【作者】 张春梅；

【导师】 方鹏骞；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2011， 博士

【摘要】 推进医疗服务信息披露规制工作是现代医疗规制体系的基本原则和要求。公立医院医疗服务信息披露的实施和开展,为社会公众寻医问药提供权威参考,并可以减少由于医疗服务市场信息不对称所带来的诱导需求的出现,缩小医疗服务供需方之间“知识差距”,同时能促使医院规范医疗、改进质量、降低服务价格,促进公立医院回归公益性本途。研究目的鉴于当前国内对医疗服务信息披露及其规制实施与研究相对薄弱,本文选择公立医院医疗服务信息披露为研究对象,在回顾国内外医院医疗服务信息披露规制理论与实践的基础上,对我国医院医疗服务信息的政府行为、医院行为、相关利益方反应等进行综合分析,从政府、医院、第三方等视角调查和分析了我国医疗服务信息披露规制现状、探讨我国公立医疗服务信息披露规制的关键环节、存在的问题和根源,提出构建我国公立医院医疗服务信息披露规制的理论框架及实现策略,以期为政府相关公共管理职能的行使提供理论参考依据。资料来源与研究方法本研究主要采取了理论探讨与实证研究相结合、定性和定量相结合的研究方法。首先在文献资料回顾分析的基础上,吸收知情权理论、信息不对称理论、信息传播理论及政府规制理论等理论基础,对公立医院医疗服务信息披露及规制的相关理论进行分析,并运用PEST分析方法、利益相关集团分析法及博弈分析法探讨了公立医院医疗服务信息披露的宏观政策环境、各利益主体的作用、利益主体的博弈关系及其行为特征。围绕公立医院医疗服务信息的政府披露行为和医院披露行为两大层次,设计实证研究方案。对政府行为的调查主要是通过互联网对全国31省(自治区、直辖市)卫生厅(局)的互联网门户网站进行调查,了解政府对医疗服务信息披露的制度建设、运行机制、向社会披露的医疗服务信息内容等现状。同时以经济发展水平作为分层依据,根据国家统计局地区分组方法,分别在东、中、西部地区选择6省12市35家公立医院作为样本医院,对样本医院的互联网门户网站进行调查；对1371位住院患者及其家属和1868位医护人员进行现场问卷调查；对样本省区卫生厅局、医院、行业协会、医疗保险部门及新闻媒体等40位关键知情人进行半结构访谈。收集资料利用EpiData3.1数据录入,运用SPSS12.0进行统计分析,包括描述性分析、卡方检验、对应分析、聚类分析、Logistic回归分析等；并进行医疗服务信息披露的典型案例分析,对研究中的访谈资料进行定性分析。主要研究结果1.公立医院医疗信息披露规制的理论研究结果首先借鉴国内外其他领域信息披露的研究成果,对医疗服务信息、医疗服务信息披露及医疗服务信息披露规制等概念进行界定。总结认为建国以来我国公立医院医疗信息披露规制制度经历了4个阶段,并提出本研究从公立医院医疗信息披露的政府行为和公立医院行为两大角度进行探讨。运用知情权理论、信息不对称理论、信息传播理论及政府规制理论等对医疗信息披露进行解析。PEST分析发现,公立医院医疗服务信息披露规制是医疗行业发展的必然趋势,具有明确的政策依据；医疗费用的高、医患关系紧张等现实状况；互联网的快速普及、网民的大量增加；以及各医院信息化建设水平都为医疗服务信息披露规制创造了良好的宏观环境。通过相关利益集团分析,对信息披露规制的利益相关集团政府、公立医院、社会公众、第三方的利益、拥有资源、动用资源能力及其立场进行剖析,为实证研究结果的解释提供方向。从微观层面,对医疗服务信息披露相关方(卫生行政部门方、公立医院方以及患者方)的多重博弈关系进行分析,并提出增加医疗服务信息披露规制有效性的基础。2.公立医院医疗信息披露的政府行为和公立医院行为分析研究结果调查和分析政府信息披露的保障体系及运行机制建设、披露内容、披露渠道等现状,结果显示,我国30个省厅(局)建立了互联网门户网站(除外西藏卫生厅),其中28家省厅(局)的网站上公布政信息披露组织保障体系信息。各地政府之间医疗服务披露保障体系建设不一,组织架构比较薄弱,运行制度的建设有待于加强。政府披露医疗服务信息主要涉及诊疗费、药品及医用医疗价格、门急诊工作量、服务效率、门诊/出院病人人均费用、专家及其服务时间等,只有部分省市卫生行政部门关注到披露公立医院内的医疗服务质量信息(41.18%)以及患方评价信息(5.88%)。互联网是政府医疗服务信息披露的主要渠道；从政府主动披露信息和依申请披露信息情况来看,政府主动信息披露相对丰富,但依申请披露渠道不够畅通,提示依申请披露渠道的建设及有效运行问题应引起重视。围绕医院方,本文从医疗服务信息医院主动披露的现状、制度建设情况、保障体等进行探讨。结果显示,公立医院对信息披露日益重视,31家公立医院中有26家医院成立院务公开领导小组,27家医院制定相关制度,披露载体比较完善；但同时发现,互联网作为医院信息披露的重要渠道与医院自我宣传的重要的平台,没有得到管理者的足够重视；医院信息咨询电话的畅通与有效性问题值得关注；公立医院应加强对社会需方的医疗服务评价的重视,真正落实信息公开的实质效果。3、相关利益方对公立医院医疗服务信息披露的评价本部分主要探讨了社会公众方、医务人员方、其他利益方(包括媒体、医疗保险、行业协会)对医疗服务信息披露的评价和认识。其中以住院患者作为社会公众的代表,结果显示,76.8%的公众很少搜寻医院医疗服务信息,提示我国社会公众主动搜寻政府信息的意识不强；仅有21.5%的人在以往医疗服务信息查询中获得所需要信息,说明政府披露信息受用性不大；部分信息指标表述过于专业,公众难以理解其真正含义；31.30%的社会公众对政府披露公立医院信息表示满意,其满意度与文化教育水平(χ2=24.802,P<0.001)、健康状况(χ2=44.103,P<0.001)分别存在对应关系；社会公众对政府的信息披露监督力度比较小,其监督力度与门诊就诊次数成对应关系(χ2=17.486,P<0.01)。住院患者对医院披露的医疗服务信息总体知晓程度比较高,54.12%患者对医院信息披露表示满意,男性患者比女性患者的满意度低(χ2=7.415,P<0.01,OR值为0.73),健康状态差的患者比健康状况好的患者满意度低(χ2=22.483,P<0.001,OR值为0.36)。37.17%医护人员对目前政府披露医疗服务信息现状的表示满意,70.28%医护人员对政府披露信息的监督力度较小或没有,其监督力度与工龄存在对应关系(χ2=13.008,P<0.05)。仅14.64%的医护人员对医院披露的医疗服务信息表示总是关注,提示医护人员对医院披露的医疗服务信息的关注程度有待于提高。行业协会在医疗服务信息披露规制中占据重要地位,但行业自律组织等相关利益集团发展水平低下,在医院医疗服务信息披露规制中发挥的作用比较小。医疗保险部门信息获取渠道受限、监管能力不足,难以获得各医院全面、客观的医疗服务信息。新闻媒体是政府向社会披露医疗服务信息的窗口,其关注点和媒体报告效应有待提高。4.公立医院医疗服务信息披露中的障碍分析通过对3家卫生行政部门和2家医院的典型案例分析,结合关键知情人访谈和其他定性资料的分析,对信息披露中存在的障碍进行了剖析。在政府行为方面,存在信息披露义务主体的保障体系薄弱、披露意识不强；披露内容单一,披露信息存在统计口径不一、比较性不足、难以真实反映医院实际服务情况；内外部监管力量不强,信息化建设水平低下等制约因素。在医院行为方面,医院对政府要求医院披露医疗服务信息的目的及意义认识不到位：缺乏经费保障和专职人员,相关保障制度,信息披露保障机制建设方面有待加强；医院信息披露的信息化建设水平不一；信息披露渠道建设应引起重视；信息披露的监督机制有待于加强等。以上因素都成为公立医院医疗服务信息披露规制的重要制约因素。主要结论与建议：本研究结合理论分析和实证研究结果,提出构建符合我国国情的、可行性、适应医院和政府的我国公立医院医疗服务信息披露规制制度。1.明确医疗信息披露的规制理念、目标与原则各级政府、医院、社会公众、相关利益方应树立正确的医疗服务信息披露规制理念,提出医疗服务信息了规制的微观目标、中观目标及宏观目标；其规制原则主要包括满足需求原则、适度性披露原则、成本效益原则、有差别设计原则、阶段性推进原则。2.构建和设计我国公立医院医疗服务信息披露规制的理论框架第一,加强信息披露主体保障机体系及运行机制的建设,培育信息披露的市场新主体；第二,公立医院医疗服务信息披露的政府行为与医院行为披露内容、披露水平及披频次进行分层设计；第三,加强信息披露渠道的建设,构建披露渠道网络；第四,加强信息披露权利主体的培训教育,构建长效教育机制；第五,构建多层次、多元化信息披露监管模式：第六,提出我国公立医院医疗服务信息披露规制的法律制度安排,在提升我国政府信息披露制度的法律地位的基础上,提出信息披露的保密审查制度、沟通协调制度、问责制度及救济制度等制度设计。3.提出公立医院医疗服务信息披露规制的策略首先,构建医疗服务信息的数据平台,便于信息数据资源共享；其次,规范数据统计分析方法,研制数据风险调整方案,以确保披露数据的准确性、客观性与可比较性,并充分利用医疗保险部门的信息数据,降低信息收集成本。最后,提出公立医院医疗服务信息披露规制分步推进的策略。创新之处：1.理论方面：鉴于国内对医疗服务信息披露研究尚缺乏系统性研究,本文主要从理论研究和实证研究的角度出发,借鉴知情权理论、信息传播理论及政府规制理论等理论基础上,从政府披露公立医疗服务信息以及公立医院自身披露医疗服务信息的两个层面进行系统研究,分析了各个层面影响信息披露规制的制约因素,创新性提出了我国公立医院医疗服务信息披露规制的目标、原则与策略,并对信息披露的内容体系的构建,提出了分层设计的方法,具有一定的理论创新价值和重要的现实意义。2.方法方面：鉴于国内学者对信息披露的研究往往从理论探讨的角度比较多,而从定量的角度进行研究相对缺乏。对此,本研究采取定性和定量结合的研究方式,通过设计调查表,对公立医院医疗服务信息披露的现状、主要影响因素进行综合分析,在研究过程中做到定性和定量结合,构成本研究的创新点。更多还原

【Abstract】 To enhance medical services information disclosure and regulation is one of the basic principles of and requirements to the modern medical regulation system. Medical services information disclosure for public hospitals is conducive to the health seeking behavior of people, can reduce the supplier induced demand caused by the healthcare market information asymmetry, and decrease the "knowledge gap" between supplier and demander of medical services. It also can promote the public hospitals to normalize medical practice, improve quality, and reduce the price of services, so that the public hospitals provide the optimal healthcare services for the public.Research ObjectivesThe current domestic practice and researches of medical services disclosure and regulation were limited. The current study focused on the medical services information disclosure for public hospitals. The research objectives were:to review the theories and practice on hospital medical services information disclosure at domestic and overseas, to comprehensively analyze macro policy environment, the roles of interest groups such as the governments, hospitals on Chinese public hospital medical services information disclosure, to investigate the current situation of information disclosure, to summarize experiences and to explore the problems and influencing factors on hospital medical services information disclosure, and to put up suggestions on hospital medical services information disclosure regulation and operational mechanism. Data Sources and MethodsThis study adopted both the theoretical and empirical, both qualitative and quantitative research methods. Medical services information disclosure and regulation for public hospital was analyzed theoretically from the perspectives of Right to Know Theory, Asymmetric Information Theory, Information Communication Theory and Government Regulation Theory. Macro policy environment of information disclosure, the roles and the relationships among and behavioral characteristics of stakeholders were analyzed using PEST Analysis, Stakeholder Analysis, and Game Theory Analysis, respectively.The empirical investigation was carried out at both government level and hospital level. At government level, portal websites of 31 provincial health administrative departments were investigated to understand the institution construction, operating mechanism, the content of the information disclosure, and etc.At hospital level, according to the level of economic development,35 public hospitals in 12 cities of 6 provinces were sampled in the eastern, central and western regions. Portal websites of the hospitals were investigated,1371 patients and their family members and 1868 health care professionals conducted the questionnaire surveys. Semi-structured in-depth interviews were conducted with forty key informants from health administrative departments, hospitals, professional associations, health insurance sectors, the media and etc. health administrative departmentsEpiData3.1 and SPSS 12.0 were used to manage data and for statistical analysis. Descriptive analysis, chi-square test, correspondence analysis, cluster analysis, and Logistic regression analysis were conducted. Typical case study was also used.Key Findings1.Theoretical Analysis on medical services information disclosure and regulation for public hospitalsThe concepts of medical services information, medical services information disclosure, and regulation were defined based on the information disclosure research conclusions in other fields. Through reviewing history of medical services information disclosure from 1949, the four stages were identified and the characteristics in each stage were described.PEST analysis presented that Macro policy environment of medical services information disclosure and regulation:disclosure and regulation of medical services for public hospitals was an inevitable trend the medical and health undertakings development; increase of health care costs and the tense physician-patient relationship made it necessary to disclose and regulate medical services information; and the rapid popularization of the Internet, the substantial increase of Internet users and the development of information construction in hospitals laid the foundation of medical services disclosure and regulations.Stakeholder Analysis pointed out the benefits, the resources, capability to apply resources, and standpoint of stakeholders the governments, hospitals, public and third-party organizations.Game Theory Analysis was used to analyze the multiple game relationships among stakeholders (health administrative departments, public hospitals and the patients) and to propose the conditions in which the efficiency of medical services disclosure and regulations could be increased.2. Empirical research findings of medical services information disclosure and regulation for public hospitals:governments’behavior and hospitals’behaviorThe investigation of the institution building, disclosure content and channels of government information disclosure practice indicated that 30 provincial health administrative departments had established portal websites (except Tibet health administrative department) and 28 departments published their institution framework of information disclosure on the websites.Information disclosure models and mechanisms of the local governments were different and institution building and support system should be strengthened. The disclosure content were mainly concerned with treatment expenses, prices of pharmaceutical and medical service, numbers of outpatient and emergency, service efficiency, expenses per outpatient/discharged patient, the health professionals and their on-duty time, and etc. Some departments disclosed the information of medical service quality (41.18%), and were concerned with the evaluation of demander (5.88%). The Internet was the main channel for information disclosure the governments. As for the active disclosure and disclosure upon application, the governments disclosed actively much information;however the channel of disclosure upon application did not work well, which should be paid more attention.At public hospitals level, the hospitals attached importance to the information disclosure, which could be seen in the evidence that among 31 hospitals,26 ones established Opening Hospital Affairs Leadership Team and 27 ones formulated relevant institutions. However, the Internet as an important channel disclosure and self-advertising had not been given sufficient attention by the managers. The availability of the information consultation phone should be increased. And the hospitals should be more concerned with the medical service evaluation of the demander.3.Stakeholders evaluation of medical services information disclosure for public hospitalsThe evaluation of the public, health professionals, and other stakeholders such as the media, health insurance sectors and professional associations on medical services information disclosure were analyzed. As for the public (represented by the inpatients), 76.8% of people seldom searched medical services information of hospitals, which indicated their active consciousness and participation was not enough.21.5% of people obtained the available information in the past experiences health care information query, which indicated that benefits of the information disclosure by the governments were not enough.Some indicators were medical terminology;therefore, it was difficult to understand for the public.31.30% of the public were satisfied with hospitals information disclosed by the governments. Correspondence analysis revealed that public satisfaction was significant related to the educational level (x2=24.802, P<0.001), health status (χ2=44.103, P<0.001). The supervision of the public was limited and there was a corresponding relationship between the extent of out-patients supervision and visiting times (χ2=17.486, P<0.01). The awareness level about medical services information disclosed by hospitals in inpatients was high.54.12% of inpatients were satisfied with information disclosure and the satisfaction of male was lower than female (χ2=7.415,P<0.01, OR=0.73) and patients with poor health status lower than patients with good health status(χ2=22.483,P<0.001,OR=0.36).37.17% of the health professionals were satisfied with medical services information disclosure by the governments.70.28% of them reported they had little or no supervision to governments information disclosure. There was a corresponding relationship between the supervision and length of working (χ2=13.008, P<0.05)..Only 14.64% hospital staff were always concerned with internal information disclosure within hospitals, which showed the concern of hospital staff should be improved.Although professional associations were an important stakeholder in medical services information disclosure and regulation, they played an unimportant role in practice because of the underdeveloped status of professional self-regulatory organizations.Health insurance sectors had limited access to information, insufficient regulatory, and were inefficient to obtain comprehensive and objective information on medical services. As one kind of channels of governments information disclosure, the media’s concerns and effects should be improved.4. The barriers of medical services information disclosure for public hospitalsBased on typical case analysis with three health administrative departments and two hospitals, key informant interviews, and other qualitative data analysis, the barriers of information disclosure were analyzed. At government level, the regulation model was single, the disclosure subject was unclear, disclosure consciousness was low, disclosure content was single, informatization construction was incomplete, supporting system should be strengthened, and etc. At hospitals level, the hospitals" cognition about the purpose and significance of the medical services information disclosure should be improved, the information construction level varied from hospital to hospital, the special funds and full-time staff lacked, information disclosure annual reporting and accountability system lacked, supporting system should be strengthened. Conclusions and SuggestionsBased on theoretical analysis and empirical findings, the suggestions on health services information disclosure and regulation for public hospitals in China were proposed, and the disclosure system should be in line with our national conditions, and feasible.1.To determine the regulation philosophy, goals and principles of medical services information disclosure and regulation for public hospitalsThe governments at all levels, the hospitals, the public, other stakeholders should play respective roles in information disclosure and regulation. The goals at macro-, medium-, and micro- levels were proposed. The principles included meeting the needs, appropriateness, cost-effective, discriminatory design, and gradual implementation.2. To establish the medical services information disclosure and regulation system construction framework for public hospitalsFirstly, to strengthen information disclosure models and mechanisms and to develop the new market subject. Secondly, to construct information disclosure and regulation hierarchical content system.Thirdly, to accelerate informationization construction and to improve information disclosure platform and channel. Fourth, to train the information disclosure subjects and strengthen capability building. Fifth, to build up hierarchy and multiple regulation models. Lastly, to improve the institution construction such as communication and cooperation mechanisms, financial assistance, accountability, and non-punitive adverse events reporting system.3.To propose the strategies of the health services information disclosure and regulationFirstly, to establish information disclosure data platform to share the resource. Secondly, to standardize the information, unify statistical analysis, and develop the risk-adjusted method for the information disclosure assessment in order to ensure the accuracy, objectivity and comparability of the data, make full use of the information in health insurance sectors, and reduce the cost of information collection. Lastly, gradual implementation strategies of medical services information disclosure and regulation system construction were proposed.Innovations1.Theoretic innovations:researches on information disclosure at domestic were mainly restricted in the fields of finance, stock market and etc. and systematic research on medical information disclosure and regulation was needed in health field. On the basis of Right to Know Theory, Asymmetric Information theory, Information Communication Theory and Government Regulation Theory, through the theatrical analysis and empirical research,the paper studied systemically and comprehensively the medical services information disclosure from both the government level and hospital level, analyzed the current situation of information disclosure and influencing factors, proposed information disclosure and regulation’s objectives, principles, and strategies, to put forward to construct information disclosure and regulation hierarchical content system, which had a theoretical and practical significance to information disclosure and regulation construction.2.Methodological innovations:the domestic references about information disclosure were mainly theoretical paper and quantitative research was scarce. In this study, qualitative and quantitative research methods were combined.更多还原