The Design of Adjustment Plans for General Outpatient Benefits of the Employee Basic Medical Insurance and Fund Expenditure Estimation under the Outpatient Mutual-Aid Policy
Han Zhiyan
Wu Min
Mu Xiaomin
Fan Qipeng
Lu Zhihong
Abstract：Objective:Promoting the continuous optimization of the outpatient mutural-aid program aid system for employee medical insurance.Methods:Grounded in the implementation of the outpatient mutual-aid reform for employee medical insurance in Shandong Province,three adjustment scenarios for general outpatient benefits were designed under the policy of"compensation exchange and fund transfer".A comparative analysis was then conducted through simulation modeling to evaluate the scale of pooled fund expenditure and its utilization efficiency.Results:With a pooled fund expenditure of 130.78 billion CNY,Plan Ⅰ would alleviate immediate fiscal pressure,but demonstrates poor efficiency in translating funds into accessible benefits.With an expenditure of 151.33 billion CNY,Plan C would push the fund utilization rate beyond the 100%threshold,posing a significant risk of insolvency.Requiring an expenditure of 141.85 billion CNY for a 95.23%utilization rate,Plan Ⅱ strikes a superior balance between meeting healthcare needs and ensuring fund sustainability,while also offering the distinct advantages of a seamless policy transition and the lowest implementation costs.Conclusion:Plan Ⅱ is recommended as a baseline model.Core parameters such as the deductible threshold and reimbursement rate should be scientifically calibrated.This should be complemented by the enhancement of intelligent monitoring capabilities,in order to provide a sustainable and operable pathway for advancing the reform of the coordinated outpatient coverage system.
Keywords：basic medical insurance for employeesoutpatient benefit adjustmentfund expenditureoutpatient mutual-aid program
Publication Date：2025-12-05
Online Publishing Date：2026-01-05(First online date of this platform, not the publication date of the document)
Pages：4( 36-39 )