EN, label=Fig.2, caption=Changes in outpatient costs for hypertensive patients in medical and pharmaceutical institutions before and after employee medical insurance outpatient mutual assistance reform, figureFileSmall=hIBF4XvnUoeV4+vPGWsZfA==, figureFileBig=Ol0vBoNqw8lwn3NJxjaBzw==, tableContent=null), ArticleFig(id=1228016576339833387, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1228016567682789530, language=CN, label=图2, caption=门诊共济改革前后医药机构高血压患者门诊费用变化, figureFileSmall=hIBF4XvnUoeV4+vPGWsZfA==, figureFileBig=Ol0vBoNqw8lwn3NJxjaBzw==, tableContent=null), ArticleFig(id=1228016576461468213, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1228016567682789530, language=EN, label=Table 1, caption=

Outpatient costs for hypertensive patients in pharmacy institutions before and after the reform of the outpatient mutual assistance system of employee medical insurance

, figureFileSmall=null, figureFileBig=null, tableContent=
指标药店（n=158 474）Z/t值P值
改革前（n=53 995）改革后（n=104 479）
次均医疗费总额/元a473.17(463.58,506.09)371.23(340.68,433.46)-3.486<0.001
次均西药费/元a435.24(417.51,456.28)324.23(291.44,391.66)-3.800<0.001
次均中成药费/元b40.05±11.3940.34±3.94-0.1100.913
次均中草药费/元a0.81(0.45,1.66)6.94(5.28,8.72)-4.229<0.001
次均个人账户支出/元a124.50(116.56,134.28)93.37(88.90,107.98)-3.4570.001
次均个人支付金额/元a155.74(148.37,165.49)129.72(122.81,143.30)-3.3710.001
次均基金支付总额/元a318.66(311.64,339.60)242.85(218.70,295.05)-3.486<0.001
), ArticleFig(id=1228016576541159999, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1228016567682789530, language=CN, label=表1, caption=

职工医保门诊共济制度改革前后药店高血压患者门诊费用情况

, figureFileSmall=null, figureFileBig=null, tableContent=
指标药店（n=158 474）Z/t值P值
改革前（n=53 995）改革后（n=104 479）
次均医疗费总额/元a473.17(463.58,506.09)371.23(340.68,433.46)-3.486<0.001
次均西药费/元a435.24(417.51,456.28)324.23(291.44,391.66)-3.800<0.001
次均中成药费/元b40.05±11.3940.34±3.94-0.1100.913
次均中草药费/元a0.81(0.45,1.66)6.94(5.28,8.72)-4.229<0.001
次均个人账户支出/元a124.50(116.56,134.28)93.37(88.90,107.98)-3.4570.001
次均个人支付金额/元a155.74(148.37,165.49)129.72(122.81,143.30)-3.3710.001
次均基金支付总额/元a318.66(311.64,339.60)242.85(218.70,295.05)-3.486<0.001
), ArticleFig(id=1228016576650211912, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1228016567682789530, language=EN, label=Table 2, caption=

Outpatient costs for hypertensive patients in medical institutions before and after the reform of the outpatient mutual assistance system of employee medical insurance

, figureFileSmall=null, figureFileBig=null, tableContent=
指标医疗机构（n=530 036）Z/t值P值
改革前（n=243 728）改革后（n=286 308）
次均医疗费总额/元b352.36±23.59294.79±21.946.972<0.001
次均西药费/元b215.61±15.70165.74±15.258.501<0.001
次均中成药费/元a102.26(96.27,109.81)94.59(92.22,99.26)-2.3710.018
次均中草药费/元b4.58±1.205.82±1.75-4.285<0.001
次均个人账户支出/元b101.00±7.6779.03±7.707.775<0.001
次均个人支付金额/元b124.68±10.67103.40±5.737.389<0.001
次均基金支付总额/元b227.71±14.02191.38±16.446.591<0.001
), ArticleFig(id=1228016576767652436, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1228016567682789530, language=CN, label=表2, caption=

职工医保门诊共济制度改革前后医疗机构高血压患者门诊费用情况

, figureFileSmall=null, figureFileBig=null, tableContent=
指标医疗机构（n=530 036）Z/t值P值
改革前（n=243 728）改革后（n=286 308）
次均医疗费总额/元b352.36±23.59294.79±21.946.972<0.001
次均西药费/元b215.61±15.70165.74±15.258.501<0.001
次均中成药费/元a102.26(96.27,109.81)94.59(92.22,99.26)-2.3710.018
次均中草药费/元b4.58±1.205.82±1.75-4.285<0.001
次均个人账户支出/元b101.00±7.6779.03±7.707.775<0.001
次均个人支付金额/元b124.68±10.67103.40±5.737.389<0.001
次均基金支付总额/元b227.71±14.02191.38±16.446.591<0.001
), ArticleFig(id=1228016576914453091, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1228016567682789530, language=EN, label=Table 3, caption=

Results of two- group interrupted time-series analysis of the impact of employee medical insurance outpatient mutual assistance reform on outpatient costs for hypertensive patients in medical and pharmaceutical institutions

, figureFileSmall=null, figureFileBig=null, tableContent=
指标次均医疗费总额/元次均西药费/元次均中成药费/元次均中草药费/元次均个人账户支出/元次均个人支付金额/元次均基金支付总额/元
β0334.73(7.95)c138.85(2.98)b60.18(2.94)b3.17(3.79)c81.31(13.26)c135.44(5.87)c199.30(8.37)c
β1-3.49(-0.95)1.07(0.33)1.22(1.02)-0.01(-0.11)0.74(1.79)-1.22(-0.83)-2.27(-0.85)
β22.95(0.05)-21.43(-0.51)-15.74(-1.30)4.23(3.47)b-17.00(-3.33)b-6.56(-0.43)9.50(0.20)
β31.19(0.22)-2.03(-0.47)-1.72(-0.91)-0.15(-1.76)-1.79(-2.84)b0.17(0.11)1.02(0.23)
β4108.28(2.47)a277.54(5.78)c-36.18(-1.77)-2.17(-2.51)a27.16(4.24)c5.60(0.24)102.68(4.04)c
β56.97(1.81)0.97(0.29)0.17(0.14)0.01(0.15)0.61(1.38)2.70(1.78)4.27(1.54)
β6-41.27(-0.63)-5.07(-0.11)1.24(0.10)-1.97(-1.12)-4.48(-0.71)-14.62(-0.85)-26.65(-0.55)
β7-12.68(-2.22)a-8.08(-1.76)0.09(0.05)0.44(3.63)c-1.27(-1.79)-3.43(2.07)a-9.25(-1.99)a
β8-2.30(-0.78)-0.96(-0.58)-0.50(-0.47)-0.15(-2.46)a-1.05(-3.22)b-1.05(-1.99)a-1.25(-0.53)
β9-8.01(-7.94)c-8.07(-8.14)c-0.23(-3.52)b0.30(3.68)c-1.72(-6.62)c-1.78(-4.93)c-6.23(-8.93)c
), ArticleFig(id=1228016577065448050, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1228016567682789530, language=CN, label=表3, caption=

门诊共济改革对医药机构高血压患者门诊费用影响的双组间断时间序列分析结果

, figureFileSmall=null, figureFileBig=null, tableContent=
指标次均医疗费总额/元次均西药费/元次均中成药费/元次均中草药费/元次均个人账户支出/元次均个人支付金额/元次均基金支付总额/元
β0334.73(7.95)c138.85(2.98)b60.18(2.94)b3.17(3.79)c81.31(13.26)c135.44(5.87)c199.30(8.37)c
β1-3.49(-0.95)1.07(0.33)1.22(1.02)-0.01(-0.11)0.74(1.79)-1.22(-0.83)-2.27(-0.85)
β22.95(0.05)-21.43(-0.51)-15.74(-1.30)4.23(3.47)b-17.00(-3.33)b-6.56(-0.43)9.50(0.20)
β31.19(0.22)-2.03(-0.47)-1.72(-0.91)-0.15(-1.76)-1.79(-2.84)b0.17(0.11)1.02(0.23)
β4108.28(2.47)a277.54(5.78)c-36.18(-1.77)-2.17(-2.51)a27.16(4.24)c5.60(0.24)102.68(4.04)c
β56.97(1.81)0.97(0.29)0.17(0.14)0.01(0.15)0.61(1.38)2.70(1.78)4.27(1.54)
β6-41.27(-0.63)-5.07(-0.11)1.24(0.10)-1.97(-1.12)-4.48(-0.71)-14.62(-0.85)-26.65(-0.55)
β7-12.68(-2.22)a-8.08(-1.76)0.09(0.05)0.44(3.63)c-1.27(-1.79)-3.43(2.07)a-9.25(-1.99)a
β8-2.30(-0.78)-0.96(-0.58)-0.50(-0.47)-0.15(-2.46)a-1.05(-3.22)b-1.05(-1.99)a-1.25(-0.53)
β9-8.01(-7.94)c-8.07(-8.14)c-0.23(-3.52)b0.30(3.68)c-1.72(-6.62)c-1.78(-4.93)c-6.23(-8.93)c
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职工医保门诊共济制度对医药机构高血压患者门诊费用影响的实证研究
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陈蒙恩 1, 2 , 贾暄 2 , 吴国平 2 , 孙赫浓 2 , 侯浩佳 3 , 丛天珍 3 , 杨敬宇 3 , 王志伟 4
现代预防医学 | 卫生政策与管理 2025,52(18): 3353-3359
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现代预防医学 | 卫生政策与管理 2025, 52(18): 3353-3359
职工医保门诊共济制度对医药机构高血压患者门诊费用影响的实证研究
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陈蒙恩1, 2, 贾暄2, 吴国平2, 孙赫浓2, 侯浩佳3, 丛天珍3, 杨敬宇3, 王志伟4
作者信息
  • 1．北京中医药大学中医学院，北京　102400
  • 2．北京中医药大学管理学院
  • 3．甘肃中医药大学卫生管理学院
  • 4．北京中医药大学国家中医药发展与战略研究院

    • 陈蒙恩（1996—），男，博士在读，研究方向：卫生政策与医疗保障

通讯作者:

王志伟，E-mail:
An empirical study on the impact of the employee medical insurance outpatient mutual assistance reform on outpatient costs for patients with hypertension in medical and pharmaceutical institutions
Meng-en CHEN1, 2, Xuan JIA2, Guo-ping WU2, He-nong SUN2, Hao-jia HOU3, Tian-zhen CONG3, Jing-yu YANG3, Zhi-wei WANG4
Affiliations
  • School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing 102400, China
出版时间: 2025-09-25 doi: 10.20043/j.cnki.MPM.202505099
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摘要
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目的

分析职工医保门诊共济改革对医药机构门诊费用的影响，为深化门诊医疗制度和优化慢性病管理提供参考。

方法

收集L市2022年1月—2023年12月高血压患者门诊费用指标，运用单因素分析和双组间断时间序列模型比较改革前后费用指标的变化。

结果

共纳入688 510条有效病例信息，其中药店158 474例（23.02%），医院530 036例（76.98%）。职工医保门诊共济制度改革前后医药机构的门诊费用整体水平，差异具有统计学意义（Z/t= -3.486/6.972，P<0.05），改革后的整体费用水平更低，但改革降低次均医保报销支付力度，且药店较医疗机构更甚；另改革促进医药机构中草药利用，其费用水平上升（Z/t= -4.229/-4.285，P<0.05）。

结论

职工医保门诊共济制度缓解了医药机构高血压患者门诊疾病经济负担，但医保支付保障能力在改革初期略下降。要做好职工门诊共济改革与相关政策衔接工作，建立完善的医疗管理、医保支付、医药供应三方联动制度，并优化慢性病门诊管理方案。

职工医保  /  门诊共济  /  高血压  /  门诊费用  /  双组间断时间序列分析
Objective

To analyze the impact of the outpatient mutual assistance reform of employee medical insurance on outpatient costs in medical and pharmaceutical institutions, offering valuable insights for deepening outpatient medical system reforms and optimizing chronic disease management.

Methods

Outpatient cost indicators for hypertensive patients in City L from January 2022 to December 2023 were collected. Univariate analysis and a two-group interrupted time-series model were employed to compare changes in cost indicators before and after the reform.

Results

A total of 688 510 valid cases were included, with 158 474 (23.02%) from pharmacies, and 530 036 (76.98%) from hospitals. The overall outpatient costs in medical and pharmaceutical institutions showed statistically significant differences before and after the reform (Z/t= -3.486/6.972, P<0.05), with post-reform data showing reduced total expenditures. However, the reform also led to a decline in the average reimbursement rate per visit, with a more pronounced effect observed in retail pharmacies than in medical institutions. Furthermore, the reform was associated with increased utilization of Chinese herbal medicines, accompanied by a significant rise in related expenditures (Z/t= -4.229/-4.285, P<0.05).

Conclusion

The outpatient mutual assistance reform of employee medical insurance has alleviated the financial burden of hypertension patients in medical and pharmaceutical institutions, though the payment capacity of health insurance slightly declined in the early stages of reform. It is essential to coordinate the outpatient mutual assistance reform with other policies, establish a comprehensive tripartite linkage system involving medical management, insurance payment, and drug supply, and optimize outpatient management strategies for chronic diseases.

Employee medical insurance  /  Outpatient mutual assistance  /  Hypertension  /  Outpatient costs  /  Two-group interrupted time-series analysis
陈蒙恩, 贾暄, 吴国平, 孙赫浓, 侯浩佳, 丛天珍, 杨敬宇, 王志伟. 职工医保门诊共济制度对医药机构高血压患者门诊费用影响的实证研究. 现代预防医学, 2025 , 52 (18) : 3353 -3359 . DOI: 10.20043/j.cnki.MPM.202505099
Meng-en CHEN, Xuan JIA, Guo-ping WU, He-nong SUN, Hao-jia HOU, Tian-zhen CONG, Jing-yu YANG, Zhi-wei WANG. An empirical study on the impact of the employee medical insurance outpatient mutual assistance reform on outpatient costs for patients with hypertension in medical and pharmaceutical institutions[J]. Modern Preventive Medicine, 2025 , 52 (18) : 3353 -3359 . DOI: 10.20043/j.cnki.MPM.202505099
正文
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随着我国人口老龄化进程加速和疾病谱系显著变化，门诊患者疾病经济负担和医保基金运行压力加重，然存在着年迈和患病职工群体个人账户资金不够，而年轻和健康职工群体资金过多沉余的并行突出问题[1-2]，控制医疗费用负担加剧和提高医保基金使用效率，是减轻患者疾病经济压力和提升门诊保障待遇的客观要求，也是职工医保门诊共济制度改革的政策初心。
职工医保门诊共济制度改革是通过权益置换的方式，将职工个人账户金额共济与配偶、父母和子女[3-4]。当前，我国31个省、自治区和直辖市均出台门诊共济统筹相关政策文件，从个人账户资金计入方式、个人账户资金适用范围、门诊“两线一比例”设计等方面做出具体要求，其中北京、上海、海南等地率先实施职工医保省级统筹，而大部分地区执行的市级统筹制度，且不同地区间门诊待遇水平存在较大差距[2]。甘肃省L市自2023年1月开始实施职工医保门诊共济制度，在遵循国家政策文件相关要求的基础上，统一设置起付标准为200元，最高支付限额为2 500元，并依据参保人员类别和就诊医疗机构等级设置差异化医保报销比例。
高血压作为一种常见的门诊慢性病，我国患病人数超过3亿，长期以来给国民经济带来沉重负担[5-6]，推行职工医保门诊共济制度是缓解高血压、糖尿病等门诊常见病经济负担的重要举措。然现阶段，国内就职工医保门诊共济政策对高血压门诊费用影响的相关研究较少，围绕医药机构展开费用比较的实证分析尚为空白，而本研究借助甘肃省L市高血压患者门诊费用的真实世界资料，对职工医保门诊共济改革实施效果展开探索与分析，为后续门诊医疗保障政策完善和推进提供启示。
1　资料与方法
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1.1　资料来源
本研究数据来源于甘肃省L市医保局城镇职工门诊医保费用结算信息系统，从该系统获取2022年1月—2023年12月职工门诊费用相关信息，提取医疗费总额、西药费、中成药费等研究指标。数据纳入标准是疾病诊断病种为高血压，排除标准是患者信息存在逻辑错误或缺失且无法依据补充。经数据清洗后，纳入688 510条有效病例信息，其中药店158 474条（23.02%），医院530 036条（76.98%）。
1.2　研究方法
间断时间序列模型是一种评价政策实施成效的实用模型，被广泛应用到卫生政策改革评价的实证研究中[7-10]。本研究采用双组间断时间序列模型，该模型方程式可表达为：
其中，Yt表示研究指标；β0代表对照组截距；β1代表改革前对照组的变化斜率；β2表示改革时对照组的水平变化；β3表示对照组改革后与改革前斜率的差值，故对照组改革后斜率值为β1与β3之和，记为β8；β4指改革前两组的水平差值；β5指改革前两组斜率差值；β6指改革时两组水平变化的差异；β7指改革前后两组斜率改变量的差异，故实验组改革后的斜率值为β1、β3、β5与β7之和，记为β9。而Xt与Z为哑变量，Xt表示职工医保门诊共济改革（改革前赋值“0”，改革后赋值“1”），L市自2023年1月执行职工医保门诊共济制度，故界定职工医保门诊共济制度改革前为2022年1月—2022年12月，而2023年1月—2023年12月界定为改革后；Z表示医药机构（药店赋值为“1”，医疗机构赋值为“2”）。Tt为时间序列，本研究以半月为基础单元进行编码，共计形成48个连续的时间节点，且改革断点编码为“25”。另外，XtTt、ZTt、ZXt以及ZXtTt为交互项；εt为随机误差。该模型示意图见图1。
本研究采用Cumby–Huizinga法对模型进行自相关检验，执行Newy-West法进行系数调整和计算[11-12]。利用Excel 2019软件进行数据清洗与整理，运用SPSS 26.0软件进行单因素分析，依据数据分布正态与否，研究指标改革前后比较分别采用配对样本t检验（以均值和标准差表示）与Wilcoxon符号秩检验（以中位数和四分位数表示），并使用Stata 15.0软件建立间断时间序列模型，以上分析统计学检验水准为α=0.05。
2　结果
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2.1　职工医保门诊共济改革前后医药机构高血压患者基本情况
本研究共纳入L市药店诊疗购药的高血压病例158 474条，其中职工医保门诊共济改革前53 995（34.07%）条，改革后104 479（65.93%）条。经单因素分析，可知改革前后药店高血压患者的次均医疗费总额、次均西药费、次均中草药费、次均个人账户支出、次均个人支付金额、次均基金支付总额，差异均具有统计学意义（P<0.05），且改革后次均医疗费总额、次均西药费、次均个人账户支出、次均个人支付金额、次均基金支付总额的整体水平均低于改革前，但改革后的次均中草药费整体水平较改革前提高，而改革前后药店高血压患者的次均中成药费变化平稳（P>0.05）。详见表1。
本研究共纳入L市医疗机构就诊的高血压患者530 036条，其中职工医保门诊共济改革前243 728（45.98%）条，改革后286 308（54.02%）条。经单因素分析，可知改革前后医疗机构高血压患者的次均医疗费总额、次均西药费、次均中成药费、次均中草药费、次均个人账户支出、次均个人支付金额、次均基金支付总额，差异均具有统计学意义（P<0.05），且改革后的次均医疗费总额、次均西药费、次均中成药费、次均个人账户支出、次均个人支付金额、次均基金支付总额的整体水平均低于改革前，但改革后的次均中草药费整体水平较改革前提高。详见表2。
2.2　职工医保门诊共济改革前后医药机构高血压患者门诊费用变化情况
L市职工医保门诊共济改革前，医疗机构高血压患者门诊的次均医疗费总额变化趋势平稳（β1= -3.49，P>0.05），改革时费用水平变化幅度小（β2=2.95，P>0.05），改革后变化趋势平稳（β8= -2.30，P>0.05）；药店高血压患者的次均医疗费总额改革前呈现略上升趋势（综合β1、β5），改革时费用水平下降约38.32元（综合β2、β6），改革后以16.02元/月呈现下降的变化趋势（β9= -8.01，P<0.05）（表3、图2A）。
就次均西药费而言，L市职工医保门诊共济改革前，医疗机构高血压患者门诊的次均西药费变化趋势平稳（β1=1.07，P>0.05），改革时费用水平变化幅度小（β2= -21.43，P>0.05），改革后变化趋势平稳（β8= -0.96，P>0.05）；药店高血压患者的次均西药费改革前变化趋势平稳（综合β1、β5），改革时费用水平略下降约26.50元（综合β2、β6），改革后以16.14元/月呈现下降的变化趋势（β9= -8.07，P<0.05）（表3、图2B）。
从次均中成药费来看，L市职工医保门诊共济改革前，医疗机构高血压患者的门诊次均中成药费变化趋势平稳（β1=1.22，P>0.05），改革时费用水平变化幅度小（β2= -15.74，P>0.05），改革后变化趋势平稳（β8= -0.50，P>0.05）；药店高血压患者的次均中成药费改革前呈现上升趋势（综合β1、β5），改革时费用水平下降约14.50元（综合β2、β6），改革后以0.46元/月呈现下降的变化趋势（β9= -0.23，P<0.05）（表3、图2C）。
就次均中草药费而言，L市职工医保门诊共济改革前，医疗机构高血压患者的门诊次均中草药费变化趋势平稳（β1= -0.01，P>0.05），改革时费用水平上升4.23元（β2=4.23，P<0.05），改革后以0.30元/月呈现下降的变化趋势（β8= -0.15，P<0.05）；药店高血压患者的次均中草药费改革前变化趋势平稳（综合β1、β5），改革时费用水平上升约2.26元（综合β2、β6），改革后以0.60元/月呈现上升的变化趋势（β9=0.30，P<0.05）（表3、图2D）。
就次均个人账户支出而言，L市职工医保门诊共济改革前，医疗机构高血压患者门诊的次均个人账户支出变化趋势平稳（β1=0.74，P>0.05），改革时支出水平下降17.00元（β2= -17.00，P<0.05），改革后以2.10元/月呈现下降的变化趋势（β8= -1.05，P<0.05）；药店高血压患者的次均个人账户支出改革前呈现略上升趋势（综合β1、β5），改革时支出水平下降约21.48元（综合β2、β6），改革后以3.44元/月呈现下降的变化趋势（β9= -1.72，P<0.05）（表3、图2E）。
从次均个人支付金额来看，L市职工医保门诊共济改革前，医疗机构高血压患者的门诊次均个人支付金额变化趋势平稳（β1= -1.22，P>0.05），改革时支出水平变化幅度小（β2= -6.56，P>0.05），改革后以2.10元/月呈现下降的变化趋势（β8= -1.05，P<0.05）；药店高血压患者的次均个人支付金额改革前呈现略上升趋势（综合β1、β5），改革时支出水平下降约21.18元（综合β2、β6），改革后以3.56元/月呈现下降的变化趋势（β9= -1.78，P<0.05）（表3、图2F）。
就次均基金支付总额而言，L市职工医保门诊共济改革前，医疗机构高血压患者的门诊次均基金支付总额变化趋势平稳（β1= -2.27，P>0.05），改革时支出水平变化幅度小（β2=9.50，P>0.05），改革后变化趋势平稳（β8= -1.25，P>0.05）；药店高血压患者的次均基金支付总额改革前变化趋势平稳（综合β1、β5），改革时支出水平下降约17.15元（综合β2、β6），改革后以12.46元/月呈现下降的变化趋势（β9= -6.23，P<0.05）（表3、图2G）。
3　讨论
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3.1　职工医保门诊共济制度改革降低医药机构门诊费用整体水平
研究结果显示，在职工医保门诊共济制度改革后，药店和医疗机构的门诊整体费用水平均显著降低，提示门诊共济制度改革在一定程度上缓解了高血压患者的医疗费用负担，但改革后次均医保支付保障能力存在阶段性下降。这可能是因为职工医保门诊共济制度改革初期，医保门诊共济人数增多，对医保支付保障能力和基金稳健运行提出更高要求，医保主管部门对医药机构各项费用监管控制更为严格，在一定程度上使得门诊整体费用水平降低。此外，职工医保共济制度改革导致个人账户资金减少，个人支付金额随之降低，基金支付总额在确保全人群医疗保障的前提下，次均保障支出水平将降低，进而导致医保报销比例相对减少，人均获得的医保保障能力变弱。
3.2　职工医保门诊共济制度改革促进医药机构中草药利用水平
研究结果显示，职工医保门诊共济制度改革后，无论药店还是医疗机构，其中草药费的整体费用水平均明显上升，提示职工门诊共济制度改革在一定程度上促进中医药的利用。职工医保门诊共济制度设定的目标之一是扩大医疗机构医保报销范围、提高门诊医疗保障待遇，而在一些慢性病治疗过程中，国家政策层面也是积极支持利用中医药开展诊疗服务，这使得部分中草药更容易被纳入医保报销范围，并获得医保基金支持，从而增加其被选择使用的几率。除此之外，中草药作为一种相对经济的治疗手段，可以帮助患者减轻医疗费用，并降低医保基金报销压力，患者能够在享受医保政策支持的同时，也愿意选择更加经济安全的治疗方式，进一步导致医药机构的中草药使用率提高。
3.3　职工医保门诊共济制度改革对药店医保报销影响程度强于医疗机构
研究结果显示，职工医保门诊共济制度改革后，药店和医疗机构的基金支付总额下降速度大于患者个人支付金额的下降速度，提示医保报销次均支持力度都相对变弱，而药店被影响的程度较医疗机构更强，其不仅基金支付总额的整体降幅远大于个人支付金额的整体降幅，且其次均基金支付总额在改革后呈现出更加明显的下降变化趋势。当然，药店医保报销支付比例相对降低，一方面是因为门诊共济改革的医保基金报销盘子扩大，人均获得医保支持将阶段性弱化，为保障医保基金健康可持续发展，医药机构面临的医保监管和药品报销限制相对更加严格；另一方面，职工门诊共济制度改革重点关注的是医疗机构的门诊待遇保障提升，当患者获得门诊医保报销支持，会愈加倾向医疗机构以获得更加规范的诊疗用药服务，这必将促进更多的医保基金流向医疗机构，造成药店所获得的医保基金支持相对减少。
综上，职工医保门诊共济制度改革促使医药机构高血压患者的门诊费用整体水平降低，在一定程度上缓解了高血压患者的疾病经济负担，然医保支付保障能力在改革初期存在阶段性下降，次均医保报销力度相对降低，且药店较医疗机构受之影响更甚，这对保障职工获取合理门诊医疗服务不利。故而，要进一步优化门诊医保支付结构，合理设定“两线一比例”，确保医保基金兜底能力稳定，并用活个人账户沉淀资金，提升医保基金使用效率，逐步提高门诊医保待遇水平[4]。其次，要强化对中草药的医保政策支持，发挥中医药在高血压等慢病治疗中的积极作用，并有效完善药店医保报销管理制度，扩大药店报销范围和报销比例，解决患者用药的最后一公里问题。最后，要进一步完善职工医保门诊共济政策，推动门诊基金市级统筹向省级统筹转变提升，医保报销制度向退休和疾病负担重的人群倾斜，并建立医保共济基金全过程、全领域、全方位的审核监督机制，促进医药机构精细化管理。总之，要统筹做好职工门诊共济改革与其他各项政策的衔接工作，建立完善的医疗管理、医保支付、医药供应三方联动制度，并同步优化慢性病门诊管理方案，以确保门诊医疗保障的可持续健康发展和人民群众真正从中获益。
基金
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  • 国家中医药管理局资助项目(ZYZB-2023-435; GZY-FJS-2022-045)
文献
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2025年第52卷第18期
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doi: 10.20043/j.cnki.MPM.202505099
  • 接收时间：2025-05-09
  • 首发时间：2026-02-10
  • 出版时间：2025-09-25
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  • 收稿日期：2025-05-09
基金
国家中医药管理局资助项目(ZYZB-2023-435; GZY-FJS-2022-045)
作者信息
    1．北京中医药大学中医学院，北京　102400
    2．北京中医药大学管理学院
    3．甘肃中医药大学卫生管理学院
    4．北京中医药大学国家中医药发展与战略研究院

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