家庭医生签约服务绩效考核评价需求与对策分析

Demands and Strategies Analysis of Family Doctors' Performance Evaluation in the Delivery of Contracted Services in China

背景随着签约服务的深入推进,新的家庭医生服务模式将逐渐形成,建立国家层面的签约服务绩效考核指标体系越来越有必要。目的了解家庭医生签约服务绩效考核评价现状,分析卫生行政部门人员和基层医疗卫生机构负责人对家庭医生签约服务绩效考核内容、指标设置以及激励措施落实情况的认知情况,总结存在的问题,并提出政策建议。方法借助我国国家卫生健康委卫生发展研究中心2017年6—7月在全国范围内开展的家庭医生签约服务政策培训会,培训会分别在我国山东济南、河南郑州、湖南长沙及重庆市4个省会城市(直辖市)开展。选取来自全国32个省级及114个地市级卫生行政部门人员227名;同时采用典型抽样的方法,选取山东济南、河南郑州、湖南长沙及重庆市4个省会城市(直辖市)的364名基层医疗卫生机构负责人为研究对象。调查于2017年6—7月举行,自行设计调查问卷。问卷的主要内容包括:研究对象(基层医疗卫生管理者)的基本情况、对签约服务绩效考核指标设置情况的认知、对家庭医生签约服务激励措施落实情况的认知。共发放问卷620份,回收问卷591份,问卷的有效回收率95.3%。结果 591名基层医疗卫生管理者中,分别有70.1%(414/591)、92.0%(544/591)、70.1%(414/591)、68.4%(404/591)认为应设置全人群签约服务覆盖率、重点人群签约服务覆盖率、农村贫困人口签约服务覆盖率、计划生育特殊人群签约服务覆盖率;分别有92.4%(546/591)、81.6%(482/591)、72.6%(429/591)认为应当设置签约对象满意率、"签约服务包"设计内容完成率、签约对象电子健康档案合格率;分别有85.4%(505/591)、78.3%(463/591)、66.2%(391/591)认为应设置签约对象基层就诊率、签约对象签约医生就诊率、签约对象预约转诊率。591名基层医疗卫生管理者中,49.1%(290/591)反映本地区/机构有签约服务费等相关激励措施。回答有签约服务费等相关激励措施的290名基层医疗卫生管理者中,78.3%(227/290)反映签约服务费能够用于家庭医生团队激励,39.0%(113/290)反映签约服务费在绩效工资总量内。290名认为有签约服务费的应答者中,27.6%(80/290)反映来源于财政补助,31.4%(91/290)反映来源于医保基金,80.3%(232/290)反映来源于基本公共卫生服务项目经费,30.0%(87/290)反映来源于签约居民个人。结论较大比例的卫生行政部门人员和基层医疗卫生机构负责人认为家庭医生签约服务绩效考核指标应同时注重服务数量和质量指标,同时应加强基层首诊的落实。另外,建议保证签约服务经费来源,发挥考核评价的激励作用,对家庭医生收入做增量,调动家庭医生签约服务积极性。

Background As the implementation of contracted family doctor services is well developing,new service delivery models are forming,it is necessary to develop a national performance evaluation system for family doctors in the delivery of such services.Objective To investigate the status of family doctors' performance evaluation in the delivery of contracted services,and the awareness levels of the contents and indicators in the evaluation system for family doctors' performance in the delivery of such services,and implementation of incentives among the government health administrators and mangers of primary health care facilities,and to put forward solutions to existing problems.Methods This questionnaire survey was conducted at the national training sessions of supportive policies for contracted family doctor services held in Jinan,Zhengzhou and Changsha(provincial capitals of Shandong,Henan and Hunan Provinces) and Chongqing(a province-level municipality) during June to July 2017 by the China National Health Development Research Centre.The final participants were 591 trainees,including all the administrative workers(227 cases) from 32 provincial health administrative departments and 114 prefectural/municipal health administrative departments,and a convenience sample of managers(364 cases) from primary care facilities in Jinan,Zhengzhou,Changsha and Chongqing.A self-developed questionnaire was used,which consists of basic demographic data,awareness level of the setting of evaluation indicators for family doctors' performance and incentives for the implementation of contracted family doctor services.The survey achieved a response rate of 95.3%(591/620).Results In terms of quantitative assessment indicators that should be included,population coverage,key population coverage,rural poverty-stricken population coverage,and coverage of special population receiving family-planning services were proposed by 70.1%(414/591),92.0%(544/591),70.1%(414/591) and 68.4%(404/591) of the respondents,respectively.Moreover,target population's satisfaction rate,completion rate of contractual service package,and eligibility rate of electronic health records of the contracted residents were put forward by 92.4%(546/591),81.6%(482/591),and 72.6%(429/591) of the respondents,respectively.What's more,rate of initial consultation in primary care,rate of visiting the contracted family doctor for medical services,referral rate of the appointed patients were recommended by 85.4%(505/591),78.3%(463/591),and 66.2%(391/591)of the respondents,respectively.As for incentive system,290(49.1%) of the respondents reported that the contracted services were delivered with a fee in their region/ facility.Among them,78.3%(227/290) reported that the service fee was used to incentivize the family doctor team,and 39.0%(113/290)reported that that the service fee was included in the total performance-related pay.The funding source for the fee was reported to come from fiscal subsidies 〔27.6%(80/290)〕,medical insurance programs 〔31.4%(91/290)〕,essential public health service funding〔80.3%(232/290)〕,and out-of-pocket money of the residents receiving contracted services〔30.0%(87/290)〕.Conclusion Most of the health administrators and managerial workers of primary care thought that quantitative and qualitative indicators should be considered as the essential part of the system for assessing the performance of family doctors in delivering contracted services.Initial consultation in primary care should be promoted and be listed as an assessment indicator as well.Furthermore,in order to incentivize the family doctors and increase their enthusiasm for work by additional bonus payments,the funding sources for the fee for contracted services should be ensured.