基于技术力的医师专业技术报酬测算及科内重分配制度研究

The current Physician Remuneration System in China inevitably stimulates physicians to be engaged in poor medical practices, such as prescribing more medicines and expensive medicines, and doing more medical checks, thereby leading to "expensive medical treatments". The keys to solve the problem "expensive medical treatments" lie in cutting off the relationship between physician income and such revenues as medicine sale revenues, scientifically measuring expertise values of physicians, and formulating a fair and incentive physician expertise remuneration system. By referring to the concept of resource-based relative value ratio, on the basis of studying a reasonable proportion of physician expertise remuneration to hospital medical revenue, the present study adopts time-action analysis, physician evaluation, Delphi method, so as to develop expertise evaluation indicators based on which physicians provide medical service items, to determine the ratio of relative importance for physician expertise values in various medical service items, and to establish the technological force-based physician remuneration estimating and calculating system; takes the balanced scorecard method, and 360-degree interviews with hospital leadership, department directors and physicians, so as to develop an in-Department physician expertise remuneration redistribution program; conducts actual measurement of data of a sample hospital in recent three years, and makes a comparison with the actual performance bonuses physician, so as to further clarify the effects. In this study, the physician expertise remuneration estimation and calculation and the in-Department redistribution system are implemented to the clinic items, and are linked with efforts and contributions while unlinked with other revenues such as medicine sales, thereby ensuring fairness and incentive, which will help reduce medical costs and, serve as reference for health care reform.

当前我国医师薪酬体系刺激医师多开药、开贵药、多做检查等不良医疗行为，导致"看病贵"。解决"看病贵"问题的关键在于切断医师收入与药品等收入的关系，科学测量医师专业技术价值，制定公平和激励的医师专业技术报酬制度。本研究引入以资源为基础的相对价值比率的理念，在研究医师专业技术报酬占医院医疗收入合理比例的基础上，采取时间动作分析、医师评价、Delphi法等，构建医师提供医疗服务项目的专业技术价值评估指标，确定各医疗服务项目中医师专业技术价值的相对重要比率，建立基于技术力的医师专业技术报酬测算制度；采取平衡计分卡法，360度访谈医院领导、科室主任和医师，制定科内医师专业技术报酬重分配方案；再以样本医院近三年数据进行实测，与实际医师绩效奖金比较，以验证效果。本研究的医师专业技术报酬测算及科内重分配制度落实到诊疗项目，与劳动付出挂钩，调动医师积极性，与药品等收入脱钩，利于降低医疗费用，可为医改提供参考。

当前我国医师薪酬体系刺激医师多开药、多做检查等不良医疗行为，导致“看病贵”。解决“看病贵”问题的关键在于切断医师收入与药品等收入的关系，科学测量医师专业技术价值，制定公平和激励的医师专业技术报酬制度。本研究在调研医师薪酬现状的基础上，引入以资源为基础的相对价值的理念，构建医师医疗服务项目的劳务价值评估指标，以影像医学科为样本医疗项目，确定影像医学医疗服务项目中医师专业技术价值的相对重要比率，建立基于技术力的医师专业技术报酬测算分配制度。主要分为五部分：（1）深入研究医疗服务劳动特性、国外医师薪酬模式以及RBRVS理论、价值导向型医疗等，总结了当前我国医师薪酬模式存在问题，提出了基于RBRVS设计医师绩效薪酬的理论基础；（2）基于薪酬满意度量表分别研究了某三甲医院和乡镇卫生院医务人员薪酬现状满意度，得出了影响医师薪酬满意度因素；（3）采取文献研究、问卷调查和专家访谈，确立了包括时间投入、劳动投入、技术投入、风险压力4个一级指标，操作前准备工作所需时间、操作中所需时间、操作完成后后续工作所需时间、脑力消耗程度、体力消耗程度、教育培训时间成本、教育培训成本、技术难度、技术繁杂程度、职业暴露风险、心理压力大小、责任压力12个二级指标的医师劳务价值评价指标体系；（4）对影像科537项医学项目进行了量值评估实测，研制出了537项影像医学项目医师劳务价值相对值表，为合理评价影像医学项目医师劳务价值提供了依据；（5）某三甲医院影像科2016年全年的工作量数据和绩效薪酬数据，借鉴参考RBRVS原理，基于影像医学相对值表计算绩效薪酬，设计影像科医生的绩效分配模式。. 研究显示，依据医师劳务价值评价指标体系，构建影像医学相对值表，可以科学合理评价医师劳务价值，据此设计的绩效分配模式落实到诊疗项目，与劳动付出挂钩，与药品等收入脱钩，确保公平和激励，也为整个医疗服务项目的医师劳务价值评定提供了模式，有益于调动医师积极性，减少不合理医疗费用。