我国城市居民就医选择行为及其影响因素：五城市实证分析
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摘要
在中国的医疗服务市场存在着未被满足的需求和过剩的供给能力。90年代以来政府开始大力推行城市居民的医疗保险,取得了较为显著的成绩。随着收入的提高和保险的普及,人们会对那种类型的医院产生更大的需求。本文利用数据采用多元logit模型来研究保险、收入及其他因素是如何影响城市居民的就医选择,希望能为解决医疗服务供给能力过剩的问题提供一些建议。
本文利用沈阳、杭州、上海、深圳和北京五个城市入户调查的数据,采用多元logit模型考察了城市居民就医选择以及影响这一行为的重要因素。从计量回归的结果我们可以看出显著影响居民就医选择的因素有保险、收入、健康自评、受教育程度、区域等。保险的存在降低了患者所面临的医疗服务价格,使得人们即使收入没有增加也会选择质量更好的省市医院。收入的增加会显著的降低人们选择基础医疗服务机构的概率,增加去较好医院的概率。同时我们也看到,特别是对于高收入人群而言,收入增加导致他们选择县级医院/省市医院的相对概率反而会增加,这主要是由于收入增加意味着他们就诊的机会成本增加,即意味着他们所面临的医疗服务价格的增加,收入和价格的同时增加可能会使个体选择较低级的医院。自评健康差的人对其身体状况非常敏感和重视,对医疗服务的质量也要求比较高。所以在控制了其它因素的情况下,他们会倾向于质量更好的省市医院。文化程度影响就医选择的原因是类似的:文化程度高的人对自身的身体健康更为重视,所以会选择质量较好的医院。
从本文的结论我们可以看出,保险的普及在一定程度上增加患者对基础医疗服务机构和省市医院的所提供服务的需求。在今后医疗服务市场供给面的发展上,我们可以促进基础医疗服务机构的发展。因为它们的可及性较高、分布广,能够满足人们基本医疗服务的需求的同时,大大地降低了居民就诊所耗费的时间成本。同时由于其定位于基础医疗服务,对人员和仪器的要求都不需要很高,所以经营成本也会相对较低,这就使它们提供低价格的医疗服务成为可能,从而有效的控制医疗费用的上涨,同时缓解大医院拥挤的情况。这一点在国外的医疗制度和医院构成上我们可以看出是有效的。在国外,家庭医生是非常重要的医疗服务的提供者,他们向患者提供初步和基本的诊治,并决定是否需要向大的医院转诊。由于家庭医生的费用相对较低,这在一定程度上降低了患者支出的医疗费用,同时也减少了大医院排队就医的问题。
但是在推行基础医疗服务机构时我们需要主要的问题就是它们所提供服务的质量问题。尽管它们不需要很高水平的人员和医用设备,但这并不意味着它们不需要提高其服务水平。医疗服务充满着信息不对称,这就使得患者对于医疗服务机构的信誉是非常敏感的,所以如果卫生诊所不注重提高自身的质量,那么就无法吸引到患者前来就诊,卫生诊所也就无法维持下去。
对县级医院,从床位使用率医生每日平均所看患者的人数上看,它的效率是比较低的。而且从需求的角度来讲,保险覆盖面的扩大会降低人们对其的需求,如果推行基础医疗服务机构得当,从而减缓大医院的排队现象,那么县级医院在就诊时间成本上也不会有多大的优势,所以人们收入增加也不一定会增加对其需求。所以今后也许可以将县级医院适当的向基础医疗机构和省市医院的方向发展。
本文利用入户调查的数据,较好的研究了一些影响城市居民就医选择的因素。但是文章还存在很大的不足。首先,由于数据的限制,我们无法考察居民就诊所花费的时间成本(包括路程和候诊),从而无法确切的评价出就医时患者所面临的实际成本。其次,我们目前无法找出评价各类医疗机构质量比较好的变量,这在一定程度上限制了我们作一步的研究。而且健康自评与就医选择可能存在内生性的问题,经常选择质量高的医院就诊、接收更高质量的医疗服务会提高人的身体健康状况。这些问题都是以后可以研究和改进的地方。
There exists, simultaneously, an unsatisfied demand for hospital specialist services and excessive supply of clinic and district hospital services in urban China's market for hospital care services. Since the 1990s, the government initiated a health insurance system for the population in the urban areas and has made a noticeable progress in expanding the coverage. With rising income and insurance coverage, the question about which type of hospital service to be selected has become an important issue for the urban population. This paper uses multinomial logit model to study the influence of health insurance and other factors on individual's hospital choice in five major cities of China. The objective is to draw some recommendations to mitigate the excess capacity and unsatisfied demand in the market for hospital services.
The paper uses the household data of five cities (Shenyang, Hangzhou, Shanghai, Shenzhen, and Beijing) in China to study the determinants affecting individuals' provider choice. The study uses multinomial logit model and finds insurance coverage, income, self-assessed health status, education and city dummy variables affecting the individuals' provider choice in urban China. The expansion of health insurance coverage for urban individuals reduces the prices they pay for obtaining medical services and, therefore, leads to higher possibility of choosing high-quality hospital. The level of income also increases the possibility of visiting high-quality hospital, but the result should be interpreted with caution as time cost of visiting providers is a rough estimation and may not be true reflection of actual cost incurred. Furthermore, individuals with higher educational level and with poor self-assessed health status are more likely to be concerned about their health status and therefore are more likely to choose high-quality providers.
In the context of the Chinese reform process, governments, local, provisional and national, do not provide sufficient financial support for providers as they previously did under the central-planned economy. The government is now asking the providers to manage their performance on their own in the market place. On the other hand, governments still restrict health service prices to a very low level. In order to compensate providers' losses in health service provision, the government implements two policies that ensure providers to generate revenues from drug sales and provision of services through the usage of medical equipment. As a result, many basic health service institutions are unsustainable as they cannot get enough revenue as they lack the access to above two sources of revenue generation. The study shows that the improvement of health insurance coverage could increase demand for both basic institutions and high-quality institutions. This is because basic institutions are convenient to access and thus inflict lower time cost for individuals to access these medial services. The new health insurance schemes should provide incentives for individual to choose basic health institution as their first choice. This would reduce the pressure on the large hospitals. But the quality of basic health institutions should also be improved to ensure that they attract patients and are economically viable.
This is an exploratory study to investigate the determinants of urban citizens' provider choice. There are a few shortcomings. Firstly, because of the limitation of data, the study does not consider the medical prices and qualities in the model, especially time cost of visiting a hospital. Secondly, the possible nature of insurance's endogeneity is ignored in this paper. However, we assume that it may not be a problematic as the proportion of commercial insurance is only 2.8%; whereas social insurance coverage is 70%. Therefore, the problem of adverse selection may not be so severe.
本文利用沈阳、杭州、上海、深圳和北京五个城市入户调查的数据,采用多元logit模型考察了城市居民就医选择以及影响这一行为的重要因素。从计量回归的结果我们可以看出显著影响居民就医选择的因素有保险、收入、健康自评、受教育程度、区域等。保险的存在降低了患者所面临的医疗服务价格,使得人们即使收入没有增加也会选择质量更好的省市医院。收入的增加会显著的降低人们选择基础医疗服务机构的概率,增加去较好医院的概率。同时我们也看到,特别是对于高收入人群而言,收入增加导致他们选择县级医院/省市医院的相对概率反而会增加,这主要是由于收入增加意味着他们就诊的机会成本增加,即意味着他们所面临的医疗服务价格的增加,收入和价格的同时增加可能会使个体选择较低级的医院。自评健康差的人对其身体状况非常敏感和重视,对医疗服务的质量也要求比较高。所以在控制了其它因素的情况下,他们会倾向于质量更好的省市医院。文化程度影响就医选择的原因是类似的:文化程度高的人对自身的身体健康更为重视,所以会选择质量较好的医院。
从本文的结论我们可以看出,保险的普及在一定程度上增加患者对基础医疗服务机构和省市医院的所提供服务的需求。在今后医疗服务市场供给面的发展上,我们可以促进基础医疗服务机构的发展。因为它们的可及性较高、分布广,能够满足人们基本医疗服务的需求的同时,大大地降低了居民就诊所耗费的时间成本。同时由于其定位于基础医疗服务,对人员和仪器的要求都不需要很高,所以经营成本也会相对较低,这就使它们提供低价格的医疗服务成为可能,从而有效的控制医疗费用的上涨,同时缓解大医院拥挤的情况。这一点在国外的医疗制度和医院构成上我们可以看出是有效的。在国外,家庭医生是非常重要的医疗服务的提供者,他们向患者提供初步和基本的诊治,并决定是否需要向大的医院转诊。由于家庭医生的费用相对较低,这在一定程度上降低了患者支出的医疗费用,同时也减少了大医院排队就医的问题。
但是在推行基础医疗服务机构时我们需要主要的问题就是它们所提供服务的质量问题。尽管它们不需要很高水平的人员和医用设备,但这并不意味着它们不需要提高其服务水平。医疗服务充满着信息不对称,这就使得患者对于医疗服务机构的信誉是非常敏感的,所以如果卫生诊所不注重提高自身的质量,那么就无法吸引到患者前来就诊,卫生诊所也就无法维持下去。
对县级医院,从床位使用率医生每日平均所看患者的人数上看,它的效率是比较低的。而且从需求的角度来讲,保险覆盖面的扩大会降低人们对其的需求,如果推行基础医疗服务机构得当,从而减缓大医院的排队现象,那么县级医院在就诊时间成本上也不会有多大的优势,所以人们收入增加也不一定会增加对其需求。所以今后也许可以将县级医院适当的向基础医疗机构和省市医院的方向发展。
本文利用入户调查的数据,较好的研究了一些影响城市居民就医选择的因素。但是文章还存在很大的不足。首先,由于数据的限制,我们无法考察居民就诊所花费的时间成本(包括路程和候诊),从而无法确切的评价出就医时患者所面临的实际成本。其次,我们目前无法找出评价各类医疗机构质量比较好的变量,这在一定程度上限制了我们作一步的研究。而且健康自评与就医选择可能存在内生性的问题,经常选择质量高的医院就诊、接收更高质量的医疗服务会提高人的身体健康状况。这些问题都是以后可以研究和改进的地方。
There exists, simultaneously, an unsatisfied demand for hospital specialist services and excessive supply of clinic and district hospital services in urban China's market for hospital care services. Since the 1990s, the government initiated a health insurance system for the population in the urban areas and has made a noticeable progress in expanding the coverage. With rising income and insurance coverage, the question about which type of hospital service to be selected has become an important issue for the urban population. This paper uses multinomial logit model to study the influence of health insurance and other factors on individual's hospital choice in five major cities of China. The objective is to draw some recommendations to mitigate the excess capacity and unsatisfied demand in the market for hospital services.
The paper uses the household data of five cities (Shenyang, Hangzhou, Shanghai, Shenzhen, and Beijing) in China to study the determinants affecting individuals' provider choice. The study uses multinomial logit model and finds insurance coverage, income, self-assessed health status, education and city dummy variables affecting the individuals' provider choice in urban China. The expansion of health insurance coverage for urban individuals reduces the prices they pay for obtaining medical services and, therefore, leads to higher possibility of choosing high-quality hospital. The level of income also increases the possibility of visiting high-quality hospital, but the result should be interpreted with caution as time cost of visiting providers is a rough estimation and may not be true reflection of actual cost incurred. Furthermore, individuals with higher educational level and with poor self-assessed health status are more likely to be concerned about their health status and therefore are more likely to choose high-quality providers.
In the context of the Chinese reform process, governments, local, provisional and national, do not provide sufficient financial support for providers as they previously did under the central-planned economy. The government is now asking the providers to manage their performance on their own in the market place. On the other hand, governments still restrict health service prices to a very low level. In order to compensate providers' losses in health service provision, the government implements two policies that ensure providers to generate revenues from drug sales and provision of services through the usage of medical equipment. As a result, many basic health service institutions are unsustainable as they cannot get enough revenue as they lack the access to above two sources of revenue generation. The study shows that the improvement of health insurance coverage could increase demand for both basic institutions and high-quality institutions. This is because basic institutions are convenient to access and thus inflict lower time cost for individuals to access these medial services. The new health insurance schemes should provide incentives for individual to choose basic health institution as their first choice. This would reduce the pressure on the large hospitals. But the quality of basic health institutions should also be improved to ensure that they attract patients and are economically viable.
This is an exploratory study to investigate the determinants of urban citizens' provider choice. There are a few shortcomings. Firstly, because of the limitation of data, the study does not consider the medical prices and qualities in the model, especially time cost of visiting a hospital. Secondly, the possible nature of insurance's endogeneity is ignored in this paper. However, we assume that it may not be a problematic as the proportion of commercial insurance is only 2.8%; whereas social insurance coverage is 70%. Therefore, the problem of adverse selection may not be so severe.
引文
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2.卫生部统计信息中心.中国卫生统计年鉴2007,[EB/OL].http://www.moh.gov.cn
3.中国卫生总费用核算小组,2004
4.卫生部统计信息中心.中国卫生统计年鉴2003[EB/OL].http://www.moh.gov.cn
5.卫生部统计信息中心.2003-2007年我国卫生发展情况简报,http://www.moh.gov.cn/moh/main?fid=open&fun=show_news&from=view&nid=20964&tr an_flag=1
6.李秀宁,任晓辉,唐敏等.患者就医意向与社区卫生服务[J].中国卫生事业管理,(152):101-102.
7.刘国祥,郝艳华,高广颖.城镇职工医疗保障制度改革对不同就业人群的卫生服务利用影响[J].中国卫生资源,2002,5(6):275-276.
8.曹宇环.包头市城区居民卫生服务需求利用与资源配置研究[D]:[硕士学位论文].太原:山西医科大学,2002.
9.李吴萍,宋琦如,刘槟红等.城市居民门诊卫生服务利用及影响因素分析[J].中国公共卫生,2005,21(5):602-603.
10.王左敏,吴明,等.威海市医疗服务利用影响因素分析[J].中国卫生经济,1999,7:31-34.
11.蒋敏,李晓松,杜娟等.关联规则在挖掘患者就医行为模式研究中的应用[J].现代预防医学,2007,34(9):1663-1669.
12.白瑞.嵌套logit模型及其在卫生服务利用分析中的应用[D]:[硕士学位论文].南京:东南大学,2006.
13.Mitchell,Jean M.and Jack Hadley(1997) "The Effect of Insurance Coverage on Breast Cancer Patients' Treatment and Hospital Choices" The American Economic Review,Vol.87,No.2,pp.448-453
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