上海民办医疗机构发展与政府管制创新
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摘要
近年来上海民办医疗机构的数量快速增长,2006年数量是2001年的4倍。民办医疗机构在满足群众医疗服务需求方面发挥了积极作用,已成为上海医疗体系中一支不容忽视的队伍。除一部分走高端服务路线以外,大部分民办医疗机构在技术、服务和规模上缺乏明显优势,在实际的经营过程中,有一部分处于亏损状态。而是否进入医保,对民办医疗机构的生存状况影响很大,纳入医保定点的民办医疗机构往往经营状况较好,反之,则可能难以为继。
国家和上海对民办医疗机构发展均有一些政策出台,如《国务院关于鼓励支持和引导个体私营等非公有制经济发展的若干意见》和上海市政府《关于本市促进社会办医发展民办医疗机构的若干意见(试行)》等,社会办医的发展已经在国家和上海市层面均有了一定的政策上的支持。
当前上海对民办医疗机构管制主要存在两个方面的问题:
一是激励性管制手段缺乏,相关政策的操作性不强。表现在相关政策虽然对民办医疗机构在医保定点、人才引进、职称评定、科研课题招标等各方面享有与公立医院同等待遇作了明确规定,但这些规定均较为原则,缺乏可操作性。实际上,民办医疗机构在以上方面也确实未能享有与公立医疗机构同等待遇。此外,对民办非营利性医疗机构投资回报和营利性医疗机构的税收等问题,政策虽留有口子,但亦不清晰。
二是在激励性管制缺失的同时,相关制约性管制也未到位,造成了监管力度的不足。上海对民办医疗机构监督执法与对公立医疗机构的监督执法所依据的法律法规和制度框架基本相同。但由于政府对民办医疗机构缺乏对公立医疗机构的人事任命权和资产终极控制权,因此造成实质上,政府对民办医疗机构的监管力度不如公立医疗机构。许多对公立医疗机构实施的管制手段,如医疗机构质量评审、医院管理评估、医疗费用总量控制、医疗费用定期检查以及报表定期上报等均不对民办医疗机构实施。民间资本一旦经准入程序进入医疗领域后,对规范其行医的制约手段远不能满足实际需要。体现在医疗执业许可标准偏低、区域卫生规划未发挥应有作用、医政监管领域法律法规滞后、收费管制和医疗质量管制有待突破、政府管理部门和相关行业协会的管制执行不到位等。
借鉴日本、美国、英国、德国、马来西亚、香港等其他国家和地区对私立医疗机构的管制经验,针对目前上海民办医疗机构管制所存在的问题,提出要完善政府医疗管制的法律框架体系,加强规划和标准建设,重点抓好质量和费用管制;并提出要探索激励性管制策略,包括开展民办医疗机构等级评审、让民办医疗机构参与政府举办的学科竞标和评优活动、对符合条件的民办医疗机构由政府或社会保险机构购买其服务等;要创新监管手段,改善监管效果,包括加强民办医疗机构信息系统建设、建立民办医疗机构退出机制、探索医疗机构监管分级管理制度、积极发挥行业协会作用、建立政府部门间的联席会议制度等。
The number of private hospitals in Shanghai grew rapidly,quadrupled over 2001-2006. They play an active role in service provision, and become an indispensable part of the city’s medical system. Except for a few good ones targeting the high-income population, the majority of the private hospitals are not as competitive as public ones in terms of techniques, quality of services, and scales. A fraction of the private hospitals even stay in deficit. It is critical for a private hospital to be authorized as a service-provider for the social medical insurance program. Those with such authorization would be relatively easier to make ends meet, vice versa.
Both the central and the municipal-level policy-makers support society managed hospitals by such publicized documents as one, Directions on encouraging, supporting, and leading the development of non-public ownership Economic by the state council, and two, the trial directions on the development of private hospitals by the shanghai municipal government.
There exist two main issues now in the government’s regulation upon private hospitals in Shanghai.
The first issue is the lack of relevant incentives, and that the current policies on the incentives arranging are not practical. Although some policies promise that private hospitals have the same rights as public ones in terms of social medical insurance provider membership, taking in good doctors, evaluation of employees’technical post, and bidding on government financed scientific research projects etc., these policies remain in theories, not practices. Actually, the private hospitals do not have the same rights as public ones in the above mentioned aspects. Besides, policies do not show a clear perspective though they give some permission such as the private hospital investors’profit sharing, and a preferential tax rate.
The other is that supervision over the private hospitals is relatively weak. The laws and other institutional frameworks are almost the same to supervise public and private hospitals in Shanghai. Nonetheless, the municipal government does not have the right to control the appointment of managers and the right of properties, which in fact leads to a weaker governmental supervision on the private hospitals than public ones. Furthermore, a number of governmental controls upon public hospitals are not applied to private ones, e.g., evaluation on hospital institution quality, assessment of hospital management, hospital global budget control, regular medical expense inspection, and regular financial forms report etc. Once private investors have complete access to medical field, the current governmental regulatory and supervisory approaches are far from needs. The main issues of regulation failure lie in the following aspects, a low threshold in medical practice access, the failure of district health planning, time delay of medical administration laws, a too firm medical charges regulation with a too loose control over medical quality, and a bad implementation of the government, doctors guild, and medical associations etc.
We can learn from experiences and lessons in the regulation of private hospitals in such other countries and regions as Japan, USA, the United Kingdom, Germany, Malaysia, and Hong Kong. The objective is to solve the issues in the governmental regulation upon the private hospitals in Shanghai. The policy alternatives recommended in this article include, to improve the law making as to the governmental regulation upon the medical service providers system, which lies in to strengthen planning and standards of the medical service providers, and in particular, planning and standards of medical quality and expense, to explore the strategy of regulation with relevant incentives for private hospitals, which contains level assessment, permission to department bidding and quality evaluation organized by the government, and admission to the contract of purchasing services from the social medical insurance program administrators for those qualified, to innovate the approaches of regulation in order to improve the regulatory performance over private hospitals, which includes to strengthen the information systems of the private hospitals, and to set up the mechanism of private hospitals’quitting, to explore the differential management according to the hospital level, to make full use of doctors guilds and medical associations, and to set up the joint committee of stake holding government sectors.
国家和上海对民办医疗机构发展均有一些政策出台,如《国务院关于鼓励支持和引导个体私营等非公有制经济发展的若干意见》和上海市政府《关于本市促进社会办医发展民办医疗机构的若干意见(试行)》等,社会办医的发展已经在国家和上海市层面均有了一定的政策上的支持。
当前上海对民办医疗机构管制主要存在两个方面的问题:
一是激励性管制手段缺乏,相关政策的操作性不强。表现在相关政策虽然对民办医疗机构在医保定点、人才引进、职称评定、科研课题招标等各方面享有与公立医院同等待遇作了明确规定,但这些规定均较为原则,缺乏可操作性。实际上,民办医疗机构在以上方面也确实未能享有与公立医疗机构同等待遇。此外,对民办非营利性医疗机构投资回报和营利性医疗机构的税收等问题,政策虽留有口子,但亦不清晰。
二是在激励性管制缺失的同时,相关制约性管制也未到位,造成了监管力度的不足。上海对民办医疗机构监督执法与对公立医疗机构的监督执法所依据的法律法规和制度框架基本相同。但由于政府对民办医疗机构缺乏对公立医疗机构的人事任命权和资产终极控制权,因此造成实质上,政府对民办医疗机构的监管力度不如公立医疗机构。许多对公立医疗机构实施的管制手段,如医疗机构质量评审、医院管理评估、医疗费用总量控制、医疗费用定期检查以及报表定期上报等均不对民办医疗机构实施。民间资本一旦经准入程序进入医疗领域后,对规范其行医的制约手段远不能满足实际需要。体现在医疗执业许可标准偏低、区域卫生规划未发挥应有作用、医政监管领域法律法规滞后、收费管制和医疗质量管制有待突破、政府管理部门和相关行业协会的管制执行不到位等。
借鉴日本、美国、英国、德国、马来西亚、香港等其他国家和地区对私立医疗机构的管制经验,针对目前上海民办医疗机构管制所存在的问题,提出要完善政府医疗管制的法律框架体系,加强规划和标准建设,重点抓好质量和费用管制;并提出要探索激励性管制策略,包括开展民办医疗机构等级评审、让民办医疗机构参与政府举办的学科竞标和评优活动、对符合条件的民办医疗机构由政府或社会保险机构购买其服务等;要创新监管手段,改善监管效果,包括加强民办医疗机构信息系统建设、建立民办医疗机构退出机制、探索医疗机构监管分级管理制度、积极发挥行业协会作用、建立政府部门间的联席会议制度等。
The number of private hospitals in Shanghai grew rapidly,quadrupled over 2001-2006. They play an active role in service provision, and become an indispensable part of the city’s medical system. Except for a few good ones targeting the high-income population, the majority of the private hospitals are not as competitive as public ones in terms of techniques, quality of services, and scales. A fraction of the private hospitals even stay in deficit. It is critical for a private hospital to be authorized as a service-provider for the social medical insurance program. Those with such authorization would be relatively easier to make ends meet, vice versa.
Both the central and the municipal-level policy-makers support society managed hospitals by such publicized documents as one, Directions on encouraging, supporting, and leading the development of non-public ownership Economic by the state council, and two, the trial directions on the development of private hospitals by the shanghai municipal government.
There exist two main issues now in the government’s regulation upon private hospitals in Shanghai.
The first issue is the lack of relevant incentives, and that the current policies on the incentives arranging are not practical. Although some policies promise that private hospitals have the same rights as public ones in terms of social medical insurance provider membership, taking in good doctors, evaluation of employees’technical post, and bidding on government financed scientific research projects etc., these policies remain in theories, not practices. Actually, the private hospitals do not have the same rights as public ones in the above mentioned aspects. Besides, policies do not show a clear perspective though they give some permission such as the private hospital investors’profit sharing, and a preferential tax rate.
The other is that supervision over the private hospitals is relatively weak. The laws and other institutional frameworks are almost the same to supervise public and private hospitals in Shanghai. Nonetheless, the municipal government does not have the right to control the appointment of managers and the right of properties, which in fact leads to a weaker governmental supervision on the private hospitals than public ones. Furthermore, a number of governmental controls upon public hospitals are not applied to private ones, e.g., evaluation on hospital institution quality, assessment of hospital management, hospital global budget control, regular medical expense inspection, and regular financial forms report etc. Once private investors have complete access to medical field, the current governmental regulatory and supervisory approaches are far from needs. The main issues of regulation failure lie in the following aspects, a low threshold in medical practice access, the failure of district health planning, time delay of medical administration laws, a too firm medical charges regulation with a too loose control over medical quality, and a bad implementation of the government, doctors guild, and medical associations etc.
We can learn from experiences and lessons in the regulation of private hospitals in such other countries and regions as Japan, USA, the United Kingdom, Germany, Malaysia, and Hong Kong. The objective is to solve the issues in the governmental regulation upon the private hospitals in Shanghai. The policy alternatives recommended in this article include, to improve the law making as to the governmental regulation upon the medical service providers system, which lies in to strengthen planning and standards of the medical service providers, and in particular, planning and standards of medical quality and expense, to explore the strategy of regulation with relevant incentives for private hospitals, which contains level assessment, permission to department bidding and quality evaluation organized by the government, and admission to the contract of purchasing services from the social medical insurance program administrators for those qualified, to innovate the approaches of regulation in order to improve the regulatory performance over private hospitals, which includes to strengthen the information systems of the private hospitals, and to set up the mechanism of private hospitals’quitting, to explore the differential management according to the hospital level, to make full use of doctors guilds and medical associations, and to set up the joint committee of stake holding government sectors.
引文
[1] 雅诺什.科尔奈,翁笙和.转轨中的福利、选择和一致性-东欧国家卫生部门改革[M].北京:中信出版社,2003.21—23
[2] 雅诺什.科尔奈,翁笙和.转轨中的福利、选择和一致性-东欧国家卫生部门改革[M].北京:中信出版社,2003.79—90
[3] 王梓. 交锋医改:政府与市场的选择[N]. 21 世纪经济报道,2007-04-14
[4] 王梓. 交锋医改:政府与市场的选择[N]. 21 世纪经济报道,2007-04-14
[5]李玲.医疗卫生事业发展中的政府责任[EB/OL].http://www.ccer.edu.cn/cn/ReadNews.asp?NewsID=7456, 2006-12-14
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[2] 梁万年.卫生事业管理学[M].人民卫生出版社,2003.162—163
[3]马进.政府所属医院管理体制与运行机制研究〔A〕.卫生部政法司 2005 年研究课题报告集〔C〕.272-300
[4] 梁万年.卫生事业管理学[M].人民卫生出版社,2003.162—163
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[2] 雅诺什.科尔奈,翁笙和.转轨中的福利、选择和一致性-东欧国家卫生部门改革[M].北京:中信出版社,2003.79—90
[3] 王梓. 交锋医改:政府与市场的选择[N]. 21 世纪经济报道,2007-04-14
[4] 王梓. 交锋医改:政府与市场的选择[N]. 21 世纪经济报道,2007-04-14
[5]李玲.医疗卫生事业发展中的政府责任[EB/OL].http://www.ccer.edu.cn/cn/ReadNews.asp?NewsID=7456, 2006-12-14
[1]马进.政府所属医院管理体制与运行机制研究〔A〕.卫生部政法司 2005 年研究课题报告集〔C〕.272-300
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