【作者】 胡洋；

【导师】 张亮；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2007， 博士

【摘要】 研究目的分析医疗费用控制过程中政府、医院、患者的行为特点及其对医疗费用增长的影响,建立行为模型;理论上构建医疗费用控制中政府、医院、患者间层次委托代理体系,并提供相应的政策解释,探索政府、医院、患者和谐互动机制,为政府解决医疗费用增长过快问题提供决策依据和新的政策思路,从而为实现社会和谐发展提供政策依据。研究方法文献研究法:查阅大量国内外关于医疗费用发展情况及控制,政府、医院和患者博弈方面的公开文献和研究成果。深入访谈法:本研究在医疗费用相关主体的行为、行为对医疗费用的影响、调查内容等方面进行了反复的访谈和严格的论证,在同济医学院医管学院、医院院长、卫生局管理人员等专家的参与下完成。问卷调查法:采用规范的、标准化问卷调查,针对政府代表、医院管理者和患者分别设计问卷,以获得三方在控费过程中行为特征及其影响因素的相关信息。数据统计分析方法:单因素分析:计数资料的卡方检验;多因素分析:非条件Logistic回归分析。调查问卷采用Microsoft Office Excel2003录入数据,采用SPSS11.5处理所有数据。研究结果1.医疗费用控制相关主体政府行为的经济学分析政府行为的理论分析结果显示:政府的价值在于维护和发展社会公共利益,其行为的目标取向是保持社会的和谐与稳定的发展。但是在现实生活中,政府利益除了可以代表公共利益,同时也可以代表政府自身权力的利益,这就容易形成政府行为两难困境,当政府利益超越了公共利益,政府行为就表现为政府功能缺位或功能限度。政府在医疗卫生体制改革中的行为实证分析结果显示:在市场经济体制改革时期,对政府来说,一方面要采用在计划经济体制下的“万能政府”的做法和相关的医疗卫生政策以维持政府作为卫生事业发展与改革的主导地位,另一方面,政府的财政能力却很难满足卫生事业迅速发展和人民群众卫生服务需求不断提高的要求。政府在医疗费用控制过程中的行为分析结果显示:政府也陷入利益困境之中——既要考虑自身经济财力又要考虑解决患者看病贵的问题。2.医疗费用控制相关主体医院行为的经济学分析医院行为的分析结果显示:医院的行为价值取向往往具有双重性,一是追求经济效益;二是体现社会效益。医院实证研究结果显示:1998-2005年卫生部综合医院总收入与总支出是同步增加的,并且其业务支出与业务收入几乎重合。医院服务提供数量增加不多,速度也不快,明显低于医院收入速度的增加。每个医生的工作负荷增长速度逐年下降,甚至不再增长的同时,他们的年业务收入却快速增长。每门诊人次医疗费用和出院者日床位费用以及出院者平均医疗费用在逐年上升,即单位服务费用在上升。出院者人均医疗费用构成中药品和检查费用占医疗费用的比例增长缓慢,有下降的趋势。3、医疗费用控制相关主体患者行为的分析门诊患者控费意识在年龄、收入分布上的差异有统计学意义。住院患者控费意识在文化、收入户口分布上的差异有统计学意义。门诊和住院患者的控费意识在性别、职业、居住地和医保形式分布方面的差异没有统计学意义。门诊和住院患者控费意识在治疗情况分布方面的差异有统计学意义。门诊患者和住院患者关注医疗费用信息在医保方面分布上的差异没有统计学意义,并且均关注医疗费用信息。住院患者看病时选择医生的情况在控费意识分布方面的差异有统计学意义。门诊患者检查情况在控费意识方面上的差异没有统计学意义,但是在医保形式方面上差异有统计学上意义。住院患者检查情况在控费意识分布情况方面的差异有统计学意义。在对检查的态度方面,门诊患者在医保方面上和控费意识方面的差异没有统计学意义。门诊患者要求医生开便宜药在控费意识分布方面的差异有统计学意义。门诊和住院患者选药情况在控费意识分布方面的差异均有统计学意义。门诊和住院患者在就诊医院药房买药情况在控费意识分布方面的差异均有统计学意义。住院患者选择医疗耗材在控费意识分布方面的差异没有统计学意义。非条件Logistic回归分析结果显示影响门诊患者控费意识的因素与月收入、关注医疗费用信息及药品选择有关;影响住院患者控费意识的因素与月收入和在就诊医院买药有关。研究结论1.提出了医疗费用控制中政府行为的特点,即政府是医疗费用控制政策供给的主体;政府是宏观调控的主体;医疗费用控制中政府行为具有公益性。并根据其行为特点构建了政府控制医疗费用增长模型。2.医院在响应我国医疗费用控制政策自觉采取措施降低药品和检查费用的同时,医院年业务收入的增加是依靠次均费用的提高而增加的。根据上述结论提出了医院控制医疗费用模型和医院增长医疗费用模型。3.提出患者在医疗费用控制中的特点即主动性和被动性。在关注医疗费用信息方面,两者的选择是一致的——门诊和住院患者均主动关注医疗费用。而在选择检查方面、选择药物方面和看病后在就诊医院购买药品的情况,具有控费意识的两者选择也是一样的,均为听从医生安排,都表现出控费的被动性。这在非条件Logistic回归分析中也得到验证。这个结果一方面证实了患者因为健康刚性需求而导致药品和检查的选择的被动性;另一方面说明医生具有信息优势,有出现道德风险的动机因素。根据上述研究构建了患者增长医疗费用的行为模型。4.医疗费用控制中政府、医院、患者和谐互动机制研究结合理论研究与实证的分析结果的探讨,本文最后总结了医疗费用控制患者、政府及医院的委托代理关系体系。这一委托代理体系存在着如下几组委托代理关系:医疗保险机构与患者;医疗保险机构与医院;患者与医疗服务提供者;患者与政府;政府与医院以及与医疗保险机构。然后根据这一委托代理关系体系,从系统的角度,研究三者之间的相互之间的关系,探讨博弈行为背后的深层次问题,构建三方的医疗费用控制和谐互动机制。这一互动机制考虑了不同关系与具体的策略之间的交互关系,同时能够反映随着相关主体的变化,控制医疗费用策略发生的变化。5.构建了医院自我激励约束机制的框架,概括为建立和完善医院内部的制度、市场竞争机制的引入、构建和谐的医院文化、医生品质的鉴别四个方面。具体来说,医疗机构激励与约束机制的建设包括以下几方面:改进医疗机构内部治理结构;设计管理者报酬机制;营造竞争的市场环境,强化市场竞争约束;建立管理者的职业风险机制,加强职业风险约束;建立科学的医院文化;加强医生的道德品质鉴别。6.根据委托代理关系以及互动机制构建政府医疗费用控制政策框架。其价值取向“以民为本,政府主导,系统控制,制度创新,道德培育”。政策框架内容包括:政府决策维度有加强政府投入,体现政府职责;建构政府管制的法律体系;进一步深入改革药品集中招标制度;尽快建立社区卫生服务体系的配套制度。医院决策维度有建立医院自我激励约束机制;改进对医疗单位的支付制度;强化对医疗服务提供方的制约和调控制度建设;建立缩小医疗信息不对称的制度;建立治理商业贿赂工作机制;设立资格处罚制,从制度上约束、规范医疗机构及医生的行为。患者决策维度有建立科学的医疗救助工作机制,保障弱势人群的基本医疗服务需求;建构各阶层平等参与的制度平台,扶持患者权利保障组织的利益调节机制;加强居民的健康教育与促进;建立约束需方道德风险的制度。更多还原

【Abstract】 Objectives:Analyzing the behavior characteristic of the government, the hospital, and the public in the process of medical expense control and its influence to medical expense increase, establishing the behavior model; Theoretically constructing the entrusting and the agent system of the government, the hospital, the public in the medical expense control, and providing the corresponding policy to explain, exploration the harmonious interaction mechanism in the government, the hospital and the public, to provide the policy-making basis and the new policy mentality in solving the excessively quickly growing of medical expense for the government, thus providing the policy basis for the realization society harmonious development.Methods:Literature methodology: Consulting massive domestic and foreign public literature and the research results about the medical expense development situation and the control, also the government, the hospital and the public gambles.Thorough interview methodology: This research has carried on repeatedly interview and strict proof in the medical expense correlation main body behavior, the influence of the behavior to medical expense and investigation content. completing in participation of experts of Tongji Medical college, hospital chief, sanitation bureau administrative personnel.Questionnaire survey methodology: Using the standardized questionnaire survey, in view of the government representatives, the hospital superintendent and the patient separately designs the questionnaire, to obtain the related information on the tripartite behavior characteristic and its the influence factor in the process of controlling expense. Statistical Analysis methods:Univariate Analysis:Chi-square for variable data; Multivariate Analysis:Unconditional Logistic Regression; All data are input by using Microsoft Office Excel 2003 and processed by SPSS for Windows 11.5.Results:1.The economic analysis of the government behavior in medical expenses control The theoretical analysis result of the government behavior showed that, Government’s value lies in the maintenance and the development society public interest,its behavior goal orientation is maintenance harmonious and stable development. But in real life, the government benefit may be the public interest which the government represents, also may be the benefit from the government authority. This is easy to form the government behavior to be in a dilemma, when the government benefit has surmounted the public interest, the government behavior is on performance for government function vacancy or function limit.Government’s behavior analysis in the medical health organizational reform demonstrated that, In the market economy organizational reform period, to the government,On the one hand the government must use the measures under the planned economy system "the multi-purpose government" and the correlative health policies and measures to maintain oneself is the public health main policy-maker and the investment, on the other hand, government’s financial resource satisfy the request with difficulty which the public health rapid development and the people health service demand unceasingly enhances.The government’s behavioral analysis result in the process medical expense controlled demonstrated that, The government also falls into in the benefit difficult position - both to have to consider own economical financial resource and to have to consider solving the patient to see a doctor with much money.2. The economic analysis of the hospital behavior in medical expenses control The hospital behavior analysis result showed that, The hospital behavior value orientation often has the ambiguity, one is pursuing the economic benefit; The other is the public benefit.The research on hospital showed that, in 1998-2005 year the gross income and the gross expense in the general hospitals of ministry of health is synchronized increasing, and its service disbursement and the service income nearly superposed. The quantity increase of the hospital service providing are not many, the speed is not quick, obviously is lower than the speed of the hospital income increase. Each doctor’s working load rate of rise drops year by year, even at the same time no longer grows, their year service income actually fast grows. The medical expense of each outpatient service, the everyday bed expense of leaving the hospital as well as the average medical expense of leaving the hospital is rising year by year, namely the unit service expense is rising. In the leaving the hospital average medical expense constitution per person, the proportion of Chinese native medicine and the inspection expense account for the medical expense grows slowly, has the tendency to drop.3. The economic analysis of the patient behavior in medical expenses control The outpatient’s consciousness of controlling spending has statistical significance in the difference of age and income. The inpatient’s consciousness of controlling spending has statistical significance in the difference of culture, income and registered permanent address. But in sex, occupation, inhabited area and the form of medicare, the difference of the outpatient’s and inpatient’s consciousness of controlling spending have no statistical significance. The difference of the outpatient’s and inpatient’s consciousness of controlling spending have statistical significance in treatment situation.The outpatient and inpatient paying attention to the medical expense information has no statistical difference in the aspect of medicare, and both pay attention to the medical expense information. The difference of the inpatient’s consciousness of controlling spending has statistical significance when they choose a doctor.The check-up of outpatient has no statistical difference in consciousness of controlling spending, but has statistical difference in the form of medicare. The check-up of inpatient has statistical difference in consciousness of controlling spending. In the attitude to check-up, the inpatient participating in medicare and having consciousness of controlling spending have no statistical difference.The outpatient requesting doctors to prescribe cheap medicine has statistical difference in consciousness of controlling spending. The outpatient and inpatient to choose the medicine have statistical difference in consciousness of controlling spending. The outpatient and inpatient to buy the medicine in the hospital pharmacy have in statistical difference in consciousness of controlling spending. Inpatient to choose the medical consuming material has no statistical difference in consciousness of controlling spending. Unconditional Logistic regression analysis result showed that the factor that influence outpatient’s consciousness of controlling spending has related to concerning medical expense and choosing drug; the factor that influence outpatient’s consciousness of controlling spending has related to the month income and buy the medicine in the hospital pharmacy.Conclusions:1. Proposed the government behavior characteristic in the medical expense control, namely the government is the supplying main body in medical expense control policy; The government is the main body of macroeconomic regulation and control; The public welfare of government behavior in medical expense control. And construct the government control medical expense growth model acted according to its behavior characteristic to.2. Responding to our country medical expense control policy ,the hospital has its own initiative to take measures to reduce the expense of drugs and checking-up, at the same time, the increase of hospital service income is actually depending on enhancing the unit service expense, and unit service expense enhancement is through increasing service intensity. Proposed the hospital control medical expense model and the hospital medical expense growth model according to the above conclusion.3. Proposed patient’s characteristic in medical expense control, go-aheadism and passivity. In the aspect of attention to medical expense information, two choices are consistent - the outpatient and inpatient having control spending consciousness both initiative pay attention to medical expense. But in the aspect of selecting checking-up, the choice of medicine and purchasing the drugs in the hospital after seeing a doctor, two choices is also the same in having control spending consciousness, both obeys doctor to arrange, both displays the passivity in controlling spending. This also obtains the confirmation in the multi-factor analysis. This result on the one hand confirmed that the patient causes the drugs and the inspection choice passivity because of the healthy rigid demand; On the other hand explained doctor has the information superiority, has appears the moral risk to induce the factor. Constructed the behavior model of patient growing the medical expense according to the above research.4. The harmoniously interacting mechanism research of the government, the hospital and the patient in medical expenses controlUnited the fundamental research and the demonstration analysis result discussion, this article finally summarized the entrusting and the agent system of the government, the hospital, the public in the medical expense control. The entrusting and the agent system at least have the following several groups relationships, Medicare organization and patient; Medicare organization and hospital; Patient and medical service provider; Patient and government; Government and hospital as well as with medicare organization.Then according to the entrusting and the agent system, from the system angle, studies the relationships between the three aspect, discussing the deep level questions behind the gambling behavior, constructs the tripartite harmonious interaction mechanism in medical expense control. This interaction mechanism had considered the alternately relations between the different relationships and the concrete strategy, simultaneously can reflect along with the change of the correlation main body, the change which the control medical expense strategy occurs.5. Constructed the frame of hospital self-encouragement restraint mechanism, summarizes for four aspects such as establishing and consummating the hospital interior system, the market competition mechanism introduction, constructing the harmonious hospital culture, the doctors’quality distinguishing. Concretely said, the inspirit and restraint mechanism construction of medical organization including the following several aspects: Improvement medical organization interior structure; Designing the superintendent reward mechanism; Building the competition the market environment, strengthens the market competition restraint; Establishing superintendent’s professional risk mechanism, strengthening the professional risk restraint; Establishing scientific hospital culture; Strengthening doctors’moral cultivation .6. According to the entrusting and the agent relations as well as the interaction mechanism construct the government medical expense control policy frame. Its value orientation is "take the people as the basic, the government leads, systemically control, system innovation, moral cultivation". The content of policy frame includes: In the government decision-making aspect, strengthening the government invest, manifests the government responsibility; Constructing the legal framework of government regulation; Further thorough reforming drugs inviting public bidding system; Establishing the necessary system of the community health service system as soon as possible; In the hospital decision-making aspect, Establishing the hospital self-encouragement restraint mechanism; Improvement the payment system to medical organization; Strengthening the restriction to the medical service supplier and the construction of regulative system; Establishment the system reducing the medical information asymmetry; Establishment the work mechanism fathering commercial bribe; Establishment qualifications punishment system, restraining and standardizing the behavior of medical organization and doctors from the system; In the patient decision-making aspect, Establishment scientific medical rescue work mechanism, safeguard the basic medical service demand of weak crowd; Constructing the system platform that various social strata can equality participate, supporting the benefit adjustment mechanism of the patient right safeguard organization; Strengthening inhabitants’health education and promotion; Establishment the system of restraining consumer moral risk.更多还原