我国医疗服务市场化指数构建及其应用研究
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摘要
研究目的
本研究的总目标是开发医疗服务市场化指数,定量分析全国层面改革开放以来医疗服务市场化进程的演变趋势,为卫生改革发展提供参考依据。
研究内容
界定医疗服务市场化概念和内涵,并建立评价框架；构建医疗服务市场化评价指标体系,设计医疗服务市场化指数的合成方法；运用这一指数,分析我国改革开放以来医疗服务市场化进程变化趋势；在此基础上,提出政策建议和研究建议。
研究方法
本文通过文献综述,回顾了国内外对医疗及其他领域市场化评价研究的现状；使用概念化方法,界定了医疗服务市场化的概念和内涵；采用德尔菲法对相关领域政府官员和研究学者进行问卷调查,用以构建医疗服务市场化评价指标体系；通过数理统计分析,检验指标体系的评价效能；最后采用综合分值法对政策类指标进行评分,从而合成医疗服务市场化指数。
结果与分析
建立医疗服务市场化评价框架。医疗服务市场化是指医疗服务领域中市场机制(资源配置、竞争、价格等方面)作用不断增强的过程,也是政府对有关医疗资源的配置、准入和监督放松管制的过程。其操作性定义是指,医疗领域的资源由政府行政配置向市场调节配置的转化,包括政府与市场的功能界定,公有制要素与非公有制要素的份额比例,公立医疗机构运行自主权的程度。在理论分析的基础上,从政府管制与市场开放程度、非公要素发展和公立机构自主权三个方面建立医疗服务市场化评价框架。
构建医疗服务市场化评价指标体系。经过两轮德尔菲调查,建立了含有13项指标的医疗服务市场化评价指标体系。政府管制与市场开放程度维度包含非公投资医疗机构准入政策、政府对医疗服务价格的管制程度等4项指标；非公要素发展维度包含医疗机构床位中非公床位所占比例、医疗机构门诊人次中非公提供所占比例等3项指标；公立机构自主权维度包含经济收益处置自主权、人员聘用与解雇自主权等6项指标。
设计市场化指数的合成方法。建立了一套政策类指标量化刻度尺,测量范围是0-1,0表示完全政府化,1表示完全市场化。总结梳理相关政府文件,对政策类指标进行定量转化。客观类指标抄录卫生统计数据,对缺失值进行推算填补。根据专家咨询对各维度和指标的评分值,确定维度和指标权重,构建了医疗服务市场化指数。
指标体系效能测量。因子分析结果显示,共提取三个公因子,分别在三个维度上载荷较高,累计贡献率达95.258%,说明指标体系结构效度较好。克朗巴赫α系数为0.734,两部分相关系数为0.877,说明指标体系信度较好。某一个指标数值上调10%或下调10%时,指数波动的绝对值除一项达到3.04%之外,均在0.04-1.75%之内浮动,说明指标体系稳健性较好。聚类分析将32年市场化指数分为五类,方差分析结果显示五类之间和每两类之内差异有统计学意义(P<0.05),说明指标体系的区分度较好。
我国医疗服务市场化进程分析结果。我国医疗服务市场化指数从1978年的18.24上升至2009的46.99(总分为100),呈逐步上升趋势,年均增幅为0.90,但2000年之后增速减缓。从结构变化来看,政府管制与市场开放程度、公立机构自主权两个维度提升幅度大、速度快,非公要素发展得分相对较低,呈先上升后下降的趋势。根据近5年市场化指数趋势预测,2014年医疗服务市场化程度将超过50%。
结论与讨论
本文研究了医疗服务市场化的内涵和定量测度问题,探索了新的卫生经济学研究领域,弥补了医疗服务市场化定量研究的空白；通过计量分析我国医疗服务领域市场化演进过程,回答了现实中关于医疗市场化演进方向的争论,促进卫生改革发展政策的调整完善。研究设计发明了政策类指标的量化刻度尺,使指标定量转化更加准确,各年份市场化指数有可比性。在进行两轮德尔菲专家咨询的过程中,通过科学选择专家、提供充分信息、采用适宜咨询形式和加强沟通联络等措施,保证了问卷的高回收率和填答有效性。
与其他领域市场化测度研究相比,本研究构建的指标体系具有以下优势：评价方法更完善,采用统计学分析验证,设立政策类指标使评价更全面,研究时间跨度长并且连续计算等。以往的市场化测度研究发现,经济领域和劳动力市场的市场化程度持续提高,2000之后市场化指数已超过60%。
改革开放以来,我国医疗领域市场化程度不断加深,整体增速在2000后也有所放缓。通过与宏观经济体制改革比较分析发现,重要的经济改革办法,如放开个体经济、国有企业改革等,对医疗市场化产生了重要的影响。20世纪80年代对公立机构自主权下放过快,导致其过分追求经济利益而出现一系列问题。2003年之后,科学发展观、和谐社会等改革发展理念的提出促使医疗领域反思市场化取向改革的得与失。
研究中还存在有一定主观性、评分刻度尺精准度不足、统计数据不够完善等不足之处有待进一步完善。
政策建议
进一步完善医疗服务市场化评价指标体系,如开展次国家级水平的市场化测度,跟踪进行连续动态评价。合理把握医疗服务市场化改革节奏和步骤,使其维持在社会可承受范围内。将政府管理与市场机制有效结合,充分发挥二者的积极作用,政府需加强宏观调控、规划、投入、监管和制度建设,在此基础上运用市场机制实现卫生改革发展的政策目标。
Objective:
This study stays focused on developing a marketization index of the medical service system and quantitatively analyzing the trend of development, at a national level, of the marketization process of the Chinese medical service system since Open and Reform, aiming to provide support for health reform.
Contents:
The concept of marketization in medical service system was identified with its contents and the evaluation framework was thus set up; an evaluation system of indicators measuring the process of marketization in medical service system was developed; the method of quantitative transition and calculation was developed, followed by the analysis on the development trend of the process of marketization in medical service system since Open and Reform. And policy and research suggestions offered thereby.
Research Methods:
This study reviewed the state-of-the-art developments of evaluation studies on the process of marketization in medical service, as well as on other non-medical service markets, from in and outside China by means of literature review; definition was given to marketization in medical service system by utilizing conceptual approach; a survey to governmental officials and researchers in the circle was conducted using Delphi Method to develop an evaluation system of indicators measuring the process; the evaluation functioning of the evaluation system was sorted by analyzing mathematical statistics; and integrated sub-value method was employed to grant value to policy related indicators.
Results and Analysis:
An evaluation framework measuring the marketization process in medical service was developed. The marketization process refers to a process in which market mechanism (allocation of resources, competition, price forming and etc) plays an increasingly more important role where government deregulates in allocation of resources, market access and supervision. Its operational definition refers to a convert in resources allocation from governmental control through administrative means to the operation of market forces, which covers, at a macro level, the clarification of governmental functions and market operations; the proportion of non-public elements against that of public elements, at a medium level; and the decision-making power granted to public medical institutions, at a micro level. The evaluation framework measuring marketization process in medical service was then developed based on three perspectives, namely, governmental control and market opening, non-public elements development and decision-making power of public institutions.
An evaluation system of indicators measuring the process of marketization in medical service was developed. A 13-indictor evaluation system was developed as a result of a two-round Delphi survey. Under the dimension of government control and market opening, there're 4 indicators namely non-public institution access policy, government control over medical service pricing and etc; 3 indicators namely non-public proportion in accommodation ability, non-public proportion in outpatient and etc were under the dimension of non-public elements developments; and 6 indicators namely revenue deposition access, discrete power to hire and dismiss were under the dimension of public institutions decision making power.
Calculation determined on the formation of the marketization index. A scale ruler was setup with 0 for total control and 1 for completely free market. A quantitative transition of policies was made through policy review and sorting. Objective indicators were copied from statistic data and missing numbers were filled up by default calculation. And the marketization index of medical service system was developed by dimension and indicator weighting allocation accordingly with the expert opinion on valuing.
Indicator system examination. Factor analysis showed that the three extracted common factors have a high load on the three dimensions with an accumulated contribution to 95.258% and accuracy thus evidenced. The Cronbach's alpha coefficient is 0.734 and the relative coefficient is 0.877, which showed good reliability. Stability was examined by adjusting a certain indicator 10% up or down to find an absolute value fluctuation within 0.04-1.75% of all indicators except one to 3.04%. In cluster analysis, the marketization indexes of the 32 years were divided into 5 groups, ANOVA analysis showed that the differences among all 5 groups and between each 2 groups are statistically significant(P<0.05), which proved sound differentiation.
Conclusion in the marketizaition process analysis. The marketization index goes steadily upward from 18.25 in 1978 to 44.15 in 2009(out of 100), at an annual growth rate of 0.90, with a slowdown in and after 2000. As detailed to the sub level, the two dimensions of government control and market opening, as well as the decision making power granted to pubic institutions increased comparatively fast while the dimension of non-public elements recorded an upward-downward curve resulting in a low level of marketization. The estimated maketization level, based on the trend reflected in the recent five years, in 2014 will be over 50%.
Conclusions and Further Discussions:
This study explored into a new area in health economics, by staying focused on the defining and quantitative measurement of the marketization in medical service system to fill the blanks in the medical service marketization studies. A quantitative analysis to the marketization of the medical service system was conducted to give an answer to the arguments over the marketization process of the medical service system and to call for policy adjustment and improvement in healthcare reform. Scale ruler to policy indicators was invented by the study to make the quantitative transition of policies more accurate and annual marketization indexes comparable. Measurements have been taken, in the two rounds of Delphi survey conducted in the study, in selecting expert candidates, providing information, choosing the way how they were consulted and communicating and collaborating with the experts to ensure correspondence.
The indicator system developed by this study, compared to others, was more perfectly conducted in evaluation approaches, statistically examined and validated, comprehensively completed with the introduction of policy orientated indicators, historically fully covered and etc. It was found that, from the already existed studies measuring marketization level, those in economy and labor force have been consistently uprising, to a level over 60% since 2000.
The marketization level, since Open and Reform, of the Chinese medical service system has been upraised in general while it slowed down its pace after 2000. It was found, by comparing the economic reform at macro level, that substantial reform measurements such as deregulating control over private owned business, as well as state-owned enterprise reform, owned great impact to the marketization of medical service system. The over paced promotion in granting public institutions with their own decision making power has led to a series of problems due to their economic overemphasis. The bring in of the ideas of Scientific Concept of Development and Harmonious Society after 2003 made the introspection to the marketization of medical service system prompted.
The study is due to be improved in objectivity, accuracy in scale ruler and statistics completeness as well.
Suggested Policies:
Further possible improvements should be made on the evaluation system measuring marketization process in medical service, namely marketization process measurement at sub-national level and consecutive and dynamic tracking. The promotion of marketization in medical service system should follow a balanced and reasonable pace and steps for the affordability purpose. The process of marketization in medical service should be promoted by the good use of both governmental control and market mechanism where government is about to strengthen macro control, investment, supervision and institutionalization, based on which to make a full use of the market mechanism to reach the goals of health reform.
本研究的总目标是开发医疗服务市场化指数,定量分析全国层面改革开放以来医疗服务市场化进程的演变趋势,为卫生改革发展提供参考依据。
研究内容
界定医疗服务市场化概念和内涵,并建立评价框架；构建医疗服务市场化评价指标体系,设计医疗服务市场化指数的合成方法；运用这一指数,分析我国改革开放以来医疗服务市场化进程变化趋势；在此基础上,提出政策建议和研究建议。
研究方法
本文通过文献综述,回顾了国内外对医疗及其他领域市场化评价研究的现状；使用概念化方法,界定了医疗服务市场化的概念和内涵；采用德尔菲法对相关领域政府官员和研究学者进行问卷调查,用以构建医疗服务市场化评价指标体系；通过数理统计分析,检验指标体系的评价效能；最后采用综合分值法对政策类指标进行评分,从而合成医疗服务市场化指数。
结果与分析
建立医疗服务市场化评价框架。医疗服务市场化是指医疗服务领域中市场机制(资源配置、竞争、价格等方面)作用不断增强的过程,也是政府对有关医疗资源的配置、准入和监督放松管制的过程。其操作性定义是指,医疗领域的资源由政府行政配置向市场调节配置的转化,包括政府与市场的功能界定,公有制要素与非公有制要素的份额比例,公立医疗机构运行自主权的程度。在理论分析的基础上,从政府管制与市场开放程度、非公要素发展和公立机构自主权三个方面建立医疗服务市场化评价框架。
构建医疗服务市场化评价指标体系。经过两轮德尔菲调查,建立了含有13项指标的医疗服务市场化评价指标体系。政府管制与市场开放程度维度包含非公投资医疗机构准入政策、政府对医疗服务价格的管制程度等4项指标；非公要素发展维度包含医疗机构床位中非公床位所占比例、医疗机构门诊人次中非公提供所占比例等3项指标；公立机构自主权维度包含经济收益处置自主权、人员聘用与解雇自主权等6项指标。
设计市场化指数的合成方法。建立了一套政策类指标量化刻度尺,测量范围是0-1,0表示完全政府化,1表示完全市场化。总结梳理相关政府文件,对政策类指标进行定量转化。客观类指标抄录卫生统计数据,对缺失值进行推算填补。根据专家咨询对各维度和指标的评分值,确定维度和指标权重,构建了医疗服务市场化指数。
指标体系效能测量。因子分析结果显示,共提取三个公因子,分别在三个维度上载荷较高,累计贡献率达95.258%,说明指标体系结构效度较好。克朗巴赫α系数为0.734,两部分相关系数为0.877,说明指标体系信度较好。某一个指标数值上调10%或下调10%时,指数波动的绝对值除一项达到3.04%之外,均在0.04-1.75%之内浮动,说明指标体系稳健性较好。聚类分析将32年市场化指数分为五类,方差分析结果显示五类之间和每两类之内差异有统计学意义(P<0.05),说明指标体系的区分度较好。
我国医疗服务市场化进程分析结果。我国医疗服务市场化指数从1978年的18.24上升至2009的46.99(总分为100),呈逐步上升趋势,年均增幅为0.90,但2000年之后增速减缓。从结构变化来看,政府管制与市场开放程度、公立机构自主权两个维度提升幅度大、速度快,非公要素发展得分相对较低,呈先上升后下降的趋势。根据近5年市场化指数趋势预测,2014年医疗服务市场化程度将超过50%。
结论与讨论
本文研究了医疗服务市场化的内涵和定量测度问题,探索了新的卫生经济学研究领域,弥补了医疗服务市场化定量研究的空白；通过计量分析我国医疗服务领域市场化演进过程,回答了现实中关于医疗市场化演进方向的争论,促进卫生改革发展政策的调整完善。研究设计发明了政策类指标的量化刻度尺,使指标定量转化更加准确,各年份市场化指数有可比性。在进行两轮德尔菲专家咨询的过程中,通过科学选择专家、提供充分信息、采用适宜咨询形式和加强沟通联络等措施,保证了问卷的高回收率和填答有效性。
与其他领域市场化测度研究相比,本研究构建的指标体系具有以下优势：评价方法更完善,采用统计学分析验证,设立政策类指标使评价更全面,研究时间跨度长并且连续计算等。以往的市场化测度研究发现,经济领域和劳动力市场的市场化程度持续提高,2000之后市场化指数已超过60%。
改革开放以来,我国医疗领域市场化程度不断加深,整体增速在2000后也有所放缓。通过与宏观经济体制改革比较分析发现,重要的经济改革办法,如放开个体经济、国有企业改革等,对医疗市场化产生了重要的影响。20世纪80年代对公立机构自主权下放过快,导致其过分追求经济利益而出现一系列问题。2003年之后,科学发展观、和谐社会等改革发展理念的提出促使医疗领域反思市场化取向改革的得与失。
研究中还存在有一定主观性、评分刻度尺精准度不足、统计数据不够完善等不足之处有待进一步完善。
政策建议
进一步完善医疗服务市场化评价指标体系,如开展次国家级水平的市场化测度,跟踪进行连续动态评价。合理把握医疗服务市场化改革节奏和步骤,使其维持在社会可承受范围内。将政府管理与市场机制有效结合,充分发挥二者的积极作用,政府需加强宏观调控、规划、投入、监管和制度建设,在此基础上运用市场机制实现卫生改革发展的政策目标。
Objective:
This study stays focused on developing a marketization index of the medical service system and quantitatively analyzing the trend of development, at a national level, of the marketization process of the Chinese medical service system since Open and Reform, aiming to provide support for health reform.
Contents:
The concept of marketization in medical service system was identified with its contents and the evaluation framework was thus set up; an evaluation system of indicators measuring the process of marketization in medical service system was developed; the method of quantitative transition and calculation was developed, followed by the analysis on the development trend of the process of marketization in medical service system since Open and Reform. And policy and research suggestions offered thereby.
Research Methods:
This study reviewed the state-of-the-art developments of evaluation studies on the process of marketization in medical service, as well as on other non-medical service markets, from in and outside China by means of literature review; definition was given to marketization in medical service system by utilizing conceptual approach; a survey to governmental officials and researchers in the circle was conducted using Delphi Method to develop an evaluation system of indicators measuring the process; the evaluation functioning of the evaluation system was sorted by analyzing mathematical statistics; and integrated sub-value method was employed to grant value to policy related indicators.
Results and Analysis:
An evaluation framework measuring the marketization process in medical service was developed. The marketization process refers to a process in which market mechanism (allocation of resources, competition, price forming and etc) plays an increasingly more important role where government deregulates in allocation of resources, market access and supervision. Its operational definition refers to a convert in resources allocation from governmental control through administrative means to the operation of market forces, which covers, at a macro level, the clarification of governmental functions and market operations; the proportion of non-public elements against that of public elements, at a medium level; and the decision-making power granted to public medical institutions, at a micro level. The evaluation framework measuring marketization process in medical service was then developed based on three perspectives, namely, governmental control and market opening, non-public elements development and decision-making power of public institutions.
An evaluation system of indicators measuring the process of marketization in medical service was developed. A 13-indictor evaluation system was developed as a result of a two-round Delphi survey. Under the dimension of government control and market opening, there're 4 indicators namely non-public institution access policy, government control over medical service pricing and etc; 3 indicators namely non-public proportion in accommodation ability, non-public proportion in outpatient and etc were under the dimension of non-public elements developments; and 6 indicators namely revenue deposition access, discrete power to hire and dismiss were under the dimension of public institutions decision making power.
Calculation determined on the formation of the marketization index. A scale ruler was setup with 0 for total control and 1 for completely free market. A quantitative transition of policies was made through policy review and sorting. Objective indicators were copied from statistic data and missing numbers were filled up by default calculation. And the marketization index of medical service system was developed by dimension and indicator weighting allocation accordingly with the expert opinion on valuing.
Indicator system examination. Factor analysis showed that the three extracted common factors have a high load on the three dimensions with an accumulated contribution to 95.258% and accuracy thus evidenced. The Cronbach's alpha coefficient is 0.734 and the relative coefficient is 0.877, which showed good reliability. Stability was examined by adjusting a certain indicator 10% up or down to find an absolute value fluctuation within 0.04-1.75% of all indicators except one to 3.04%. In cluster analysis, the marketization indexes of the 32 years were divided into 5 groups, ANOVA analysis showed that the differences among all 5 groups and between each 2 groups are statistically significant(P<0.05), which proved sound differentiation.
Conclusion in the marketizaition process analysis. The marketization index goes steadily upward from 18.25 in 1978 to 44.15 in 2009(out of 100), at an annual growth rate of 0.90, with a slowdown in and after 2000. As detailed to the sub level, the two dimensions of government control and market opening, as well as the decision making power granted to pubic institutions increased comparatively fast while the dimension of non-public elements recorded an upward-downward curve resulting in a low level of marketization. The estimated maketization level, based on the trend reflected in the recent five years, in 2014 will be over 50%.
Conclusions and Further Discussions:
This study explored into a new area in health economics, by staying focused on the defining and quantitative measurement of the marketization in medical service system to fill the blanks in the medical service marketization studies. A quantitative analysis to the marketization of the medical service system was conducted to give an answer to the arguments over the marketization process of the medical service system and to call for policy adjustment and improvement in healthcare reform. Scale ruler to policy indicators was invented by the study to make the quantitative transition of policies more accurate and annual marketization indexes comparable. Measurements have been taken, in the two rounds of Delphi survey conducted in the study, in selecting expert candidates, providing information, choosing the way how they were consulted and communicating and collaborating with the experts to ensure correspondence.
The indicator system developed by this study, compared to others, was more perfectly conducted in evaluation approaches, statistically examined and validated, comprehensively completed with the introduction of policy orientated indicators, historically fully covered and etc. It was found that, from the already existed studies measuring marketization level, those in economy and labor force have been consistently uprising, to a level over 60% since 2000.
The marketization level, since Open and Reform, of the Chinese medical service system has been upraised in general while it slowed down its pace after 2000. It was found, by comparing the economic reform at macro level, that substantial reform measurements such as deregulating control over private owned business, as well as state-owned enterprise reform, owned great impact to the marketization of medical service system. The over paced promotion in granting public institutions with their own decision making power has led to a series of problems due to their economic overemphasis. The bring in of the ideas of Scientific Concept of Development and Harmonious Society after 2003 made the introspection to the marketization of medical service system prompted.
The study is due to be improved in objectivity, accuracy in scale ruler and statistics completeness as well.
Suggested Policies:
Further possible improvements should be made on the evaluation system measuring marketization process in medical service, namely marketization process measurement at sub-national level and consecutive and dynamic tracking. The promotion of marketization in medical service system should follow a balanced and reasonable pace and steps for the affordability purpose. The process of marketization in medical service should be promoted by the good use of both governmental control and market mechanism where government is about to strengthen macro control, investment, supervision and institutionalization, based on which to make a full use of the market mechanism to reach the goals of health reform.
引文
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