【作者】 李林；

【导师】 扈长茂； 田文华； 刘国恩；

【作者基本信息】 第二军医大学 ， 社会医学与卫生事业管理， 2009， 博士

【摘要】 目前在我国,营利性医疗机构发展面临很多争议和阻力。营利性医疗机构在医疗服务市场参与医疗服务提供,是否会对医疗费用产生影响?产生了怎样的影响?这对当前的医疗卫生体制改革有什么政策涵义?为回答这些问题,本研究在对相关背景进行描述分析的基础上,应用计量经济学方法进行了深入探讨。通过对营利性医疗机构发展相关数据的描述性分析,我们发现营利性医疗机构发展虽然迅速,但整体上看规模小,诊治能力低下;在政策和体制方面的诸多障碍制约了营利性医疗机构的发展。在实证研究部分,本文利用三个数据库从不同角度分别研究了营利性医疗机构对医疗费用的影响。首先,通过对省级层面面板数据的研究,发现上一年营利性医院的工作量指标特别是年出院人次比重越高,该省卫生部门综合医院的人均门诊费用和住院费用越低;营利性医院绝对规模与相对规模越大,该省卫生部门综合医院的人均医疗费用也越低。其次,采用南京市职工医保数据,控制病种、个人和医疗机构等的影响后发现,上一年营利性医疗机构收治门诊病人占总体门诊病人比重增加,则当年非营利性医疗机构门诊平均费用、营利性和非营利性两类机构总体门诊平均费用下降。这说明,营利性医疗机构在医疗服务市场存在价格“溢出效应”。第三,采用9个城市的入户调查数据研究发现,在控制其他因素的情况下,营利性医疗机构次均门诊费用显著低于非营利性机构,且二者的费用差别约有相当一部分可由这两类机构的系统差别解释;同时这两类机构在服务满意度方面不存在显著差别。这为剖析营利性医疗机构对非营利性医疗机构产生竞争的途径提供了证据。研究表明,营利性医疗机构的发展为我国医疗服务市场带来了竞争,因此鼓励其发展有利于控制医疗费用。基于研究发现,本文最后对如何加快营利性医疗机构发展提出了若干政策建议。本研究主要有以下创新之处:首先,本研究第一次对我国营利性医疗机构发展对医疗费用控制的作用进行研究,在研究内容上填补了国内在该领域的空白。第二,本研究探讨在我国特定的政策环境下,竞争在医疗市场中所发挥的作用,加深了人们对竞争和医疗市场的理解。第三,本研究运用计量经济学模型对研究营利性医疗机构与医疗费用的关系进行实证研究,在研究方法上有创新。第四,本研究对营利性和非营利性医疗机构在医疗费用上的差别进行量化并分解,加深了我们对营利性医疗机构和医疗费用关系的认识,对于两类医疗机构医疗费用的研究有了新的深度。更多还原

【Abstract】 Currently, there are a lot of debates and obstacles facing the development of for-profit medical institutions in China. Does the existence of the for-profits affect medical expenses in the health care market? If it does, what is the magnitude of the effect? And what are the policy implications for China’s health care reform? In order to find the answers to these questions, our study explores the relationship of market share of for-profits and medical expenses intensively with the help of econometric approaches after introducing the related background information.From the descriptive analysis on the for-profit providers, we find that although they have developed quickly since 2000, their overall scales are relatively small and their capacity of deliverying health care services is very limited compared with not-for-profits. The institutional settings in which they survive have much constraint against their further development.Further, we empirically investigate the effect of for-profits on the medical expenses taking advantage of three datasets. First of all, using provincial level panel data, we find that the higher the proportion of total discharges from for-profit hospitals in the last year in a province, the lower the outpatient expenses per visit and the inpatient expenses per visit in general hospitals in the current year; also, the larger the absolute as well as the relative scale of for-profit hospitals in the previous year, the lower the medical expenses per visit in general hospitals in the current year. Secondly, from the Nanjing Urban Employee Basic Medical Insurance data, it is found that other things being equal, the average outpatient expenses in not-for-profit providers and the overall expenses of both types of providers in this year decrease as the proportion of outpatient visits to for-profit providers in the last year increases. This implies that for-profits have brought about a price“spillover effect”on the not-for-profits in the market. Lastly, by employing a household survey data collected in 9 cities, we find that the outpatient expenses per visit in for-profits are significantly lower than that in not-for-profits, and a notable part of the expenses gap between these two types of providers could be attributed by the systematic difference between for-profits and not-for-providers. In addition, there isn’t a significant difference in consumer satifacition between these two types of providers after controlling for demographics and medical institution characteristics. This presents evidence that helps unfold the pathway of for-profit providers competing with their not-for-profit counterparts in the health service market.Our findings shed light on the fact that development of for-profit medical providers can enhance competition in health care market in China. Therefore, encouraging the entry of for-profits is helpful in controlling medical expenses. Some policy implications are discussed at the end of the dissertation based on our research results.There is some innovation in our study.To best of our knowledge, this is the first attempt to explore the impact of for-profit medical service providers’development on the medical expenditures, which fills the gap in this area in China. Secondly, this study intensively address the role of competition in medical care market in a unique policy settings in China, which us helpful to further understand medical care market and competition. Thirdly, there is some technical innovation in that we carry out empirical study on the relationship between for-profit in medical service instutitions and medical expenditures using econometric approaches. Fourthly, the differences between medical expenditures in for-profits and that in not-for profits are decomposed into several parts, which is useful for us to learn more about the relationship between profit status of institutions and medical expenditures.更多还原