医疗保障制度的效率分析：OECD国家的经验和启示
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摘要
长期以来,人们认为生命是无价的,政府、个人和家庭投入人力、财力、物力建立医院等机构获得医疗服务是为了身体健康着想,可以忽略或者不考虑成本。世界卫生组织报告表明在2000年到2009年人均医疗卫生费用从485美元增加到900美元,年增长率超过了6%,其中人均政府医疗卫生支出也从280美元增加到了549美元,增长了近2倍。随着全球性医疗卫生费用投入的不断增加,人们希望获得与之相应的医疗服务和卫生安全。但是事实上大量的医疗资源并没有转化为理想的医疗服务效果,普遍存在的医疗失误造成的医疗事故,患者花费了大量的资金没有达到理想的治疗效果而造成资金和医疗设备的浪费,医务人员技术的差异、临床试验的不足和监管不足等多种原因造成了医疗资源浪费,效率低下。此外,诸如道德风险和逆选择等医疗服务市场上的医患信息不对称问题都会使得医疗服务市场失效。
因此,世界上绝大多数国家都通过建立医疗保障制度来干预医疗服务市场,保障人们获得健康的权利。但是在政府干预医疗服务市场的过程中同样面临着各种难题,诸如不健全的管理方法以及卫生系统的贿赂、欺诈行为造成了资金的浪费问题,政府缺乏专业的医疗技术知识来履行监管职能,政府财力有限难以独立支撑医疗保障制度运行的所有环节等等问题。尤其是在人口老龄化愈演愈烈的趋势下,一方面长期被居民诟病的“看病贵、看病难”问题没有彻底解决,另一方面,各国政府的医疗费用支出上涨压力巨大,政府面临着两难的局面。在此背景下,我们认为努力提高医疗保障制度的效率是缓解医疗费用上涨压力,充分发挥医疗服务市场功能的重要措施之一。基于这样的背景以及对我国的参考性和借鉴作用以及数据的性质和可得性等因素考虑,选择了OECD国家作为研究的对象展开对医疗保障制度效率问题的研究。我们借鉴前人的研究成果采用两步法进行研究：首先基于医疗保障制度的最终目标是提高健康水平这一事实,我们用健康生产效率来代表医疗保障制度效率,因此构建了健康生产函数,然后采用DEA方法和SFA方法来衡量医疗保障制度效率。第二步是衡量构建面板数据模型来衡量医疗保障制度效率的影响因素。
论文的主要内容包含四大部分：
首先是文献综述。我们分别从人力资本理论、卫生服务的公平性、医疗服务市场失灵和信息不对称三大方面对国内外学者近年来的相关研究成果进行了系统的梳理和分析。然后,从介绍效率理论基础和方法入手,进而对医疗保障制度效率的定义和当前的研究现状进行了详细的分析,系统阐述了学者们对这一问题的研究成果。
其次是国际经验介绍。采用定性分析方法系统阐述OECD国家的典型医疗保障制度的运行情况。根据各国政府作用、公共医疗筹资、患者自付比例和低收入及老年人医保状况四个指标可将OECD国家的医疗保障制度划分为区域性全民公共医疗保障制度、国家医疗保障制度、法定医疗保障制度和商业医疗保障制度四种典型的模式,我们选择了实施上述四种医疗保障制度的七个国家来介绍他们各自的运行历史、运作情况及特点。
再次,通过效率非参数法(选用了DEA方法)和效率参数法(选用了SFA方法)两种效率模型来考察OECD国家医疗保障制度效率的情况,试图分析医疗保障制度选择模式与其运行效率之间的关系。我们选择OECD国家作为研究对象,他们中既包括了美国、日本、英国、德国和法国等高收入国家,也包括了智利、墨西哥、土耳其这样的中等收入国家,而且它们分布在亚洲、欧洲、大洋洲、北美洲和南美洲,具有很强的代表性。不同的医疗保障制度模式有不同的筹资机制、保障水平、运行方式和管理方法,另外还受到各国经济社会等因素的影响,这就造成了不同的经济效率,那么是否存在着一种或者几种医疗保障制度模式本身就会产生较高的经济效率呢?我们希望通过比较分析来对其进行研究和测算,试图找到影响各国医疗保障制度效率的共性因素,于是在测算效率值的基础上,我们通过构建面板数据模型实证分析效率的影响因素,为进一步的效率改进提供理论和实证支持。
最后是政策建议。与OECD国家类似,我们同样存在着医疗费用不断增加、医疗资源效率不高、看病贵和看病难等问题,而且由于城乡二元经济结构,我们还面临至今没有建立统一的医疗保障制度,居民医疗待遇差异大,商业医疗保险发展不足等问题,这些问题的解决都可以从OECD国家那里吸取经验并避免其不足。结合我国医疗保障制度的运行环境、实施状况和未来改革方向提出改善和提高我国医疗保障制度效率的建议。当然,这并不意味着我们可以完全复制OECD国家的医疗保障制度。
For a long time, people think that life is priceless, so Government, individuals and families should invest human resources, capital and material resources to establish hospitals and other institutions to obtain medical services for the interest of the health The World Health Organization report shows that health care cost per capita is from$485to$900in2000to2009, an annual growth rate is more than6%, government health expenditures per capita increased from$280to$549, increaseing nearly2times. With the increasing global health expenditure, people want to get proper medical services and health. However, the fact is that a large number of medical resources has not translated into the ideal effect of medical services, prevalence of medical mistakes caused by medical malpractice, patients spend a lot of money does not achieve the desired therapeutic effect resulting in a waste of funds and medical equipment, medical staffthe technical differences, the lack of clinical trials and inadequate supervision lead to the waste and inefficient of medical resources.In addition,asymmetric information problems in medical services market such as moral hazard and adverse selection ultimately lead to medical services market failure.
Therefore, the vast majority of countries in the world through the establishment of the medical security system to interfere with the medical services market, to protect the basic human rights of the people obtaining health. Government faces various problems in the process of intervention, such as unsound management practices, the bribery and fraud resulted in the waste of funds, the lack of professional knowledge of medical technology to perform its regulatory functions, limited government financial resources to run all aspects of the medical security system, etc.. Especially in the growing trend of population aging, on the one hand the problem which "medical treatment is expensive and difficult is not completely resolved, on the other hand, the Governments undertakes much pressure from rising medical expenditure.In this context, we believe that efforts to improve the efficiency of the medical security system can ease the pressure of rising medical expenditure, and can improve the functions of medical market. We selected OECD countries as the object of this study based on the nature and availablity of data. We can learn from the results of previous studies using the two-step method for the study:First, based on the ultimate goal of the medical insurance system is to improve the health level,we use health production efficiency to represent the efficiency of the medical security system.we build health production function, ues the methods of DEA and SFA to measure the efficiency of the medical insurance system. The second step,we construct a panel data model to measure the influencing factors of efficiency of the medical security system.
The main content of the paper contains four parts:
The First part is the literature rebiew.The paper introduces the literatures focusing on the following areas:the theory of the relationship between human capital, the fairness of the health service, medical service market failure and the medical security system, the theory and methods of efficiency,the theory of the efficiency of the medical security system.We introduce the theoretical and empirical thesis with great effects in these fields worldwide.
The seconde part is the international experience.We introduce the typical operation of the medical security system in the OECD countries which can be divided into the regional universal public medical security system, the national medical security system, the legal medical security system and the commeicial medical security system according to four indicators including governments role, public financing on health, out-of-pocket expenditur on health and the medical coverage of low-income and elderly.This paper highlights on the history,operation and feature of the medical security system in Australia,Canada,United Kingdom, Sweden, Germany, Japan and United States.
The Third part is calculating the effciency of the OECD countries by the DEA method and the SFA method, in order to analyze the relationship between the medical security system and the efficiency.We select OECD countries as the object of this study because they have a strong representation because they include both high-income countries such as the United States, Japan, Britain, Germany and low-middle income countries such as Chile, Mexico, Turkey.Forthmore,these countries distributed in Asia, Europe, Oceania, North America and South America. Different medical security system has different funding mechanisms, level of protection, operation and management methods, which result in different economic efficiency,then is there a kind of medical security System in itself will generate higher economic efficiency? We hope that conclude the result through compare the efficiency of diffirent countries.Moreover, we hope that find the Factors affecting the efficiency by empirical analysis based on the panel data model.
The final part is the policy proposal. Similar to the OECD countries, China also faces the problem of increasing medical expenses, inefficient medical resources and and difficulty for obtaining medical services, so we want to lern some experiences from OECD countries.Additionally,there are many other problems such as different people given different medical treatment, lack of development of the commercial health company and so on. So we put forward some advices on the improvement of medical security system.Of course, this does not mean that we can fully replicate the medical security system in the OECD countries.
因此,世界上绝大多数国家都通过建立医疗保障制度来干预医疗服务市场,保障人们获得健康的权利。但是在政府干预医疗服务市场的过程中同样面临着各种难题,诸如不健全的管理方法以及卫生系统的贿赂、欺诈行为造成了资金的浪费问题,政府缺乏专业的医疗技术知识来履行监管职能,政府财力有限难以独立支撑医疗保障制度运行的所有环节等等问题。尤其是在人口老龄化愈演愈烈的趋势下,一方面长期被居民诟病的“看病贵、看病难”问题没有彻底解决,另一方面,各国政府的医疗费用支出上涨压力巨大,政府面临着两难的局面。在此背景下,我们认为努力提高医疗保障制度的效率是缓解医疗费用上涨压力,充分发挥医疗服务市场功能的重要措施之一。基于这样的背景以及对我国的参考性和借鉴作用以及数据的性质和可得性等因素考虑,选择了OECD国家作为研究的对象展开对医疗保障制度效率问题的研究。我们借鉴前人的研究成果采用两步法进行研究：首先基于医疗保障制度的最终目标是提高健康水平这一事实,我们用健康生产效率来代表医疗保障制度效率,因此构建了健康生产函数,然后采用DEA方法和SFA方法来衡量医疗保障制度效率。第二步是衡量构建面板数据模型来衡量医疗保障制度效率的影响因素。
论文的主要内容包含四大部分：
首先是文献综述。我们分别从人力资本理论、卫生服务的公平性、医疗服务市场失灵和信息不对称三大方面对国内外学者近年来的相关研究成果进行了系统的梳理和分析。然后,从介绍效率理论基础和方法入手,进而对医疗保障制度效率的定义和当前的研究现状进行了详细的分析,系统阐述了学者们对这一问题的研究成果。
其次是国际经验介绍。采用定性分析方法系统阐述OECD国家的典型医疗保障制度的运行情况。根据各国政府作用、公共医疗筹资、患者自付比例和低收入及老年人医保状况四个指标可将OECD国家的医疗保障制度划分为区域性全民公共医疗保障制度、国家医疗保障制度、法定医疗保障制度和商业医疗保障制度四种典型的模式,我们选择了实施上述四种医疗保障制度的七个国家来介绍他们各自的运行历史、运作情况及特点。
再次,通过效率非参数法(选用了DEA方法)和效率参数法(选用了SFA方法)两种效率模型来考察OECD国家医疗保障制度效率的情况,试图分析医疗保障制度选择模式与其运行效率之间的关系。我们选择OECD国家作为研究对象,他们中既包括了美国、日本、英国、德国和法国等高收入国家,也包括了智利、墨西哥、土耳其这样的中等收入国家,而且它们分布在亚洲、欧洲、大洋洲、北美洲和南美洲,具有很强的代表性。不同的医疗保障制度模式有不同的筹资机制、保障水平、运行方式和管理方法,另外还受到各国经济社会等因素的影响,这就造成了不同的经济效率,那么是否存在着一种或者几种医疗保障制度模式本身就会产生较高的经济效率呢?我们希望通过比较分析来对其进行研究和测算,试图找到影响各国医疗保障制度效率的共性因素,于是在测算效率值的基础上,我们通过构建面板数据模型实证分析效率的影响因素,为进一步的效率改进提供理论和实证支持。
最后是政策建议。与OECD国家类似,我们同样存在着医疗费用不断增加、医疗资源效率不高、看病贵和看病难等问题,而且由于城乡二元经济结构,我们还面临至今没有建立统一的医疗保障制度,居民医疗待遇差异大,商业医疗保险发展不足等问题,这些问题的解决都可以从OECD国家那里吸取经验并避免其不足。结合我国医疗保障制度的运行环境、实施状况和未来改革方向提出改善和提高我国医疗保障制度效率的建议。当然,这并不意味着我们可以完全复制OECD国家的医疗保障制度。
For a long time, people think that life is priceless, so Government, individuals and families should invest human resources, capital and material resources to establish hospitals and other institutions to obtain medical services for the interest of the health The World Health Organization report shows that health care cost per capita is from$485to$900in2000to2009, an annual growth rate is more than6%, government health expenditures per capita increased from$280to$549, increaseing nearly2times. With the increasing global health expenditure, people want to get proper medical services and health. However, the fact is that a large number of medical resources has not translated into the ideal effect of medical services, prevalence of medical mistakes caused by medical malpractice, patients spend a lot of money does not achieve the desired therapeutic effect resulting in a waste of funds and medical equipment, medical staffthe technical differences, the lack of clinical trials and inadequate supervision lead to the waste and inefficient of medical resources.In addition,asymmetric information problems in medical services market such as moral hazard and adverse selection ultimately lead to medical services market failure.
Therefore, the vast majority of countries in the world through the establishment of the medical security system to interfere with the medical services market, to protect the basic human rights of the people obtaining health. Government faces various problems in the process of intervention, such as unsound management practices, the bribery and fraud resulted in the waste of funds, the lack of professional knowledge of medical technology to perform its regulatory functions, limited government financial resources to run all aspects of the medical security system, etc.. Especially in the growing trend of population aging, on the one hand the problem which "medical treatment is expensive and difficult is not completely resolved, on the other hand, the Governments undertakes much pressure from rising medical expenditure.In this context, we believe that efforts to improve the efficiency of the medical security system can ease the pressure of rising medical expenditure, and can improve the functions of medical market. We selected OECD countries as the object of this study based on the nature and availablity of data. We can learn from the results of previous studies using the two-step method for the study:First, based on the ultimate goal of the medical insurance system is to improve the health level,we use health production efficiency to represent the efficiency of the medical security system.we build health production function, ues the methods of DEA and SFA to measure the efficiency of the medical insurance system. The second step,we construct a panel data model to measure the influencing factors of efficiency of the medical security system.
The main content of the paper contains four parts:
The First part is the literature rebiew.The paper introduces the literatures focusing on the following areas:the theory of the relationship between human capital, the fairness of the health service, medical service market failure and the medical security system, the theory and methods of efficiency,the theory of the efficiency of the medical security system.We introduce the theoretical and empirical thesis with great effects in these fields worldwide.
The seconde part is the international experience.We introduce the typical operation of the medical security system in the OECD countries which can be divided into the regional universal public medical security system, the national medical security system, the legal medical security system and the commeicial medical security system according to four indicators including governments role, public financing on health, out-of-pocket expenditur on health and the medical coverage of low-income and elderly.This paper highlights on the history,operation and feature of the medical security system in Australia,Canada,United Kingdom, Sweden, Germany, Japan and United States.
The Third part is calculating the effciency of the OECD countries by the DEA method and the SFA method, in order to analyze the relationship between the medical security system and the efficiency.We select OECD countries as the object of this study because they have a strong representation because they include both high-income countries such as the United States, Japan, Britain, Germany and low-middle income countries such as Chile, Mexico, Turkey.Forthmore,these countries distributed in Asia, Europe, Oceania, North America and South America. Different medical security system has different funding mechanisms, level of protection, operation and management methods, which result in different economic efficiency,then is there a kind of medical security System in itself will generate higher economic efficiency? We hope that conclude the result through compare the efficiency of diffirent countries.Moreover, we hope that find the Factors affecting the efficiency by empirical analysis based on the panel data model.
The final part is the policy proposal. Similar to the OECD countries, China also faces the problem of increasing medical expenses, inefficient medical resources and and difficulty for obtaining medical services, so we want to lern some experiences from OECD countries.Additionally,there are many other problems such as different people given different medical treatment, lack of development of the commercial health company and so on. So we put forward some advices on the improvement of medical security system.Of course, this does not mean that we can fully replicate the medical security system in the OECD countries.
引文
1 数据来自2010年世界卫生报告：Ⅹ-Ⅺ页
1 The Price of excess:identifying waste in healthcare spending.Pricewaterhouse Coopers' Health Rearch Institute,2009,来自http://www.pwc.com/us/en/healthcare/publications/the-price-of-excess.ihtml. accessed7 July 2010
2 The financila cost of healthcare fraud.European Healthcare Fraud and Corruption Network,2010,来自 http://www.ehfcn.org/media/documents/the-financial-cost-of-healthcare-fraud-final-(2).pdf.accessed 2 July 2010
1 《2010年世界卫生组织报告》第Ⅺ页
1 Naokilegami等人,Japanese Universal Health Coverage:Evolution,Achievements,and Challenges,published www.thelancet.com2011(9):1106-1115
1 来自2000年世界卫生报告第50页
Health Care Systems Efficiency and Institutions,OECD Publishing,2010(5)
1 数据来自OECD Health Data 2011
2 数据来自the World Bank的数据库
1 宋晓梧,建国60年我国医疗保障体系的回顾与展望[J],中国卫生政策研究,2009(10)
1 数据来自中华人民共和国人力资源和社会保障部公布的2000年、2001年、2002年度劳动和社会保障事业发展统计公报
1 数据来自2012年中国卫生统计年鉴、2010年和2011年中国人力资源与社会保障事业发展统计公报
1 数据来自国家统计局发布的2010年全国人口普查公报
1 数据来自2011年中国卫生统计年鉴
1 数据来自2001-2012年sigma杂志
2 数据来自2011年中国统计年鉴
1 保险与中国农村经济发展-中法农业保险论坛论文集,北京,2003年4月
2 孙祁祥等,经济社会发展视角下的中国保险业-评价、问题与前景,经济科学出版社,2007年6月
3 数据来自2008年第四次全国卫生服务调查研究
1 数据来自2011年中国统计年鉴
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1 The Price of excess:identifying waste in healthcare spending.Pricewaterhouse Coopers' Health Rearch Institute,2009,来自http://www.pwc.com/us/en/healthcare/publications/the-price-of-excess.ihtml. accessed7 July 2010
2 The financila cost of healthcare fraud.European Healthcare Fraud and Corruption Network,2010,来自 http://www.ehfcn.org/media/documents/the-financial-cost-of-healthcare-fraud-final-(2).pdf.accessed 2 July 2010
1 《2010年世界卫生组织报告》第Ⅺ页
1 Naokilegami等人,Japanese Universal Health Coverage:Evolution,Achievements,and Challenges,published www.thelancet.com2011(9):1106-1115
1 来自2000年世界卫生报告第50页
Health Care Systems Efficiency and Institutions,OECD Publishing,2010(5)
1 数据来自OECD Health Data 2011
2 数据来自the World Bank的数据库
1 宋晓梧,建国60年我国医疗保障体系的回顾与展望[J],中国卫生政策研究,2009(10)
1 数据来自中华人民共和国人力资源和社会保障部公布的2000年、2001年、2002年度劳动和社会保障事业发展统计公报
1 数据来自2012年中国卫生统计年鉴、2010年和2011年中国人力资源与社会保障事业发展统计公报
1 数据来自国家统计局发布的2010年全国人口普查公报
1 数据来自2011年中国卫生统计年鉴
1 数据来自2001-2012年sigma杂志
2 数据来自2011年中国统计年鉴
1 保险与中国农村经济发展-中法农业保险论坛论文集,北京,2003年4月
2 孙祁祥等,经济社会发展视角下的中国保险业-评价、问题与前景,经济科学出版社,2007年6月
3 数据来自2008年第四次全国卫生服务调查研究
1 数据来自2011年中国统计年鉴
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