【作者】 周小梅；

【导师】 王俊豪；

【作者基本信息】 浙江工商大学 ， 企业管理， 2008， 博士

【摘要】 进入20世纪80年代,发达国家在政府的支持下,基本建立了医疗保险体系和医疗服务提供体系,以保障公众享受医疗服务的权力。而要长期维持这种享受医疗服务的公平,政府将会面临很大的财政压力。鉴于此,不少发达国家通过增加私人部门的活动以及引入市场竞争机制以提升医院绩效。在这个过程中,各国都面临着如何选择有利于提升医院绩效的制度安排问题。20世纪80年代初,迫于政府财力缺乏、公立医院表现出的不良绩效等压力,中国亦采取了对公立医院的产权和允许民营医院进入医疗服务市场等在内的改革措施。改革的目的是减轻政府的财政负担以及提升医院绩效。然而,通过这些年的改革,中国目前仍广泛存在医院绩效不良的问题。针对各国面临的提升医院绩效这个难题,本文从提升医院绩效的特殊性出发,以产权理论、交易成本理论为视角,研究有利于提升医院绩效的组织形式。通过权衡不同制度安排交易成本的高低,为医疗服务提供组织形式的选择提供基本的理论依据与实证资料。本文研究可让政策制定者认识到,盲目地把医疗服务推向市场或简单地通过政府直接控制医院对提升医院绩效都是不利的。医疗改革必须从医疗服务市场交易的基本规律出发,在确定医院所有权格局的基础上,通过市场与管制间的有机融合达到有效提升医院绩效的目的。鉴于此,本文可为中国政府相关部门制定医院改革政策提供基本思路。基于以上研究背景和研究目的,本文的主要内容如下:第一章,导论。从研究背景与意义出发,对提升医院绩效的相关研究进行较全面的梳理,继而阐述本文的研究内容、研究方法以及本文的研究创新和不足之处。第二章,所有权、市场与管制安排的一般理论分析。探讨所有权激励和企业治理结构对医院绩效的影响。从交易成本理论出发,分析在进行企业与市场组织以及市场与管制组织间选择时交易成本的决定性作用。基于交易成本分析的基础上,借助可竞争性与可度量性矩阵模型以及制度可能性边界模型对不同制度安排进行比较分析。第三章,医疗服务市场的交易特征。医院绩效提升的制度安排取决于医疗服务市场的特殊性。首先,医疗服务市场中最典型的特征就是信息的不完备性以及由此产生的委托代理关系;其次,医疗服务市场表现出明显的垄断性、非价格竞争以及特有的可竞争性;再次,医疗服务是具有外部性的公共物品,同时又是具有竞争性和排他性的私人物品。第四章,提升医院绩效制度安排的理论框架。本文围绕提升医院绩效问题,通过比较提升医院绩效的内部方法和外部方法,强调了外部方法对提升医院绩效的特殊作用。进而针对外部方法中的市场和管制对医院的激励和约束作用,阐明市场与管制间的关系。然后从所有权对医院绩效的激励作用,以及市场与管制间的权衡全面分析提升医院绩效的理论框架。第五章,发达国家提升医院绩效的制度安排:以美国和英国为例。围绕提升医院绩效问题,各国采取了在市场与管制间权衡的不同政策,其中以美国和英国最具有代表性。本文通过对美国和英国为提升医院绩效的医疗改革实践的梳理,总结出可以为中国借鉴的经验。第六章,提升中国医院绩效的制度安排。本文在对中国医院改革的演变历史进行简单回顾的基础上,分析目前中国医院改革面临的困惑。基于所有权对医院绩效的激励作用,研究建立符合中国实际的医院所有权格局和公立医院法人治理结构,进而设计市场与管制相融合的有利于提升医院绩效的模式及其制度框架。基于以上分析,本文得到以下结论:1.提升医院绩效是确保公众享受医疗服务公平性的基本前提;2.由于医疗服务市场的多种不完备性,提升医院绩效具有特殊性;3.提升医院绩效的制度安排应以交易成本最小化为基本原则;4.基于市场机制提升医院绩效,应不断完善法规以及提高管制效率;5.通过竞争促进医院绩效提升应考虑引入市场竞争的层面;6.应以交易成本最小化构建具有中国特色的提升医院绩效的制度安排。本文采用的主要方法有:理论与实践相结合的研究方法、实证分析和规范分析相结合的研究方法以及制度分析方法。本文研究的创新主要有:1.以产权理论和交易成本理论的视角,深入系统地研究了提升医院绩效的制度安排问题。国内对医院绩效研究主要从医院微观经营管理角度分析较多,尚缺乏从制度角度的分析。而关于如何通过不同的制度安排提升医院绩效问题,从国外研究来看,目前尚处于探索阶段,亦是个较新的课题。2.提出并论证了应根据医疗服务的特征选择不同的提升医院绩效的制度安排。由于各种医疗服务市场的可竞争性与可度量性的组合特征存在差异,本文提出在考虑提升医院绩效制度安排的过程中,应通过医疗服务市场可竞争性与医疗服务的可度量性矩阵模型对医疗服务进行分类,根据这种分类对不同医疗服务所选择的制度安排进行界定,政府对不同医疗服务控制程度应实施差异性政策,这种区分可以防止政府在实施医院改革过程中的盲目性。3.构建了所有权、市场与管制有机融合的医院绩效提升模式。在发达国家,为提升医院绩效,政府的改革政策往往会对医院所有权格局进行调整,并在市场与管制间进行权衡。在医院所有权格局既定的情况下,在特定时期,政府政策可能会过多倾向于管制;而另一个阶段则会偏重于引入市场竞争,这种改革的结果很难全面提升医院绩效。因此,本文从中国实际出发,建议应通过在医院所有权格局进行调整的基础上,构建市场与管制有机融合起来的全面提升医院绩效的模式。4.提出中国应实施反应灵敏型的“多元化”医院管制政策。根据交易成本理论,不同制度安排所表现出的交易成本高低与市场发育程度、政府管制效率以及组织本身的管理水平存在密切的关系。一方面,与落后地区(城市)相比,中国发达地区(城市)的市场发育较成熟,且政府管制效率较高。因此,政府政策制定过程中,在进行市场与管制安排的选择时,应根据市场发育程度以及政府管制效率地域上的“多元化”特征,实施区别对待的反应灵敏型的医院管制政策。另一方面,由于不同的医院组织的内部管理能力的差异,医院发展亦存在“多元化”特征,政府在实施管制政策时亦应该区别对待。更多还原

【Abstract】 In the 1980s, under the government support, healthcare insurance system and health care service delivery and provision system are built in developed countries to ensure the right of public’s access to the healthcare service. To maintain the equity of the access to healthcare service, the government will face a great fiscal financial pressure. In many developed countries, substantial private sector activities in healthcare provision to improve hospital performance. Every country faces the problem of institution arrangement of hospital performance improvement.Since the early of the 1980s, under the pressure of the shortage of fiscal financial, and the poor performance of public hospital, Chinese government took the measures of the reform of public hospital property right and the private hospital involved in the financing, delivery and provision of healthcare services. The goals of reform are to decrease the fiscal finance pressure and to improve hospital performance. However, the hospital performance is still poor after the reform in China. Facing the problem of hospital performance improvement, this paper discuss the form that fit for the hospital performance improvement based on the property right theory and transaction cost theory according to the particularity of hospital performance improvement. After trading off the transaction cost of different institution arrangement, the theory and practice information can be obtained for the choice of healthcare organization. Furthermore, the paper can remind the policy constitutor of avoiding to privatize completely blindly or to control under government directly simply. Healthcare reform must follow the rule of the healthcare service market transaction. Based on the form of hospital ownership, the market and regulation must be combined to improve the hospital performance. This paper can provide the basic idea of establishing policies by the government sector.According the background information and the goals, this study includes the contents as follows:Chapter one does a theoretic preparation for the whole thesis. This chapter discusses the background and the significance of hospital performance improvement. Literatures of the studies about hospital performance improvement are concluded. Then the content, method, innovation and deficiency are illustrated.Chapter two is about the general theory analysis of ownership, market and regulation arrangement. This thesis discusses the influence of ownership incentives and the firm governance structure. Based on the transaction cost theory, the role of transaction cost is analyzed during the discussion of the choice between the firms and market organization, and between the market and the regulation organization. Then the different institution arrangements are compared by the models of contestable-measurable matrix and the models of frontier of the institutional possibility.Chapter three analyzes the characters of healthcare services market. The institutional arrangement of the hospital performance improvement is dependent on the particularity of the healthcare service market. The typical characters are the incomplete information and the principal-agent relationship. In the healthcare service market, hospitals have the market power, non-price competition and contestable. Healthcare service is the public goods that have externality. At the same time, it is the private goods that are rival and exclusive.Chapter four illustrates the theory framework of institutional arrangement of hospital performance improvement. This chapter emphasize the external approaches have the special role for hospital performance improvement by comparing the internal approaches with the external approaches. Furthermore, it discusses the roles of market incentives and regulation constraint, and illustrates the relationship between the market and regulation. Based on the discussion of incentives of ownership for the hospital performance and trading-off between the market and the regulation, this chapter states the institutional framework that benefits for hospital performance improvementTaking the examples of America and England, Chapter five concludes the international experience of institutional arrangement of improving hospital performance. To improve the hospital performance, each country took different policies. Based on the practices of American and British institutional arrangement for hospital performance improvement, this chapter concludes the experience that can be used for reference by China.Chapter six discusses the institutional arrangement of hospital performance improvement of China. After retrospection the history of healthcare reform simply, this chapter analyses the puzzles of the reform of healthcare service provision in China. Considering the incentives of ownership, the forms of hospital ownership and public hospital governance structure should be considered. Furthermore, the model that market and regulation are combined and the institutional framework are designed.Based on these above, the conclusions can be summarized as follows:1. Hospital performance improvement is the basic precondition that publics access to healthcare service;2. As the healthcare service market has varieties of incompletion, hospital performance improvement is special.3. The basic principle of the institutional arrangement of hospital performance improvement is the transaction cost minimization.4. The perfect law and high efficient regulation are benefits for the hospital performance improvement through the market mechanism.5. The competition level must be considered when hospital performance is improved by the market competition.6. The institution arrangement of hospital performance improvement of China should be framed based on the transaction cost minimization.This paper bases its analysis on the approach of theory and practice combination, positive statement and normative statement combined, and the approach of institutional analysis.The main innovations of the paper can be summarized as follows:1. The institutional arrangement of hospital performance improvement is deeply analyzed by the theory of property right and transaction cost. In China, most studies about the hospital performance improvement are from the management science, not from the institutional economics. This topic is also a new area in other countries.2. The paper illustrates that the different institutional arrangement of hospital performance improvement is chosen by the character of healthcare service. Because the combinations of contestable and measurable of varieties of healthcare service market are different, this paper holds that the healthcare services must be classified by the combinations of contestable and measurable when the institutional arrangement of hospital performance improvement is chosen. The policy should be different according to classification. Doing so, the blindness can be avoided when government implement the hospital reform.3. The model has been built based on the combination of ownership, market and regulation. To improve the hospital performance, the formation of hospital ownership is often adjusted, and market mechanism and regulation must be traded off by the reform policy in developed country. Given the ownership of hospital, government may be inclined to regulation during some special period, but next they may lay particular stress on market competition. The result is that the hospital performance is improved incompletely. Therefore, this study gives a suggestion that the model of complete hospital performance improvement is built based on the formation of ownership, and the combination of market mechanism and regulation.4. The paper states that the hospital regulation policy must be ’pluralistic’. The transaction cost of different institutional arrangements is related with the development of market, the efficiency of regulation and the level of organization management. On the one hand, the market is more developed and the regulation is more efficiency in developed areas than the underdeveloped areas in China. Therefore, the government should implement the responsive regulation policy according to the character of ’pluralistic’ when they constitute the policies. On the other hand, the level of each hospital management is different, the hospital development is also ’pluralistic’, and thus the policy of regulation must be different among hospitals.更多还原