Page 67 - 南京医科大学社会科学版

第5期 总第136期 南京医科大学学报（社会科学版）京医科大学学报（社会科学版） ·
南
2026年10月 Journal of Nanjing Medical University（Social Sciences）of Nanjing Medical University（Social Sciences） · 511
Journal
17（11）：35-43 任”［J］. 中国医学伦理学，2025，38（5）：565-573
［15］张小娟，周德水. 基本医保参保人门诊医疗服务利用、 ［17］ 刘慧玲，赵恒伯，谢志勤，等. 2022 年江西省罕见病治
费用及风险分析［J］.中国卫生政策研究，2023，16（1）： 疗费用核算分析——基于 SHA2011［J］. 卫生经济研
36-41 究，2025，42（2）：46-50
［16］ 杨婕娱. 效益与公平：政府保障罕见病患者的“弱势责 （本文编辑：姜 鑫）

Heterogeneity in China’s outpatient chronic and special disease benefit

schemes：evidence from four disease categories

1 1 1 1 2
Zhang Xiaojuan ，Ye Yuan ，Peng Bo ，Liu Yang ，Zhu Kun
1. Institute of Medical Information，Peking Union Medical College，Chinese Academy of Medical Sciences，Beijing 100020；
2. Social Development Research Center，China Academy of Fiscal Sciences，Beijing 100142，China
Abstract：This study analyzes the inter⁃provincial differences in the outpatient chronic and special disease
guarantee policies across four major categories of diseases，including digestive system diseases，nervous system
diseases，heart diseases，and rare diseases. Drawing on policy documents and medical insurance statistics from
27 provinces，this study combines literature analysis and quantitative research methods to assess the inter ⁃
provincial differences. The research results show substantial inter⁃provincial differences in the scope of disease
coverage，which is associated with some extent with general outpatient pooling levels in each province. The
level of treatment guarantee for the same disease varies considerably across different provinces. In addition，the
outpatient chronic and special disease guarantee system for rare diseases remains inadequate，with insufficient
coverage. Three recommendations are proposed to address the above problems. First，the medical insurance
treatment coverage system that emphasizes inpatient care over outpatient care should be reformed to improve the
general outpatient care coverage system，while promoting the transformation of the chronic and special disease
coverage model from expanding disease coverage to sharing cost risks. Second，it is essential to rely on big data
technology to reasonably identify diseases with high medical costs， standardize coverage standards， and
strengthen inter ⁃ provincial policy coordination. Third，this study recommends establishing a multi ⁃ level and
diversified coverage mechanism for rare diseases to effectively improve the equity of outpatient coverage for
chronic and special diseases.
Key words：outpatient chronic and special disease；inter⁃provincial differences；risk diversification