摘要
医疗服务直接关系到人民群众的生命健康,从维护公共利益的角度出发,政府需要对医疗服务进行规制。同时医疗服务市场又具有技术垄断性、信息高度不对称性及准公共品等特性,使其和完全竞争市场发生偏离,各种市场失灵也要求政府对医疗服务进行规制。医疗服务的政府规制主要包括进入规制、价格规制和质量规制。规制均衡是指在规制市场中规制供给恰好能够满足规制需求时的一种状态。按照利益集团规制理论,规制需求方是利益集团,规制供给方是政府规制机构。规制均衡具备两种状态:短期静态和长期动态。而影响规制均衡状态形成的两个内生因素是成本约束和利益集团博弈。而当规制供需不等时,规制市场状态被称之为非均衡。规制非均衡状态包括两个种类型:规制缺位和规制越位。
医疗服务市场是一个受政府严格规制的市场,但我国医疗服务市场在不断纳入市场经济体制范围的过程中,政府规制的供给并没有满足规制的需求,政府规制或缺位、或越位,处于规制非均衡状态。医疗服务规制的非均衡状态导致了医疗资源的分配不公、医疗服务供给方的行为扭曲、医疗服务需求方负担的医药费用飞速上涨,以及医患冲突不断升级等一系列问题。“看病难、看病贵、医疗诉讼低效”已经成为整个社会关注的焦点之一。我国医疗服务规制并没有产生良好的社会经济效果,其原因很多,但从规制供需均衡的角度看,是由于医疗服务规制处于明显的非均衡状态。而影响规制均衡状态形成的主要内生因素是成本约束和利益集团博弈,从这两个因素出发考察我国医疗服务规制非均衡的现状、问题和成因,揭示造成我国医疗服务规制现有困境的内在机理,提出解决非均衡状况的对策,促进规制均衡状态的形成,为我国医疗服务规制的理论研究与实践工作提供参考。
本文按照问题导向的原则,主要回答以下问题,目前我国医疗服务的进入规制、价格规制和质量规制非均衡状况如何形成,以及该如何由规制非均衡状态向规制均衡状态发展。
本文以中国医疗服务规制为研究对象,运用规制经济学中的利益集团规制理论、一般经济分析方法和演化博弈论的相关分析方法,以影响规制均衡的两个主要因素为切入点,在“医疗服务规制—影响因素—非均衡分析”框架之下,研究中国医疗服务规制目前的非均衡状况如何形成,如何由非均衡状态向均衡状态发展。
本文共7章,除绪论外,主要分为3个部分。
第一部分,即第2章和第3章。第2章中的第一部分是规制均衡理论的国内外文献综述。从成本收益视角和利益集团视角及它们的综合应用视角梳理了国内外有关规制均衡理论的研究,并以此作为第3章研究的起点。第2章中的第二部分内容主要围绕着医疗服务规制的三项主要内容:进入规制、价格规制和质量规制对国内外医疗服务规制的各种观点进行了分类和述评,并以此作为第4、5和6章研究内容的基础。而第3章是在第2章第1部分研究的基础上,对规制均衡理论作了进一步的论述。在利益集团规制相关理论的基础上,围绕规制均衡的两个因素——成本约束和利益集团博弈,展开了规制均衡理论的创新性研究。首先,提出了沟通成本和规制强度这两个概念,并在它们的作用下,针对利益集团规制理论中规制供需均衡问题给出了更为具体的模型化处理,同时给出了规制均衡时沟通成本存在性的证明,而且模型包括静态和动态两种情况。其次,将演化博弈理论的相关知识引入到规制均衡分析中,阐明了演化博弈分析用于医疗服务规制均衡研究的可行性。
第二部分,即第4、5、6章。分别详细讨论了我国医疗服务规制三项主要内容的规制非均衡问题。首先,都考察了各项规制内容的历史演进、非均衡的现状和问题,发现进入规制和质量规制属于规制缺位类型,而价格规制则属于规制越位类型;其次,从影响规制均衡的两个因素角度出发,运用第3章阐述的规制均衡理论,分析各项规制内容出现的非均衡问题的原因,进而揭示我国医疗服务规制目前困境的内在机理。
第三部分,即第7章。基于第二部分中的各项规制内容的非均衡现状和问题分析,根据规制均衡形成的影响因素,提出推动我国医疗服务规制由非均衡向均衡状态发展的政策和建议,为我国医疗服务规制的实践提供参考依据。
Medical service has close relationship with people’s life and health, we need governmental regulation for medical service from protect the public interest. At the same time, medical service market embraces technique monopolization, information asymmetry and impure public goods’properties, which make it run away from the complete competition one, so the market failure asks for the governmental regulation. Regulation of medical service mainly includes entry regulation, price regulation and quality regulation.
Regulation equilibrium means a state that regulation supply just meet for regulation demand. According to the interest groups, the groups are the demander, and the government institutions are the suppliers. The equilibrium state has two types, short-term static and long-term dynamic. Moreover, the cost restrictions and interest groups game influence the regulation equilibrium. As the supply doesn’t equals to the demand, we call the regulation market state disequilibrium one, which has two types, vacancy and offside.
The medical service market is a strict regulatory one. When we are making it into the market economic system, governmental regulation is either in vacancy or in offside which could not be the stable situation in the regulatory equilibrium. This led to the unfair collocation for medical sources, the embarrassment that the serious distortion for medical service suppliers, the increasing payments for demanders and the more terrible conflicts among hospitals and patients. Problems like difficulty and expensiveness in getting medical service and the inefficiency in medical lawsuits have become one of the focuses of the whole society. There are many reasons in explaining the bad social and economic effect from the governmental regulation in medical service. At the point of regulatory supply and demand, our medical service regulation now is in the obvious disequilibrium state. So this paper explains the problems of regulatory supply and demand from the above point, and studies deeply the regulation in the medical service, analyses the regulatory contents and explores the two critical influencing factors (cost restriction and game of interest groups) forming the regulatory equilibrium in order to find the internal mechanism of our dilemma in the regulation of our medical service and bring some suggestions for our regulation.
Based on the rule of problems orientation, this paper tries to answer these questions that how the disequilibrium state of the entry regulation, the price regulation and the quality regulation of the medical servicre in China have been shaped and how we can change the regulation disequilibrium state to the equilibrium one.
It is the regulation of Chinese medical service that is the main object here. At view of the two factors influcing regulation equilibrium above, this paper uses the interest groups regulation theory, the general economics analysis and the evolutionary game theory to explore how our regulation of medical service became the disequilibrium state and how to approach the equilibrium one. And all the discussion is under the framework of medical service regulation—effect factors—disequilibrium analysis.
There are seven chapters in the dissertation and they are divided into three parts except the introduction.
The first part includes the second and the third chapters. The former of the second chapter is the literature review of regulatory equilibrium theorem and mainly cards the study on regulatory theorem at home and abroad at the view of the cost restriction and the interest groups, which is the research foundation of the next chapter. And the latter of the second chapter gives the classification and the review at home and abroad about entry regulation, price regulation and quality regulation for the medical service, which also are the research foundation of the forth, fifth and sixth chapters. Basing on the first part of the second chapter, the third chapter makes a deeper study on the regulation equilibrium theorem. It supplies a creative research on the theorem around the two factors of the cost restriction and the interest groups. Firstly, it brings forward two concepts—communication cost and regulation intensity that help to form the specialization modal on the regulation supply and demand with the interest groups regulation theorem and prove the beigness of the communication cost on the regulatory equilibrium state. Moreover, the model has the static and dynamic types. Secondly, it introduces the relative content about the evolutionary game into the analysis on the regulation equilibrium, and explains the feasibility of using this game to study the regulation of medical services.
The second part are the forth, fifth and sixth chapters. These three ones embrace the three contents of the regulation on the medical services in China. There are similar structures in the three chapters, but which discuss the three different regulation means and their regulation equilibrium analysis. Firstly, they explore their historical evolution, status and problems of these three regulation means. Secondly, from the point of two effect factors influencing regulatory equilibrium, it studies how the cost restriction and the interest groups influence the regulation problems using the regulation equilibrium theorem, deeply analyzes the disequilibrium reasons of three regulation contents and finds the internal mechanism of the current dilemma in our medical service regulation.
The third part is the seventh chapter. Basing on the study of the regulation equilibrium about the different regulation contents, it advances the countermeasures and corresponding suggestions for the entry regulation, the price regulation and the quality regulation of the medical service in China.
引文
①2010年11月5日,河南南阳一男子心脏不适去医院,医生开具多张检查单让其检查,6小时内排队等待检查,却没吃上一粒药,后猝死。来自《华商晨报》2010年11月12日:B21。
②2007年全国统计数据表明,在全国耐药菌监测中,儿童肺炎患者对青霉素的不敏感率已高达88.5%,对红霉素的耐药率更高。近几年,头孢三代的不敏感率已经从2.8%迅速上升到24.7%。来自《华商晨报》2010年11月13日:A6。这种结果有患者自身的选择因素,但更重要的是医生的治疗决策因素。
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②Szczech L. A., Klassen, P. S. & Chua B., er al. Assocations between CMS’s clinical performance measures project benchmarks, profit structure, and mortality in dialysis units[J]. Kidney International, 2006,69(11): 2094-2100
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①1982年, J. Maynard Smith因出版了Evolution and the Theory of Games,而被称为演化博弈论之父。
①张新华,赖明勇.基于演化博弈的电力竞价市场均衡分析[J].管理工程学报,2008,22(2):144-147
②张青.浅析金融创新的内在机理与对策—基于演化博弈的动态分析[J].生产力研究,2009(12):158-160
③左昊华,林泉.寻租与腐败的运行路径与长期均衡预测—基于演化博弈的分析[J].生产力研究,2009(24):21-23
④纪玉山.解决“以药养医”问题的演化博弈分析[J].医学与哲学(人文社会医学版),2010(7):45-48
①已有一些国内外学者应用这种方法来研究医疗资源的分布公平性情况,如小林安木(1993),饶可勤等人(1998),张鹭鹭等人(2009)。
①多个省份的《医疗服务项目价格说明》显示:“价格”指完成该项目服务可以收取的费用。其中手术费、护理费按不同地区、不同等级医院制定的价格为中准价格,允许医院在15%的幅度内上下浮动;部分大型仪器检查治疗费为不同等级医院中准价格,允许医院在15%的幅度内上下浮动;其余价格均为最高标准,医院可以向下浮动,但不得突破该价格。
②转引自Xinzhu Liu, Yuanli Liu & Ningshan Chen.The Chinese experience of hospital price regulation[J]. Health Policy and Planning. 2000,15(2):157-163
①李丽.我国医疗服务价格规制的理论与实证分析[J].博士学位论文,山东大学,2007
①转引自刘智勇等.基于词频与内容分析的医疗服务质量管理研究的重点与热点分析[J].《中国医院管理》2007(1):16-17
①罗乐宣,侯泽蓉,王跃平等.我国医疗服务质量监督管理现状分析及其对策研究[J].中国卫生经济,2006(9):56
②我国医疗事故鉴定依然有缺陷[EB/OL].http://health.51ttyy.com/news/200704/76639_2.shtm, 2007.4/2010.10
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