【作者】 陈良侠；

【导师】 姚岚；

【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】 研究目的基于我国新的医药卫生体制改革精神关于坚持公立医疗机构为主导,鼓励和引导社会资本发展医疗卫生事业,形成公立医院与非公有医院相互促进、共同发展的多元办医格局的原则,为进一步促进我国非公有医院健康和公平发展,从而真正形成优质非公有医院医疗资源,使非公有医院能以可靠的质量和合理的费用不断满足人民群众不同层次的医疗服务需求,深入调查研究目前我国非公有医院存在和面临的问题,以及各利益相关者对非公有医院的评价和对其发展策略的观点,并借鉴国外私立医院发展经验,结合理论研究,探讨和提出我国下一步发展非公有医院的重点策略,为我国进一步完善非公有医院政策提供参考。研究方法文献研究：查阅大量国内外关于私立医院发展存在问题、分类管理、政策支持、监管等方面的主要做法及其经验方面的公开文献和研究成果。现场调查：通过调查表调查和问卷调查获取定量资料,通过深度访谈和专题组讨论获得定性资料。对武汉市的7所非公有医院和2所公立医院做了典型调查并作比较,对山东省17个市的15所非公有医院与41所公立医院进行了医疗质量管理方面的专题典型调查并作比较。对武汉市400名医生、360名居民和250名病人进行了问卷调查。对武汉市、上海市、宁波市、济南市的卫生局领导、非公有医院负责人、公立医院负责人、非公有及公立医院的医生和管理人员共做了33个深度访谈,召开2个专题组讨论。理论分析：借鉴委托代理理论、规制经济学理论(重点是激励性规制合同设计理论和新规制经济学的规制俘获理论)、博弈论、卫生经济学理论等进行理论分析。数据统计分析方法：包括描述性分析、x2检验、logistic回归分析、两样本比较的Mann-Whitney U检验、组问比较的方差分析及Kruskal-Wallis H检验、两两比较的SNK法及Games-Howell法。所有数据分析采用SPSS for Windows 12.0专业统计软件处理。研究结果1.部分非公有医院发展较好,走上了良性发展的道路。2.非公有医院一定程度上满足了群众的部分医疗需求。3.不少非公有医院自身存在较多问题,并没有真正形成优质医疗资源。表现为：不少非公有医院经营理念上过于追求经济利益;多数非公有医院难以吸引优秀人才‘,人员技术力量薄弱；不少非公有医院缺乏自律,诚信不足,医疗行为不规范甚至有欺骗行为。4.多数民众对非公有医院认知不足,存在明显信息不对称。5.部分政策或制度不完善,不利于非公有医院公平健康发展。主要包括：非公有医院面临不公平待遇,加大了其发展难度；非公有医院准入管理制度不完善；对非公有医院的医疗价格(付费)管理制度不合理；非公有医院分类管理的政策和措施不完善；非营利性非公有医院对投资者缺乏吸引力,面临筹资困难；医疗服务信息披露和公开制度不完善；税收政策对营利性医院赋税较重,各地税收标准不统一。6.非公有医院监管体制和机制不完善,监管乏力。主要包括：多头监管、权力分散；主要监管机构缺乏独立性和中立性；监管体系不健全；监管绩效无考核、无问责机制,存在“监管俘获”；监管方式与程序不合理；违规处罚力度较小,违规成本低。7.公立医院医疗行为监管也不到位,对非公有医院有影响。研究结论提出了以下几个方面我国发展非公有医院的策略：(一)总体思路基于四个方面,第一,优化非公有医院人员技术力量；第二,规避非公有医院道德风险行为；第三,营造非公有医院公平发展环境；第四,完善监管体制机制以提高监管效力,提出我国发展非公有医院的各项具体策略。并应该综合采取多种措施,发挥协同作用,以最大限度地促进非公有医院健康发展。(二)各项具体策略1.改进非公有医院准入管理制度。调整非公有医院机构设置和投资准入管理,加强医务人员准入管理,提高医务人员准入标准,加强医疗技术和医疗设备准入管理。2.鼓励社会资本参与现有医院转制。3.鼓励发展非营利性非公有医院,谨慎合理发展营利性医院。一是提出了鼓励发展非营利性非公有医院的措施,包括拓宽非营利性非公有医院的筹资渠道,如发行免税债券、鼓励居民出资等；完善医院分类管理中对非公有医院性质的核定原则。二是提出加强对非营利性非公有医院的财务监管,保证其非营利性质。三是谨慎合理发展营利性医院。合理确定其服务项目,主要允许其开展信息不对称程度较轻的诊疗项目,或治疗手段明确、疗效确切,容易制定“临床路径”的疾病诊疗项目,或非基本医疗保险不予支付费用的美容、整形、不育(孕)症、性功能障碍等特需服务项目。尽量减少其开展目前医学上尚无明确特效疗法、治疗效果不确切或难以观察的难治性慢性病诊疗项目等。调整和完善营利性医院的税收政策,免征营业税及其附加；降低所得税税率；制定专门政策明确统一税收标准和办法。4.政策上给予非公有医院平等待遇,并且要改进政策执行机制,如明确对执行机构的具体操作要求和问责条款,以保证政策得到落实,营造其公平发展环境。5.进一步完善非公有医院医疗服务信息披露和公开制度。从信息披露和公开的内容、机构、程序和方式四个方面进行完善。6.加强非公有医院信用体系和制度建设。建立全国统一联网的非公有医院信用档案系统,积极推行非公有医院不良执业行为记分管理制度。7.改进非公有医院医疗价格(费用)管理制度。改变目前的按服务项目付费方式。对营利性医院实行医患双方协商签订“单病种医疗总费用合约”制度,实行备案制,并向社会公开。对非营利性非公有医院,在政府指导价基础上,结合制定临床路径,形成单病种费用标准,实行单病种定额付费。对属于医疗保险支付费用的服务项目,在费用支付总量上,宜实行人均定额付费制,并设置上限和下限,采取不同的结算方法,防止降低服务质量。8.完善非公有医院监管体制和机制,提高监管效力。一是构建联席会议制度。应由卫生行政部门联合药监、医保、财政、审计、物价、质监、民政、工商、税务部门等相关部门构建。二是进一步完善监管体系。建立包括政府部门监管、行业自律组织和消费者保护组织参与以及公众舆论监督在内的较完善的现代监管体系。三是建立独立的、专业化的监管机构。四是提高监管程序的透明度,改进监管方式。让公众对监管情况、监管结果有所了解;在监管方式上,适当应用“突击式检查”、“追踪检查法”、专(兼)职医生巡回式驻点检查。五是明确监管重点,建立非公有医院监管绩效考核和问责机制。绩效考核监管目标的设置要针对目前的薄弱环节,重点包括医疗质量、医疗行为、医疗广告、非营利性非公有医院财务支配、医疗费用方面的指标；建立监管失职问责制度,提高社会公众参与水平,充分发挥消费者保护组织、行业自律组织和社会舆论的监督作用,并接受公众的有效问责。六是加大非公有医院违规处罚力度,增加其违规代价。9.对非公有医院和公立医院实行同步监管。更多还原

【Abstract】 Objectives:Base on the principle of the spirit of new medical and health system reform, uphold the lead status of the public medical institutions, encourage and guide the social capital to develop medical and health services, form the pattern of multi-running promotion and common development of public hospitals and non-public hospitals, aims to promote the non-public hospitals developing healthly and fairly, then form a genuine high-quality non-public hospital medical resources, to meet the people’s different levels demand for medical services, deeply research the development of China’s non-public hospital status and presence problems, and various stakeholders on the evaluation of non-public hospitals and their development strategy point of view, and learn from foreign experience in the development of private hospitals, combined with theoretical study, discuss and puts forward the strategy of next stage development of non-public hospitals, provide a reference for further improving China’s development policy of non-public hospitals.Methods:Literature:access to a large number of private hospitals on the development of domestic and foreign problems, classification management, policy support, regulatory and other aspects of the practice and experience the major open literature and research results.On-site survey:The survey questionnaire and survey to obtain quantitative data, through depth interviews and thematic group discussions were qualitative data. Wuhan City, 7 non-public hospitals and two public hospitals in a typical survey, Shandong Province 15 non-public hospitals and 41 public hospitals, medical quality management feature typical survey.400 doctors in Wuhan,360 residents and 250 patients a questionnaire survey. In Wuhan, Shanghai, Ningbo, Jinan City Health Bureau and the non-public hospitals who were in public hospitals, non-public and public hospital doctors and managers made a total of 33 interviews, held two special group discussion.Theoretical analysis:learning from principal-agent theory, regulatory economics (with emphasis on design of incentive regulation theory and the new contract, regulatory capture theory of regulatory economics), game theory, health economics theory to theory.Statistical analysis of data:descriptive analysis,χ2 test, logistic regression analysis, two sample comparison Mann-Whitney U test, analysis of variance and Kruskal-Wallis H test were used between groups, SNK and Games-Howell method were used to compare every two groups. All data were analyzed using SPSS for Windows 12.0 professional statistical software.Results:1.Part of the non-public hospitals develope better, embarked on a healthy development.2. Non-public hospitals meet part of the medical needs of the masses in certain extent.3. A lot of non-public hospital has many problems itself, and not really the formation of high-quality medical resources. As follows:many non-public hospitals over the pursuit of philosophy, on the economic interests; the majority of non-public hospitals is difficult to attract the best talent, personnel and technical weakness; many non-public hospitals lack self-discipline, lack of integrity, health behavior is not normative and even fraud.4. Most people lack of knowledge on non-public hospitals, there are significant information asymmetries.5. Part of the policy or system is imperfect, is not conducive to fair and healthy development of non-public hospitals. Include:the non-public hospitals facing unfair treatment, increased the difficulty of its development; non-public hospital access management systems; on non-public hospital system price (paid) management system is unreasonable; non-public hospital classification management policies and measures imperfections; non-profit non-public hospitals less attractive to investors, faced with funding difficulties; medical services and public information disclosure system is imperfect; tax policy on heavy profit hospital tax, local tax standards are not uniform.6. System and mechanism for monitoring non-public hospitals are incomplete with inadequate supervision. Include:long supervision, decentralization; major regulatory agencies lack independence and neutrality; regulatory system is not perfect; regulatory performance without examination, no accountability mechanism, there is "regulatory capture"; unreasonable regulatory methods and procedures; violation penalties small, non-compliance and low cost.7. Public hospital supervision of medical acts is not in place, there is an impact on non-public hospitals.Conclusions:Give the following aspects of non-public hospitals in our country’s development strategy:The general idea:Based on four aspects, first, the optimization of non-public hospital personnel and technical personnel; second, to avoid moral hazard behavior of non-public hospitals; third, to create a fair environment for the development of non-public hospitals; Fourth, improve management systems and mechanisms to improve regulatory effectiveness, puts forward the development of specific non-public hospitals policy. And should be integrated to take various measures to play a coordination role in order to maximize the promotion of healthy development of non-public hospitals.Specific strategies:1. Improve access management systems of non-public hospitals. Ajust non-public access to the hospital institutional arrangements and investment management, strengthen access to medical personnel management, improve access to medical standards, to enhance access to medical technology and medical equipment management.2. Encourage social capital to participate conversion of existing hospitals.3. Encourage the development of non-profit, non-public hospitals, the rational development of for-profit hospitals. First, encourage the development of proposed non-profit non-public hospital measures, including expanding non-profit non-public hospital funding sources, such as issuing tax-free bonds to encourage investment and other residents; improve the management of hospital classification on the approved non-public nature of the principles of hospital. Second is to strengthen non-profit, non-public hospitals, financial supervision, to ensure their non-profit. Third, the rational development of for-profit hospital care. Ascertain their services rationally due mainly to allow information asymmetry to a lesser extent its conduct clinics project, or treatment clear, effective, safe, easy to develop "clinical pathway" diagnosis and treatment of disease project, or basic medical insurance will not pay for beauty, plastic surgery, infertility (pregnant) disorders, sexual dysfunction and other special needs services. Reduce its conduct to the best there is no clear effects of current medical therapy, inaccurate or difficult to observe the treatment of refractory chronic treatment projects. Adjusted and improved hospital profit tax policy, exempt from business tax and additional; lower income tax rates; adopted special policies to specific uniform tax standards and methods.4. Policy gives equal treatment for non-public hospitals, and to improve policy implementation mechanisms, such as clear to the implementing agencies of the specific operational requirements and accountability provisions to ensure that policies have been implemented to create a fair environment for development.5. To further improve system of information disclosure and opening of the non-public hospitals. From information disclosure and public content, organization, procedures and methods were improved in four areas.6. Strengthen the construction of credit system of the non-public hospitals. Establish a national network system of non-public hospitals credit files. Actively promote the practice of medical bad points management system.7. Improve the non-public hospital medical price (cost) management system. Change the current payment by way of service. Profit hospitals on the consultation between doctors and patients sign a "single disease contract the total cost of health care" system, file and record system to an open society. On the non-profit non-public hospitals, in government guidance based on the combined development of clinical pathways, the formation of the standard cost of a single disease, the single disease scale fees. Belonging to the medical insurance paid for services, fees paid in total, the fixed per capita payment system should be implemented, and set the upper and lower limits, to take a different billing method, to prevent the lower quality of service.8. Improve the monitoring system and mechanism of non-public hospitals to improve control effectiveness. First, to construct joint meeting system. Joint Drug Administration by the health administrative departments, health care, finance, audit, price, quality supervision, Home, Business, Construction of the tax department and other related departments. Second, to further improve the regulatory system. Including monitoring the establishment of government departments, industry self-regulatory organizations and consumer protection organizations, including participation and public supervision by public opinion than the perfect modern regulatory system. Third, the establishment of independent, professional regulatory bodies. Fourth, improve the transparency of regulatory procedures and improve monitoring methods. Enable the public to monitor the situation, monitoring the results have to understand; the regulatory approach, the proper use of "assault-style inspections", "check-up Act," specifically (and) recruited doctors rotational stagnation inspection. Fifth, a clear regulatory focus, the establishment of non-public hospital performance assessment monitoring and accountability mechanisms. Performance appraisal regulatory objectives set to address the current weaknesses in the focus of medical quality, medical practices, medical advertising, non-profit non-public hospital financial dominance, the index of medical costs; a regulatory system of accountability for dereliction of duty to improve public participation level, give full play to the consumer protection organizations, industry self-regulatory body and the supervisory role of public opinion, and subject to public accountability and effective. Sixth, increase penalties for violations of non-public hospital efforts to increase non-compliance costs.9. Perform synchronized control on non-public hospitals and public hospitals.更多还原