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县级医院成本应摸得着底探得到边

提交者：jiuding发表时间：2014-6-12点击次数：2581来源:本站整理

　　核心阅读

　　作为公立医院改革突破口的县级医院，科学严谨的成本核算是其改革成功的重要基础。当前县级医院成本核算工作是否规范，能否实现科室全成本核算，成本数据是否具有可比性等问题，似乎没人能讲清楚。摸不着县级医院成本的底，这可不是个小事。

　　国家卫生计生委卫生发展研究中心研究员李卫平和北京中医药大学专家吴颖慧，从17个公立医院改革国家联系试点城市中，分别选取浙江省A市3县6所医院、安徽省B市4县8所医院及青海省C市3县6所医院，每个县选取1所综合医院及1所中医医院，共20所，分别作为东部、中部、西部地区代表，调查县级医院成本核算基础条件、开展科室成本核算的现状等。所有调查医院均为县级医院综合改革首批试点县医院。

　　调查发现，多数医院已开展不完全成本核算，具备一定基础，但成本意识不够强，数据缺乏可比性，核算人力不足，业务能力有待提高，信息系统缺乏整合，后勤服务管理较弱。建议完善成本核算组织体系，搭建区域成本核算平台，建立二级库存管理制度，培训专兼职成本核算员，进而规范县级医院成本核算工作。

　　稀里糊涂的成本核算

　　未能实现“实耗实销”

　　县级医院后勤服务管理最突出的问题是药品物资消耗管理不到位，虽通过HIS系统的相关模块进行管理，但却未能实现“实耗实销”。

　　医院采用一级库房管理模式，没有建立二级库存管理制度。一级库房管理药品和物资的入库、出库，出库数据只能反映科室的领用情况，而不能对具体消耗进行全程跟踪，不能将消耗与每个患者相对应，导致管理出现真空地带。二级库存，即各科室在一级库房领用药品或物资后所形成的库存，无人管理。

　　除了门诊药品消耗能“实耗实销”外，病房药品消耗和物资消耗全部采用“以领代销”模式，以科室领用作为科室消耗来确认成本。这不仅不利于控制库存，也无法体现成本核算的收支配比原则。另外，后勤服务科室未实现电算化，内部服务量统计由人工获得，也可能会影响数据采集的准确性。

　　根据调查，总务库房管理的办公用品等内部消耗，一般由总务科按月统计，个别医院按季度统计。关于科室房屋面积，35%医院已测量，50%医院部分测量，15%尚未测量。而多科室共用房屋的情况未做具体处理。对于水、电、气用量统计，只有1所医院在各科室单独安装了电表，两所医院在供应室、食堂等大用户科室单独安装水表，其余17所均未安装独立测量表。没有单独安装的原因主要是医院搬迁、房屋老旧安装困难等。对于内部服务量，如供应室、洗衣房、氧气组、总务班组（包含电工、电梯、汽车、锅炉房、维修等）的服务，70%医院手工统计到核算单元，30%医院未统计。以上问题将会给分摊系数的合理确定带来困难，最终影响成本核算结果的准确程度。

　　数据缺乏可比性

　　各调查医院对成本归集的方法和程度有一定差异，如大部分医院未计算无形资产摊销和提取医疗风险基金，门诊和住院未分开、跨科室服务如“双肩挑”的科室人员经费难以准确归集，以科室为单位发放的津贴等无法采集到个人。成本分摊方面，各医院虽采用了三级分摊方式，但三个省均对分摊方法无明确规定，各医院使用的方法不尽相同，多数只是简单地按人员比例、面积比例分摊，未做到分项分次分摊。影响区域内成本核算数据的真实性、准确性和可比性，对医院内部管理，政府经济决策的意义有限。

　　具体表现在：

　　1.核算单元设置不规范。

　　归类错误：如将手术科、麻醉科、血透室等医技科室划入临床类，输血科、药剂科等医技科室划入医辅类。划分过粗：如将药剂科与器械科合并为药械科。划分过细：如将急诊护理与急诊医学科平行设置。

　　名称不规范：如一病区、二病区指代不明。特殊单元：如将分院、所管辖社区卫生服务机构等独立核算的法人单位列入医院成本核算单元。

　　核算单元是成本归集与分摊的基础，划分不规范会给成本核算造成直接影响。

　　2.成本归集和分摊标准不同。

　　从一定意义上来说，成本核算的难点就是成本归集和成本分摊两大过程。定性访谈提到，县级医院未进行无形资产摊销，原因是医院内的无形资产非常少，所购置的软件已超出使用年限，不再摊销。而由于省里未规定提取医疗风险基金的比例，医院没有归集该类成本。在归集和分摊方法上，即使同一项成本，各医院的方法也不尽相同。如水电费，安装了独立测量表的医院按照科室耗用量直接计入科室，没有安装测量表的，有的按科室人数计算计入水费，按科室面积计算计入电费，有的则将水电费归集至总务科，作为管理费用，统一采用人员比例直接进行一级分摊。

　　核算口径不一致导致了数据的不可比。

　　成本核算人力不足

　　长期以来，我国的医院管理基本上是以医、教、研为中心，围绕这三方面建立了相应的财务、人事、后勤、临床管理体系。县级医院更是缺乏高素质的管理人才。

　　根据调查结果，只有8所医院在财务科设立了专职成本核算岗位，而临床、医技、医辅及其他行政后勤科室均未设立兼职核算员。有些县级医院规模小，财务科只有2人~3人，既负责会计核算、成本核算、账务管理，还负责人员工资、医保报销等。2012年新《医院财务制度》和《医院会计制度》实施后工作量大幅增加，工作负担较重。

　　医院管理人员的电算化能力薄弱，年纪较大的人甚至连常用的EXCEL表格计算都不熟悉。虽然经过一些培训，但多是半路出家，广度和深度难以满足成本核算要求，知识结构相对单一和非专业性，限制了成本核算工作效用发挥，加上缺乏思路、有畏难情绪，开展成本核算的主动性和责任感有待提高。

　　被调查医院财务科共361人，其中会计师93人，占总数的25.76%。从总体学历来看，本科占15.79%，大专占34.63%，中专及以下学历占47.92%，无学历1.66%。其中青海以大专学历为主，比例为56.47%，安徽和浙江以中专及以下学历为主，分别为57.5%、54.31%。从职称来看，有90人取得职称，占财务人员总数的24.93%。其中安徽和浙江取得学历的比例约为42%，明显高于青海的13%。另外，在财务科设置成本核算员岗位的有12所医院，但兼职比例达58%。可见县级医院财务人员少，学历和职称不高，主要以中专及以下学历、助理会计师为业务骨干，专业技术水平有限的现象比较普遍。

　　成本意识不强

　　被调查的20所县级医院中，有三级医院2所，二级医院18所。已经开展科室成本核算的医院占60%，绝大多数为综合医院。安徽开展的比例高于青海和浙江，未开展的均为中医医院。1/4的医院院长及主管领导对成本核算有较好的认识，15%较差。开展核算的目的普遍是为了绩效考核，为科室奖金分配提供依据。实施的均为不完全成本核算，核算基础与核算水平各有差异。核算结果并没有对医院精细化管理产生积极作用。

　　个别医院认为，将行政后勤成本分摊至临床科室后，造成临床成本增加，会挫伤医务人员积极性。原因可能是目前县级医院正处于扩张规模、发展医院业务的上升阶段，医院管理基础薄弱，成本核算没有得到足够重视，全员成本意识不强，积极性不够。

　　信息系统缺乏整合

　　调查发现，医院的信息系统可谓五花八门，即使同一县域的相同系统也会有不同厂商或不同的软件版本，各系统间几乎未建立数据接口。

　　当前医院的信息系统都是软件公司根据医院需要自行开发，操作平台、数据结构、程序编写风格各有不同，系统间基本上是独立作业，没有接口，数据只能从一个系统导出后再手工导入到另一个系统，难以保证数据完全一致，也会产生大量的重复劳动和数据二次加工。即使可以将部分数据批量导入，也同样耗费时间和人力进行数据核对。

　　医院虽能产出成本核算报表，但却不明白系统后台的计算原理，无法保证数据准确性。各医院希望有一个统一、科学的成本核算系统，系统间相互联网，数据共享，提高数据质量和工作效率，使成本信息能真正为医院控制成本、政府调整医疗服务价格和增加补偿提供参考。

　　核算要“有组织有纪律”

　　完善组织体系建议成立院长负责制的成本核算领导小组，分管院长及财务科、医务科、信息科、总务科、药剂科、器械科等多部门参与，科学划分到最小成本核算单元，制定配套的成本核算实施细则、考评办法等规章制度，以财务科为核算办公室，鼓励全员参与，强调成本核算的重要性，增强成本意识。

　　统一核算口径建议以原卫生部《医疗机构诊疗科目名录》为依据，建立县（市）级统一的成本核算单元设置及编码，医院将各信息系统中的科室编码对应到统一版本。信息系统间建立稳定接口，实现成本数据从源头上自动采集和生成。将每项成本的归集和分摊方法标准化，以县（市）为单位开发成本核算软件，在县（市）级层面建立区域端核算平台，各医院安装医院端核算软件。对于西部地区规模小、管理水平弱的中医医院，可考虑依托县人民医院共享核算平台。

　　建二级库存管理制度通过HIS系统中的药品管理模块和物资管理模块，详细登记入库和领用记录，并借助这两个模块辅助建立二级库存管理制度。一是采用“实耗实销”原则，当HIS系统确认医疗收费的同时，由该系统实时扣除耗用科室领用的记录。这种方式适用于与收费项目有一对一关系，并且能单独收费的药品和物资。二是品种管理方式，即医疗收费次数与药品物资的品种分别汇总后相互抵消，适用于品种单一、多规格、拆零使用（如纱布）或不能单独收费的药品和物资。同时要定期盘点核查，对二级库存的入库、领用、消耗同步跟踪。对于医院内部消耗的，如办公用品等，可由总务科专人登记反馈。有条件的医院应给各核算单元安装独立的水电表，提高成本的准确性。

　　设专兼职成本核算岗位在医院管理人员不足的情况下，优化人力资源配置，先建立会计核算及总务、药剂、器械、供应等部门的内层核算网络。在此基础上，再建立向临床、医技、医辅及其他科室延伸的表层核算网络，明确各核算单元专(兼)职核算员及职责。加强业务水平和电算化能力的培训。据了解，医院各类软件的开发与维护均由软件公司承担，每次软件升级、另加模块或提取数据均需向软件公司付费，有的软件公司维护员太少，甚至无法提供后续支持。建议在建立成本核算系统的过程中，以县或市为单位，组织医院培养一批系统管理维护专业人员，让医院由被动变主动。

　　（作者单位分别为：北京中医药大学国家卫生计生委卫生发展研究中心）

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_SERVER["SCRIPT_NAME"]	/index.php
_SERVER["SCRIPT_FILENAME"]	D:\wwwroot\yyjg.net\wwwroot\index.php
_SERVER["REQUEST_URI"]	/index.php/index-view-aid-9499.html
_SERVER["REQUEST_METHOD"]	GET
_SERVER["REMOTE_USER"]	no value
_SERVER["REMOTE_PORT"]	49041
_SERVER["REMOTE_HOST"]	216.73.216.63
_SERVER["REMOTE_ADDR"]	216.73.216.63
_SERVER["QUERY_STRING"]	no value
_SERVER["PATH_TRANSLATED"]	D:\wwwroot\yyjg.net\wwwroot\index.php\index-view-aid-9499.html
_SERVER["PATH_INFO"]	/index-view-aid-9499
_SERVER["LOGON_USER"]	no value
_SERVER["LOCAL_ADDR"]	172.16.121.93
_SERVER["INSTANCE_META_PATH"]	/LM/W3SVC/1
_SERVER["INSTANCE_NAME"]	WWWROOT
_SERVER["INSTANCE_ID"]	1
_SERVER["HTTPS_SERVER_SUBJECT"]	CN=www.yyjg.net
_SERVER["HTTPS_SERVER_ISSUER"]	C=PL, O=Asseco Data Systems S.A., CN=Certum DV TLS G2 R39 CA
_SERVER["HTTPS_SECRETKEYSIZE"]	2048
_SERVER["HTTPS_KEYSIZE"]	256
_SERVER["HTTPS"]	on
_SERVER["GATEWAY_INTERFACE"]	CGI/1.1
_SERVER["DOCUMENT_ROOT"]	D:\wwwroot\yyjg.net\wwwroot
_SERVER["CONTENT_TYPE"]	no value
_SERVER["CONTENT_LENGTH"]	0
_SERVER["CERT_SUBJECT"]	no value
_SERVER["CERT_SERIALNUMBER"]	no value
_SERVER["CERT_ISSUER"]	no value
_SERVER["CERT_FLAGS"]	no value
_SERVER["CERT_COOKIE"]	no value
_SERVER["AUTH_USER"]	no value
_SERVER["AUTH_PASSWORD"]	no value
_SERVER["AUTH_TYPE"]	no value
_SERVER["APPL_PHYSICAL_PATH"]	D:\wwwroot\yyjg.net\wwwroot\
_SERVER["APPL_MD_PATH"]	/LM/W3SVC/1/ROOT
_SERVER["IIS_UrlRewriteModule"]	7.1.0871.0
_SERVER["HTTP_USER_AGENT"]	Mozilla/5.0 AppleWebKit/537.36 (KHTML, like Gecko; compatible; ClaudeBot/1.0; +claudebot@anthropic.com)
_SERVER["HTTP_HOST"]	yyjg.net
_SERVER["HTTP_ACCEPT_ENCODING"]	gzip, br, zstd, deflate
_SERVER["HTTP_ACCEPT"]	/
_SERVER["HTTP_CONNECTION"]	close
_SERVER["FCGI_ROLE"]	RESPONDER
_SERVER["PHP_SELF"]	/index.php/index-view-aid-9499.html
_SERVER["REQUEST_TIME_FLOAT"]	1789658960.1865
_SERVER["REQUEST_TIME"]	1789658960

PHP Authors
Contribution	Authors
Zend Scripting Language Engine	Andi Gutmans, Zeev Suraski, Stanislav Malyshev, Marcus Boerger, Dmitry Stogov, Xinchen Hui, Nikita Popov
Extension Module API	Andi Gutmans, Zeev Suraski, Andrei Zmievski
UNIX Build and Modularization	Stig Bakken, Sascha Schumann, Jani Taskinen
Windows Port	Shane Caraveo, Zeev Suraski, Wez Furlong, Pierre-Alain Joye, Anatol Belski
Server API (SAPI) Abstraction Layer	Andi Gutmans, Shane Caraveo, Zeev Suraski
Streams Abstraction Layer	Wez Furlong, Sara Golemon
PHP Data Objects Layer	Wez Furlong, Marcus Boerger, Sterling Hughes, George Schlossnagle, Ilia Alshanetsky
Output Handler	Zeev Suraski, Thies C. Arntzen, Marcus Boerger, Michael Wallner

SAPI Modules
Contribution	Authors
AOLserver	Sascha Schumann
Apache 1.3 (apache_hooks)	Rasmus Lerdorf, Zeev Suraski, Stig Bakken, David Sklar, George Schlossnagle, Lukas Schroeder
Apache 1.3	Rasmus Lerdorf, Zeev Suraski, Stig Bakken, David Sklar
Apache 2.0 Filter	Sascha Schumann, Aaron Bannert
Apache 2.0 Handler	Ian Holsman, Justin Erenkrantz (based on Apache 2.0 Filter code)
Caudium / Roxen	David Hedbor
CGI / FastCGI	Rasmus Lerdorf, Stig Bakken, Shane Caraveo, Dmitry Stogov
CLI	Edin Kadribasic, Marcus Boerger, Johannes Schlueter, Moriyoshi Koizumi, Xinchen Hui
Continuity	Alex Leigh (based on nsapi code)
Embed	Edin Kadribasic
FastCGI Process Manager	Andrei Nigmatulin, dreamcat4, Antony Dovgal, Jerome Loyet
ISAPI	Andi Gutmans, Zeev Suraski
litespeed	George Wang
NSAPI	Jayakumar Muthukumarasamy, Uwe Schindler
phpdbg	Felipe Pena, Joe Watkins, Bob Weinand
phttpd	Thies C. Arntzen
pi3web	Holger Zimmermann
Sendmail Milter	Harald Radi
thttpd	Sascha Schumann
tux	Sascha Schumann
WebJames	Alex Waugh

Module Authors
Module	Authors
BC Math	Andi Gutmans
Bzip2	Sterling Hughes
Calendar	Shane Caraveo, Colin Viebrock, Hartmut Holzgraefe, Wez Furlong
COM and .Net	Wez Furlong
ctype	Hartmut Holzgraefe
cURL	Sterling Hughes
Date/Time Support	Derick Rethans
DB-LIB (MS SQL, Sybase)	Wez Furlong, Frank M. Kromann
DBA	Sascha Schumann, Marcus Boerger
DOM	Christian Stocker, Rob Richards, Marcus Boerger
enchant	Pierre-Alain Joye, Ilia Alshanetsky
ereg	Rasmus Lerdorf, Jim Winstead, Jaakko Hyvätti
EXIF	Rasmus Lerdorf, Marcus Boerger
fileinfo	Ilia Alshanetsky, Pierre Alain Joye, Scott MacVicar, Derick Rethans
Firebird driver for PDO	Ard Biesheuvel
FTP	Stefan Esser, Andrew Skalski
GD imaging	Rasmus Lerdorf, Stig Bakken, Jim Winstead, Jouni Ahto, Ilia Alshanetsky, Pierre-Alain Joye, Marcus Boerger
GetText	Alex Plotnick
GNU GMP support	Stanislav Malyshev
Iconv	Rui Hirokawa, Stig Bakken, Moriyoshi Koizumi
IMAP	Rex Logan, Mark Musone, Brian Wang, Kaj-Michael Lang, Antoni Pamies Olive, Rasmus Lerdorf, Andrew Skalski, Chuck Hagenbuch, Daniel R Kalowsky
Input Filter	Rasmus Lerdorf, Derick Rethans, Pierre-Alain Joye, Ilia Alshanetsky
InterBase	Jouni Ahto, Andrew Avdeev, Ard Biesheuvel
Internationalization	Ed Batutis, Vladimir Iordanov, Dmitry Lakhtyuk, Stanislav Malyshev, Vadim Savchuk, Kirti Velankar
JSON	Omar Kilani, Scott MacVicar
LDAP	Amitay Isaacs, Eric Warnke, Rasmus Lerdorf, Gerrit Thomson, Stig Venaas
LIBXML	Christian Stocker, Rob Richards, Marcus Boerger, Wez Furlong, Shane Caraveo
mcrypt	Sascha Schumann, Derick Rethans
MS SQL	Frank M. Kromann
Multibyte String Functions	Tsukada Takuya, Rui Hirokawa
MySQL driver for PDO	George Schlossnagle, Wez Furlong, Ilia Alshanetsky, Johannes Schlueter
MySQL	Zeev Suraski, Zak Greant, Georg Richter, Andrey Hristov
MySQLi	Zak Greant, Georg Richter, Andrey Hristov, Ulf Wendel
MySQLnd	Andrey Hristov, Ulf Wendel, Georg Richter, Johannes Schlüter
OCI8	Stig Bakken, Thies C. Arntzen, Andy Sautins, David Benson, Maxim Maletsky, Harald Radi, Antony Dovgal, Andi Gutmans, Wez Furlong, Christopher Jones, Oracle Corporation
ODBC driver for PDO	Wez Furlong
ODBC	Stig Bakken, Andreas Karajannis, Frank M. Kromann, Daniel R. Kalowsky
OpenSSL	Stig Venaas, Wez Furlong, Sascha Kettler, Scott MacVicar
Oracle (OCI) driver for PDO	Wez Furlong
pcntl	Jason Greene, Arnaud Le Blanc
Perl Compatible Regexps	Andrei Zmievski
PHP Archive	Gregory Beaver, Marcus Boerger
PHP Data Objects	Wez Furlong, Marcus Boerger, Sterling Hughes, George Schlossnagle, Ilia Alshanetsky
PHP hash	Sara Golemon, Rasmus Lerdorf, Stefan Esser, Michael Wallner, Scott MacVicar
Posix	Kristian Koehntopp
PostgreSQL driver for PDO	Edin Kadribasic, Ilia Alshanetsky
PostgreSQL	Jouni Ahto, Zeev Suraski, Yasuo Ohgaki, Chris Kings-Lynne
Pspell	Vlad Krupin
Readline	Thies C. Arntzen
Recode	Kristian Koehntopp
Reflection	Marcus Boerger, Timm Friebe, George Schlossnagle, Andrei Zmievski, Johannes Schlueter
Sessions	Sascha Schumann, Andrei Zmievski
Shared Memory Operations	Slava Poliakov, Ilia Alshanetsky
SimpleXML	Sterling Hughes, Marcus Boerger, Rob Richards
SNMP	Rasmus Lerdorf, Harrie Hazewinkel, Mike Jackson, Steven Lawrance, Johann Hanne, Boris Lytochkin
SOAP	Brad Lafountain, Shane Caraveo, Dmitry Stogov
Sockets	Chris Vandomelen, Sterling Hughes, Daniel Beulshausen, Jason Greene
SPL	Marcus Boerger, Etienne Kneuss
SQLite 3.x driver for PDO	Wez Furlong
SQLite3	Scott MacVicar, Ilia Alshanetsky, Brad Dewar
Sybase-CT	Zeev Suraski, Tom May, Timm Friebe
System V Message based IPC	Wez Furlong
System V Semaphores	Tom May
System V Shared Memory	Christian Cartus
tidy	John Coggeshall, Ilia Alshanetsky
tokenizer	Andrei Zmievski, Johannes Schlueter
WDDX	Andrei Zmievski
XML	Stig Bakken, Thies C. Arntzen, Sterling Hughes
XMLReader	Rob Richards
xmlrpc	Dan Libby
XMLWriter	Rob Richards, Pierre-Alain Joye
XSL	Christian Stocker, Rob Richards
Zip	Pierre-Alain Joye, Remi Collet
Zlib	Rasmus Lerdorf, Stefan Roehrich, Zeev Suraski, Jade Nicoletti, Michael Wallner

PHP Documentation
Authors	Mehdi Achour, Friedhelm Betz, Antony Dovgal, Nuno Lopes, Hannes Magnusson, Georg Richter, Damien Seguy, Jakub Vrana, Adam Harvey, Peter Cowburn
Editor	Philip Olson
User Note Maintainers	Daniel P. Brown, Thiago Henrique Pojda
Other Contributors	Previously active authors, editors and other contributors are listed in the manual.

Websites and Infrastructure team
PHP Websites Team	Rasmus Lerdorf, Hannes Magnusson, Philip Olson, Lukas Kahwe Smith, Pierre-Alain Joye, Kalle Sommer Nielsen, Peter Cowburn, Adam Harvey, Ferenc Kovacs, Levi Morrison
Event Maintainers	Damien Seguy, Daniel P. Brown
Network Infrastructure	Daniel P. Brown
Windows Infrastructure	Alex Schoenmaker