【作者】 王箐；

【导师】 魏建；

【作者基本信息】 山东大学 ， 法经济学， 2012， 博士

【摘要】 提高居民健康水平,稳步改善医院市场绩效关系国计民生,是医疗卫生体制改革的重要目标和内容。医院是我国医疗服务体系的主体和关键环节,深化医院改革意义重大。近年来,我国医院市场的微观运行有了较大改善,而宏观效率却没有同步改善。二者的差异与医院的外部治理环境不无关系。深化医院市场改革,改善医院市场的绩效绝非简单的堵住医院管理的某一个漏洞,亟待调整医院的外部治理环境。Hirschman的“退出-呼吁”理论将消费者的退出和呼吁视为改善组织绩效的两种重要途径。我国医院的组织实质与“退出-呼吁”理论的研究对象相契合,医院市场面临改善绩效的难题,且我国医院市场存在综合利用患者退出和呼吁的必要性和合理性。因此,本文基于“退出-呼吁”理论,分析引进患者的退出和呼吁对医院外部治理环境,乃至医院市场绩效的影响,为我国医院市场改革提供理论和实践证据。国外对医院市场竞争的研究主要以美国医院市场发展为主线,运用理论和实证研究方法讨论了质量竞争和价格竞争的效果,以及伴随着兼并衍生的竞争的结果。总的来说,关于竞争结果,还没有一致结论。不同的学者研究了呼吁不同层面的问题,但没有形成系统研究。与国外研究相比,国内对医院市场竞争的研究显得单薄很多,理论研究还是浅层次的,多为描述性研究,定量研究比较少。至于呼吁,国内仅有几篇研究涉及医院市场呼吁。有待于结合我国医院市场的实际特点,分析“退出-呼吁”在我国医院市场的表现。从经营内容来看,我国医院产业属于多产品的厂商,医院既经营住院部门,也同时经营大型门诊部门。从产权来看,我国医院市场呈现所有权多元化的态势。但囿于规模,尽管营利医院按结果度量的质量不必公立医院低,营利医院还不能形成对公立医院强有力的竞争压力。我国医院市场仍然以公立医院为主导。从竞争机制来看。我国患者可以自由选择就医医院,且在现行的激励机制下,我国公立医院自负盈亏,因此,我国医院之间的竞争由患者驱动。政府对医院产业实行高度价格管制。医院之间主要通过改善质量吸引患者,提高服务量规避价格管制,我国医院市场的竞争形态主要是服务量的竞争和非价格竞争。近年来,我国医院服务量呈现上升的趋势。医院使用高科技医疗服务吸引病患,导致医疗质量提高的同时,医疗费用持续上升和医院规模不断扩张。引进患者退出,即市场竞争机制有可能改善医院市场绩效。市场竞争机制能够激励医院投资于医疗质量的改善；市场竞争机制能够改变营利资本发展不平衡的状态,形成营利医院的竞争优势。公立医院和营利医院还能展开纵向竞争,遏制公立医院横向规模不断扩张的趋势。实证研究表明竞争在控制医疗费用,改善医疗质量方面仍然发挥了积极作用。但市场竞争机制不是万能的,存在不足。政策运行环境影响竞争的结果。在我国现行的政策环境下,市场竞争机制可能引致了质量投资冒进,拉动费用上涨,局部看病难等问题。考虑到医院市场竞争的种种限制,以及“自上而下”调整政策运行环境方面的困难,我们进一步研究呼吁的效果。目前,我国医院市场的患者呼吁渠道较为狭窄,仅有的呼吁制度存在执行缺陷。然而,在患者水平呼吁和垂直呼吁方面,都存在可资利用,可以发展的渠道,能够降低患者呼吁成本,提高患者呼吁能力。在竞争的医院市场上,引进患者“自下而上”呼吁可以提高患者的整体福利,遏制医疗机构扩大规模和过分改善质量的倾向。当医院处理患者的成本较低时,患者呼吁还可以提高医院的生产者剩余。呼吁对竞争起到了补充作用。而存在竞争威胁的情况下,患者呼吁效果更好。理论和实证研究均表明,我国医院市场上,患者的退出和呼吁相辅相成,在质量改善和费用控制方面相互补充。由于医院多投入多产出的特点,采用质量和费用来评价医院绩效存在不足,不能全面评价医院绩效。本文应用DEA方法评价省级医院的效率,研究“退出-呼吁”的关系及对医院效率的影响。在提高医院效率方面,退出和呼吁呈现了互补的关系。然而。现阶段,“退出-呼吁”在医院效率方面的积极作用并没有发挥出来。有待于进一步推动我国医院市场上,患者的退出和呼吁能力。医生作为医疗消费的直接决策者,医生在医疗服务的提供中扮演了重要角色,我国公立医院筹资市场化和行政管理的二元化特征扭曲了医生的激励约束机制。医生也不愿参与现行的公立医院改革。引进患者“退出-呼吁”重构医生的激励约束体系,能够有效约束医生合理医疗。市场竞争机制还能激励医生主动合理医疗。外部治理环境与医院内部治理结构相辅相成,外部治理约束落到实处需要医院内部治理的配合。因此,应根据患者“退出-呼吁”所形成的外部治理环境,重构公立医院的产权和治理结构。产权制度方面,重新布局国有资本,调整公立医院的产权结构,鼓励营利资本的进入。治理结构方面,理事会法人治理体系较适应中国医院市场的特点,应建立理事会法入治理结构。相应的,配合法人治理体系,对政府职能进行改革和调整,实现政医分开,所有者与监管者分开,确立卫生行政部门作为全行业监管者的独一无二的地位。本文应用“退出-呼吁”理论,研究了竞争和呼吁在我国城市医院市场改革中可能扮演的角色,为我国深化公立医院改革寻找理论基石。本文第一次将“退出-呼吁”理论系统应用到我国医院市场。根据我国医院市场特点,数理化,模型化了“退出-呼吁”理论,分析我国医院市场的特点；一方面有助于发展和验证该理论；另一方面,也为我国医院市场的研究提供了独特的研究视角。本文系统分析了我国医院市场上竞争的作用。按照“结构-行为-绩效”框架系统介绍了我国医院市场现状的前提上,综合理论和实证的方法系统研究了医院竞争的作用。在实证研究方面,分析了竞争对医疗费用(包括门诊和住院费用)、质量乃至医院整体效率的综合影响,避免了单一指标评价医院效果的不足。本文讨论了消费者呼吁“自下而上”推动医改的可行性和对医院市场绩效的影响,并首次实证检验了呼吁的效果,为“自上而下”推行但状态胶着的医改提供了新的改革思路。本文还存在若干不足,留待以后完善。理论方面,限于篇幅,本文没有系统分析政府管制这一医院外部治理环境的重要要素；考虑到退出和呼吁交互作用在医生行为和医疗机构行为的趋同性,没有具体分析退出和呼吁的交互作用对医生决策行为的影响；理论假设也有待进一步放开。实证研究方面,受制于微观数据的不可得,没有分析退出-呼吁”与医生行为的关系,竞争的衡量较为粗糙。更多还原

【Abstract】 Steadily improving the health level of the residents and hospital market performance relationship are beneficial to the people’s livelihood, which are also important goal and content of medical and health system refonn. The hospital is the main and key link of medical service system in China. To deepen the hospital reform is of great significance.In recent years, the microcosmic operation in our country’s hospital market has been greatly improved; however, the macro efficiency is not simultaneously improved. The difference between the two is related to hospitals’external governance environment. In order to deepen hospital market reform and improving the hospital market performance, it is not easy to block a loophole of hospital management, instead of adjusting hospital exterior governance.Hirschman brought about "exit-voice" theory, which consider consumers’exit and voice as two important ways to improve organizational performance. The character of hospital on China fits to the organization instinct in "exit-voice" theory. Our coutry’s hospital market is face to performance-improving problem. And there is necessity and rationality in our hospital market to systymetic utilizes patient exit and voice. So we analyze the effect of exit and voice on hospital exterior governance and system performance wirh the basis of Hirschman’s "Exit-Voice" theory that we can provide theoretical and practical evidence on reform of hospital market.The studies on hospital market competition by foreign researchers regard the United States hospital market development as the main line, using the theory and empirical research method to discuss the effect of quality competition and price competition, as well as the competition results accompanied by the merger. In general, there is no unanimous conclusion about the competition results. Different scholars have studied patients voice from different aspects.However, there is no systematic research. Compare with abroad research on hospital market competition, domestic research is weak, the theoretical researchs are superficial, most are descriptive study; quantitative research is relatively small. Only a few studies involve patients’voice. It is worthwhile of analyzing the effect of exit-voice by combining with our hospital market characteristics.From the content point of view, hospital industry in our country belongs to multiple products manufacturers, operating inpatient departments as well as a large outpatient department. From property right, our country’s hospital ownership is diversity. But because of the scale, although according to the results of measurement quality, non-profit hospitals’quality does not lower than public hospitals’, non-profit hospitals still cannot form strong competition pressure on public hospitals. Public hospitals are dominant in our country’s hospital marketFrom the competitive mechanism, patients are free to choose hospitals, and public hospitals are self-financing in our country’s current incentive mechanism.therefore, the competition between hospitals is driven by patients. Government own high pricing power. Hospitals attract patients mainly through quality-improving, and avoid price regulation by enhancing service quantity. The main pattern of our country’s hospital market competition is service quantity competition and non-price competition.In recent years, our hospital volume showed a rising trend. Hospital invests in high-tech medical services to attract patients, which leads to medical quality improvement as well as rising medical costs and the expaning scale.The introduction of exit, namely the market competition mechanism has the potential to improve hospital market performance. The market competition mechanism can inspire the hospital invests in medical quality improvment; the market competition mechanism can change the unbalanced development of profit capital, forming for-profit hospitals’competitive advantage. Public hospital and non-profit hospital can also act longitudinal competition, curbing expanding public hospital horizontal scale. The empirical research shows that competition has played an active role in the control of medical costs and improvmeng of the quality.The market competition mechanism is not omnipotent, but insufficient. Policy environment affects the outcome of competition. Under China hospital market’s current policy environment, market competition mechanism can cause rash quality investment, pull the rising costs and local treatment difficult problems. Considering the competition restrictions in hospital market, as well as the difficulties in adjusting policy environment in "top-down" ways, we further study the effect of voice. At present, the channels for patients to voice in our country hospital market is relatively narrow, some channels are formalization. However, there are many available level and vertical voice channels in our hospital market which can reduce the cost and ehance the capability to voice.Due to the characteristics of multiple inputs and outputs, there are shortcomings on the evaluation of hospital performance by quality and cost, which are not comprehensive. The paper applies DEA method to evaluate the relationg between provincial hospital efficiency and "exit-voice". Exit and voice presented a complementary relationship to improve hospital efficiency.However. At this stage, the positive role of "exit-voice" in hospital efficiency has not showed. It is necessary to further promote the capability of patients’exit and voice in China hospital market.The doctors who mke decision on medical consumption play an important role in the provision of medical services. Due to the two dimension characters of public hospital operation that the market-ran public financing and the administration, the physician incentive and constraint mechanism has been distorted. Doctors are not reluctant to participate in the current public hospital reform, too. The introduction of patients" exit-voice" can reconstructe physician incentive and constraint system and effectively restrain doctors to behave properly. The market competition mechanism can also inspire doctors to actively provide reasibly medical treatment.The external management environment and the hospital internal management structure are complementary. The hospital internal management should be coordination with the external governance, so that the external governance can fall to real point. Therefore, according to the external governance environment reformed by patients exit and voice, the paper reconfigures the public hospitals’property rights and governance structure. Avout the property right system, government should relayout state-owned hospital, adjust public hospital property right structure, encourage tprofit the introduction of profit capital. On the governance structure, the corporate governance system should be appliyed. The Council is consistent with the characteristics of Chinese hospital market, so the Council governance structure should be established. Accordingly, the functions of the government should be reform and adjusted to reach the division of regulator and the owner of public hospital and establish the administrative department of public healtha as the one and only industry regulator.The paper studyes the role that competition and voice may play in our country hospital reform wirh the application of theory of "exit and voice" by the form of mathematical and model, in order to find the the retical cornerstone of the ways to deepen reform of public hospitals. It is the first time that the "Exit-Voice" theory is applied to our country’s hospital market.On one hand, we develop and test the theory. On the other hand, we provide new perspective for hospital market research.The paper systematicly analyzes the competition effect in our country hospital market, based on the systematical introduction of the hospital market structure, construct and performance,the paper uses the theoretical and empirical methods to Evaluate the hospital competitive effects. The paper includes more comprehensive index such as medical care expense, quality and technical efficeiency to study exit effect, avoiding the deficiency of single index. This paper studies the voice effect on hospital market performance with empirical test for the first time, and reasons the possible that voice push health care reform from " bottom-up",bringing out new thinking for the "top-down" but stalement health reform.This paper has certain insufficiencies, remain to be perfected. In theory, the first deficiency is that because of the limited space, this paper does not analyse government regulation which profoundly affect the hospital external governance environment.The second one is that there is no specific analysis about exit and voice interaction effect on physician decision-making behavior.Considering the interaction outcome of exit and voice in physician behavior is similar to the one of hospitals,the paper doesn’t include the part. The third one is that the theoretical hypothesis has yet to be further open. In Empirical research, subjecting to the microscopic data is not available, there is no analysis of exit and voice effect on physician behavior and competition is measured by rough index.更多还原