《保险研究》20251009-《医保门诊共济保障如何促进分级诊疗？——基于准自然实验的实证研究》（段雪怡、刘宏）

［摘   要］加快建设以基层为重点的分级诊疗体系是我国深化医药卫生体制改革的重要任务。本文基于三医协同发展的视角，利用2012~2018年部分城市职工医保门诊共济保障政策实施的准自然实验，结合中国健康与养老追踪调查数据，探究门诊共济保障对患者就医选择的影响。研究发现，门诊共济保障显著提高了职工患者在基层医疗机构门诊就诊的概率和诊疗次数占比，同时减少了其前往综合医院门诊的次数。这一效应在高血压、糖尿病患者以及较低收入患者中更为明显。研究还揭示了门诊共济保障通过价格杠杆引导患者行为、提升基层医疗服务能力、与强基层建设协同增效的三重机制。此外，门诊共济保障提高了参保职工的就医满意度，降低了门诊就医的交通成本，但对基层住院行为没有显著影响。本研究为“三医”协同发展框架下的政策实践提供了实证支持，为完善门诊共济保障机制、推进分级诊疗体系建设、提升人民群众就医满意度提供了政策启示。

［关键词］门诊共济；基层门诊就医；协同发展

［基金项目］本研究得到国家社会科学基金重大项目“发展银发经济和增进老年福祉的政策研究”(24&ZD167)的资助。

［作者简介］段雪怡，中国人民大学劳动人事学院博士研究生；刘宏（通讯作者），中国人民大学劳动人事学院教授、博士生导师。

How Outpatient Cost-sharing Promotes Tiered Health Care Delivery?—Evidences from a Quasi-experiment in China

DUAN Xue-yi,LIU Hong

Abstract：Establishing a well-structured tiered healthcare delivery system is the key task of China’s health system reform.This paper examines the impact of outpatient cost-sharing reform on patients’ choices of outpatient care facilities from the perspective of the coordinated development of medical services and medical insurance.We employ a quasi-natural experiment based on the implementation of the outpatient cost-sharing pilot programs on some cities’ Urban Employee Basic Medical Insurance from 2012 to 2018,using data from the China Health and Retirement Longitudinal Study.The results show that the pilot program significantly increases the likelihood and share of outpatient visits to primary care facilities,while reducing visits to general hospitals.These effects were stronger among hypertensive,diabetic,and low-income patients.These changes primarily arise from price incentives,improvements in primary care quality,and coordination between outpatient insurance and the efforts to strengthen primary care.Additionally,the reform boosts patient satisfaction and reduces transportation costs for outpatient visits,though it has no significant effect on inpatient care at primary facilities.This study offers empirical support for policy practices under coordinated healthcare reform and provides valuable insights for enhancing the outpatient cost-sharing mechanism,advancing the tiered healthcare system,and improving patient satisfaction.

Key words：outpatient cost-sharing;primary care utilization;coordinated development