上海市医保质量评价指标体系构建与政策优化研究

Construction of Medical Insurance Quality Evaluation Index System and Policy Optimization Research in Shanghai

摘要: 在全民医保体系日趋成熟的大背景下，医保的质量问题愈发显得重要，这要求对医保质量进行更为精细化的把控和管理。本文聚焦医保质量评价的研究动向，通过对专家学者的相关成果进行分析与拓展，进一步完善上海市的医保质量评价指标体系，旨在为上海市医保质量提升提供坚实的理论支撑和科学依据。为确保评价指标的科学性和实用性，采用专家打分法和层次分析法，构建了一个由3个一级指标、9个二级指标以及47个三级指标共同构成的医疗保险质量评价指标体系。这一体系紧密连接医保机构、医疗机构与患者三方，确保医保质量的全面、综合评估。基于对该医保质量评价指标体系的综合分析，进一步提出了推动上海市医保质量持续提升的政策建议，意在加强医保机构与医疗机构的协同合作、优化医保资源配置、提高医疗服务质量、降低患者负担，从而推动上海市医保体系向更加健康、高效的方向发展。

Abstract: In the context of the increasingly mature national medical insurance system, the quality of medical insurance has become increasingly important, which requires more refined control and management of medical insurance quality. This article focuses on the research trends of medical insurance quality evaluation, analyzes and expands on the relevant achievements of experts and scholars, further improves the evaluation index system of medical insurance quality in Shanghai, and aims to provide solid theoretical support and scientific basis for improving the quality of medical insurance in Shanghai. To ensure the scientificity and practicality of evaluation indicators, an expert scoring method and Analytic Hierarchy Process (AHP) were used to construct a medical insurance quality evaluation index system consisting of 3 primary indicators, 9 secondary indicators, and 47 tertiary indicators. This system closely connects medical insurance institutions, medical institutions, and patients, ensuring comprehensive and comprehensive evaluation of medical insurance quality. Based on a comprehensive analysis of the quality evaluation index system of medical insurance, policy recommendations are further proposed to promote the continuous improvement of medical insurance quality in Shanghai. The aim is to strengthen the collaborative cooperation between medical insurance institutions, optimize the allocation of medical insurance resources, improve the quality of medical services, and reduce the burden on patients, thereby promoting the development of Shanghai’s medical insurance system towards a healthier and more efficient direction.