目的: 分析职工医保门诊统筹对参保职工健康水平、就医行为选择及自付医疗费用的影响,为完善职工医保门诊统筹制度提供政策建议。方法: 基于中国健康与养老追踪调查数据库和样本城市的职工医保门诊报销政策文件,采用OLS回归、Probit回归、倾向得分匹配、工具变量法等探究门诊统筹制度的政策效应。结果: 门诊统筹制度能够显著改善参保职工的健康状况,减轻参保职工的医疗负担并改善其过度利用住院服务的行为。改革带来的政策效应在不同参保群体中存在显著异质性,受在职退休情况、收入水平和健康状况的影响。综合来说,“无封顶线或高封顶线”的门诊保障模式对提升参保职工健康水平、优化就医行为和减轻个人医疗负担效果最为显著。结论: 门诊统筹制度显示出显著的政策效应,建议有条件的地方逐步提高门诊统筹保障水平,可参照并探索实行“无封顶线或高封顶线”的门诊统筹保障方式,从而最大化实现职工医保门诊统筹的政策效果。建议各地区在调整门诊统筹的支付比例时,可以考虑适当对退休人员以及生理健康状况较差、面临更大健康风险的健康弱势群体进行政策倾斜。同时,加强对门诊统筹制度实施效果的长期跟踪评估,及时总结经验和改进不足之处。

Objective: The paper analyzes the impact of outpatient overall planning of employees’ medical insurance on the health level, medical treatment behavior choice and out-of-pocket medical expenses of insured employees, in order to provide policy suggestions for improving the outpatient overall planning system of employees’ medical insurance. Methods: Based on the China Health and Retirement Longitudinal Study and the outpatient reimbursement policy documents of employees’ medical insurance in sample cities, OLS regression, probit regression, propensity score matching, instrumental variable method and other methods were used to explore the policy effect of outpatient overall planning system. Results: The outpatient overall planning system could significantly improve the health status of insured employees, reduce the medical burden of insured employees, and improve their overuse of inpatient services. There is significant heterogeneity in the policy effects of the reform among different insured groups, which is affected by the employment and retirement status, income level and health status. On the whole, the outpatient insurance model of "no cap line or high cap line" has the most significant effect on improving the health level, optimizing medical treatment behavior and reducing personal medical burden of insured employees. Conclusion: The outpatient overall planning system has shown significant policy effects. It is recommended that places with favorable conditions gradually improve the level of outpatient coordination and guarantee. It is possible to refer to and explore the implementation of "no cap line or high cap line" outpatient coordination and guarantee methods, in order to maximize the policy effect of employees’ medical insurance outpatient overall planning. It is suggested that when adjusting the payment ratio for outpatient overall planning, regions can consider giving appropriate policy preferences to retirees and vulnerable groups with poor physical health conditions and facing greater health risks. At the same time, we should strengthen the long-term tracking and evaluation of the implementation effect of the outpatient coordination system, timely summarize experience and improve shortcomings.