【作者】 韩玉珍；

【导师】 赵金楼；

【作者基本信息】 哈尔滨工程大学 ， 管理科学与工程， 2008， 博士

【摘要】 随着我国以公立医院为主体的医疗卫生事业的蓬勃发展,医疗费用支出也飞速增长,“看病贵、看病难”等现象愈演愈烈,引起了经济、社会、政治等一系列问题,基本抵消了由医药卫生改革给民众带来的好处。从医疗服务实践和众多研究结果来看,公立医院中广泛存在的过度医疗挤占了有限的医疗资源,是导致以上医疗服务问题的主要原因,而医、患、督三方信息不对称则是过度医疗产生的根源。因此,从信息对称的角度来探讨治理过度医疗的对策,对稳固医药改革成果,回归公立医院的公益性、公平性与可及性具有重大的理论意义和现实意义。首先,从理论上阐述了过度医疗是如何形成的。分析了医方与患者、医方与监督方、患者与监督方的委托代理关系,根据委托代理理论,代理人相对处于信息优势地位。采用不完全信息博弈理论对三方行为进行研究,结果显示在激励约束机制不健全的情况下,医方将选择对患者诱导需求,患者则会选择与医方合谋过度消费医疗服务,而诱导需求和过度消费都可能导致过度医疗。其次,剖析了过度医疗产生的机理。通过对机理内涵的深入理解,确定了“构成要素—相互关系—作用路径—结果”的机理研究模式。指出了医疗服务供给、医疗服务需求、内外作用力构成了过度医疗产生的基本要素。采用供需理论对医疗服务供需进行了分析,提出了特殊的供需关系使过度医疗成为可能。另外用逻辑推理的方法对过度医疗产生的内外因进行了剖析,结果显示医药利益链上主体追求利益而形成的利益驱动机制是过度医疗产生的内因,由于信息不对称导致的监督失效则是过度医疗产生的外因。然后,探讨了治理过度医疗的对策。在总结了国外治理过度医疗经验的基础上,分析了治理过度医疗的模式、内容和方法。在前文深入研究的基础上,指出应以医方为切入点,采取内部治理和外部监管同时开展的模式,主要解决医患、医督、患督信息不对称来达到治理过度医疗的目的,并论证了临床路径在治理过度医疗中的有效性。再者,为了科学准确地对过度医疗治理效果进行评价,从医患督三方构建了评价过度医疗治理绩效的指标体系,运用层次分析法确定了各指标的相对权重,并通过对多种评价方法的对比分析,建议选择模糊综合评价法对公立医院过度医疗治理绩效进行评价。从改善医患督三方信息不对称的角度给出了有效治理过度医疗的保障措施。最后,以剖腹产临床路径为例,对过度医疗治理进行了实证研究。通过与传统治疗模式相比较,临床路径能有效改善医患、医督、患督问的信息不对称,达到治理过度医疗的目的。更多还原

【Abstract】 In China, along with the rapid development of medical and health services based in public hospitals, medical expenditures have also been increasing exponentially. The difficulties and extremely high cost of seeing a doctor have become more prominent. It has caused economic, social, political and other issues, and for the most part counter-balanced the savings for the populace due to medical reforms. From the angle of the medical services practice and the results of numerous studies, widespread over-treatment in public hospitals wastes limited medical resources, which is the main reason for the aforementioned medical services problems, but the information dissymmetry between the hospitals, patients and health administrative executors is the root of over-treatment. Therefore, we can deal with over-treatment from the point of information symmetry, which would be very helpful for stabilizing the achievements of medical reform and the return of the equality, fairness and the accessibility of public hospitals in theory and practice.Firstly, how did over-treatment theoretically come into being? According to the Principal and Agent Theory, we analyze the principal-agent relationship between the patients, hospitals and health administrative executors, and we find that agents are in a relatively advantageous position insofar as the information they possess. Using an analysis based on incomplete information, as in Game Theory, the results show that hospitals induce patient demand and patients cooperate with them, as a result leading to excessive medical treatment.Secondly, we study the generating mechanism of over-treatment. We build "the elements - the interrelation among elements - acting pattern - results" model upon a deep understanding of this mechanism connotation. The medical service supply and demand, and the interior and exterior interrelation actions constitute the basic elements of over-treatment. We analyze the supply and demand for medical services through supply and demand theory, and find that the special relationship between supply and demand makes over-treatment possible. In addition, we use the logical reasoning method to analyze the internal and external interrelation of over-treatment, where the results show that the benefit stimulating mechanism which causes the main body to pursue the benefit in the medicine benefit chain is the internal interrelation, and disabled supervising behavior caused by the information dissymmetry is the external interrelation.Finally, we discuss the countermeasures to rectify over-treatment. On the basis of the experience of rectifying over-treatment abroad, we analyze the model, content and method of rectifying over-treatment. We find that the hospital is the breakthrough point for rectifying over-treatment base on the the former. We adopt the pattern which the internal government and the exterior supervision simultaneously develop to solve the information dissymmetry between the hospitals, patients and health administrative executors to rectify over-treatment. And we prove that the clinical pathway is effective in rectifying over-treatment.Furthermore, in order to evaluate the effects of rectifying over-treatment accurately and scientifically, we establish a performance evaluation system from the view of the hospitals, patients and health administrative executors, and we use the analytic hierarchy process to determine the various targets’ relative weight. We comparatively analyze a variety of evaluation methods and select the fuzzy comprehensive evaluation to evaluate the performance of rectifying over-treatment in public hospitals. We propose some security measures for rectifying the over-treatment from the angle of holding down the information dissymmetry between the hospitals, patients and health administrative executors.In the end, taking the clinical pathway of caesarean birth as an example, we study the rectification of over-treatment in a practical way. We compare traditional treatment modalities with the clinical pathway to explain that the clinical pathway can rectify the information dissymmetry between the hospitals, patients and health administrative executors and can achieve the goal of rectifying over-treatment.更多还原