利益集团博弈与我国医疗卫生制度变迁研究
|
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。
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 Method
1. 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 Research
1. 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.
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。
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 Method
1. 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 Research
1. 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.
引文
[1]道格拉斯·C·诺斯.制度、制度变迁与经济绩效[M].上海：上海三联书店,1994.
[2]诺曼·杰·奥恩斯坦等.利益集团、院外活动和政策制订[M].北京：世界知识出版社,1981.
[3]James Madison, "The Federalist, No.10, " in Hamilton, Madison, Jay. The Federalist Papers. New York:New American Library,1961.
[4]汉密尔顿.《联邦党人文集》[M].商务印书馆1980版,第45页.
[5]Bentley, Arthur, The process of government:a study of social-Pressures[M]. Chicago:Chicago University Press.1908.
[6]Arthur Bentley, The Process of Government[M]. Cambridge, BelknapPress of Harvard University Press,1967. p.205, p.222, p.208, p. pxix, p.269, p.272, p.415.
[7]David BTruman:The Government Process. N. Y., Alfred Knopf,1951, p.15, p.4-15, p.57, p.64, p.139, p.368, p.523.
[8]David K Ryden:Representation in Crisis:The Constitution, Interest Groups, and Political Parties. Albany, State University of New York Press,1996, p.70.
[9]谭融.美国利益集团政治研究[M].北京：中国社会科学出版社,2002.
[10]顾杰善,刘纪兴.当代中国社会利益群体分析[M].黑龙江教育出版社,1995：4.
[11]安东尼·唐斯.官僚知内幕[M].北京：中国人民大学出版社,2006：12
[12]韩兆柱.新公共管理中的自由主义与转型中的善治[J].理论与改革,2006,(1)：20-21
[13][法]卢梭.社会契约论[M]何兆武,译.北京：商务印书馆,2002.4
[14]王颖转型时期中国政府利益研究的必要性分析中国行政管理2007(7)：75-77
[15]马克思恩格斯选集：第4卷[M].北京：人民出版社,1995：246.
[16]刁田军,伏宁等.中国机构改革的理论与实践：机构改革调控机制研究[M].北京：法律出版社,1999：89,93.94.
[17]张宇燕利益集团与制度非中性[J]改革,1994(2)“制度非中性”是张宇燕提出的一个重要概念,“所谓制度非中性是指,同一制度对不同人意味着不同的事情。在同一制度下不同的人或人群所获得的往往是各异的东 西,而那些已经从既定制度中、或可能从未来某种制度安排中获益的个人或集团,无疑会竭力去维护或争取之。”
[18]樊纲渐进改革的政治经济学分析[M].上海远东出版社,1996.第129页
[19]Ruttan, V. an Y. Hayami,1984, Toward a Theory of Induced Institutional Innovation., Journal of Development Studies, Vol.20, No.4, pp.203-223.
[20]North Douglass C.,1994. "Institutional Change:A Framework Of Analysis, " Economic History, No.1, (Dec.1994).
[21]North, Douglass C,1991. "Institutions, " Journal of Economic Perspectives, American Economic Association, vol.5(1), pages 97
[22]MasahikoAoki, Information, Corporate Governance, and Institutional Diversity:Competitiveness in Japan, the United States, and the Transitional Economies (Stacey Jehlik trans.,2000).
[23]Becker, G. S. A Theory of Competition among Pressure Groups for Political Influence[J], Quarterly Journal of Economics,1983,98(August);
[24]Posner, R. A. Theories of Economic Regulation[J], Bell Journal of Economics, 1974 (Autumn)
[25]North, D., and Thomas, R. P., The rise of western world:A new economic history, Cambridge University Press.(中文版,1999,华夏出版社)
[26]Richard A Posner'The Social Costs of Monopoly and Regulation. JPE,1975, Vol 83. Aug.
[27]Buchanan, James M. and Tollison, Robert D. The Theory of Public Choice[M], The University of Michigan Press,1984.
[28]Stigler, G. J. The Theory Of Economic Regulation[J]. Bell journal Of economics,2. spring.1971.
[29]S. Pelzman. Growth of government [J]. Journal of Law and Economics, October 1980.
[30]Becker, G. S. A Theory of Competition among Pressure Groups for Political Influence[J], Quarterly Journal of Economics,1983,98(August), pp.371-400.
[31]Becker, G. S., public policies, pressure groups and deadweight costs[J], Journal of Public Economics,1985,28:329-347.
[32]杨凤部门利益理论与新规制经济学[J].江淮论坛200(5)
[33]Viscusi, W. k., etc,1992, Economics of Regulation and Antitrust, Cambridge: MTT press.
[34]Coase, R., "The Problem of Social Cost, " Journal of Law and Economics, Oct,1960:1-44.
[35]North, D., "Institutions, Institutional Change, and Economic Performance, " Cambridge University Press:Cambridge,1990.
[36]North, D. (1989). "Institutional change and economic history. " Journal of Institutional and Theoretical Economics, v.145:238-45.
[37]Williamson,0, E., "Transaction—Cost Economics:The Governance of Contractual Relations, " Journal of Low and Economics,22(2),1979, pp.233-261
[38]Schultz. t. w. institutions and the rising economic value of man. american journal of agricultural economics,1968
[39]Douglass C. North, Institutions, Institutional Change and Economic Performance, trans. by Liu Shouying, Shangha:i Shanghai JointPublishing Company,1994.
[40]盛洪.现代制度经济学(上卷)[M].北京：北京大学出版社,2003
[41]卢现祥《西方新制度经济学》[M].中国发展出版社1996年版,第100页。
[42]洪远朋等制度变迁与经济利益关系演变[J].社会科学研究2005(3)
[43]刘铭制度变迁经济增长与利益分配——制度变迁的“三角螺旋”模型及其应用[J].东岳论丛2009,30(3)：117-121
[44]石光美两国卫生资源配置的制度经济学解释[J]中国卫生经济2005,24(11)：51-53
[45]Pablo Gottret and George Schieber, Health Financing Revisited:A Practioner's Guide, The World Bank,2006
[46]傅卫陈迎春姚岚等.市场经济条件下合作医疗运行的经验和教训[C].中国 农村卫生改革与发展国际研讨会专集,中国卫生部卫生经济研究所和英国国家发展研究院主办,2000年11月7-9日。
[47]当代中国的卫生事业[M].人民卫生出版社,1984.第31-41页.城市三级医疗机构是指街道卫生院及保健站、区级卫生院和职工医院、省市级综合医院、教学医院和各大企业的中心医院。农村三级是指村卫生室、乡镇卫生院和县级医院。
[48]李培林《中国新时期阶级阶层报告》,分报告一,辽宁人民出版社,1995.
[49]张静利益组织化单位——企业职代会案例研究[M].中国社会科学出版社2001.第24页
[50]周翼虎,杨晓民中国单位制度[M].中国经济出版社,1999.第30页
[51]中国卫生统计年鉴1997
[52]中华人民共和国卫生部.关于允许个体开业行医问题的请示报告[R].1980-09-02
[53]Hsiao W C. Transformation of health care in China [J]. New England Journal of Medicine,1984(310):932-936
[54]中华人民共和国国务院.关于卫生工作改革若干政策问题的报告[R].1985-04-25
[55]中华人民共和国国务院.关于扩大医疗卫生服务有关问题的意见[Z].1989-01-15
[56]薄先锋董践真.医疗卫生改革举步维艰.医疗卫生改革,1993：56-58
[57]李风圣中国制度变迁的博弈分析(1956-1989)博士学位论文2000年152页
[58]中华人民共和国国务院.关于深化卫生医疗体制改革的几点意见[Z].1992-09-23
[59]中共中央、国务院.关于卫生改革与发展的决定[Z].1997-01-15
[60]国务院体改办,国家计委等.关于城镇医药卫生体制改革的指导意见[Z].2000-02-21
[61]中国农村统计年鉴(1999)
[62]陈佳贵王延中主编2007中国社会保障发展报告——转型中的卫生服务与医疗保障(节选)71页
[63]张维迎博弈论与信息经济学[M]上海三联书店上海人民出版社2004年11月第一版
[64]李玲江宇等.改革开放背景下的我国医改30年[J].中国卫生经济,2008(2)：5-9
[65]钟东波我国的公立医院体制改革——历程、绩效、原因机制及政策建议第64 次中国改革国际论坛论文集[C].2008年11月.
[66]陆丁.寻租理论,载于汤敏、茅于轼.现代经济学前沿专题(第二集)[C].商务印书馆,1996年
[67]道格拉斯·C·诺斯经济史中的结构与变迁[M],陈郁、罗华平等译,上海三联书店、上海人民出版社,1994年第1版.第24页
[68]张晓燕.我国社会医疗保险制度变迁机理分析[J]现代商贸工业2009(23)：73-74
[69]Hsiao WC. Transformation of health care in China:.. N Engl J Med.1984 Apr 5
[70]郭艳茹.社会权力结构调整与中国经济转轨的路径选择[J].经济社会体制比较(双月刊)2007,3：39-44.
[71]丁菊红,邓可斌.内生的分权与中国经济体制改革[J].经济社会体制比较(双月刊),2009,3：52-57.
[72]顾昕.全球性公立医院的法人治理模式变革——探寻国家监管与市场效率之间的平衡[J].经济社会体制比较(双月刊),2006,1：46-55.
[73]国务院发展研究中心社会政策研究部医改课题组：葛延风等
[74][加]迈克尔·豪利特等公共政策研究——政策循环与政策子系统[M].三联书店,2005.第10、270页
[75][英]H.K.科尔巴奇：政策[M].吉林人民出版社,2005.第47-48页
[76]郭道晖.当代中国立法[M].北京：中国民主法制出版社,1998.
[77]中华人民共和国卫生部.国家发展和改革委员会工业和信息化部监察部财政部人力资源和社会保障部商务部国家食品药品监督管理局国家中医药管理局等国家基本药物目录管理办法(暂行),2009-8-18.
[78]杨团,施育晓.治理与规管——试析如何走出医疗卫生改革困境[J].江苏社会科学,2006(5)：82-88.
[79]卫生部、国家发改委、人力资源和社会保障部等9部委.关于建立国家基本药物制度的实施意见[Z].2009-08-18；国家基本药物目录管理办法(暂行)[Z].2009-08-18.
[80][美]Paul Samuelson, William Nordhaus Economics[M]. Sixteenth Edition 机械工业出版社1998.将市场权力定义为：单个企业或少数企业控制某一产业的价格和生产决策的程度。
[81]李卫平.公立医院体制改革与治理[J].江苏社会科学,2006(5)：72-77
[82]顾听.矫正医疗市场双失灵[J].财经时报,2006-03-03(32)
[83]中华人民共和国卫生部,国家发展和改革委员会.关于建立国家基本药物制度的实施意见,2009-08-18.
[84]Tullock G. "The Welfare Costs of Tariffs, Monopolies and Theft", Western Economic Journal.1967,5.
[85]Krueger, Anne 0.1974. The Political Economy of Rent-Seeking Society[J]. American Economic Review 64:291-303.
[86]Buchanan J M. Tollison R D. Tullock G Toward a Theory of the Rent-Seeking Society[M].1980 U.S.A:Texas A&M University Press.
[87]Bhagwati, Jagdish.1982. "Directly Unproductive Profit-Seeking (DUP) Activities," Journal of Political Economy 90, (October), pp.988-1002.
[88]苏建红论医药商业贿赂之成因及治理对策[J]理论观察2007(3)：111-112
[89]茅竟伟.2006治理医药商业贿赂元年[J].当代医学,2006(6).
[90]吴明.药品服务提供过程中的寻租行为产生原因分析[J].中国卫生经济2002(237)：4-6.
[91]Gordon Tullock:The Welfare costs of Tariffs, Monopolies and Theft[J]. Western Economic Journal,1967,5.
[92]Richard A Posner. The Social Costs of Monopoly and Regulation[J]. JPE, 1975,83(8).
[93]Gordon Tullock:"Rent Seeking", in The New Palgrae:A Dictionary of Economics,1987.
[94]赵必仰.国际药品平均价格水平比较的方法学初探[J].价格月刊,2008(7)：41-43.
[95]World Health Organization and Health Action International. Medicine prices:a new approach to measurement. Working draft for field testing and revision[R]. Ceneva, WHO,2003:75-79.
[96]Danzon PM, Kim JD. International price comparisons for pharmaceuticals: Measurement and Policy Issues [J]. Pharmacoeconomics,1998(14):115-128.
[97]夏冕,张文斌.“管办分离”语境下的公立医院管理体制研究[J].中国卫生经济2010(3)
[98]复旦大学经济学院课题组.公立医院管理体制改革的国际经验[J].中国卫生,2008(3)：68-71.
[99]张屹山,金成晓.真实的经济过程：利益竞争与权力博弈——经济学研究的权力范式
[100]迟福林.公共需求变化与政府转型——在政府转型与建设和谐社会国际论坛上的演讲[EB/OL].人民网http://theory.people.com.cn/GB/40557/50023/50025/3499600.html,2005-06-27
[101]John Langenbrunner, Eva Orosz, Joe Kutzin and Miriam Wiley. "Purchasing and Paying Providers", in Josep Figuers, Ray Robinson and Elke Jakubowski edited, Purchasing to Improve Health Systems Performance. European Observatory on Health Systems and Policies. Open University.2005.
[102]A Duran, I. heiman, M. Schneider and J. Ovretveit. "Purchasers, Providers and Contracts".In Josep Figuers, Ray Robinson and Elke Jakubowski edited, Purchasing to Improve Health Systems Performance. European Observatory on Health Systems and Policies. Open University.2005.
[103]Josep Figuers, Ray Robinson and Elke Jakubowski edited, Purchasing to Improve Health Systems Performance. European Observatory on Health Systems and Policies. Open University.2005.
[104]张春霖如何为医疗服务筹资：可行的体制和政策选择[J]洪范评论2007(3)：1-28
[1]诺曼·杰·奥恩斯坦等.利益集团、院外活动和政策制订[M].北京：世界知识出版社,1981年版.
[2]汉密尔顿.联邦党人文集[M].商务印书馆1980版,第45页.
[3]David B Truman:The Government Process. N. Y., Alfred Knopf,1951.
[4]David K Ryden:Representation in Crisis:The Constitution, Interest Groups, and Political Parties[J]. Albany, State University of New York Press,1996.
[5]谭融.美国利益集团政治研究[M].北京：中国社会科学出版社,2002年版.
[6]Buchanan, James M. and Tollison, Robert D. The Theory of Public Choice[M], The University of Michigan Press,1984.
[7]Stigler, G. J. The Theory Of Economic Regulation[J]. Bell journal Of economics,2. spring.1971.
[8]S. Pelzman. Growth of government [J]. Journal of Law and Economics, October 1980.
[9]Becker, G. S. A Theory of Competition among Pressure Groups for Political Influence[J], Quarterly Journal of Economics,1983,98(August), pp.371-400.
[10]Becker, G. S., public policies, pressure groups and deadweight costs[J], Journal of Public Economics,1985,28:329-347.
[11]Posner, R. A. Theories of Economic Regulation [J]. Bell Journal of Economics, 1974 (Autumn)
[12]Posner, R. A. The Social Costs of Monopoly and Regulation [J]. JPE,1975, Vol 83. Aug.
[13]Viscusi,W. k., etc,1992, Economics of Regulation and Antitrust, Cambridge: MTT press.
[14]曼瑟尔·奥尔森.权力与繁荣[M].中译本,上海人民出版社,2005年版.
[15]曼瑟尔·奥尔森.国家兴衰探源[M].中译本,商务印书馆,1999年版.
[16]曼瑟尔·奥尔森.集体行动的逻辑[M].中译本,上海人民出版社、上海三联书店,1995年.
[17]道格拉斯·诺斯.经济史上的结构与变迁[M].上海：上海三联书店,1991.175-177.
[18]道格拉斯·诺斯.制度变迁理论纲要[M].北京大学中国经济研究中心.经济学与中国经济改革.上海：上海人民出版社,195：8.
[19][美]阿维纳什·K·迪克西特.经济政策的制定——交易成本政治学的视角[M].中国人民大学出版社2004年版,第17页,21页.
[20]Ruttan, V.an Y. Hayami,1984,Toward a Theory of Induced Institutional Innovation., Journal of Development Studies, Vol.20, No.4, pp.203-223.
[21]North Douglass C.,1994. "Institutional Change:A Framework Of Analysis, " Economic History, No.1, (Dec.1994).
[22]North, Douglass C,1991. "Institutions, " Journal of Economic Perspectives, American Economic Association, vol.5(1), pages 97
[23]MasahikoAoki, Information, Corporate Governance, and Institutional Diversity:Competitiveness in Japan, the United States, and the Transitional Economies (Stacey Jehlik trans.,2000).
[24]樊纲.公共选择与改革过程盛洪主编《现代制度经济学》[C]下卷第168-180页.北京大学出版社2003年出版.
[25]张宇燕.利益集团与制度非中性盛洪主编《现代制度经济学》[C]下卷第157-168北京大学出版社2003年出版.
[26]胡汝银.中国改革的政治经济学[A]盛洪.中国的过渡经济学[C].上海：上海三联书店,上海人民出版社,1994.74.
[27]盛洪.关于中国市场化改革的过渡过程的研究[J].经济研究,1996,(1)
[28]孙广振,张宇燕.利益集团与“贾谊定理”：一个初步的分析框架[J].经济研究,1997,(6)
[29]Mitchell &Wood, Toward a theory of stakeholder identification and salience: Defininf the principle of who and what really counts [J]. Academy of Management Review,1997.
[30]Eric A. Nordlinger. On the Autonomy of the Democratic State[M]. Harvard University Press.1981:63-81.
[31]张奇林.美国医疗保健制度研究[M].北京：人民出版社,2005.
[32]小夏.美国医疗改革的困境在哪里[J].医院领导决策参考,2006,8.
[33]岳公正,张金鑫等.社会保障公共选择、利益集团与政策垄断[J].生产力研究,2007,14.
[34]蔡亮.利益冲突过程中的制度变迁[D].北京大学毕业论文,1998.
[35]王一方.医改的逻辑与利益集团的阳光博弈——兼谈美国医疗保障制度演进中的博弈规则[J].医学与哲学(人文社会医学版),2007,28(10).
[36]何国忠,罗五金等.医药分开管理制度的利益集团分析[J].卫生政策,2005,9.
[37]潘迎冰,罗力等.新型农村合作医疗有关利益集团力场分析[J].中国卫生资源,2005,8(6).
[38]刘丽杭.医疗价格规制过程中的政治分析[J].江苏社会科学,2005,5.
[39]王一方.医改的逻辑与利益集团的阳光博弈——兼谈美国医疗保障制度演进中的博弈规则[J].医学与哲学(人文社会医学版),2007,28(10).
[40]将天文,樊志宏.中国医疗系统的行为扭曲机理与过程分析[J].经济研究,2002,11.
[41]孙庆文,吴百杰.博弈论在医疗卫生体制改革中的应用[J].中国医院管理,2002,22(7).
[42]周文杰,刘赞周.医院医保管理困境[J],世界医学杂志,2004,8(22).
[43]王前强.利益集团博弈与公立医院产权制度改革[J].卫生经济研究,2006,6.
[44]左宏.医疗市场博弈分析与医疗体系结构优化初探[J].卫生经济研究,2005 8.
[45]吴传检.社会医疗保险道德风险博弈与防控措施研究[J].医学与哲学：人文社会医学版,2006,27(7).
[46]弓宪文,王勇等.信息不对称下医患关系博弈分析[J].重庆大学学报：自然科学版,2006,27(7).
[47]赵劲.新型合作医疗为何向“农民筹资难”?——豫东某县调研基础上的动态搏弈[J],卫生经济研究,2006,5.
[2]诺曼·杰·奥恩斯坦等.利益集团、院外活动和政策制订[M].北京：世界知识出版社,1981.
[3]James Madison, "The Federalist, No.10, " in Hamilton, Madison, Jay. The Federalist Papers. New York:New American Library,1961.
[4]汉密尔顿.《联邦党人文集》[M].商务印书馆1980版,第45页.
[5]Bentley, Arthur, The process of government:a study of social-Pressures[M]. Chicago:Chicago University Press.1908.
[6]Arthur Bentley, The Process of Government[M]. Cambridge, BelknapPress of Harvard University Press,1967. p.205, p.222, p.208, p. pxix, p.269, p.272, p.415.
[7]David BTruman:The Government Process. N. Y., Alfred Knopf,1951, p.15, p.4-15, p.57, p.64, p.139, p.368, p.523.
[8]David K Ryden:Representation in Crisis:The Constitution, Interest Groups, and Political Parties. Albany, State University of New York Press,1996, p.70.
[9]谭融.美国利益集团政治研究[M].北京：中国社会科学出版社,2002.
[10]顾杰善,刘纪兴.当代中国社会利益群体分析[M].黑龙江教育出版社,1995：4.
[11]安东尼·唐斯.官僚知内幕[M].北京：中国人民大学出版社,2006：12
[12]韩兆柱.新公共管理中的自由主义与转型中的善治[J].理论与改革,2006,(1)：20-21
[13][法]卢梭.社会契约论[M]何兆武,译.北京：商务印书馆,2002.4
[14]王颖转型时期中国政府利益研究的必要性分析中国行政管理2007(7)：75-77
[15]马克思恩格斯选集：第4卷[M].北京：人民出版社,1995：246.
[16]刁田军,伏宁等.中国机构改革的理论与实践：机构改革调控机制研究[M].北京：法律出版社,1999：89,93.94.
[17]张宇燕利益集团与制度非中性[J]改革,1994(2)“制度非中性”是张宇燕提出的一个重要概念,“所谓制度非中性是指,同一制度对不同人意味着不同的事情。在同一制度下不同的人或人群所获得的往往是各异的东 西,而那些已经从既定制度中、或可能从未来某种制度安排中获益的个人或集团,无疑会竭力去维护或争取之。”
[18]樊纲渐进改革的政治经济学分析[M].上海远东出版社,1996.第129页
[19]Ruttan, V. an Y. Hayami,1984, Toward a Theory of Induced Institutional Innovation., Journal of Development Studies, Vol.20, No.4, pp.203-223.
[20]North Douglass C.,1994. "Institutional Change:A Framework Of Analysis, " Economic History, No.1, (Dec.1994).
[21]North, Douglass C,1991. "Institutions, " Journal of Economic Perspectives, American Economic Association, vol.5(1), pages 97
[22]MasahikoAoki, Information, Corporate Governance, and Institutional Diversity:Competitiveness in Japan, the United States, and the Transitional Economies (Stacey Jehlik trans.,2000).
[23]Becker, G. S. A Theory of Competition among Pressure Groups for Political Influence[J], Quarterly Journal of Economics,1983,98(August);
[24]Posner, R. A. Theories of Economic Regulation[J], Bell Journal of Economics, 1974 (Autumn)
[25]North, D., and Thomas, R. P., The rise of western world:A new economic history, Cambridge University Press.(中文版,1999,华夏出版社)
[26]Richard A Posner'The Social Costs of Monopoly and Regulation. JPE,1975, Vol 83. Aug.
[27]Buchanan, James M. and Tollison, Robert D. The Theory of Public Choice[M], The University of Michigan Press,1984.
[28]Stigler, G. J. The Theory Of Economic Regulation[J]. Bell journal Of economics,2. spring.1971.
[29]S. Pelzman. Growth of government [J]. Journal of Law and Economics, October 1980.
[30]Becker, G. S. A Theory of Competition among Pressure Groups for Political Influence[J], Quarterly Journal of Economics,1983,98(August), pp.371-400.
[31]Becker, G. S., public policies, pressure groups and deadweight costs[J], Journal of Public Economics,1985,28:329-347.
[32]杨凤部门利益理论与新规制经济学[J].江淮论坛200(5)
[33]Viscusi, W. k., etc,1992, Economics of Regulation and Antitrust, Cambridge: MTT press.
[34]Coase, R., "The Problem of Social Cost, " Journal of Law and Economics, Oct,1960:1-44.
[35]North, D., "Institutions, Institutional Change, and Economic Performance, " Cambridge University Press:Cambridge,1990.
[36]North, D. (1989). "Institutional change and economic history. " Journal of Institutional and Theoretical Economics, v.145:238-45.
[37]Williamson,0, E., "Transaction—Cost Economics:The Governance of Contractual Relations, " Journal of Low and Economics,22(2),1979, pp.233-261
[38]Schultz. t. w. institutions and the rising economic value of man. american journal of agricultural economics,1968
[39]Douglass C. North, Institutions, Institutional Change and Economic Performance, trans. by Liu Shouying, Shangha:i Shanghai JointPublishing Company,1994.
[40]盛洪.现代制度经济学(上卷)[M].北京：北京大学出版社,2003
[41]卢现祥《西方新制度经济学》[M].中国发展出版社1996年版,第100页。
[42]洪远朋等制度变迁与经济利益关系演变[J].社会科学研究2005(3)
[43]刘铭制度变迁经济增长与利益分配——制度变迁的“三角螺旋”模型及其应用[J].东岳论丛2009,30(3)：117-121
[44]石光美两国卫生资源配置的制度经济学解释[J]中国卫生经济2005,24(11)：51-53
[45]Pablo Gottret and George Schieber, Health Financing Revisited:A Practioner's Guide, The World Bank,2006
[46]傅卫陈迎春姚岚等.市场经济条件下合作医疗运行的经验和教训[C].中国 农村卫生改革与发展国际研讨会专集,中国卫生部卫生经济研究所和英国国家发展研究院主办,2000年11月7-9日。
[47]当代中国的卫生事业[M].人民卫生出版社,1984.第31-41页.城市三级医疗机构是指街道卫生院及保健站、区级卫生院和职工医院、省市级综合医院、教学医院和各大企业的中心医院。农村三级是指村卫生室、乡镇卫生院和县级医院。
[48]李培林《中国新时期阶级阶层报告》,分报告一,辽宁人民出版社,1995.
[49]张静利益组织化单位——企业职代会案例研究[M].中国社会科学出版社2001.第24页
[50]周翼虎,杨晓民中国单位制度[M].中国经济出版社,1999.第30页
[51]中国卫生统计年鉴1997
[52]中华人民共和国卫生部.关于允许个体开业行医问题的请示报告[R].1980-09-02
[53]Hsiao W C. Transformation of health care in China [J]. New England Journal of Medicine,1984(310):932-936
[54]中华人民共和国国务院.关于卫生工作改革若干政策问题的报告[R].1985-04-25
[55]中华人民共和国国务院.关于扩大医疗卫生服务有关问题的意见[Z].1989-01-15
[56]薄先锋董践真.医疗卫生改革举步维艰.医疗卫生改革,1993：56-58
[57]李风圣中国制度变迁的博弈分析(1956-1989)博士学位论文2000年152页
[58]中华人民共和国国务院.关于深化卫生医疗体制改革的几点意见[Z].1992-09-23
[59]中共中央、国务院.关于卫生改革与发展的决定[Z].1997-01-15
[60]国务院体改办,国家计委等.关于城镇医药卫生体制改革的指导意见[Z].2000-02-21
[61]中国农村统计年鉴(1999)
[62]陈佳贵王延中主编2007中国社会保障发展报告——转型中的卫生服务与医疗保障(节选)71页
[63]张维迎博弈论与信息经济学[M]上海三联书店上海人民出版社2004年11月第一版
[64]李玲江宇等.改革开放背景下的我国医改30年[J].中国卫生经济,2008(2)：5-9
[65]钟东波我国的公立医院体制改革——历程、绩效、原因机制及政策建议第64 次中国改革国际论坛论文集[C].2008年11月.
[66]陆丁.寻租理论,载于汤敏、茅于轼.现代经济学前沿专题(第二集)[C].商务印书馆,1996年
[67]道格拉斯·C·诺斯经济史中的结构与变迁[M],陈郁、罗华平等译,上海三联书店、上海人民出版社,1994年第1版.第24页
[68]张晓燕.我国社会医疗保险制度变迁机理分析[J]现代商贸工业2009(23)：73-74
[69]Hsiao WC. Transformation of health care in China:.. N Engl J Med.1984 Apr 5
[70]郭艳茹.社会权力结构调整与中国经济转轨的路径选择[J].经济社会体制比较(双月刊)2007,3：39-44.
[71]丁菊红,邓可斌.内生的分权与中国经济体制改革[J].经济社会体制比较(双月刊),2009,3：52-57.
[72]顾昕.全球性公立医院的法人治理模式变革——探寻国家监管与市场效率之间的平衡[J].经济社会体制比较(双月刊),2006,1：46-55.
[73]国务院发展研究中心社会政策研究部医改课题组：葛延风等
[74][加]迈克尔·豪利特等公共政策研究——政策循环与政策子系统[M].三联书店,2005.第10、270页
[75][英]H.K.科尔巴奇：政策[M].吉林人民出版社,2005.第47-48页
[76]郭道晖.当代中国立法[M].北京：中国民主法制出版社,1998.
[77]中华人民共和国卫生部.国家发展和改革委员会工业和信息化部监察部财政部人力资源和社会保障部商务部国家食品药品监督管理局国家中医药管理局等国家基本药物目录管理办法(暂行),2009-8-18.
[78]杨团,施育晓.治理与规管——试析如何走出医疗卫生改革困境[J].江苏社会科学,2006(5)：82-88.
[79]卫生部、国家发改委、人力资源和社会保障部等9部委.关于建立国家基本药物制度的实施意见[Z].2009-08-18；国家基本药物目录管理办法(暂行)[Z].2009-08-18.
[80][美]Paul Samuelson, William Nordhaus Economics[M]. Sixteenth Edition 机械工业出版社1998.将市场权力定义为：单个企业或少数企业控制某一产业的价格和生产决策的程度。
[81]李卫平.公立医院体制改革与治理[J].江苏社会科学,2006(5)：72-77
[82]顾听.矫正医疗市场双失灵[J].财经时报,2006-03-03(32)
[83]中华人民共和国卫生部,国家发展和改革委员会.关于建立国家基本药物制度的实施意见,2009-08-18.
[84]Tullock G. "The Welfare Costs of Tariffs, Monopolies and Theft", Western Economic Journal.1967,5.
[85]Krueger, Anne 0.1974. The Political Economy of Rent-Seeking Society[J]. American Economic Review 64:291-303.
[86]Buchanan J M. Tollison R D. Tullock G Toward a Theory of the Rent-Seeking Society[M].1980 U.S.A:Texas A&M University Press.
[87]Bhagwati, Jagdish.1982. "Directly Unproductive Profit-Seeking (DUP) Activities," Journal of Political Economy 90, (October), pp.988-1002.
[88]苏建红论医药商业贿赂之成因及治理对策[J]理论观察2007(3)：111-112
[89]茅竟伟.2006治理医药商业贿赂元年[J].当代医学,2006(6).
[90]吴明.药品服务提供过程中的寻租行为产生原因分析[J].中国卫生经济2002(237)：4-6.
[91]Gordon Tullock:The Welfare costs of Tariffs, Monopolies and Theft[J]. Western Economic Journal,1967,5.
[92]Richard A Posner. The Social Costs of Monopoly and Regulation[J]. JPE, 1975,83(8).
[93]Gordon Tullock:"Rent Seeking", in The New Palgrae:A Dictionary of Economics,1987.
[94]赵必仰.国际药品平均价格水平比较的方法学初探[J].价格月刊,2008(7)：41-43.
[95]World Health Organization and Health Action International. Medicine prices:a new approach to measurement. Working draft for field testing and revision[R]. Ceneva, WHO,2003:75-79.
[96]Danzon PM, Kim JD. International price comparisons for pharmaceuticals: Measurement and Policy Issues [J]. Pharmacoeconomics,1998(14):115-128.
[97]夏冕,张文斌.“管办分离”语境下的公立医院管理体制研究[J].中国卫生经济2010(3)
[98]复旦大学经济学院课题组.公立医院管理体制改革的国际经验[J].中国卫生,2008(3)：68-71.
[99]张屹山,金成晓.真实的经济过程：利益竞争与权力博弈——经济学研究的权力范式
[100]迟福林.公共需求变化与政府转型——在政府转型与建设和谐社会国际论坛上的演讲[EB/OL].人民网http://theory.people.com.cn/GB/40557/50023/50025/3499600.html,2005-06-27
[101]John Langenbrunner, Eva Orosz, Joe Kutzin and Miriam Wiley. "Purchasing and Paying Providers", in Josep Figuers, Ray Robinson and Elke Jakubowski edited, Purchasing to Improve Health Systems Performance. European Observatory on Health Systems and Policies. Open University.2005.
[102]A Duran, I. heiman, M. Schneider and J. Ovretveit. "Purchasers, Providers and Contracts".In Josep Figuers, Ray Robinson and Elke Jakubowski edited, Purchasing to Improve Health Systems Performance. European Observatory on Health Systems and Policies. Open University.2005.
[103]Josep Figuers, Ray Robinson and Elke Jakubowski edited, Purchasing to Improve Health Systems Performance. European Observatory on Health Systems and Policies. Open University.2005.
[104]张春霖如何为医疗服务筹资：可行的体制和政策选择[J]洪范评论2007(3)：1-28
[1]诺曼·杰·奥恩斯坦等.利益集团、院外活动和政策制订[M].北京：世界知识出版社,1981年版.
[2]汉密尔顿.联邦党人文集[M].商务印书馆1980版,第45页.
[3]David B Truman:The Government Process. N. Y., Alfred Knopf,1951.
[4]David K Ryden:Representation in Crisis:The Constitution, Interest Groups, and Political Parties[J]. Albany, State University of New York Press,1996.
[5]谭融.美国利益集团政治研究[M].北京：中国社会科学出版社,2002年版.
[6]Buchanan, James M. and Tollison, Robert D. The Theory of Public Choice[M], The University of Michigan Press,1984.
[7]Stigler, G. J. The Theory Of Economic Regulation[J]. Bell journal Of economics,2. spring.1971.
[8]S. Pelzman. Growth of government [J]. Journal of Law and Economics, October 1980.
[9]Becker, G. S. A Theory of Competition among Pressure Groups for Political Influence[J], Quarterly Journal of Economics,1983,98(August), pp.371-400.
[10]Becker, G. S., public policies, pressure groups and deadweight costs[J], Journal of Public Economics,1985,28:329-347.
[11]Posner, R. A. Theories of Economic Regulation [J]. Bell Journal of Economics, 1974 (Autumn)
[12]Posner, R. A. The Social Costs of Monopoly and Regulation [J]. JPE,1975, Vol 83. Aug.
[13]Viscusi,W. k., etc,1992, Economics of Regulation and Antitrust, Cambridge: MTT press.
[14]曼瑟尔·奥尔森.权力与繁荣[M].中译本,上海人民出版社,2005年版.
[15]曼瑟尔·奥尔森.国家兴衰探源[M].中译本,商务印书馆,1999年版.
[16]曼瑟尔·奥尔森.集体行动的逻辑[M].中译本,上海人民出版社、上海三联书店,1995年.
[17]道格拉斯·诺斯.经济史上的结构与变迁[M].上海：上海三联书店,1991.175-177.
[18]道格拉斯·诺斯.制度变迁理论纲要[M].北京大学中国经济研究中心.经济学与中国经济改革.上海：上海人民出版社,195：8.
[19][美]阿维纳什·K·迪克西特.经济政策的制定——交易成本政治学的视角[M].中国人民大学出版社2004年版,第17页,21页.
[20]Ruttan, V.an Y. Hayami,1984,Toward a Theory of Induced Institutional Innovation., Journal of Development Studies, Vol.20, No.4, pp.203-223.
[21]North Douglass C.,1994. "Institutional Change:A Framework Of Analysis, " Economic History, No.1, (Dec.1994).
[22]North, Douglass C,1991. "Institutions, " Journal of Economic Perspectives, American Economic Association, vol.5(1), pages 97
[23]MasahikoAoki, Information, Corporate Governance, and Institutional Diversity:Competitiveness in Japan, the United States, and the Transitional Economies (Stacey Jehlik trans.,2000).
[24]樊纲.公共选择与改革过程盛洪主编《现代制度经济学》[C]下卷第168-180页.北京大学出版社2003年出版.
[25]张宇燕.利益集团与制度非中性盛洪主编《现代制度经济学》[C]下卷第157-168北京大学出版社2003年出版.
[26]胡汝银.中国改革的政治经济学[A]盛洪.中国的过渡经济学[C].上海：上海三联书店,上海人民出版社,1994.74.
[27]盛洪.关于中国市场化改革的过渡过程的研究[J].经济研究,1996,(1)
[28]孙广振,张宇燕.利益集团与“贾谊定理”：一个初步的分析框架[J].经济研究,1997,(6)
[29]Mitchell &Wood, Toward a theory of stakeholder identification and salience: Defininf the principle of who and what really counts [J]. Academy of Management Review,1997.
[30]Eric A. Nordlinger. On the Autonomy of the Democratic State[M]. Harvard University Press.1981:63-81.
[31]张奇林.美国医疗保健制度研究[M].北京：人民出版社,2005.
[32]小夏.美国医疗改革的困境在哪里[J].医院领导决策参考,2006,8.
[33]岳公正,张金鑫等.社会保障公共选择、利益集团与政策垄断[J].生产力研究,2007,14.
[34]蔡亮.利益冲突过程中的制度变迁[D].北京大学毕业论文,1998.
[35]王一方.医改的逻辑与利益集团的阳光博弈——兼谈美国医疗保障制度演进中的博弈规则[J].医学与哲学(人文社会医学版),2007,28(10).
[36]何国忠,罗五金等.医药分开管理制度的利益集团分析[J].卫生政策,2005,9.
[37]潘迎冰,罗力等.新型农村合作医疗有关利益集团力场分析[J].中国卫生资源,2005,8(6).
[38]刘丽杭.医疗价格规制过程中的政治分析[J].江苏社会科学,2005,5.
[39]王一方.医改的逻辑与利益集团的阳光博弈——兼谈美国医疗保障制度演进中的博弈规则[J].医学与哲学(人文社会医学版),2007,28(10).
[40]将天文,樊志宏.中国医疗系统的行为扭曲机理与过程分析[J].经济研究,2002,11.
[41]孙庆文,吴百杰.博弈论在医疗卫生体制改革中的应用[J].中国医院管理,2002,22(7).
[42]周文杰,刘赞周.医院医保管理困境[J],世界医学杂志,2004,8(22).
[43]王前强.利益集团博弈与公立医院产权制度改革[J].卫生经济研究,2006,6.
[44]左宏.医疗市场博弈分析与医疗体系结构优化初探[J].卫生经济研究,2005 8.
[45]吴传检.社会医疗保险道德风险博弈与防控措施研究[J].医学与哲学：人文社会医学版,2006,27(7).
[46]弓宪文,王勇等.信息不对称下医患关系博弈分析[J].重庆大学学报：自然科学版,2006,27(7).
[47]赵劲.新型合作医疗为何向“农民筹资难”?——豫东某县调研基础上的动态搏弈[J],卫生经济研究,2006,5.