摘要
目的提升职工医保门诊统筹定点药店(简称定点药店)的管理水平。方法采用计算机检索湖北省及其17个市/州/区人民政府、医疗保障局官方网站及微信公众号,中国知网的定点药店相关政策文件,检索时限截至2024年11月,采用ROST CM 6软件对政策文本进行词频统计和语义网络分析;通过湖北政务服务网检索湖北省17个市/州/区的定点药店数量,通过湖北省17个市/州/区医疗保障局官方网站获取电子处方流转人次,检索时限截至2025年1月,分析湖北省17个市/州/区相关政策发布与实施现状及面临的困境,并提出针对性建议。结果湖北省定点药店政策多聚焦药品使用、医保支付待遇和具体管理细则等;湖北省17个市/州/区定点药店数量共有23180家,其中纳入门诊统筹的定点药店16817家,其中武汉市纳入最多(4667家);门诊统筹待遇上,多数市/州/区在职职工最高支付限额2000元,退休人员最高支付限额普遍高于在职职工,其中武汉市、襄阳市和咸宁市最高支付限额均超过3000元;电子处方流转人次排名前3的为武汉市(21097次)、荆州市(9370次)、襄阳市(9315次);各市/州/区的医保控费、基金监管也存在较大差异。实际运行中面临着定点药店布局、药店报销待遇、电子处方流转、医保控费及基金监管等问题。结论为促进定点药店更好地持续发展,建议做好门诊统筹定点药店布局规划,建立“有进有出”动态调整机制;优化定点药店待遇设计,持续推动分级诊疗落地;规范流转管理流程,大力推进电子处方流转;完善控费激励约束机制,加强医保基金监管力度。
Objective To improve the management level of designated drugstores for employee medical insurance outpatient pooling.Methods The policy documents related to designated drugstores in the official website and WeChat official account of the People´s Government Websites and the Medical Security Bureau of Hubei Province and 17 cities,autonomous prefectures,and districts in Hubei Province,and CNKI were searched as of November 2024,and the ROST CM 6 software was used to perform word frequency statistics and semantic network analysis on policy texts.The number of designated drugstores in 17 cities,autonomous prefectures,and districts in Hubei Province was retrieved through the Hubei Government Service Network as of January 2025,and the number of electronic prescription circulation was obtained through the official websites of the Medical Insurance Bureau of 17 cities,autonomous prefectures,and districts in Hubei Province as of January 2025,and the Excel 2017 was used to analyze the current situation and challenges faced by the implementation of relevant policies in 17 cities,autonomous prefectures,and districts in Hubei Province,and targeted suggestions were put forward.Results The policies of designated drugstores in Hubei Province mainly focus on drug use,medical insurance payment benefits,and specific management rules.A total of 23180 designated drugstores were in 17 cities,autonomous prefectures,and districts in Hubei Province,including 16817 designated drugstores included in outpatient coordination,ranking first in Wuhan(4667 designated drugstores).In terms of outpatient treatment,the maximum payment limit for in-service employees in most cities,autonomous prefectures,and districts was higher than CNY 2000,and the maximum payment limit for retirees was generally higher than that for in-service employees.Among them,the maximum payment limits for Wuhan,Xiangyang,and Xianning all higher than CNY 3000.The top three cities in terms of electronic prescription circulation were Wuhan(21097 times),Jingzhou(9370 times),and Xiangyang(9315 times).There were also significant differences in the cost control and fund supervision of medical insurance funds among various cities,autonomous prefectures,and districts.In actual operation,it had problems such as the layout of designated drugstores,reimbursement benefits for drugstores,electronic prescription circulation,medical insurance fund fee control,and fund supervision.Conclusion In order to promote the sustainable development of designated drugstores,it is recommended to do a good job in the layout planning of outpatient pharmacies and establish a dynamic adjustment mechanism of"in-and-out",optimize the design of designated drugstores and continue to promote the implementation of tiered diagnosis and treatment,standardize the circulation management process and vigorously promote the circulation of electronic prescriptions,improve the incentive and restraint mechanism for cost control,and strengthen the supervision of medical insurance funds.
作者
彭逸伦
郑洋洋
李秋月
王超群
李佑生
肖忠虎
李嘉星
马代炬
PENG Yilun;ZHENG Yangyang;LI Qiuyue;WANG Chaoqun;LI Yousheng;XIAO Zhonghu;LI Jiaxing;MA Daiju(Xiangyang No.1 People′s Hospital,Hubei University of Medicine,Xiangyang,Hubei 441000,China;School of Public Health and Health,Hubei University of Medicine,Shiyan,Hubei 442000,China;School of Public Administration,Central China Normal University,Wuhan,Hubei 430079,China;Xiangyang Medical Security Bureau,Xiangyang,Hubei 441000,China)
出处
《中国药业》
2026年第1期14-19,共6页
China Pharmaceuticals
基金
国家社会科学基金[24BRK024]
湖北医药学院卫生管理与卫生事业发展研究中心开放基金项目[2024YB005]
湖北医药学院附属襄阳市第一人民医院新引进博士人才科研启动金资助计划项目[XYY2023D06]
湖北医药学院研究生科技创新项目[YC2024062]。
关键词
职工医保
门诊统筹
定点药店
门诊共济
处方流转
政策文本
employee medical insurance
outpatient pooling
designated drugstores
outpatient mutual assistance
prescription circulation
policy text
