【作者】 孙杨；

【导师】 方鹏骞；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2011， 博士

【摘要】 1.研究目的基于监管理论起源和我国改革开放以来公立医院运行监管情况的回顾性研究,并引入监管经济学对公立医院运行监管行为理论及其影响因素进行分析,并运用博弈方法学对公立医院监管过程中政府、运行监管部门以及公立医院之间的行为互动进行分析。通过实证研究发现公立医院运行监管现状,探讨适合未来公立医院运行监管的相关监管体系和监管途径,对初步构建公立医院的运行监管体系提供建议。2.研究方法理论研究方面,通过文献收集和专家咨询,获得监管理论和已有的监管实践资料,通过对比分析、趋势分析判断我国的“监管”概念内涵、发展趋势和监管体系的一般形式,以及公立医院运行监管的体系概念框架；通过博弈模型的构建,就监管者和公立医院之间的监管博弈进行分析。实证研究方面,通过收集已有年鉴数据,分析我国公立医院资产情况；在部分公立医院改革国家联系试点城市(镇江、深圳、鄂州、株洲、遵义)和湖北省“8+1”城市圈(黄石、黄冈、仙桃、潜江)进行实证调研,通过对已出台政策、措施和地区公立医院运行相关资料、数据进行收集,以及通过知情人半结构式访谈和专家咨询,分析公立医院运行和监管现状已经改革背景下公立医院运行监管体系建立的探索经验。3.主要结论第一,监管的内涵界定与我国对监管概念的辨析。监管源于英文regulation,指政府基于一定的理念,通过制定规则,对具体产业的活动的干预行为。区别于我国计划经济模式下政府的微观经济管理,宏观调控和监管则是建立市场经济模式下,政府作用于经济的一般手段。在国内"regulation"的译名和使用存在差异,首先在regulation的译名上,有规制、管制和监管,其中监管更能体现regulation的内涵。同时在具体的使用方面又容易与“监督”(supervision)一词相互混用和混淆。第二,监管发展历程与我国监管制度的趋势分析。由我国和资本主义国家的监管实践差异来看,西方资本主义国家的监管发展可以概括为从无监管到行业监管再到行业监管和运行监管伴生的过程,而我国则是由计划监管到行业监管和运行监管伴生的过程。虽然路径上存在差异,但实际上都是从某个极端,即完全自由市场或完全政府干预,通向寻求政府干预和市场机制相平衡的过程。在我国的监管体系建设中,可以看出开放市场,使更多的竞争者进入是一个必然的选择,而是否需要进行私有化则是一个需要慎重考虑的决策命题。从国际的经验来看,在准备不充分的情况下进行私有化,则很有可能会因为行业监管制度的不完善或缺失而严重影响到市场的正常秩序,同时运行监管制度的不健全将造成严重的国有资产流失。第三,我国公立医院运行监管的体系设计与博弈分析。公立医院运行监管应该体现政府作为产权所有者“办”(举办和运营)医院的责任,并通过制度设计改善公立医院的运行效率,体现公益性。通过构建政府监管者与公立医院的博弈模型,发现在公立医院运行监管中,政府作为监管者对公立医院趋利行为的认定、监管者的监管成本以及政府对公立医院的干预力度综合影响监管者和公立医院博弈行为的均衡。第四,公立医院资产和运行监管的现状分析。首先,公立医院国有资产近年来迅速增加,从侧面说明公立医院国有资产增值过快的事实可能已经对公立医院公益性产生负面的影响。而相关财务、会计管理制度的设计缺陷以及政府对公立医院没有明确的资产运行目标成为公立医院资产规模迅速扩大的重要原因。其次,公立医院在运行上呈现两极化,公立医院对自主权的需求产生明显的两极性倾向,而公立医院以盈利作为基本的运营出发点,这明显违反了公立医院运行以社会效益最大化这一基本的资产意志。再次,公立医院运行监管职责和权力分配上存在不匹配,导致公立医院运行监管效率低下,这一问题集中表现为卫生行政部门“出资人职责履行机构”角色有名无实。最后,各地的运行监管实践都没有对公立医院国有资产是否应该保值增值、什么是资产的合理增值程度和幅度,这些公立医院国有资产运行的本质问题进行明确的回答,这些基本问题将影响到公立医院运行监管的效率和体系建立。第五,公立医院运行监管内容确定与监管职责权力重构分析。政府对公立医院运行监管内容应包含国有资产安全、国有资产保值增值以及公立医院运行效率三个方面,以公立医院运行效率和国有资产安全为主,保值为辅。同时对公立医院运行监管职责和权力重构,提出建立公立医院运行目的明确,监管管理成本相对较低,干预有效,分工明确、权责匹配的监管体制机制保障的目标,以及明确运行目的、降低监管成本和保障干预强度三个基本原则。4.政策建议第一,形成国家层面的公立医院运行监管体系框架顶层设计,包括梳理医院行业监管职能与公立医院运行监管职能,实现“管办分开”；明确成立政府层面公益性国有资产运行与管理委员会作为公立医院产权所有者的具体组织形式；明确由卫生行政部门作为公立医院出资人职责履行机构。第二,建立健全公立医院运行相关法律、法规和政策设计,包括建立健全以实现公立医院运行公益性为目标的公法《公益性事业单位国有资产法》和私法《非营利性机构法》等法律法规体系；完善公立医院经济运行和效率运行等方面相关政策和规章制度。更多还原

【Abstract】 1. ObjectiveBased on regulation economic, regulation theories and countries’regulation practices, the study concerned the.on public hospital internal regulation within the China’s health care reform,. Furthermore, using the game theory to analysis the interactions among the government, the internal regulation institution and public hospital. After the evidence study, discussed the suitable-system and approach of public hospital internal regulation in China, and gave the suggestions to the national public hospital internal regulation system building.2. MethodIn the theoretical research, using literature review and expert consultation to get the information on regulatory practice, and using comparative analysis, trend analysis to define the meaning of regulation in China, determine the trend of regulation progress and the general form of regulation system, and the public hospital internal regulation system framework. Based on the game theory model building, discuss the interaction between the government regulation institution and the public hospital.In the evidence research, getting the data from yearbooks of health to analyze the assets of public hospital in China. conducted field survey in national public hospital reform pilot city which including Zhenjiang, Shenzhen, Ezhou, Zhuzhou, Zunyi,and Hubei provice "8+1"Metropolitan(including Huangshi, Huanggang, Xiantao, Qianjiang). Collecting the issued policies, measures and public hospital operation data eg. Based on the key people Semi-structured interviews and expert consultation, discussed the public hospital internal regulation situation and the internal regulation system building experiences under the reform background.3. Conclusions(1) The content definition of regulation in China and several concept analysis. Regulation, comes from the English word "regulation", it means based on specific concept, the government built the rules to intervene the behavior of specific industries. Different from the micro-economic management in Planned economy, regulation and macro-control are formal measure to intervene the economy in Market economy. There are several translations of regulation in China, and difference in translation leading many difficult in regulation research in China. Chinese word "JianGuan" is the most suitable definition of "regulation" in China. Using of regulation usually confused with supervision, which mean is different from regulation.(2) the analysis of history of regulation development in Capitalist countries and China regulation system. Based on the practice of China and capitalist countries, regulation history in capitalist countries came from non-regulation to external regulation and then external & internal regulation. China regulation history should be come from planned regulation to external & internal regulation. Although there are differences on the path, actually they both from an extreme, totally free market or totally government intervention, to the balance between market function and government intervention.Continual open the market, and make more competitors in is a inevitable choice to China regulation system building, but it dosen’t mean China must get into the road of privatization immediately. Based on the international experience, privatization in inadequate preparation may cause unstable market order because of external regulation system deficiency, and lost of state assets because of unsound of internal regulation system.(3)The analysis of China public hospital internal regulation system design and game theory. The internal regulation of public hospital should reflect the responsibility of government holding and operation public hospital as property owner, and besides, government promotes the public hospital efficiency to display public welfare based on the policy design.By constructing the game theory model between government regulator and public hospital, the regulator’s judgment of the seeking profit behavior of public hospital, the cost of regulation and the intensity of intervention are combined effect of the balance between the regulator and public hospital in the game theory model.(4) The assets situation, operational situation and internal regulation of public hospital. First of all, the assets of public hospital increased rapidly in recent years. It means that the rapid increase of the public hospital assets may have damage the public welfare, and the defect of public hospital finance and accounting system, non-clear assets operation goal are the important reasons of the rapid assets increase. In the second, the operation situation of public hospital shows polarization, and that causes the different need of autonomy in different hospital. Seeking profits as the basic hospital operation concept, has damage the assets will of public hospital, which usually contented as max the public welfare. Thirdly,public hospital internal regulation responsibility and authority are not appropriate in different regulators, that cause the inefficiency of public hospital internal regulation. The focus of the problem is the nominal of Health administrative department as the institution to fulfill the responsibilities of investor. Finally, the experiences of public hospital internal regulation didn’t answer whether the assets of public hospital should increasing the value, and what is the suitable level and margin, which are important to the regulation efficiency and system building.(5) Public hospital internal regulation content and responsibility& authority reconstruction analysis. The content of public hospital internal regulation should contain three parts, the security of assets, the efficiency of operation and the increase value of assets, security and efficiency should be the main content, increase value is the assisted. In the reconstruction of public hospital internal regulation responsibility & authority, the goal is to build operation purpose clear, the cost relatively lower, effective intervention and authority match responsibility’s mechanism, and clear the purpose, low the cost and protect the intervention power as the basic principles.4. Suggestion(1) Building top design of the national public hospital internal regulation system, including card the external regulation content and internal regulation content to achieve separating held from management, establish the national state-owned assets of public welfare operation and management committee as the owner of public hospital, define the Health administrative department as the institution to fulfill the responsibilities of investor.(2) Establishing the operation related laws and policy design of public hospital, including establish the public law "public institution state-owned assets law" to achieve public welfare, establish the private law "non-profit institution law" and so on, and improve the policy of economy operation and efficiency operation of public hospital.更多还原