摘要
目的：在我国,由于公立医院的定位是不以营利为目的的,为广大人民群众提供安全、有效、方便且价廉的卫生服务的公益性事业单位,承担着保护、维护、恢复人群健康和公共卫生服务的责任。因此,我国卫生事业一贯将坚持和维护公立医院的社会公益性质视为己任,并且这也完全契合国际上共同认可的价值理念。但目前现实情况来看,由于我国多年来在改革政策取向上的模糊不清及市场经济体制改革大环境下卫生改革的被动适应,使得公立医院在卫生服务体系中的功能定位不准,加之政府投入不足且补偿机制不合理,从一定程度上导致我公立医院公益性质淡化、存在不同程度的逐利行为、内部管理低效等问题,影响并加剧了群众看病难和看病贵的问题,成为和谐社会构建过程中的焦点问题。同时,由于改革滞后,导致了医疗费用不合理上涨加剧、医务人员医德滑坡、医患关系紧张以及医疗服务体系调整困难等现象日趋明显。毫无疑问,在一个高效、合理卫生服务体系中,公立医院占据重要地位,因此,公立医院改革也必然成为新医改的核心内容。综上所述,以上现状使得本研究具备了一定程度的现实意义。具体内容上,本研究将重点对医院运行的外部环境中建立合理的补偿机制这一命题展开探索,主要以国际国内的经验总结和案例剖析的方式,全面系统地进行理论与政策研究,以期为今后公立医院改革措施的评估与推广提供理论指导和科学依据。
方法：(1)文献研究。收集国内外公立医院补偿机制研究领域相关理论和实践研究进展和目前我国公立医院改革的相关政策,在此基础上归纳总结具有借鉴意义的理论和方法。(2)实证研究：以武汉市市直、区属两级政府举办的公立医院为研究对象,通过访谈、问卷及文献检索查阅等方法,获取武汉市公立医院2007-2010年基本资源现状、收支状况等相关资料,对比分析对公立医院补偿现状并对未来几年状况进行分析描述。在参考充足文献资料、征询专家意见以及对国际经验进行归纳总结的基础上,提出为确保公立医院回归公益政策建议。(3)案例分析：通过对典型国家补偿机制进行具体案例分析。
结论：(1)坚持政府主导地位。目前我国在政府投入的不足的情况下,对公立医院的要求却在不断提高,迫于发展,公立医院不得不走向逐利轨道。因此无论是从国际视野的角度而言,还是从我国公立医院改革进程而言,为了扭转我国公立医院偏离公益性轨道这一现状,虽然我们也提出公立医院补偿渠道应当多元化,但是,总体而言,强调政府主导地位才是维护我国公立医院公益性质的根本前提。(2)科学合理的政府补偿范围和方式不仅有助于保证服务的效率,而且也能保证公立医院提供适宜的公立医疗服务。公立医院补偿采取全额预算方式,能够有效地从总量上对公立医院的固定成本进行控制,从而避免公立医院因过度扩张而导致趋理行为的发生,达到控制医院开支上涨过快的目的。(3)促进合理用药。
本文提出的建议主要有：
(1)强调政府主导责任,建立稳定筹资来源,对公立医院的补偿应当是有条件的、合理的补偿；
(2)废除“以药补医”机制是关键环节,进行医疗服务价格改革,因改革带来的政策性亏损,可通过调整医疗技术服务价格、增加政府投入等途径补偿。提高诊疗费、手术费、护理费收费标准,体现医疗服务合理成本和医务人员技术劳务价值。医疗技术服务收费按规定纳入医保支付范；
(3)强力推进支付方式改革,采取总额预付、按人头、按病种付费等复合支付方式,引导医疗机构主动控制成本。
本文的主要创新点主要有：
(1)本文尝试系统分析了武汉市公立医院2007-2010年总体经济运行状况,并分析、总结了目前财政投入现状对投入方式变革的诉求；并通过以上分析结合财政投入测算理论模型,进一步对公立医院财政投入方式的理论探讨和具体测算进行归纳总结。
(2)研究提出政府对公立医院的投入应当是符合区域卫生规划的要求,并根据现行国家政策,实行的有条件的补偿；
(3)就医保补偿角度,提出通过支付方式的变革,采用单病种付费的方式覆盖公立医院运行成本以及实行药品零差率带来的亏损等。本研究不足之处：
(1)由于本身核心研究很多方面没有定论,证据性较为不足,因此现提出的政策的建议还有待通过进一步研究与深入探讨,予以佐证；
(2)国际经验本土化程度不够,在我国现行体制下是否具有适宜性,仍需要通过进一步深入探索,得出结论。
Objective:Public hospitals are public service sectors with public welfare feature, which don't target at making profit but deliver safe, efficient, convenient and inexpensive health services for the population. They are micro-providers in medical service system and shoulder important responsibilities for protecting, safeguarding and restoring people's health as well as providing public health services. It is the constant requirement of developing health system in China and in accordance with internationally general concepts of value to adhere to and safeguard public welfare feature of public hospitals all long. The social responsibilities of public hospitals are embodied in meeting people's increasing health needs, providing accessible basic health care services for everyone, catalysing development of medical technologies and medical researches, orienting and affecting other non-stated-owned health facilities to develop healthily and correctly. It is adequately manifest of the central government making preoccupations with people's livelihood and having firm stance to advance reform. Through thirty years' preparations and discussions, basic concepts and goals of the reform have been formed and many measures are being taken. Presently, the goal of the new health reform is to establish a basic medical health system that covers the whole population. Public hospitals reform with protecting and realizing their public welfare feature provides the foundation for realizing the goal of health reform. On basis of so many years' policy practice and studies, consensus is reached that reforms of management system and operational mechanism of public hospitals are the key to carry out the new health care system reform successfully. This study will mainly focus on the research of funding system of public hospital system in China. Along with foreign experiences and case study, a theoretic study will be conducted in order to provide evidence and resources for future public hospital reform.
Methodology:1. Literature review. Both theoretic and experiment studies on funding system of domestic and foreign public hospital system will be collected and the current policies will be collected as well.2. Empirical analysis:The public-run hospital operation data are uses as the key cases in this study.3. Case study:mainly targeted on foreign countries.
Results:1. Government should always be the leading role of the reform. Current situation shows that the public hospitals in China are running with sufficient government funding. Under this circumstance, they have to create more benefit by themselves to survive. Government should still be the key element for them to get back their nature of welfare.2. A rational and scientific standard of government funding will not only guarantee the efficiency of health services but also ensure public hospitals providing suitable public services. The global budget will work efficiently on cost-control.3. Drug income should be eliminated from public hospital's revenue.
Recommendations:1. To strengthen government's leading role and establish a steady funding system; 2. The old drug policy should be replaced by increasing the price of medical services; 3. Payment reform should be implemented.
引文
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