目的: 总结与分析门诊共济改革下职工普通门诊统筹保障的待遇设计现状和职工医疗服务利用变化情况,为完善职工门诊保障机制提供参考。方法: 通过检索各地区医保局官方发布内容,系统梳理与分析全国统筹地区的职工普通门诊统筹起付线、封顶线和报销比例。利用南京市的职工医保门诊数据,分析政策实施前后职工医保门诊医疗服务利用变化情况。结果: 各地区职工普通门诊统筹待遇设计形式与保障水平差异较大。政策实施后,南京市职工医保门诊就诊量、医疗费用以及统筹基金支出均有明显增长,另外高年龄段就诊人数、高费用段人数和年末门诊费用增长幅度较为突出。结论: 需进一步优化职工普通门诊统筹待遇设计,强化基层首诊引导,加强门诊系统监管,促进实现职工医保门诊保障机制的公平性和可持续性以及分级诊疗制度建设。

Objective: This study aims to offer insights for enhancing the outpatient security mechanism for employees, by summarizing and analyzing the current situation of general outpatient coordination benefits design and examining the changes in employees’ medical services utilization after the implementation of the outpatient mutual aid reform. Methods: By searching for policy documents on the official websites of healthcare security administration, this study systematically reviewed and analyzed the deductible, cap, and reimbursement rate of general outpatient coordination across all coordinated regions. Additionally, outpatient data from employees’ medical insurance in Nanjing City were used to assess changes in outpatient medical services utilization before and after the policy implementation. Results: The design of general outpatient coordination benefits and the guarantee level for employees varied across regions. After the implementation of the policy, there was a noticeable increase in outpatient visits, medical expenses and the expenditure of the pooling fund in Nanjing City, with more pronounced increases in the number of patients in the elder group, the number of high-cost segments and year-end costs. Conclusion: It is necessary to further optimize the design of general outpatient coordination benefits, strengthen the guidance for primary care visits, enhance the supervision of the outpatient medical services system, in order to achieve fairness and sustainability in the outpatient guarantee mechanism for employees as well as to promote the construction of a hierarchical medical system.