【作者】 陈瑶；

【导师】 罗五金；

【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】 本研究的研究目的是基于利益均衡原理，研究与新型农村合作医疗制度相契合的供方支付方式的理论模式和实践模式。本研究的资料来源主要包括文献资料和现场调研资料。文献资料包括经济学、公共政策选择、博弈论中有关利益均衡的专著、研究论文，有关国内外支付方式改革进展的专著、研究论文。现场调研资料又包括重庆黔江区和陕西镇安县有关支付方式改革的政策文件、相关人员的访谈、统计年鉴相关数据收集、新型农村合作医疗运行数据收集、医疗机构收支及服务量数据收集以及住院医疗费用数据收集。本研究的研究方法包括理论研究部分的文献分析法、利益相关者分析方法、博弈论的均衡理论以及委托代理博弈模型；在实证研究部分的典型案例法、专题小组访谈、固定效应模型、最小二乘线性回归模型；在实践模式研究部分的不完全信息静态博弈模型。本研究总体研究框架遵循“理论(?)实践”的研究范式，从理论研究切入，构建利益均衡支付方式的理论模型，以第二部分的陕西镇安县和重庆黔江区支付方式改革的实证研究加以证明，并以实证研究结论进一步修正和完善理论模型，在此基础上，以理论模型和实证结论指导实践模型的构建，将理论模型转化为操作层面的实践模型。主要研究内容如下：本研究首先从理论上分析了经济学、制度经济学和公共政策选择理论中利益均衡相关概念和理论的内涵，得出利益均衡是市场经济、制度建设和公共政策达到稳定状态的根本原因。由此引入利益相关者理论，分析新型农村合作医疗作为一项制度和公共政策的内部利益均衡问题，认为经办机构、医疗机构和参合农民是新型农村合作医疗制度中三个主要利益相关者，拥有各自不同的利益诉求，形成不同的利益集团。经办机构代表政府和参合农民的利益。在一定条件下，它的利益最大化，应成为新型农村合作医疗这项公共政策的核心价值观和根本目标，在此基础上形成的利益均衡才能维系新型农村合作医疗制度正确良好的可持续发展。而适宜的供方支付方式正是达到这一均衡状态的途径。供方支付方式是新型农村合作医疗制度内部利益分配的阀门和渠道，不同的供方支付方式形式，会引导新型农村合作医疗制度内不同的利益分配形式。通过对目前主要供方支付方式的优缺点分析，以及对新型农村合作医疗制度内利益分配的不同影响的剖析，本研究提出按病种定额付费、按病种限额付费和总额预算制相结合的混合支付方式形式，是适宜的利益均衡支付方式。为证明这一命题，本研究运用不完全信息动态博弈理论，构建博弈树，以及经办机构与医疗机构之间的委托—代理博弈模型，分两步进行推理证明：第一步，通过建立不完全信息动态博弈树，论证预付制与后付制相结合的混合支付方式是利益均衡支付方式；第二步，通过建立经办机构与医疗机构之间的委托—代理博弈模型，进一步论证单病种定额付费、按项目付费和总额预算制相结合的混合支付方式是利益均衡支付方式。依据第一部分的理论模型构建，第二部分是寻找到实施了与利益均衡支付方式相似的混合支付方式改革的陕西省镇安县和重庆市黔江区，通过对这两个地方混合支付方式效果的分析与评估，寻求实证依据支持第一部分的理论模型，并通过实践经验的分析与总结，进一步完善理论模型。实证研究说明，镇安县“单病种定额付费+限额付费”的混合支付方式，具有良好的费用控制效果，同时不影响医疗机构收支结余和医务人员收入的增加，也没有出现医疗质量的下降，不足之处在于辅助费用监管措施不足，缺乏费用总额控制措施。黔江区“单病种限额付费+总额预算控制”的混合支付方式，与镇安县相比，费用控制效果较弱，但费用构成更加合理化，提示单病种定额付费的必要性，限额付费的合理性以及辅助费用监管措施的重要性。实证研究还提示了，经办机构的支付方式改革及相应费用监管措施，应该与医疗机构体制机制改革联动进行，才能达到预期目的，取得事半功倍的效果。第三部分是利益均衡支付方式的实践模式构建。基于第一、二部分的理论研究和实证研究，利益均衡支付方式的实践模式具有操作性和实践性的特点，共分四个内容：(1)单病种定额付费标准、限额付费标准和总额预算标准制定方法和程序；(2)单病种定额付费病种选择方法；(3)利益均衡支付方式费用监管机制构建。本研究通过构建经办机构与医疗机构的监管博弈模型，推导出监管机制通过三个途径建立：建立严格的处罚制度；组织监管委员会，引导县级医疗机构良性竞争形成，减监管成本；加大政府和公众监督力量。(4)联动医疗机构体制机制改革，包括乡镇卫生院能力建设，县乡医疗机构管理体制改革、成本核算财务制度改革和分配制度改革。基于以上三个部分的研究，本论文的研究结论是：(1)新型农村合作医疗制度中主要利益相关者是农村医疗机构、参合农民和经办机构，农村医疗机构的利益是机构收支平衡，参合农民的利益是疾病经济负担的减轻，经办机构的利益是新农合基金的合理有效使用。(2)新型农村合作医疗可持续发展的必要条件是制度内达到以经办机构利益为价值核心的利益均衡。(3)这种利益均衡的实现途径是利益均衡支付方式，表现形式为：以单病种定额付费为主，单病种限额付费为辅，加以总额预算控制。(4)在实践中，利益均衡支付方式的实施机制，即实践模型，由三部分构成：定额、限额和总额的费用标准制定方法和程序；单病种选择原则；费用辅助监管机制。利益均衡支付方式与相应的实施机制共同构成利益均衡支付制度。(5)利益均衡支付制度需要与医疗机构体制机制改革联动进行，方能达到预期效果。相应的医疗机构体制机制改革包括乡镇卫生院的能力建设；医疗机构管理体制改革；医疗机构分配制度改革；医疗机构成本核算的财务制度改革。更多还原

【Abstract】 OBJECT:The object of this paper is to research the academic model and the practical model ofthe payment in the New Rural Cooperative Medical Scheme, based on the interestequilibrium theory.DATA:The data of this paper include literature data and investigation data.literature datainclude research papers and monograghs on interest equilibrium and payment.Investigation data include the documents of the payment reform, the interview of theinterrelated people, the related statistic yearbook, the data of the New RuralCooperative Medical Scheme and the data of the medical institutions in Zhenan Xianof Shan Xi Province and Qianjiang area of Chong Qing Province.METHOD:The research methods of this paper include document surveys, stakeholder’s analysis,game theory, principal-agent model in theory research part, and investigation,interview, incomplete information static game model, fix effect model and ordinaryliner square regression in empirical and practical model research part. CONTENT:The total research frame is to design the academic model of the interest equilibrium payment, prove it through empirical research, and then found the practical model with the guidance of the the conclutions of the the academic model and the empirical research, based on the research pattern of "from the theory to the practice, and then from the practice to the theory".This paper analysis the interest equilibrium is the reason why the market, the system and the public policy will be stable situation, by several related concepts and theory analysis in economic, New Institutional Economics and Public Choice Theory. And then the paper remain that the agency, medical institutions and rural are the main stakeholders, and have different interests, through the interest equilibrium analysis of the New Rural Cooperative Medical Scheme. The agency is representative of the interests of the rural and the government. Under certain conditions, the maximum of the agency’ interest should be the core value and ultimate goals of the New Rural Cooperative Medical Scheme, based on which the interest equilibrium can promote sustainable development of the New Rural Cooperative Medical Scheme. And the suitable payment is the exactly way to the interest equilibrium situation. Payment is the valve and channel of benefit allocation in the New Rural Cooperative Medical Scheme and different payments will lead different benefit allocations. This study proposes the mixes payment of quota for single disease payment, limiting expenses payment of a single disease and total budget payment is the appropriate interest-equilibrium payment, through the analysis of the payments’ merits and demerits, and the benefit allocation influence. To demonstrate the proposition, this paper uses dynamic game of incomplete information, construct game tree, and principal-agent model to prove that the mixed payment of prospective payment and post payment is the interest-equilibrium payment firstly, and that the mixed payment of quota for single disease payment, limiting expenses of a single disease and total budget payment is the interest-equilibrium payment.Based on the first part’ theoretical model, the second part research the empirical data of the Zhenan Xian in Shan Xi Province and Qianjiang area in Chong Qing Province, to further improve the theoretical model.The empirical study results show that the mixed payment of quota for single disease payment and limiting expenses of a single disease in Zhenan has good effect on expense control and no bad effect on the balance of payments surplus of the medical institutions, the revenue of the medical staffs and the medical quality, but the deficiencies are that supervisory measures are not enough, and the total expenses control is inadequate. The empirical study results also indicates that the mixed payment of limiting expenses of a single disease and total budget payment in Qianjiang area has less expense control effect, but more reasonable expense structure. These results show the rationality of limiting expenses payment of a single disease, the importance of expenses supervisory measures and that the supervisory measures should be implemented with the system mechanism reforms of the medical institutions.The third part researches the practical model of the interest-equilibrium payment, including four main contents: (1) the formulation methods and programs of the expenses standards of quota for single disease payment, limiting expenses payment of a single disease and total budget payment.(2) the single disease choice methods of quota for single disease payment.(3) the expenses supervisory mechanism construction of the interest-equilibrium payment. There are three ways to build the supervisory mechanism by the supervisory game model: one is to build strict punishments system, second is to organize the supervisory committee to reduce the supervisory cost and lead the good competition between medical institution for Xian level, third is to enlarge supervisory power of the government and peasants.(4) implementation with the system mechanism reforms of medical institutions, including the capability construction of township clinics, the management system reform of medical institutions for Xian level and township clinics, constructing the financialinstitution of cost accounting, wage and income distribution system reform.CONCLUSION:The research conclusions of this paper are: (1) The main stakeholders of the NewRural Cooperative Medical Scheme are the medical institutions, the peasants and the agency.The benefit of the medical institutions is to make both ends meet, the benefit of the peasants is to reduce the economic burden of diseases, and the benefit of the agency is the security and the validity of the money’s use. (2) It is the necessary condition of the sustainability for the New Rural Cooperative Medical Scheme that the interest equilibrium with the interest of the agency is the core value. (3) The interest-equilibrium payment is the way to realize the interest equilibrium, the content is that quota for single disease payment is major, with limiting expenses payment of a single disease and total budget payment. (4) The practical model of the interest-equilibrium payment consists of three parts: the formulation methods and programs of the expenses standards, the single disease choice methods and the supervisory mechanism. The interest-equilibrium payment and the practical model form the interest-equilibrium payment system. (5) The interest-equilibrium payment system should be implemented with the system mechanism reforms of the medical institutions, including the capability construction of township clinics, the management system reform of medical institutions for Xian level and township clinics, constructing the financial institution of cost accounting, wage and income distribution system reform.更多还原