【作者】 张佳慧；

【导师】 方鹏骞；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2009， 博士

【摘要】 在我国的医疗服务提供体系中，非营利性医院占据绝对主体地位，为提供基本医疗卫生服务、维护国民健康作出了巨大贡献。然而，近年来政府投入萎缩、医院过分依赖业务收入的发展模式制约了医院的发展，也加重了整个社会的医疗费用负担。如何理顺非营利性医院的融资机制、拓展筹资渠道、筹集足够的资金用以弥补成本，使医院可以更好的关注社会效益，回归公益性的本途，是政府需要重点思考的问题。研究目的：在全面总结国内外营利、非营利性医院以及非营利性组织、大型基础设施建设等领域融资形式的基础上，对国内医疗卫生领域相关政策法规等外部宏观环境、各利益相关集团的作用、主要投资方的意愿等外部因素进行综合分析，评价非营利性医院内部资金运营情况，总结现有的非营利性医院融资模式及其存在的问题，综合评判医院融资所面临的外部环境和内部条件，提出可供非营利性医院选择的融资策略组合，并为非营利性医院融资外部支持体系的构建提供建议，为构建适合我国国情的非营利性医院融资模式提供理论支持。资料来源与研究方法：本文资料来源于国家自然科学基金面上项目《我国非营利性医院投融资机制及其策略选择动态博弈研究》，选择东部、中部地区4省11市23家非营利性医院进行现场典型调研，收集各医院2005-2007年财务相关数据，并对医院分管院长、财务、设备、基建相关负责人进行访谈；同时对相关地区卫生行政部门主要负责人进行深入访谈；收集2003-2008年中国卫生统计年鉴，摘取2002年-2007年全国各类综合医院资产负债、业务收支等基本信息进行汇总分析。主要研究方法：①对国内外相关研究和文献进行理论分析和综合述评；②运用宏观政策分析、PEST分析、利益相关集团分析等方法，对非营利性医院融资相关的政治、经济、社会、技术等方面的影响因素及各利益相关主体的作用、主要投资方的意愿进行综合分析；③运用财务会计学基本理论与方法，对2002-2008年全国各类综合医院资产负债结构、收支结构、运营能力、偿债能力、发展能力等进行综合分析，并运用杜邦财务分析体系对医院的资金运营效率进行综合评价；按照不同级别对现场典型调查医院的财务运营状况进行综合评价；④运用比较分析法对国际上主要国家和地区医院筹资体系进行总结和分析，对高等学校及大型基础设施等项目的融资模式进行总结和归纳。主要研究结果：①国内外非营利性医院大都采用多渠道的融资模式，主要融资途径包括：政府补助、医疗保险补偿、免税债券、商业借款、项目融资、慈善捐赠、资产证券化等；高校融资模式包括政府拨款、学费收入、发行债券、募捐等；大型基础设施的融资方式则包括项目融资、资产证券化等。②非营利性医院融资机制改革的动因：非营利性医院的融资模式经历了从政府单一投入、全额管理到医院自主经营、以内部积累为主，再到依靠资本运作等外向型融资方式的转变；在政府补偿模式转变、运营成本上涨、竞争压力增大、居民医疗服务需求提高等内外因素的推动下，医院必须开展多渠道融资的尝试。③非营利性融资机制改革的宏观政策环境：政府对民生问题的关注改善了整个医疗卫生体系的发展环境；新的医疗体制改革方案将带来现有卫生体系利益格局的重大调整，基层医疗服务体系、基本医疗保障体系、基本药物制度的建立都将对医院内部资金积累带来限制，政府主导多元投入体制的建立将为医院多渠道融资创造更宽松的环境。④非营利性医院资金运营现状：我国非营利性医院资产负债率基本处于安全范围内，偿债能力较强，但财务的杠杆作用发挥不明显；医院业务收支结构有所调整，药品收支所占比重略有下降，而医疗收支所占比重略有上升，造成医院整体资产收益率下降；三级医院近年来处于快速扩张阶段，以固定资产规模快速增长为标志，而二级医院规模增长缓慢，经营运转效率较低。⑤非营利性医院融资现状：医院融资的主要渠道仍未内源性融资；医院、卫生行政部门普遍反映政府财政投入比例过低，加大政府投入、减轻医院负担的呼声较高；受公益事业单位国有资产不能抵押的限制，医院多采取授信贷款形式，不同级别医院授信等级不同，银行贷款有向大医院集中的趋势；与药品、设备供应商的延期付款是缓解医院资金压力的主要途径之一，但这种利益捆绑的方式对医院发展不利；在东部地区民营资本较发达的城市，产权多元化的模式比较多见，但政府与民营资本混合持股会带来一系列后续问题；我国公益捐赠事业不发达，慈善捐款用于非营利性医院融资比较少见，与治理机制变革相协调往往可以起到更加明显的效果；东部民营资本发达的地区，民间借贷是营利性医院可选择的融资方式之一；融资租赁方式易与项目合作相混淆，相关政策规定需明确。⑥主要外部投资主体投资意愿：非营利性医院主要提供基本医疗服务，是卫生事业公益性职能的体现，政府增大投资的意愿很强，但受财政能力限制，有多渠道融资的诉求；非营利性医院社会公信力强、收益稳定的特点使其成为银行贷款的营销对象，但在具体客户的选择上银行有“嫌贫爱富”的倾向；社会资金进入非营利性医院的意愿很强，但投资者回报的问题亟待明确。主要结论：①非营利性医院的融资渠道选择：应对非营利性医院进行进一步细分以选择不同的融资策略；政府办非营利性医院以政府投入补偿基础设施建设、医疗保险补偿日常运营成本为主，辅以适当规模的负债；应通过设立非营利性基金会的形式，在社会资本与非营利医院间形成缓冲带，引导社会资本改革政府办、企事业单位办非营利性医院；应积极倡导慈善捐赠，并尝试债券发行、卫生福利彩票等多种融资形式。②非营利性医院融资支持体系构建：政府应重点解决非营利性医院产权归属、补偿机制、区域卫生规划及医院适度规模等问题，并坚持政事分开的医疗机构管理方向、确保非营利性医院的政府支持、协调医疗保险机构与非营利性医院的关系、通过区域卫生规划合理配置为卫生资源、通过税收优惠等政策促进慈善捐赠事业发展等措施，为非营利性医院融资创造和谐的外部环境。特色与创新：①从非营利性医院融资外部政策环境、内部资金运营效率两方面综合分析，为构建非营利性医院融资策略集合及支持体系提供支持；②将非营利性医院进一步细分为政府办、企事业单位办及其他社会组织办三种类型，分别提出可供选择的融资模式；③结合最新医疗体制改革的重点和难点问题，为非营利性医院融资宏观支持体系的构建提供政策依据。更多还原

【Abstract】 Non-profit hospitals are the main part in the health delivery system. Due to the decreasing of the financial input, the operational income is playing more and more important role in the hospitals’ evolution, which is not good for the long term development, and also increased the financial burden of health care for the whole society. Thus, finding ways to collect money for the hospitals is urgent for the policy makers in the health care field.ObjectivesSummarize internal and international financing models in for-profit hospitals, non-profit hospitals, NGO, infrastructure project, etc. Consider the effectives of policies in health care field, the effect of the stakeholders, and the willingness to investors. Appraise the internal-capital running effective of non-profit hospitals. Summarize the existing financing models for non-profit hospitals, and analysis the advantages and disadvantages. Propose the strategies for the non-profit hospital financing and suggestions for supporting the financial system.Data sources and methodsData sources This paper is related to the study on investment and financing mechanism and strategies choice based on game in non-profit hospital in china, which supported by the NSFC. 23 non-profit hospitals in 11 cities of east and middle China were investigated. Financial data from 2005 to 2007 were collected in all the hospitals. And the president in charge of financing, dean of financial department, equipment department, and capital structure department of the selected hospitals were interviewed. Principals of financial and medical affaires department in the health bureaus were also interviewed. Financial data on the national wide non-profit hospitals in 2002 to 2007 were drawn from the China Health Statistics Yearbook.Methods 1. Literature analysis; 2. Macro-policies analysis, PEST analysis, Stakeholder analysis were used to explore the external conditions for the non-profit hospital financing; 3. Capital and debt structure, input and output structure, operational ability, debt-paying ability and development ability of the non-profit hospitals were appraised. And Du pont system was used to evaluate the efficiency of capital use in non-profit hospitals. 4. Comparative analysis was used to summarize the different hospital financing model in different countries, and financing model for different fields.Main Results1. Multi-channel financing model for non-profit hospitals were universal in all countries. The main financing methods include: financial budget, health insurance reimbursement, tax-free bond, business loan, project finance, charity and donation, Asset-backed securitization, etc. Financial budget, tuition fees, bond, fund-raising, etc, was used in colleges and universities. Project finance and asset-backed securitization are commonly used in infrastructure project.2. Reasons for financing system reform: Financial budget is shrinking, operational cost is increasing, competitive pressure is increasing, and residents’ demand is improving.3. Macro-environment for non-profit hospitals’ financing: The governments are paying more and more attention on people’s health, which created a better political surrounding for the non-profit hospitals. New health care reform scheme will largely change the existing health care system. Establishment of primary health care delivery system, basic health security system and primary pharmaceutical system may put stricter restrain on internal capital accumulation for the hospitals, while the government dominant multi-channel input system may bring more external capital for the non-profit hospitals.4. Capital running conditions in non-profit hospitals: Asset-debt ratio of non-profit hospital is in a rational scale with a comparatively strong debt repaying capability, but the lever effect of finances does not effectively used. The decreasing of medicine income and the increasing of health service income makes the return on assets decreased. The third level hospitals are largely expanding recent years, while the second level hospitals increased slowly, and the operational efficiency is relatively low.5. Financing status of the non-profit hospitals: Internal capital accumulation is still the main capital resource for the non-profit hospitals. Financial budget from the government needs to be increased. Business banks prefer to the large hospitals, while the small hospitals which need the loan can hardly get the capital. Deferred payment to the medicine and equipment suppliers is commonly seen in hospitals, but this kind of interest tied is not good for the long term development of the hospitals. In east China, where the private capital markets are well developed, property reformation is attempted. But the mix of state-owned property and the private owned ones may induce some side effect. Charity and donation is not well developed in China. Private lending exists in some western cities. Finance release for the equipment needs to be regulated.6. Willingness of the external investors: The governments are pleased to increase the financial budget, but constraint by the financial ability. Business banks are like to lend to the hospitals, but prefers to the large hospitals. Social capitals are eager to enter the health care field, but the return mode needs to be defined. Conclusions:1. Financing model for different non-profit hospitals: The non profit hospital system should be divided as state-owned, enterprise -owned and civil-owned subgroups. Different subgroups should choose different financing strategies. Government should insure the financial budget to the state-owned hospitals on infrastructures built, the social health security funds should reimburse the operational costs, and debts scale must be strictly controlled. Non profit foundations should be set up to raise the social-founded non profit hospitals, and the social capital should be leaded to corporate-system reform the enterprises owned hospitals. Social charity should be encouraged, and bond or lottery may be used in health capital raising.2. Supporting system building: As to reform the non profit hospital financing system, property rights issues, governance model, compensation systems, regional health planning and moderate scale of hospitals should be considered and resolved. The financial support, supervision from the government, coordination with the health security institutions and taxes reducing policies should be enhanced to support the development of on profit hospitals.Innovations:1. Analysis the external policy surroundings and internal capital utilization efficiency to formulate the strategies model and supporting scheme for non-profit hospital financing system. 2. Subdivide the non-profit hospitals as state-owned, enterprise -owned and civil-owned subgroups, and propose different financing model for different subgroups. 3. Referenced the new health care system reform scheme for the establishment of supporting policy and strategies.更多还原