【作者】 夏冕；

【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， 2010， 博士

【摘要】 一、研究内容：前言部分说明选题背景、研究意义、研究思路、研究方法、创新及不足之处。第一部分研究内容,主要对政府是否能够作为利益集团以及什么是医疗卫生制度的基本问题进行界定。对政府的利益结构进行解析,结合该内容界定本文的研究层次。即通过两个层次来研究政府利益与制度变迁,其一,从国家层面上,制度变迁是国家垄断租金效用与微观经济主体效率的选择。其二是分析不同利益集团争夺政府资源的冲突,从部门利益的角度详细论述不同利益集团在本次医改中的资源优势与行为策略。第二部分研究内容,是在经济史研究和比较制度研究范式下,对我国医疗制度变迁的进行历史回顾。以医疗卫生制度变迁与利益集团的内在逻辑关系为主线,分析我国不同阶段制度形成于利益集团博弈行为之间的双向关系,并且挖掘分析不同阶段利益集团从“萌芽——成长——成熟”的历程,以及利益集团与制度变迁的互动关系。形成以利益集团为分析对象的“利益集团——制度”共同演化的范式下的医疗卫生制度变迁的路径分析。第三部分研究内容是本文的重点。通过实证分析了我国医疗卫生体制改革的两个重要规则的改变：一是分权化特征,即权力向地方政府和微观经济主体让渡,其中公立医院的各项权限开始具有经济主体的产权属性特征。二是筹资规则的变迁。即财政筹资向多元筹资模式转化。并且通过两个模型对其实证解释：其中模型Ⅰ为一般均衡模型,解释了外部环境发生变化导致制度可能性曲线的变化,当国家租金效用递减或者租金效用殆尽时,国家代理人政府会实施供给型强制制度变迁,其效用函数导向将从租金偏好转向效率偏好。模型Ⅱ为中央和地方财政关于卫生经费投入的智猪博弈模型,是局部均衡模型。它是对医疗卫生制度变迁的局部博弈结果分析。通过中央和地方政府的财政支付博弈解释医疗卫生经费投入的短缺和资金的投入分布,通过双方的战略和收益函数分析卫生经费主要由地方政府投入的必然性,同时也证明了利益集团博弈行为形成了中央和地方卫生投入的格局。第四部分研究内容,以利益集团分析的第二个层次——部门利益为切入点,重点分析新医药卫生体制改革背景下,不同利益集团的资源优势与行为策略。包括对政府部门争夺政府资源的冲突的分析。通过专家咨询的方法,请有关专家审定利益相关者名单及排序,具体分析现阶段利益集团的类型。对各类型的部门及微观利益集团的资源和参与制度变迁的途径和策略进行系统分析。结合米切尔评分法,对筛选出的利益相关者的合法性、权力性和紧迫程度三个维度的数据进行调研并对结果进行描述性统计和差异性检验,最终形成我国医疗卫生体制改革的利益相关者利益诉求和利益集团力场分析。第五部分研究内容,主要对于现阶段医疗卫生改革的两个局部问题进行博弈分析。一是通过寻租经济学中经典的寻租模型对以药养医的寻租博弈中租的来源进行理论解释,比较了公立医疗机构与零售药店在药品价格的差异,以实证分析说明以药养医的背后的寻租博弈现象对于社会福利的损失。二是对现阶段医疗卫生体制改革的另一个重点问题——公立医院治理改革进行博弈分析,从理论上证明法人治理制度是我国公立医院管理体制改革的有效途径。第六部分在全文的理论分析与实证分析的基础上,进行规范分析并对我国医疗卫生体制改革提出政策建议。二、研究方法1.文献研究法：主要通过国内外学术期刊网收集期刊、论文、相关年鉴等文献,通过国家统计局、各级卫生行政部门相关网站收集了国内外的考察报告、政策动态信息、各种年鉴、年报、统计报表和资料汇编。2.抽样调查方法：收集武汉市12家公立医院和14家零售药房的药品价格数据,同时选择全国市场销售排名前100的药品全部纳入研究样本,调查的主要内容包括名称、剂型、规格、价格等。比较了公立医疗机构与零售药店在药品价格的差异。抽样方法是样本地区根据医院的级别选择采取4层次分层随机抽样。采用完全随机的方法分别从每个层次按20%的比例抽取。选取二级以上的医院12家,其中二级医院5家,三级医院7家。二级医院构成是4家二甲,1家二乙医院。三级医院构成是5家三甲,2家三乙医院。3.德尔菲技术：邀请30位卫生经济学、医院管理、医药卫生体制改革、经济学、公共管理学方面的专家进行咨询,对医疗卫生制度涉及的利益集团进行界定、分类,在此基础上,系统分析分析其博弈的策略和路径选择及其对医疗卫生改革的影响。4.博弈分析法：利用博弈模型模拟出利益集团博弈的路径,策略选择和结果。三、研究结果1.制度在交易中起着指导交易主体间的利益分配和交易费用分摊的作用。我国的医疗卫生制度变迁与利益集团博弈之间存在双向演化关系。本文遵循新制度经济学“交易费用-制度选择-制度变迁”的分析范式。对我国利益集团博弈与医疗制度变迁的内在关系进行解析。(1)建立医疗卫生制度变迁的内在机理模型,提出“制度可能性曲线的”说法。通过国家效用函数的变化解释了外部环境发生变化导致制度可能性曲线的变化,当国家租金效用递减或者租金效用殆尽时,国家代理人政府会实施供给型强制制度变迁,其效用函数导向将从租金偏好转向效率偏好。证明当效率产权制度的交易费用递减效应,国家会将其效用函数的均衡点从租金偏好向效率偏好转移。政府效用函数结构的变动是解释制度变迁的关键线索。通过该模型解释了我国医疗卫生制度变迁的重大规则的变化：一是以放权让利为前导的公立医院产权模式的改变,公立医院产权模式为什么由国家垄断产权安排向产权多元化发展；二是筹资制度变迁,财政筹资向多元筹资模式转化,医疗保险制度为什么由国家财政型体制向保险型体制过渡。(2)通过博弈论的智猪模型解释在中央和地方政府医疗卫生投入问题上,中央和地方政府的利益关系和策略、结果。在中央和地方财政博弈的行为中,一方面,中央政府和地方政府对于医疗卫生投资收益的定位比较低,因此双方投入的意愿均不高；另一方面,地方政府相对于中央政府会有更多的投入,因为医疗卫生经费由地方政府更多程度受益。因此,地方政府会有更多的投入。无论中央政府是否投入,地方政府的最优选择是投入,该博弈的纳什均衡是(不投入,投入)。2.本文的第二个研究途径是公共选择路径。(1)一方面,在经济学垄断模型的基础上进一步分析得出结论：“垄断”是租的来源。医疗服务是必需品,其弹性小,垄断利润高。在理论分析基础上通过实证分析,比较了公立医疗机构与零售药店在药品价格的差异,结果发现公立医院价格均高于零售药店药品价格。从而佐证了公立医院的“销售垄断权”,是药品价格虚高的根源之一。通过对药品价格背后的寻租博弈行为的分析,得出结论：医院在出售药品方面的垄断是变相行政垄断的结果,直接的经济监管造成了社会福利的损失,为制度变迁提供了可能性和空间。另一方面,通过寻租博弈模型计算出寻租和接受寻租的最优概率,在此情况下可使其额外收益达到最大。(2)公立医院改革的出路在于如何从制度上确定各博弈方权利的边界,只有合理的边界界定,才能实现公共权力和行政权力之间的均衡。对于公立医院权力(利)博弈结构的分析提示：产权和契约的明确是解决医疗卫生领域无序博弈的有效手段。3.新医药卫生体制改革背景下,各个利益集团之间的力量均衡度非常低。如何使医疗保险不被部门利益左右,成为平衡各方利益的关键点,是影响中国医改和医疗卫生制度变迁的方向的一个重要决策切入点。四、本研究的创新性1.采用利益集团博弈这一独特视角研究医疗卫生制度变迁。从制度经济学研究角度对医疗卫生制度的内在规则进行概括,揭示制度与利益集团的共同演化过程。2.采用抽象分析与具体分析相结合,“一般均衡”与“局部均衡”分析相结合进行研究。本文在均衡分析的指导下,对医疗卫生制度变迁与其背后利益集团关系进行了抽象的一般均衡分析。构建政府效用模型解释医疗卫生制度变迁中一般性现象,并对中央和地方财政对于卫生经费投入的博弈现象,以及医药分利集团对于药品垄断利润的控制进行解释。更多还原

【Abstract】 Employing theories of institutional change in institutional economics etc, this thesis delves into the root cause of institutional changes in the medical sector. While focusing on its central theme:Health Institutional Change & the Game Behavior of Interest Groups, this thesis, which consists 6 parts, has made a multi-dimensional analysis on the interactive mechanisms of the health care institutional reform, where its theoretical and practical value lies.Ⅰ. Research contents:The background of subject-selection, the significance, rationale, approaches, innovations and limitations of this research are briefed in the prelude.PartⅠdefines the elementary concepts and issues such as Interest Groups, the role of government in the gaming and health care system. Government interest and institutional change are analyzed in two frameworks:1. In the national framework, institutional change is a choice between the utility of government monopoly rent and the efficiency of the micro-economic subjects; 2. In the sectoral framework, the conflicts of different sectors in grabbling government resources are analyzed to show the resource advantages and behavior strategy of each sector in the ongoing medical reform.Part 2 makes a retrospective study on the institutional changes of China’s health care system, within the paradigm of economic history and comparative study. A Path Analysis is thus made on the co-evolution of "Interest Group & Institution" in health care system, along the "path" of their intrinsic logical relationship:their interaction and gaming behavior are analyzed in chorological order, while each Interest Group’s "emerging—growing—maturing" progression is depicted. Part 3 constitute the focal points of this thesis, changes of two important rules guiding the health care reform of our country are analyzed empirically:first, Decentralization. Namely, local governments and microeconomic entities are empowered with transferred rights, public hospitals are empowered with various property rights characteristic of profit-making entities; Second, public financing rules have changed from unidimensional to multi-dimensional. Two empirical models provide evidence:1. General Equilibrium model, which accounts for changes of the possibility curve as a result of changing external conditions. When state rent diminish or exhaust, government—the national agent, will enforce institutional changes that prefer supply, the utility function will be reoriented from rent-Preference to efficiency-Preference.2. Boxed-Pigs game-model, which is a partial equilibrium model depicting the health financing behavior of central and local finance authorities. Model 2 interprets the inevitable results in the wake of institutional changes in China’s health care system:the shortage of health financing and the imbalance of its distribution. Through the analysis of strategic objective function and revenue function of these 2 parties, it has been proven that it is necessary for the local governments to provide the lion’s share of health financing, and that the status quo of the central-local investment structure is thus formed by the gaming behavior of these interest groups.Part 4 focus on the analysis of the sectoral framework of Interest Groups in the setting of new health care reform. The conflicts of different sectors in grabbling government resources are analyzed to show the resource advantages and behavior strategy of each sector. Through expert consultancy, the list of the Interest Groups and their rank of importance are decided for concrete classification. Systematic analysis is made on the disposable resources of different sectors, micro-economic Interest Groups and their approaches and strategies in participating institutional changes. Adopting Mitchell Score-Based Approach, descriptive statistics and variation test are made on the three-dimensional data concerning the legitimacy, authority and urgency of the sifted Interest Groups. A Force Field Analysis is thus made for interest group in health care reform, in view of their interest demands.Part 5 makes game analysis on two essential issues in the ongoing health care reform: "subsidizing medical sector with drug sales", and Corporate Governance for public hospitals. First, through classical rent-seeking models in rent-seeking economics, theoretical interpretations are made on the source of rent in the rent-seeking gaming in the process of subsidizing medical sector with drug sales. Differentiated drug prices in public health institutions and retailing pharmacies are compared to demonstrate the loss of social benefit which underlies the rent-seeking gaming. Second, game analysis is made with respect to Corporate Governance for public hospitals, which is proven to be an effective reform strategy therewith.Part 6 undertakes normative analysis on the basis of the theoretical and empirical study above, and put forward policy recommendations to the systematic reform of health care in China.II. Research Method1. Literature Research:The major source of periodicals, thesis and yearbooks is academic journal webs, and that of investigation reports, policy information, statistical reports and data compilations is the websites of State Statistical Bureau and administration of public health department of different levels.2. Sampling Method:The population of the samples is the prices of medicine drugs of 12 public hospitals and 14 retail pharmacies. The varieties contain the top 100 drugs in nationwide sales ranking, and main factors include name, form, specification and price. The method for sampling is stratified random sampling based on 4 layers identified by the ranking of hospitals, and for every layer,20% samples are selected. The samples are comprised of 12 hospitals and 5 of which fall into the second-class (4 upper and 1 middle)and 7 are categorized as third-class(5 upper and 2 middle).3. Delphi technique method:Consult 30 experts on medical economics, hospital management, health system reform, economics and public management, to define and assort the interest group related to health and medicine, and based on which, analyze the gaming strategy and path selection and the affect on the reform of health and medicine on a systematic basis.4. Game Analysis:Simulation of the path, strategy selection and result of interest group based on the gaming model.Ⅲ. Results:1. System takes effect in the instruction of the interest allocating and transaction cost sharing among groups in transaction. There is 2-way evolutional relationship between the changes in health and medical system and the gaming of interest groups, and this article analyzed this relation in depth, adhering to the paradigm of "transaction cost-system selection-system change" of neoinstitutional economics. (1) Establish the model of intrinsic motivation of health and medical system changes, and raise the definition of "system probability curve". The change of government utility function framework is the key clue of system change. When rental utility decreases or wears out, the representative of nation-government will execute system change in the form of supply, and the utility will turn from rent preference to efficiency preference. The model explained the substantive changes in the rule of the health and medical system change:First, the changes in property right of public hospitals from state monopoly to diversified form, based on the premise of decentralization of power and transfer of profits; Second, the changes in financing system from government finance to diversified channels, and why the health and medical system transited from national finance to insurance system. (2) Explain the interest relation, strategy and result of the investment of national and local government. In the game of finance between national and local government, on one hand, the desire for investing in health and medicine is not strong mainly due to the expected low investment income; on the other hand, the local government will benefit more from the expenditure in health and medicine which resulted in more investment, in comparison with that of the national government. Consequently, the optimal choice of the local government is investing, regardless of the strategy of the national government, thus, the Nash Equilibrium is (not invest, invest).2. The second approach in this article is public choice route. (1) The conclusion that monopoly is the source of rent was made on the further analysis based on the monopoly model in economics. Medical service is necessity, and the monopoly profit is high due to the small flexibility. The empirical study analyzed the price variance between public hospitals and retail and concluded that the drug prices in public hospitals are higher than those of retail stores, which is the evidence of the fact that the source of false high price is public monopoly power in sales. Through the game analysis of rent seeking in drug price, the article concluded that the monopoly of hospitals in the sales of drugs is the result of administrative monopoly, and the direct economic supervision brings about the loss in social welfare and provides the probability and opportunity for system changes. On the other hand, The optimum probabilities of rent seeking and acceptance of rent seeking was calculated based on the game model of rent seeking, which causes the best extra profit. (2) The way out of the public hospital reform lies in how to determine definite boundary of the gaming parties in the system, which is the foundation for the realization of the equilibrium between public and administrative power. The analysis pointed out that the definition of property rights and contract is an effective way in dealing with the disorder of gaming in the field of health and medicine.3. Under the background of the reform of health and medical system, the power balance in interest parties is fairly low. How to prevent the affection of department interest on medical insurance is not only the key point of the balance of interest for each party, but an important breakthrough point of health care reform and system changes.Ⅳ.Innovation of the Research1. Research on changes of health and medical system through the unique perspective.The summary and generalization of the inherent law of the health and medical system were made through the view angle of institutional economics,and based on which, the common evolutionary process of system and interest group was discoverd.2. The combination of method of abstract analysis and concrete analysis, and the analysis of general equilibrium and partial equilibrium. Based on the equilibrium analysis, this artical analyzed the relation of the changes of health and medical institution and the interest groups behind in the abstract and general equilibrium way. The artical explained the general phenomenon in the changes of health and medical system by the structure of government utility model, and based on which, explained the gaming of medical expenditure of central and local government, and the control of monopoly profit of drug sales by the distributional coalitions.更多还原