基于德尔菲法的三级定点医疗机构医保绩效评价指标体系构建研究  

Research on the Construction of Medical Insurance Performance Evaluation Index System of Tertiary Designated Medical Institutions Based on Delphi Method

作　　者：何庆南 常维夫[1] 

机构地区：[1]中南大学湘雅三医院,长沙410013

出　　处：《中国医疗保险》2023年第4期25-30,共6页China Health Insurance

基　　金：国家医疗保障局(医药管理司)委托课题“定点医疗机构绩效考核指标体系研究”;湖南省自然科学基金青年项目“DRG支付背景下医保基金监管体系构建研究”(2022JJ40734)。

摘　　要：目的:构建三级定点医疗机构医保绩效考核指标体系,为进一步探索建立三级定点医疗机构医保精细化管理提供参考。方法:通过政策分析和专家咨询,初步构建三级定点医疗机构医保绩效考核指标体系;采用德尔菲法,邀请来自医保管理部门、医疗机构以及学术界的专家人员共21名,收集专家对三级定点医疗机构医保绩效考核指标体系的意见和建议。结果:确立了基础管理与保障措施、医疗质量及安全、医保基金使用效率、参保人员满意度等4个一级指标,合理诊疗、费用控制等14个二级指标,以及42个三级指标,作为绩效评价体系的主要内容。结论:该评价体系综合了不同地区医保管理部门所制定的评价指标,并咨询了医疗、医保等领域专家的意见,具有一定的可靠性和参考价值,可作为三级定点医疗机构医保绩效考核的有效工具。Objective:The paper develops a performance assessment indicator system for tertiary designated medical institutions,providing a reference for further exploration of refined medical insurance management within these institutions.Methods:Through the policy analysis and the expert consultation,a preliminary performance evaluation indicator system for tertiary designated medical institutions was constructed.Using the Delphi method,we invite 21 participants from medical insurance management departments,medical institutions,and academia to collect their opinions and suggestions for the performance evaluation indicator system for tertiary designated medical institutions.Results:4 primary indicators including basic management and security measures,medical quality and safety,efficiency of medical insurance fund,and satisfaction of the insured,14 secondary indicators including reasonable diagnosis and treatment,and cost management,and 42 tertiary indicators were established as the main content.Conclusion:This evaluation system refers to the evaluation indicators formulated by medical insurance management departments in different regions,and consults experts from the medical treatment and medical insurance fields.It is to some extent reliable and valuable,and can be used as a tool for performance evaluation of tertiary designated medical institutions in China,providing a reference for evaluating the medical service level of tertiary designated medical institutions.

关 键 词：定点医疗机构 绩效评价 评价指标体系 德尔菲法 

分 类 号：F840.684[经济管理—保险] C913.7[社会学]