当量法在社区卫生服务机构成本核算和绩效评价中的应用研究

The Application of Equivalent Method for Cost Accounting and Performance Management in Community Healthcare Institutions

背景在社区卫生服务机构推进“公益一类财政保障、公益二类绩效管理”的背景下,如何合理确定保障水平、科学评定绩效是目前卫生行政部门的管理难点。目的在利用当量法测算社区成本消耗的基础上,结合数据包络分析(DEA)法对机构运行效率进行评价。尝试建立成本与绩效相结合的社区卫生服务机构投入与管理模式,通过当量法成本核算为社区各项资源精准、科学投入提供依据,通过效率评价为不同特点社区进行绩效评价提供数据基础。方法以2019—2020年14家社区卫生服务机构的财务和人员等真实数据为原型,基于各机构卫生财务报表,以及医院信息系统(HIS)、妇幼保健和慢性病管理等系统导出数据,结合焦点小组访谈,获取相关资料。利用当量法对医疗和公共卫生服务项目进行全成本核算,利用超效率DEA对14家样本机构运行效率进行评价及分析。结果以1次标准的全科门诊服务(15 min)为1个标准服务当量,2019年和2020年14家机构的每当量成本平均为67.64元和69.80元。基本医疗服务的每当量成本高于公共卫生服务(2019年分别为167.14元和18.86元,2020年分别为215.43元和19.78元),且机构间差异性更大。不同机构的特点不同:S1以基本医疗为主,基本医疗服务总量和效率明显高于其他社区;S9则注重公共卫生服务,且公共卫生服务效率最佳。2020年,14家机构共提供新型冠状病毒感染疫情防控相关服务13.48万当量,成本消耗为103.78万元。2019年和2020年,14家机构中均只有2家机构达到了综合效率相对有效,≥50.0%的机构能够达到纯技术效率有效,综合效率无效的机构主要由规模效率无效导致,且主要为规模效益递增。结论当量法可提供一个相对统一的“标尺”,实现不同类型社区卫生服务机构服务效率的标准化,为卫生行政部门分类补偿提供“抓手”,有助于社区卫生服务机构有特色、高水平发展。无论是基本医疗服务,还是公共卫生服务,多呈规模效益递增状态,提示可通过增加社区卫生服务机构人/财/物投入、精准补偿来提升服务产出效率。

Background During the promotion of category-based management for community healthcare institutions(class 1 institutions obtain the financial security,and class 2 institutions implement a performance management system),how to appropriately determine the security level and scientifically evaluate the performance is a difficulty to tackle for health administrative departments.Objective To assess the operational efficiency of community healthcare institutions with the data envelopment analysis(DEA) using the information of costs of these institutions calculated using the equivalent method,then attempt to develop an input and management model of integrating cost accounting and performance management for these institutions,providing a theoretical basis for accurate and scientific input of various resources into the community through cost measurement with equivalent method,and a data basis for performance assessment in communities with different characteristics through efficiency evaluation.Methods The real data(financial status and staffing) of 14 community healthcare institutions during 2019 to 2020 were collected from their financial reports,hospital information system,maternal and child healthcare information system,chronic disease management information system,as well as focus group interviews.The equivalent method was used to calculate the total costs of medical services and public health services.The super-efficiency DEA was used to evaluate and analyze the operational efficiency of the 14 sample institutions.Results (1)The average cost of one equivalent service(a general medical outpatient service lasting for 15 minutes was defined as one standard service equivalent unit) was 67.64 yuan in 2019 and 69.80 yuan in 2020 for the 14 institutions.The average cost of one equivalent essential medical service was higher than that of one equivalent public health service in both 2019(167.14 yuan vs 18.86 yuan) and 2020(215.43 yuan vs 19.78 yuan).The institutions demonstrated significant differences in the average cost of one equivalent essential medical service and the average cost of one equivalent public health service.(2)Each institution had its own peculiar characteristics.For example,S1 institution mainly provided essential medical services,and had higher total equivalent essential medical services and efficiency than other institutions,while S9 institution focused on providing public health services,and had the highest efficiency in delivering public health services.(3)In 2020,the 14 institutions provided 134 800 equivalent COVID-19-related services,with a cost of 1.037 8 million yuan.(4)In 2019 and 2020,only two institutions were relatively overall efficient,and ≥ 50.0% institutions were pure technically efficient.The institutions with overall operational inefficiency were mainly caused by scale inefficiency primarily due to increasing returns to scale.Conclusion The equivalent method provides a relatively unified "scale" to standardize the service efficiency of different types of community healthcare institutions,provides support for health administrative departments implementing category-based compensation for the institutions,benefiting the featured and high-level development of community healthcare institutions.Either institutions delivering essential medical services or those delivering public health services,mainly present increasing returns to scale,suggesting that the efficiency of these institutions can be improved by increasing the human/financial/material input into the institutions and providing precise compensation for them.