城市社区卫生服务机构医疗保险工作考核指标体系的构建

Construction of Evaluation System for Health Insurance in Urban Community Health Services

目的研究制定城市社区卫生服务机构医疗保险工作考核指标体系,推进社区卫生服务机构在保障基本医疗质量的前提下合理、有效和充分地利用医疗卫生资源。方法从医保监督管理、社区卫生服务机构医保管理和临床等三方面选取咨询专家,根据拟定的评价指标体系模型,设计两轮专家调查问卷,按照德尔菲专家咨询法(Del-phimethod)的要求,咨询活动以专家"背靠背"填写咨询表的方式进行。第一轮专家咨询运用综合指数法对拟定的考核指标体系模型进行筛选,确定考核指标;第二轮专家咨询运用专家赋值法对第一轮专家咨询统计整理的指标体系确定权重。结果两轮咨询问卷的回收率分别为95.05%、89.71%,专家权威程度均在0.8以上。最终确定了一级指标5项,二级指标27项,并制定考核指标权重体系。结论本考核指标体系以上海市医保局、上海市医疗保险监督所及辖区内医疗保险定点医疗机构的检查指标为基础,以规范医疗行为、管理医保基金为关注点,此指标体系可为城市社区卫生服务机构医保管理工作评估提供参考信息。

Objective To develop the evaluation index system for health insurance in urban community health services （CHS） so as to promote a reasonable, efficient and full use of medical and health resources in CHS institutions under the premise keeping basic medical quality. Methods The consultation experts were selected in three fields of health insurance surveillance, CHS health insurance management and clinical practice. Delphi method was used in two rounds of questionnaire survey according to indexes in drafted evaluation system model. The drafted indexes were screened by comprehensive index method in the first round experts＇ consultation so as to determine the appraisal indicators. Then the weight of each settled index in the first round was set by experts＇ evaluation in the second round. Results The recovery rates in the two rounds of questionnaire consultation were 95.05%and 89.71% respectively. The level of expert authority was more than 0. 8. The finally determined indicators were 5 as primary and 27 as second level. Then the indicator weight system was set up. Conclusion This evaluation system is set up based on the examination indexes designated by Shanghai Health Insurance Bureau and its subordinate governmental institutions, with foei being on normalizing medical behavior and management of health insurance fund. This system provides a good reference to evaluation of health care management in urban CHS.