天津市医保质量评价指标体系构建研究

Quality evaluation system for medical insurance in Tianjin

目的:提高天津市医保质量,为医保机构完善医疗保险制度提供科学依据。方法:采用专家咨询的方法对医保运行情况进行调查,并采用层次分析模型确定评价指标及其权重。结果:建立了一套由3个一级指标、9个二级指标、47个三级指标的连接医保机构、医疗机构和患者三方的医保质量评价指标体系,发现患者个人负担率、患者自费率、基金结余情况、药品费用、统筹基金支付情况是影响天津市医保质量的关键指标。结论:构建合理的医保质量评价指标体系是必要的,同时提高天津市医保质量需要制定和完善一系列医保政策。

Objective To improve the quality of medical insurance in Tianjin and to offer a scientific basis for the medical insurance institution to consummate the medical insurance system. Methods Investigation of the operational situation of medical insurance is based On expert consultation and analytic hierarchy process is used to determine the evaluation indexes and its weights. Results A quality evaluation system for medical insurance has been built with 3 primary indicators,9 secondary indicators and 47 tertiary indicators which connect the medical insurance institutions, hospitals and patients as well. What＇s more,it is found that personal burden rate, patients＇ self--paid expense rate, fund balance situation,drug cost along with paying situation of overall planning fund are 5 key indicators to influence Tianjin＇s medical insurance quality. Conclusions It is necessary to build a reasonable quality evaluation system for medical insurance and it calls for a series of policies on medical insurance to improve the quality of medical insurance system in Tianjin.