【作者】 张翔；

【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】 随着我国经济社会的不断发展和改革开放的深入进行,在计划经济条件下形成的医患关系的弊端逐渐暴露。目前我国的医疗改革正逐步深化,医院和医生作为医疗服务最直接的供给方,与医疗服务的需求方——患者一起,构成了医疗服务的供求关系。医患关系中,一个最突出的特征是医方和患者处于信息不对称状态,从而导致医疗市场失灵。这就构成了本文的研究主题:在信息不对称框架内分析医患关系。1研究目的医疗服务作为一种特殊的产品,在提供服务过程中存在影响医患交易行为的非对称信息,而这些非对称信息的存在造成了医疗服务市场的低效率,医疗资源的浪费和因医疗服务价格过高导致的需求不足并存的“悖逆”现象。深入剖析医疗服务过程中医患间的非对称信息,探讨医患信息调节的优化机制和以信息互动为基础的医患关系良性互动模式不仅有利于深入了解医疗服务市场,也可能成为制定医疗服务市场管理政策的基本依据。本研究的目的有二:(1)分析医患间医疗服务信息需求特征以及非对称信息对医疗服务交易行为的影响,探讨医患间医疗服务信息调节优化模型,为政府完善医疗服务市场管理政策提供理论基础。(2)理论上提出医疗服务医患信息良性互动模型实施的条件、策略以及互动效果评价方法,探讨多方参与的社会干预模式,为建立良性的医患关系互动提供理论基础,为提高医院医疗服务管理水平提供理论依据和借鉴经验。2资料来源与分析方法根据经济发展水平、地区分布、城市规模等方面的不同选择深圳市、哈尔滨市、武汉市和黄石市作为现场调查点,其中深圳市选取深圳市福田医院(公立)、博爱医院(民营);哈尔滨市选取哈尔滨医科大学附属第二医院(公立);武汉市选取湖北省新华医院(公立);黄石市选取黄石市爱康医院(民营)。具体调查对象包括:患者、医院行政部门和医务人员。主要采用问卷调查的方式,对不同产权性质的医疗服务机构内接受医疗服务的患者主观感受的分析,结合各医疗服务机构管理人员和医务人员的访谈,以获取本研究所需的社会经济学、消费心理学、医疗服务需求、供给及医疗服务费用支出、成本、医疗服务的意愿等方面的信息,以进一步了解医患双方信息不对称的需求主要表现在哪些方面,为建立医患关系良性互动模型提供参考。描述性分析:问卷调查所收集的计量资料的均值、标准差计算。卡方检验:将患者基本情况与患者择院原因、获取医疗服务信息的途径、对就诊的期望、对医生诊疗工作中的满意部分、对医生诊疗工作中的不满意部分等进行差异分析;将医生基本情况与医生对医疗服务信息提供认知、医患关系的认知、就诊细节的认知等进行差异分析。多项有序分类资料的Logistic回归分析:找出医院信息公布内容分别对医生、患者总体满意度的影响因子。所有数据分析采用SPSS for windows 13.0专业统计软件处理。3研究结果(1)医患间信息不对称是直接导致医患关系破裂的重要原因首先,通过文献研究发现,医患关系主要表现为经济利益关系、法律关系、伦理关系、社会关系,其中,后三个角度的研究偏多,经济关系研究中的医患关系主要表现为医疗服务过程中医患之间的信息不对称而导致的逐利现象。相应的医患关系的特征主要表现为医患关系的动态性、不平等性和不对称性。运行模式按照医患间信息不对称程度的大小主要表现为三种:主动——被动型、指导——合作型、共同参与协商型;上述这些关系、模式、特征等医患关系内涵也在发生变化,并直接影响了市场经济条件下医患关系的发展趋势:向经济利益化、法制化、公平化发展。其次,通过对当前医患双方信任度下降,医疗纠纷日益增多的原因以及信息不对称条件下的医患关系进行论述,并以信息不对称发生时间为依据,分别研究事前和事后信息不对称问题。首先,考虑事前信息不对称带来的逆向选择问题以及如何通过发送信号来求得分离均衡,并揭示了当前我国“小病去大医院”这种特殊的逆向选择的深层次原因。接着,分析事后信息不对称导致的道德风险,进而说明信息不对称导致的医患交易的低效率。(2)医疗服务过程中的医患信息需求与现状研究从收集的深圳、哈尔滨、武汉、黄石等四个城市中医患双方问卷调查显示,不同情况的患者对医院公示的药品价格、专家介绍、医疗流程、医院重要的规章制度等信息有不同的需求反应。同时,医患双方对医疗服务的期望基本上是没有差异的,医患双方对医疗技术重要性的认识是一致的;对于非技术层面,如服务态度,就诊环境和医护人员的人文关怀等方面的认识尽管存在一定的偏差,但总体上的认识趋于一致。患者从自身健康出发,不论年龄、性别、文化程度、社会地位和经济状况等如何,对健康的期望是一致的,不存在个体差异,都希望医院能优先医治疾病。患者对于医方的期望和评价的重心都集中在医治疾病方面,其次才考虑医方的服务态度、方便的就医服务措施、积极主动的人文关怀、医疗费用的合理性和经济性、患者的隐私权和知情权的保护等方面。从医方的调查结果分析来看,医方的性别、年龄、文化程度和月收入等对于医务人员提供医疗服务、促进医患关系和谐相处,明确医疗服务过程中的就诊细节方面均是没有显著差异,说明医方从治疗疾病,维护患者健康方面的认识是一致的,这也是医务人员医德医风的基本要求和职责所在。4研究结论在信息不对称条件下,需要建立医患间信息调节优化机制,并引入CRM相关理论、博弈分析理论、制度学理论及管理学理论,探讨建立在相互信任和交流基础上的医患关系互动模型的理论研究,并针对我国实际情况提出了相关的政策建议。从医疗服务信息角度深入发掘医患互动的驱动力,从信息经济学的角度为医患关系现况和互动提供理论上的指导和解释,并对医患互动涉及的医疗服务相关要素之间的分析,对于改善医疗机构内部的服务管理和医疗服务市场的宏观管理都将是有益的探索。在信息不对称客观存在的情况下,如何在当前的医疗环境下,通过理论和实践研究,进一步缩小医疗服务过程中医患间的信息差距,增进医患间的互信、增强医患间的互动,使医患间达到真正的和谐还需要进一步研究和探讨,有关信息不对称下医患关系的研究还需要进一步完善和深入,当然在某些方面也需要政府和“第三方”的高度重视和积极参与,如出台相关的政策文件以进一步规范医疗市场,拉近医患之间的距离,促进医患之间的平等沟通与交流等。5创新之处本文选题主要是针对当前医疗服务信息不对称下医患关系紧张的现实情况,在理论和实证研究的基础上,提出基于信息不对称条件下的医患互动模型,有较强的现实意义。(1)在研究方法上,从微观角度将医疗供给方和需求方作为两个博弈主体,说明信息不对称对医患关系紧张的影响并提出解决方案。(2)引入经济学、社会学、法律学和伦理学的相关理论知识,较全面分析信息不对称条件下的医患关系影响因素,并建立医患非对称信息调节优化模型。(3)通过研究不同信息分布状态下医患双方交易行为的统计学特征,结合经济人和社会人的行为理论,以及引入客户关系管理理论,建立信息不对称条件下的医患互动模型。更多还原

【Abstract】 The deficiency of the Doctor-patient Relationship under planned economy system was exposed gradually with the unceasing developing of the economy-society in our country and the in-depth reform and open. Now day’s medical reformation in China is developed toward marketization step by step, hospital and doctor who’s the direct provider of medical treatment service and the patient have constituted the supply and demand of medical treatment service together. Malfunction of the market system result in information dissymmetry state between doctor and patient is the most notable character of the Doctor-patient Relationship and it constitutes the main subject: analyze the Doctor-patient Relationship under the frame of information dissymmetry.ObjectiveAs a kind of special production, there have some asymmetric information in the process during medical treatment service providing. Those so called reversion phenomena such as low efficiency of medical treatment service, waste of medical treatment resource and Lack of Demand result in high medical treatment service price occur together because of the existing of asymmetric information. Studying on optimizing the adjustment of Doctor-patient information and the benign interactive mode of Doctor-patient Relationship based on information interaction does not only benefit to in-depth understanding the medical treatment service market but also be the basic foundation of establishing the management policy in the medical treatment service market. There are two objections of this research:①To analyze the requirement characteristic of Doctor- patient asymmetric information and the affection to medical service trading action result from it. To discuss the adjustment mechanism of medical service Information model between doctor and patient. To provide the theory elements for perfecting the policy of medical service market management.②To rise the theory about the conditions, strategy and appraise method of interaction effect of doctor-patient interactive model in medical service providing system. To provide the theory elements of establishing a benign doctor-patient interaction and the theory evidences and experiences for advance the medical service management of hospital by discussing the multilateral society intervene model.Data source and analyze methodThe article choose Shenzhen, Harbin, Wuhan and Huangshi as investigate object according to it’s development level, region distributing and City scale. The investigated hospital include: Shenzhen Futian Hospital (public) and Boai Hospital (private) in Shenzhen, Harbin Medical University The 2nd affiliated Hospital (public) in Harbin, Xinhua Hospital (public) in Wuhan, Love & Health Hospital (private) in Huangshi. The investigate object include: patient, Administrative department and medical personnel of the hospital.In order to research the aspects of the requirement in doctor-patient information dissymmetry condition further and provide a reference for establishing the doctor-patient interactive model in medical service providing system, this research has used the questionnaire investigation to analyze the impressions of patients who has taken in the medical service between the hospital with different property right and get the information of social economics, Consumption psychology, medical service requirement and providing and the payout, cost, medical service desire of medical service expenses by interview the manager and medical personnel in medical service organization.Descriptive analyze: The mean and standard deviation of the computation data from questionnaire investigation.χ~2 test: Do diversity analyze between the basic information of patient and the reason of hospital choosing, the way to get the medical service information, the expectation to the service, both satisfactory and dissatisfactory part in the service; Do diversity analyze between the basic information of doctor and the understanding of the doctor about medical service information providing, doctor-patient relationship, the detail in the service.Logistic regression analyze of multi-order classification material: To find out the affection factor of the published content of hospital information to the satisfaction of both doctor and patient.All data is analyzed by SPSS for windows 13.0 Results of the research①Doctor-patient information dissymmetry results in the break of doctor-patient relationship directly.Firstly, it can be found through literature research that doctor-patient relationship is performed in economic interest relations, legal relations, ethics relations and social relations, the last three are researched more, the doctor-patient relationship in economic relations research is mainly performed in the interest chasing result from doctor-patient information dissymmetry. The characteristic of relative doctor-patient relationship is performed in dynamic, not equivalent and dissymmetry. The action model, divided in different grade of doctor-patient information dissymmetry is performed in three kinds: Initiative-passive, instruction–cooperation, participating and consulting together. The relationship, models, characteristic above were changed, and it directly affects the develop direction of doctor-patient relationship under market economy: more interest, legalization and more justice.Secondly, it has researched the information dissymmetry in both beforehand and afterwards by using the time it happened as evidence through discussing the reason of decreasing of credit between doctor and patient and increasing of Medical dispute. first, To consider the converse choice that was brought by information dissymmetry beforehand and the way of seeking the separate equilibrium through sending a signal, and exposed the deep-level reasons of the kind of special adverse selection called“Large-Scale Hospital choice with normal disease”in our country. Then analyze the moral risk caused by afterward information dissymmetry and try to narrate the low efficiency result in information dissymmetry.②research on the doctor-patient information requirement and actuality in the process of medical service providing.It can be found through the questionnaire investigation from Shenzhen, Harbin, Wuhan and Huangshi that different patient have different requirement of the drugs price, expert introduction, medical flow, important rules and regulations in hospital. At the same time, there has no difference about the expectation of medical service between doctor and patient and they have the same ideas of the importance of medical technology between doctor and patient, but totally tends to the same even there have some diversity in non-technical service such as service attitude, environment, humanities concern.The patients have the same expectation to the health no matter their age, years of schooling, occupation and month income; they firstly consider the disease curing and then are those such as service attitude, convenience service measure, positive and initiative humanities concern, rational and economical medical expense, the protection of privacy and right to know.From the analyze result of the investigation to doctor, it can be found that to the different Sex, age, years of schooling and month income there have no diversity in medical service providing, doctor-patient relationship promoting, ascertaining the details in medical service process. It means that the doctors have the same attitude of disease curing and patient health maintaining which are the duties of them.Conclusions of the researchIt need to establish a adjustment mechanism of information between doctor and patient under information dissymmetry and use the theory of CRM, gambling analysis , institutional,management to discusse the theory research of doctor-patient interactive model based on trusts and intercommunion, and give out some relative policy suggestion aim at the practical situation of our country which are good for alleviating the tense relations between doctor and patient, reduce the information gap between doctor and patient, promoting mutual trust and interaction between doctor and patient. It is an advance exploration to perfecting the service management in medical establishment and the macroscopically management of medical service market by excavating the power of doctor-patient interaction in the medical information way, providing the instruction and interpretation of the actuality and interaction of doctor-patient relationship in Information economics way.How to reduce the information gap during medical service process, increase the interactive trust between doctor and patient, promote doctor-patient interaction through theory and practice research under now days medical environment, which the information dissymmetry is existed objectively need a further discussion. And it need the regard and participation from government and the third party, such as publishing some relative policy to regulate the medical market, shorten the distance between doctor and patient, promote the equal intercommunion between doctor and patient.InnovationThe topic of this article is main aim at the realistic fact of doctor-patient relationship that under the asymmetry of medical serve information currently, on the base of theory and demonstration research, it gives a benign interactive mode of doctor-patient relationship under the asymmetry of medical serve information which has strong realistic significance.Firstly, on the method of it, which has regarded the supplier and demander of medical treatment as two subjects in game in the microcosmic way, explains the influence factors which under the asymmetry of medical serve information and gives solving project.Secondly, I introduce correlative academic knowledge which combines of economics, sociology, jurisprudence and ethnics analyze the influence factor of doctor-patient relationship which under the asymmetry of medical serve information, and then establish a adjustment model of information between doctor and patient.Lastly, through researching statistic characteristics of bargaining behavior between doctor and patient under different information distributing, I integrate the behavior theory of Economic man and Social man, then quote Customer Relationship Management (CRM), establish benign interactive mode of doctor-patient relationship under the asymmetry of medical serve information.更多还原