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آشنایی با ماهیت، ضرورت، انواع و مشکلات انجام مطالعه بهره‌مندی به منظور بررسی و کنترل مصرف خدمات درمانی در سازمان‌های بیمه‌گر

نوع مقاله : مقاله مروری نقلی

نویسندگان

1 دانشیار، مدیریت خدمات بهداشتی درمانی، گروه مدیریت خدمات بهداشتی درمانی، دانشکده مدیریت و اطلاع‌رسانی پزشکی و مرکز تحقیقات مدیریت و اقتصاد سلامت، دانشگاه علوم پزشکی اصفهان، اصفهان، ایران

2 استادیار، اقتصاد سلامت، گروه اقتصاد سلامت، دانشکده مدیریت و اطلاع‌رسانی پزشکی و مرکز تحقیقات مدیریت و اقتصاد سلامت، دانشگاه علوم پزشکی اصفهان، اصفهان، ایران

3 پزشک عمومی، اداره نظارت و ارزشیابی، اداره کل بیمه سلامت ایران استان اصفهان، اصفهان، ایران

4 دکتری تخصصی، علوم اعصاب شناختی، اداره رسیدگی به اسناد پزشکی، اداره کل بیمه سلامت ایران استان اصفهان، اصفهان، ایران

5 دانشجوی کارشناسی ارشد، مدیریت خدمات بهداشتی درمانی، گروه مدیریت خدمات بهداشتی درمانی، دانشکده مدیریت و اطلاع‌رسانی پزشکی، دانشگاه علوم پزشکی اصفهان، اصفهان، ایران

چکیده

مصرف مراقبت‌های سلامت را «بهره‌مندی» می‌نامند. مطالعات بهره‌مندی در سازمان‌های بیمه‌گر برای مدیریت مصرف خدمات درمانی جمعیت تحت پوشش استفاده می‌شود. پژوهش حاضر از نوع مروری نقلی بود که با هدف آشنایی با مطالعات بهره‌مندی و کاربرد آن در سازمان‌های بیمه‌گر در سال 1397 صورت گرفت. در این مطالعه، مقالات پایگاه‌های ProQuest، ScienceDirect، PubMed، Scopus و ISI Web of Science بدون محدودیت زمانی انتخاب گردید و از 50 مقاله مرتبط، ماهیت، ضرورت، انواع و موانع انجام مطالعات بهره‌مندی استخراج شد. در مجموع می‌توان گفت که در حال حاضر سازمان‌های بیمه بیشترین تمرکز خود را بر بررسی رفتار ارایه دهندگان قرار داده‌اند و از بررسی رفتار مصرف‌کنندگان (مطالعات بهره‌مندی) غفلت می‌ورزند. استانداردسازی فرمت داده‌های دریافتی از مراکز ارایه دهنده، ذخیره‌سازی یکپارچه داده‌ها و حساس بودن نرم‌افزارهای بیمه‌ای به افراد با مصارف غیر عادی، انجام مطالعات بهره‌مندی را ‌تسهیل می‌نماید.

کلیدواژه‌ها

عنوان مقاله [English]

Reviewing the Nature, Necessity, Types, and Problems of Utilization Studies in Health Services to Assess and Control the Consumption of Healthcare Services in Health Insurance Organizations

نویسندگان [English]

  • Masoud Ferdosi 1
  • Mohammad Reza Rezayatmand 2
  • Abbas Feizbakhsh 3
  • Hamid Reza Dehghani 4
  • Golnoosh Aghili-Dehkordi 5

1 Associate Professor, Health Services Management, Department of Health Services Management, School of Management and Medical Information Sciences AND Health Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

2 Assistant Professor, Health Economics, Department of Health Economics, School of Management and Medical Information Sciences AND Health Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan, Isfahan, Iran

3 General Practitioner, Monitoring and Evaluation Office, Iran Health Insurance Headquarters of Isfahan Province, Isfahan, Iran

4 PhD, Neurosciences, Medical Document Investigation Office, Iran Health Insurance Headquarters of Isfahan Province, Isfahan, Iran

5 MSc Student, Health Services Management, Department of Health Services Management, School of Management and Medical Information Sciences, Isfahan University of Medical Sciences, Isfahan, Iran

چکیده [English]

Consuming medical services is labeled as utilization. Utilization studies are used by insurance companies to study the behavior of medical service consumers. Currently, insurance companies focus more on caregivers' behavior, and neglect the consumers’ side. This was a narrative review study carried out in year 2018 to emphasize the necessity of utilization reviews and their importance. In this study, we used ProQuest, ScienceDirect, PubMed, Scopus, and ISI Web of Science databases without any time limitation. We chose 50 articles and reviewed them to found 5 essential questions about utilization reviews, and their importance, differences, and challenges, as well as factors affecting them. Our study revealed that having standardized data formats for service providers, integrated data pools, and relevant software sensitive to unusual service consumers, facilitate the utilization review studies.

کلیدواژه‌ها [English]

  • Utilization
  • Health Services
  • Health Insurance
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مدیریت اطلاعات سلامت
دوره 15، شماره 5 - شماره پیاپی 5
دی 1397
صفحه 247-252
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هم رسانی
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