建立健全门诊高额医疗费用保障机制,是进一步推进门诊共济保障机制落实的重要内容。本研究通过政策对比分析发现,广东省普通门诊政策有一定优越性。其不设起付线或起付线较低,报销比例普遍高于省外对标城市,或待遇水平与省外对标城市持平,但是普通门诊统筹年度最高支付限额低于省外对标城市。通过医保基金可承受性测算发现,在门诊费用按照历史最高增幅并实施全额报销的情况下,执行门诊高额医疗费用保障政策对广东省各地医保基金累计结存的影响仍在可承受范围之内。因此,建议广东省在全省范围内推行门诊高额医疗费用保障政策,各地制定适宜的起付标准和报销比例;持续完善该政策与现行政策的衔接,优化参保患者就医管理;提升医疗机构门诊服务能力;积极探索适宜的门诊支付方式等配套措施;织牢医保基金监管网络,确保政策协同高效推进。

Establishing and improving the safeguard mechanism of high medical expenses for outpatient services is a key step toward strengthening the outpatient mutual aid mechanism. Through comparative policy analysis, this study reveals that Guangdong Province's general outpatient policy has certain advantages, which implements a zero or low deductible, the reimbursement rate generally exceeds reference cities in other provinces, or the benefit level is comparable to reference cities in other provinces. However, the annual maximum payment limits for the general outpatient pool are set lower than those in the reference cities in other provinces. Affordability assessments of the medical insurance funds show that even under the scenario featuring both high outpatient cost growth and full reimbursement, the impact of a high-cost outpatient guarantee policy on the accumulated balance of the funds remains manageable across all cities in Guangdong Province. Therefore, it is recommended that Guangdong Province implement a policy to cover high outpatient expenses across the province, with local cities setting appropriate deductible standards and reimbursement ratios. It is also recommended to continuously improve the alignment between the policy to cover high outpatient expenses and existing medical insurance policies, optimize the medical management of insured patients, enhance the outpatient service capabilities of medical institutions, actively explore suitable outpatient payment methods and other supporting policy, and strengthen the supervision of medical insurance funds to ensure efficient and coordinated policy execution.