【作者】 艾伟强；

【导师】 蒋萍；

【作者基本信息】 东北财经大学 ， 国民经济核算， 2011， 博士

【摘要】 跨入21世纪,世界各国的医疗卫生体制改革成为了热点问题,中国也到了医疗体制改革的关键时刻。但一个争论不休的世界性难题始终摆在我们面前：如何建立一个更为科学的医疗卫生体制,全面而合理地满足人民的健康需求,使医疗卫生体制更符合公平、可及和高效的原则?曾负责美国医疗卫生体制改革的希拉里·克林顿在她的回忆录中写到：“这个难题犹如人类社会政策领域的珠穆朗玛峰。”医疗卫生体制改革涉及到医院的改革与管理、卫生政策研究、医疗保障模式的转变等多个方面,开展上述论证的基础是如何建立一套可行的医疗卫生核算理论和测度方法体系。因为要对发展医疗卫生事业的相关要素及各个环节做出准确的测度,对医疗卫生体系在各国或一国各个地区的发展阶段等给予准确的定位,要说明整个社会在医疗卫生方面的投入与产出等方面情况,了解一国医疗卫生事业的进展状况,这一切均建立在对医疗卫生活动的科学测度的基础之上,它是从事医疗卫生研究、预测、评价和管理的前提。显然,离开了科学的医疗卫生测度理论和方法的指导,相关核算将无法进行,对医疗卫生的研究、改革与管理就缺乏数据基础。因此,开展医疗卫生服务测度理论和方法等的分析研究具有十分重大的理论价值与现实意义,是一项重要且紧迫的工作。另外,随着时代的变迁,现阶段的医疗卫生行业又有了新的、更深的内涵,ISIC中的医疗卫生行业分类已经不能够全面反映医疗卫生体系的全部内容,例如,随着社会劳动生产力的发展,新的医疗模式更加注重医疗设备的使用,这使得医疗器械生产部门在医疗卫生体系之中的重要程度日益提升,但是,现阶段医疗器械生产部门并没有被纳入医疗卫生行业的范围之内,类似的部门还有很多。医疗卫生行业分类范围覆盖不全面势必会产生诸多弊端。因此,本文以现阶段医疗卫生行业的发展状况和发展方向为依据,以ISIC4.0为基础,并参照由OECD出版的SHA1.0,以及由OECD、Eurostat和WB联合出版的SHA2.0草案,提出了全口径医疗医疗卫生行业的概念,并确定了全口径医疗卫生行业的分类体系,规范了全口径医疗卫生行业的分类结构。在明确了医疗卫生行业口径的基础上,本文从生产和使用两个角度重点研究了全口径医疗卫生行业生产核算和使用核算的理论与方法。生产核算是增加值核算,使用核算是服务的最终消费、资本形成和进出口核算。在现行的国民经济核算体系中,医疗卫生行业的产出核算遵循SNA的生产范围,基于全口径医疗卫生行业产出核算的生产范围与现行SNA的生产范围差别很大,因此,有必要对上述生产核算和使用核算的理论与方法进行再界定、再研究。本文共分为八章。第一章,引论。在引论部分阐述了本文的研究背景和研究意义,综述了全口径医疗卫生行业产出核算问题的国内外文献,确定了全文的研究思路与结构安排,同时点明了本文所做的主要工作以及本文的主要缺陷。除导论外,本文主要围绕以下七个章节展开研究。第二章,现行医疗卫生行业分类体系的评介及比较。本章以及第三章是全文的基础。医疗卫生行业分类决定了医疗卫生行业产出核算的生产范围,因此,明确医疗卫生行业分类的主体是医疗卫生行业产出核算的基础。目前,涵盖医疗卫生行业的国际分类体系包括ISIC和ICHA-HP两种,但二者对医疗卫生行业的划分却存在较大的差异,本章在明确上述差异的基础上,探寻了产生差异的原因。第三章,全口径医疗卫生行业的提出及分类体系。本章承接第二章,首先提出了全口径医疗卫生行业的概念,并对全口径医疗卫生行业提出的背景、范围、分类及意义进行概述,然后介绍了SNA界定的医疗卫生行业的生产范围,并对其进行评析,指出现阶段SNA界定的医疗卫生行业生产范围的局限,进而界定了全口径医疗卫生行业的生产范围。第四章,全口径医疗卫生行业的费用核算及帐户体系。本章是医疗卫生行业产出核算的起点,主要研究医疗卫生行业的使用核算。本章首先从医疗卫生服务的使用角度阐释了医疗卫生费用的含义,以及现行医疗卫生费用核算体系的基本内容,然后介绍了医疗卫生行业产出核算的国际分类体系,研究了此分类的三维轴心系统,即医疗卫生服务功能分类、医疗卫生服务供方分类和医疗卫生服务筹资机构分类,在此基础上引入了医疗卫生费用核算的帐户体系,最后明确了医疗卫生行业的核心费用核算体系和扩展费用核算体系。第五章,全口径医疗卫生行业的价格及物量核算。本章承接第四章,研究医疗卫生行业的生产核算,价格和物量核算是生产核算的核心,本章在参考了OECD出版的SHA1.0及教育与医疗卫生物量产出核算指导手册(2007)的基础上,首先明确了医疗卫生服务的数量指标,提出了完整治疗是计量医疗卫生服务物量产出的最佳方法,并对完整治疗物量指数和价格指数的计算加以说明。此外,本章还纳入了医疗卫生服务质量调整方法的选择、产出汇总权数的选择等问题,并对这两个问题加以分析,提出了最佳的解决方案。第六章,医疗卫生行业产出的国际比较。在世界各国医疗卫生行业高速发展的今天,医疗卫生行业产出及增加值的国际比较日益重要,但此领域研究方法的发展却很缓慢。本章首先介绍了现阶段医疗卫生行业产出的国际比较方法,包括投入法卫生行业PPPs法和支出法卫生行业PPPs法两种,并解释了这两种方法不能够反映医疗卫生行业劳动生产率的缺陷。鉴于此,本章提出了生产法卫生行业PPPs法,并对此方法的前提、计算思路、应用的可行性与前景等问题进行了阐释。第七章,医疗卫生行业产出核算的国际经验。对医疗卫生行业产出核算的研究最早始于OECD国家,OECD国家在该领域的研究走在了世界的前列。其他国家在发展、完善本国的医疗卫生行业产出核算体系时,势必要吸收、借鉴OECD国家的经验,中国也不例外,因此,本章的主要目的就是总结、归纳OECD国家在开展该问题研究与实践中的成功经验。另外,由于各个国家之间的经济发展水平不同,不同经济发展水平的国家在处理具体的问题时也会产生偏差,所以,本章也引入了其他非OECD国家在发展医疗卫生行业产出核算体系时的经验。第八章,中国医疗卫生行业产出核算的现状及展望。中国作为发展中国家,对医疗卫生行业产出核算的研究与实践起步较晚,最初所使用的概念和方法多是引自OECD国家,但随着近年来对该问题认识的逐渐深入,目前,中国也已经初步形成了适应中国国情并融入了中国医疗卫生行业特殊性的核算体系,因此,本章首先介绍了中国医疗卫生行业产出核算的现状,在此基础上,提出了在中国开展全口径医疗卫生行业产出核算的设想,并对现阶段中国所具备的有利条件,以及需要完善的方面做出了分析。更多还原

【Abstract】 With the reform of world-wide medical and healthcare system being hot issue since 21st century, the reform of medical and healthcare system has came into the critical moment as well in China. A controversial and global puzzle always set before us:how to establish a set of more scientific medical and healthcare system, to satisfy people’s demand on health services comprehensively and reasonably, by which make medical and healthcare system accord with the principle such as fair, accessible and efficient? Hillary Clinton, who was in charge of the reform of medical and healthcare system in America, wrote:"this puzzle is just like Everest of policy field in human social" in her memoir.The reform of medical and healthcare system involves the reform and management in hospital, policy research on health, the change on medical security pattern, etc. The basement of carrying out the arguments above is how to establish a set of viable accounting theory and system of healthcare industry. If we want to measure the related elements of health services accurately, giving an accurate position to the development stage of medical and healthcare system in some country or region, explaining the input and output supported by whole society in healthcare industry, understanding the progress of healthcare industy in some country, which are all based on scientific measurement on medical activities, which is the premiss of researhing, forecasting, evaluation and management. Obviously, without the instruction of scientific theory and method on measurement, relevant accounting would not undertake;and it will be short on data base on healthcare industry researching, reform and management. Therefore, it will be great significance in both theory and reality to carry out the theory and method of health service on measurement and revelent analysis and research, which is also an important and urgent work.In addition, as the changes of times, healthcare industry has new and deeper connotation at this stage. Healthcare industry classification in International Standard Industrial Classification system has not been able to reflect the whole content of medical and healthcare system. For example, along with the improvement on social productivity, it will need a new medical model paying more attention to the use of medical equipment, which makes the importance of manufacturing sector of medical equipment in medical and healthcare system rise. But the manufacturing sector of medical device has not been incorporated into the healthcare industry classification at the moment, and the similarly is a lot. The healthcare industry classification which is not comprehensive is bound to cause many disadvantages. Therefore, based on the current situation and direction of healthcare industry development, on the basis of ISIC4.0, and refer to System of Health Accounts version 1.0 by OECD, and System of Health Accounts version 2.0 draft version by OECD, Eurostat and World Bank, this paper puts forward the concept of healthcare industry based on whole caliber, and ascertain the range of healthcare industry based on whole caliber, regulate the structure of classification of healthcare industry based on whole caliber.As a result of clearing the range of healthcare industry based on whole caliber, this paper studied the theory and method of production and use accounting from the production and use perspective. The content of production accounting is value added and the content of use accounting is the final consumption, the capital formation and net export of service. In current SNA, the output accounting of healthcare industry followed the production range of SNA. Because the production range of output accounting of healthcare industry based on whole caliber is different from the production range of SNA, it is necessary to define and research the theory and method of production and use accounting again.This paper includes eight chapters.Chapter One:introduction. This chapter describes the background and significance of the research, reviews domestic and foreign literatures on the output accounting of healthcare industry based on whole caliber, determines the research idea and the structure arrangement, and points out the main work and defects of this paper. Except the introduction, this paper mainly centres on the following seven chapters.Chapter Two:The review and comparison of classification system of current healthcare industry. This and next chapters are the foundation of full text. The classification of healthcare industry determines the range of output accounting of healthcare industry, the classification subject of healthcare industry which is clear is the basis of output accounting of healthcare industry. At present, the international classification systems which cover healthcare industry including ISIC and ICHA-HP, but the division of the healthcare industry differentiate a lot between them. On the basis of clarifying these differences, this chapter explores the reasons for the differences.Chapter Three:The definition and production range of healthcare industry based on whole caliber. This chapter is the foundation of this paper, puts forward the definition of health care industry based on whole caliber firstly, and explains the background, range, classification and the meaning, then introduces and evaluates the production range which is defined by SNA, points out the limitations, defines the production range of healthcare industry based on whole caliber at last.Chapter Four:The system of expense accounting of healthcare industry based on whole caliber. This chapter is the starting point of output accounting of healthcare industry based on whole caliber, and the use accounting of healthcare industry is mainly studied. First of all, this chapter explains the meaning of health expense from the perspective of use of health services, the basic content of current health expense accounting, then introduces the international classification system of output accounting of healthcare industry, investigates the 3d axis system of this classification, namely, the classification of health service function, provider and funding, based on above, this chapter introduces the system of health expense accounting and clear the system of expense accounting and expanded expense accounting of healthcare industry based on whole caliber.Chapter Five:The volume output accounting of healthcare industry based on whole caliber. This chapter studies the production accounting of healthcare industry followed chapter three, as volume accounting is the core of production accounting, on the basis of the reference to the System of Health Accounts(2000) and Towards Measuring Education and Health Volume Output:An OECD Handbook(2007) published by OECD, this chapter introduces the quantity indicators of health services firstly, presents that the method of complete treatment is the best method on measuring the volume output of health service, and explains the price and volume indicator of complete treatment. In addition, the chapter also includes the choice of the method of the quality adjustment on health service, and the weight of output aggregation, this paper puts forward the best solution about these two problems.Chapter Six:International comparison of output of healthcare industry based on whole caliber. Healthcare industry are developing with a high-speed in the world at the moment, international comparison of the output and value added of healthcare industry are increasingly important, however, the research method in this field is developed very slowly. Firstly, this chapter introduces the current international comparison method of output of healthcare industry, including input method PPPs on healthcare industry and expenditure method PPPs on healthcare industry, and explains the defect that these two methods can not reflect the labor productivity on healthcare industry. In view of this, this chapter puts forward a kind of method, namely, production method PPPs on healthcare industry, and explains the premise, calculation ideas, application feasibility and prospects of this method.Chapter Seven:International experience of output accounting of healthcare industry. The research on output accounting of healthcare industry started in OECD countries, which are in the forefront of the world in this field. When developing, improving their own system of output accounting of healthcare industry, other countries will inevitably absorb and reference the experience of OECD countries. China is not exceptional as well. Accordingly, the main purpose of this chapter is to sum up successful experience that OECD countries used to carriy out in the research and practice about this problem. In addition, as the level of economic development among countries are different, these countries are different in dealing with concrete problems as well. This chapter also introduces some experience on output accounting of healthcare industry from non-OECD countries.Chapter Eight:The status quo and prospect on output accounting of healthcare industry based on whole caliber carried out in China. As developing country, the practice and research on output accounting of health care industry starts late in China, and the concepts and methods used originally are adapted from OECD countries, however, China has initially formed the system of accounting that adapts to national circumstance and integrates into the particularity on healthcare industry, with the cognition about this problem thorough in recent years, therefore, this chapter introduces the current situation on output accounting of healthcare industry firstly, puts forward the assumption to carry out output accounting of healthcare industry based on whole caliber in china, then makes analysis about favorable conditions and what needs to be improved in China.更多还原