Exploration and Implications of the Supervision of Outpatient Medical Insurance Funds in the United States Under the Background of Payment Reform

doi:10.19546/j.issn.1674-3830.2025.5.016

China Health Insurance ›› 2025, Vol. 0 ›› Issue (5) : 118-126. DOI: 10.19546/j.issn.1674-3830.2025.5.016

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Abstract

Payment method and fund supervision are both the cores of improving the quality and efficiency of medical insurance fund operation. Based on the analysis of the relevant achievements of domestic scholars, combined with a systematic review of the main payment methods and supervisory practice of the US outpatient health insurance fund, this study reveals that the US has constructed a composite outpatient medical insurance payments and established an outpatient medical insurance fund supervision system focusing on the entire process. These arrangements significantly improve outpatient medical insurance fund utilization efficiency while offering valuable insights for improving the management of outpatient medical insurance fund in China. Regarding payment methods, it is necessary to strengthen the budget management, taking the outpatient medical insurance payment method reform as an entry point to deepen the zero-base budget reform. Under the premise of clear payment expectation, the key to scientifically determining payment methods lies in the formulation of payment units and standards, which builds a solid foundation for reform. Regarding fund supervision, efforts should be made in multiple aspects such as the effectiveness of regulatory authorities, the participation mechanism of third-party institutions, the construction of cross-regional regulatory networks, and the application of intelligent regulatory means to improve the supervision system of outpatient medical insurance funds.

Key words

outpatient medical insurance / payment method / fund supervision / practice and exploration

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Exploration and Implications of the Supervision of Outpatient Medical Insurance Funds in the United States Under the Background of Payment Reform[J]. China Health Insurance. 2025, 0(5): 118-126 https://doi.org/10.19546/j.issn.1674-3830.2025.5.016

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