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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 study and formulate the evaluation index system of medical insurance in urban community health service institutions and to promote the reasonable, effective and full utilization of medical and health resources by community health service institutions on the premise of ensuring the quality of basic medical services. Methods Consultants were selected from three aspects: health insurance supervision and management, community health care management and clinical management. According to the proposed evaluation index system model, two rounds of questionnaires were designed. According to the requirements of Del-phimethod, Consultation activities to experts “back to back ” fill out the consultation form. The first round of expert consultation using the integrated index method of the proposed assessment index system model screening to determine the assessment indicators; the second round of expert advice using the method of expert assignment to the first round of expert advice and statistics to determine the weight of the index system. Results The recovery rates of the two rounds of questionnaires were 95.05% and 89.71% respectively, and the experts’ authority was above 0.8. Finally, it has identified 5 first-level indicators and 27 second-level indicators, and formulated a weighting system for assessment indicators. Conclusion The assessment index system is based on the inspection indexes of Shanghai Medical Insurance Bureau, Shanghai Medical Insurance Superintendent and medical insurance designated medical institutions in the jurisdiction, with the focus on standardizing medical behaviors and managing medical insurance funds. The indicator system can be urban community Health care services to assess the health care management to provide reference information.