【作者】 刘飞跃；

【导师】 肖水源；

【作者基本信息】 中南大学 ， 公共管理学， 2013， 博士

【摘要】 研究背景与目的健康权是每个公民的基本权利,提供基本的医疗卫生服务、保障公民的健康权是政府不可推卸的责任或义务。我国建国后建立的医院服务系统,在保障人人享有基本医疗卫生服务上比一些发展中国家的医院服务系统更为完善、具体和有效,但是,相较于西欧发达国家医院服务系统的医院服务效率而言,却仍有较大的差距。本研究以湖南地区政府举办的医院为研究对象,通过对政府办医院的目的、目标、数量、结构与网点布局、成本与社会效果等方面的研究,明确政府办医院的社会功能定位,预测未来5年湖南省政府办公立医院的数量和规模,对湖南未来5年公立医院的发展结构及服务网点地区布局提出按需求、病种的动态变化进行规划的政策性建议。以此为基础,提出政府对医院财政投入的新理念,测算湖南省政府在未来5年内对医院的财政投入水平,并对建立相对完善的医院财政补偿机制提出政策建议,以期为湖南省区域医疗卫生规划制定提供可靠的参考依据。研究方法通过对历史文献的研读与总结,构建一个新的研究框架；根据影响当前公立医院社会功能实现因素外部因素分析,重新分类分级定位公立医院的社会功能；设计《湖南省二级以上公立医院信息采集表》,抽样调查35家二级以上公立医院,获取各医院运营的基本数据信息在Excel上建立原始数据库；应用二次指数平滑模型和单序列一阶灰色动态模型GM(1,1)预测湖南省域内居民的医疗服务需求量；借助文献选优法和专家咨询法确定湖南省二级以上公立医院相对效率评价的数据包络分析(DEA)评价指标,同时利用DEA中的CCR模型和BCC模型评价样本医院的相对效率,并根据评价结果的排序情况确定湖南省各类各级公立医院的适宜规模值；综合应用二次指数平滑模型和DEA中CCR模型和BCC模型,预测2013年湖南省公立医院财政补偿水平。研究内容及研究结果1.公立医院适宜规模及财政补偿机制的理论与现实基础首先,对涉及本研究的几个基本概念进行了探讨,如对公立医院的内涵与外延进行了重构。从公共管理学的角度,重新审视了公立医院之“公立”的内涵与外延,认为公立医院之“公立”的侧重点应落在公众利益或共同利益的实现上,而不应过多纠缠于举办公立医院的主体上,无论医院的举办主体是谁,凡是围绕公众利益而设立的非营利性医院,均可称之为公立医院。换言之,公立医院是指不同社会主体举办、并为社会公众利益服务而设立和运营的非营利性医疗服务机构。该概念突破了公立医院的传统定义,使其内涵和外延得以扩展；对医院适宜规模度的释义,则不仅考虑单体医院在纵横两向上的适宜度分析,而且从区域医疗卫生服务规划的层面出发,探讨公立医院在纵横两向上的适宜度。同时,在公立医院适宜规模的基础上,扩大了公立医院财政资金补偿的内容,如对医院财政补偿不仅仅限于对医院的直接投入,还应该包括其政策性收益。第二,对政府办医院的理论依据进行了梳理,并在分析当前政府办医院的现实困境基础上,确定了政府办医院的责任边界。政府办医院的主要理论依据有三：一是基于保障国民生命健康权的社会契约理论；二是基于满足国民对基本医疗服务产品需求的公共产品理论；三是基于国家积累发展资本需要的人力资本理论。尽管政府办医院是其职责之所在,但当前我国政府办医院在发展过程中面临着四大问题：一是政府办医院的社会功能定位不明,医院的公益性本质流失严重；二是政府办医院的财政投入过少和融资渠道过窄,医院实现公益性本质功能的运转资金短缺；三是政府办医院在市场经济还不完善的前提下的过度市场化所导致的医院聚集化、逐利化倾向,使医院服务的可及性和公平性比较差；四是政府在办医院过程中既做运动员又做裁判员的行为,使医院缺乏有效监管。因此,政府办医院的责任边界应当包括：定位公立医院社会功能、引领社会资本入驻公立医院、确定公立医院发展适宜规模和网点布局,加强公立医院监管体系建设。第三,对公立医院规模设置的理论进行了较为系统的阐述。公立医院规模设置分为两个层面,一是纵向规模,二是横向规模。纵向规模设置的主要理论依据是交易成本理论；横向规模设置的主要理论依据则是规模经济与范围经济理论。第四,对公立医院财政补偿机制建构的理论与现实依据进行了描述。医疗服务产品的属性表明,在市场经济条件下,只有政府利用其强大财政资源才有可能满足人们对纯公共医疗服务产品的需求,准公共医疗服务产品则可以采用多种模式来提供,既可以是政府完全提供,亦可以由市场完全提供,更可以是政府和市场共同提供。但需要注意的是,无论是政府提供还是市场提供,两者均存在失效的可能。现实证明,我国政府对医院的财政补偿方式、水平、机制等存在较大问题,迫使政府对医院系统进行全方位改革。2.公立医院社会功能定位研究公立医院存在的价值在于其社会功能。公立医院的社会功能是指公立医院所具有的医疗服务供给能力和市场调节能力在满足社会及其成员对公益性医疗卫生服务需求方面所产生的积极作用与结果。换言之,即生产和提供公益性医疗服务产品是公立医院应承担的社会功能或应履行的社会责任之一。针对公立医院社会功能即公立医院履行社会责任之学说,国内一些学者从公立医院服务的公益性本质和服务功能层面出发,在整体上把公立医院的社会功能定位为四功能或五功能。然而,问题的关键是,对于公立医院社会功能的实现,并不是只要从整体上定位就能解决好的。因为各公立医院的构成物及组合方式不同,其所显示的特性及其所承负的社会功能必然存在差异,所以,本研究在坚持公立医院总体社会功能的前提下,根据我国有关新医改的文件精神,结合各类各级医院的实际供给能力和公众的医疗服务实际需求,对我国公立医院的社会功能按类别、分等级进行了重构。如一级综合医院主要承担普通人群的诊治和防治,二级医院由承接高危人群的诊治和防治,三级医院则主要承接特殊人群的诊治。3.湖南省公立医院发展的适宜规模分析湖南作为我国一个以农业为主的中部大省,近年来的经济发展水平(地区生产总值)和年末人口总数不仅始终处于中部六省的前列,同时,域内居民的医疗服务需求亦同样处于中部六省的前列和全国的前列,因此,以湖南为个案研究我国政府办医院的适宜规模及其财政补偿机制具有一定代表性。面对域内居民巨大的医疗服务需求,湖南省政府及市、县级地方政府,该如何回应才能有效缓解公立医院公益性医疗服务产品供给与居民对基本医疗服务需求矛盾?管理学理论认为,解决医疗服务供需矛盾的有效行动很多,其中扩大或缩减医院生产规模被认为是市场经济条件下最有效的行动之一。为此,本部分对湖南省公立医院的规模效率及未来五年应达到的规模值进行了预测。研究结果表明,2010年至2015年,湖南省公立医院的总量增长空间达92%,按年均增长量计,约为15%。其中,三级综合医院还可以增加53家左右；公立医院所需注册护士总人数约为9,7591人；注册医师总量约为50,580人—55,179人；药师、技师及其他技术人员的实际需求量分别为16,296人、18,332人和16,296人；非营利性医院(这里主要指公立医院)床位规模总量将达338,869张。为证明公立医院的上述增长空间及单体医院规模的适宜度,本研究以抽样调查的方式对湖南省28家公立医院的相对效应进行了数据包络分析(DEA),结果表明,19家综合医院(包括中医医院)中7家医院的DEA得分无效或低效,占综合医院的36.8%；9家专科医院中6家医院的综合效率、纯技术效率和规模效率值均为1,占专科医院的66.7%,2家医院规模报酬呈递增状态,1家医院的规模报酬呈递减状态。通过对DEA得分无效或低效医院的投入冗余分析,医院的各类投入(人、财、物)均有不同程度的扩张要求。与此同时,本研究根据不同类别、不同等级公立医院的规模效率值预测出了未来5年综合性医院和专科性医院的适宜规模值范畴,其中综合性三级医院的床位规模应控制在1200张床位以下,二级综合性公立医院的适宜规模值范畴应介于300-500张床位之间,低于300和高于500均可能失效。为验证上述推算结果的可信度,本研究又利用数据处理系统软件(Data Processing System, DPS)对我国公立医院改革试点地区株洲市4家县属医院(二级医院)2013年至2017年居民医疗服务需求总量(即4县属医院的病源量)进行了预测。预测结果表明,株洲市4县居民医疗服务需求总量以及医院规模发展的适宜度与前文对湖南省居民医疗服务需求总量和湖南医院规模发展适宜度的预估结果基本吻合。2013年至2017年株洲4县属医院的病人总量将分别达到4,479,756人、510,716人、582,331人、664,058人和757,312人。4.新医改背景下公立医院的财政补偿研究一般认为,当前我国公益性医疗服务供需矛盾产生的重要原因在于政府对公立医院的财政投入不足和不合理的“以药养医”补偿机制。而这种不合理机制的产生,主要在于理念有误。因为理念是行为的先导。改革开放初期,国家对公立医院的财政投入理念是“效率优先,兼顾公平”(注,此时“公平”等同于“平等”),然而,在这种理念主导下的医院财政补偿行为却并没有有效缓解国民的求医看病难题,反而人为地为我国公立医院的可持续发展和公立医院医疗服务的可及性与公平性最大化目标实现造成了诸多阻力。通过对公平、平等及其与效率关系的哲学剖析(公平与效率在哲学上要求且在现实中可以达成高度统一,而平等与效率在哲学要求达到高度统一,但由于在现实中的主客观间巨大鸿沟而只能是一种道德理想),结合建国以来我国政府对公立医院的“效率优先,兼顾公平”财政投入理念之分析,提出了新时期的医院财政投入新理念——公平优先,兼顾平等。在“公平优先,兼顾平等”医院财政投入理念的支撑下,本研究对湖南省14个地区的572家综合性公立医院的财政投入情况进行了抽样调查；利用时间序列分析法和DEA数据包络法中基于松弛的超效率评价模型(Slacks-Based Measure of Super-efficiency, Super-SBM),根据公立医院社会功能的定位和当前国家对公立医院财政补偿项目内容,以医院的医疗服务量——门急诊和住院量作为因变量,以生产和提供公益性医疗服务产品的支出量(即所谓的政策性支出)作为自变量,推算出了湖南省公立医院财政的所谓政策性亏损补偿额,再加上离退休人员费用和医院基本建设和大型设备购置投入、重点学科建设投入、医院承担的公共卫生任务补助以及政府指定的紧急救治、援外、支农、支边等投入费用等,计算出了湖南省2013年公立医院财政补偿的总值将有可能突破100亿元。结论1.政府办公立医院是其职责所在,确定政府责任边界是提高政府办医院效益的关键；2.公立医院存在的价值在于其社会功能,对公立医院社会功能进行分类分级定位是保持公立医院公益性本质的要件之一；3.未来5年湖南省三级公立医院规模应控制在1200张床位左右,二级公立医院的规模应控制在300-500张床位左右；4.“公平优先,兼顾平等”理念应作为新时期湖南省公立医院财政投入的新理念；5.2013年湖南省公立医院财政补偿总额将突破100亿元,政府应加强对公立医院的财政投入力度。更多还原

【Abstract】 Background and PurposeRight to health is the fundamental right of every citizen. Providing basic medical and health services and guaranteeing the right to health is the inescapable responsibilities and obligations of government. The hospital service system that built after the founding of the nation, comparing to some developing countries, is more thorough, specific and effective in terms of guaranteeing every citizen to enjoy basic medical and health services. But it still have greater disparity with the efficiency of hospital service system of the western countries. The object of study would be the hospitals which conducted by Hunan government in this paper. By studying the aim, quantity, construction and network layout, cost and social effects of the hospitals managed by government, I will clarify the social functions of the action, predict the quantity and scale of the hospitals which will be establishing by Hunan government in the future five years as well as putting forward policy hospitals in the next five years in Hunan area according to the requirements and the dynamic changes of the disease. Based on it, I put forward the new idea of government financial input to the hospital, estimating the level of financial input to the government of Hunan province to the hospital in the next five years and making policy Suggestions about establishing relatively perfect hospital finance compensation. and providing reliable reference frame for regional health plan in Hunan province.MethodsThrough the study and summary of the historical documents, this research build a new research framework; According to the factors affecting the current social function implementation of public hospital, we reclassified classification positioning of the social function of public hospitals; we designed of the public hospital information collection form, and made a sample survey of more than35secondary public hospitals to get the basic data of operating information in Excel to create original database; Using the quadratic exponential smoothing model and single sequence first-order grey dynamic model GM (1,1) forecast residents demand for medical services; Using literature and expert consultation method to determine data envelopment analysis (DEA) evaluation index of public hospitals in Hunan Province, at the same time using DEA CCR model and BCC model of relative efficiency evaluation sample hospitals, and the sort of situation according to the results of the evaluation to determine the proper size value of various types of public hospitals at all levels in Hunan Province; Using quadratic exponential smoothing model and DEA CCR model and BCC model to predict public hospital financial compensation level of Hunan Province in2013.Contents and Results1The theoretical and practical foundation of the suitable scale and financial indemnity mechanism of the public hospitalFirst, I discussed some basic concepts related to this research, such as reinterpreting the connotation and extension of public hospital. From the perspective of public administration, I reexamine the connotation and extension of’public’in the’public hospital’, believing that the emphasis of’public’in the’public hospital’should rest on the achievement of public interest or common interest instead of struggling too much on the subject of public hospital. No matter who conduct the public hospitals, any non-profit hospital aiming at public interest can be called as public hospital. In other words, public hospitals are those non-profit health care organizations held by different social subject, aiming at serving social public interest. Such a definition has broken through the traditional conception of public hospital, expanding its connotation and extension. The interpretation of the appropriate scale of hospital, not only considering the analysis of suitability degree on monomer hospital vertically and horizontally, but also discussing the suitability degree of public hospital vertically and horizontally on the basis of regional health service planning. At the same time, based on the appropriate scale of public hospital, public hospital added the content of financial compensation. For an instance, the financial compensation to hospitals should include not only direct input, but also policybenefits.Second, theoretical basis for government to establish hospitals are teased out and the boundary of social responsibility of it are confirmed on the basis of the analysis of practical difficulties. There are three theoretical basis for government to establish hospitals:firstly, social contract theory which based on guaranteeing the rights of life and health of citizens; secondly, the public goods theory which based on the basic requirement on health care products for citizens; thirdly, the human capital theory which based on the demand of capital accumulation for national development. Although it is the responsibility for government to establish hospital, there are four problems faced when our government are trying to do its job:the first problem would be the ambiguity of the social functions for government operating hospitals, which directly result in that the public welfare nature go away; the second problem is that too little financial investment and financing channels caused that the operation for hospital realizing its public welfare nature lacks enough funds; and the third challenge is that excessive mercerization lead to the tendency of clustering and chasing interests under the circumstances of the inadequate development of market economy; the last problem is that government plays two roles at the same time-athlete and judge, which makes the hospitals lack of effective supervision. There for, the boundary of responsibilities for government establishing hospitals should include: locating the social functions of public hospitals, channeling social capital into public hospitals, confirming the suitable scale and the network layout of public hospitals, and reinforcing the construction of supervision system of public hospitals. Third, systematically elaborate the theory of the scale of public hospital. the scale of public hospital is divided into two aspects, lengthways scale and the horizontal scale. The main theoretical basis of setting the lengthways scale is transaction costs theory, while the horizontal scale setting basis is scale economy and scope economy theory.The last but not the least, describe the theoretical and practical basis of the construction of public hospital financial compensation mechanism. The property of health care products show that under the circumstance of market economy, only government using its strong financial resources can satisfy the need of people for pure public health service products. The products could be offered by different subjects, entirely by government, totally by market, even both. But what is worth noticing is that no matter offered by government or by market, both exist the possibility of invalidity. The reality proved that there exist serious problems about the pattern, level and mechanism of financial compensation that our government provide to hospitals, which force the government undertake comprehensive reform to hospital system.2The Social Functional Orientation of Public HospitalThe existence value of public hospital lies in its social function that their own ability of supplying medical services and market regulation can have positive effects through meeting people’s needs of medical treatment and health services. In other words, one of the functions of public hospital is manufacturing and supplying public medical treatment and health services. On the social function of public hospital, the public hospital’s social function has been divided into four or five parts by some domestic scholars from the perspective of its public nature and service function. However, the main problem is that the realization of its social function doesn’t depend on its overall positioning. Since different public hospital has different structure and composition, thus, they have shown different features and functions. Under the premise of upholding the overall function of public hospital, according to the sprint of our national health care reform, combined withdifferent kinds and levels of public hospital’ sactualsupply capacityandpeople’s actual needs ofpublichealth services, this study reconstructs public hospital’s function by category and level. For instance, the first-class hospital is mainly responsible for the diagnosis, treatment and prevention of general population; the second-class hospital is responsible for High-risk groups’diagnosis and treatment; the third-class hospital is responsible for special populations’ treatment.3Analyses on the Appropriate Development Scale of Public Hospital in Hunan ProvinceHunanProvince, as a predominantly agricultural province in central china, not only its Level of economic development (GDP) and total population are Always in the forefront of the six central provinces but its residents’demand for medical services is equally at the forefront of the six central provinces and even the whole country. Therefore, TakingHunanProvince as an exampleto studythe suitability of the scale of government-run hospitals and their financial compensation mechanism is representative. In face of its people’s huge demand for medical services, how should governments at all levels of Hunan Province do to ease the contradiction between people’s demand for medical services and public hospital’s supply? From the view of management, there are lots of effective solutions to solve this contradiction and to expand or reduce the production of hospital is considered to be one of the most effective actions under the condition of market economy. Thus, this section makesa prediction on public hospitals in HunanProvince on its scale efficiency and the scalewhich the next five years they should reach. The study shows that the growth of total number of public hospital in HunanProvince is going to be up to92%from2010to2015. That is to say, the average annual growth is about15%. Among them, the number of third-class hospital can still be increased about53; the total required number of registered nurses of public hospital is approximately97,591; the registered physician number is about50,582-55,179; the actual demand for pharmacists, technicians and other technical staff is about16,296.16,296.18332.40; thetotal number of beds of nonprofit hospitals (here mainly refers to the public hospital) will reach338,869.In order to prove the above growth of public hospital and The suitability of a single hospital size, this research uses sample survey on28public hospitalsin Hunan Province of their relativeeffectswith dataenvelopment analysis (DEA). We find that among all the19general hospitals (TCM hospitals included),7hospitals’DEA is ineffective or inefficient, accounting for36.8%; of all9specialty hospitals,6hospitals only get1in their overall efficiency, pure technical efficiency and scale efficiency values, accounting for66.7%;2hospitals’returns to scale is increasing and the remaining1hospital’s return to scale is decreasing. Through the input redundancy analysis on all these DEA ineffective and inefficient hospitals, we find thatdemand for various input(human, finance, material) of the hospital is expanded in varying degrees. Meanwhile, according to the scale efficiency value of hospitals of different classes and levels, we predict the appropriate numerical range of scale efficiency value of general hospitals and specialist hospitals in areas suitable scale value in the next five years:the beds number of comprehensive tertiary hospital should be controlled below1200; the appropriate beds number of comprehensive second-class hospital should be controlled at the range of300to500and it may not be able to work if the number is More than500or less than300.In order to verify the reliability of the results, this study also predicts the residents’ total demand for medical services (the patient amount of the4county hospitals) of4county hospitals (the second-class hospital) in Zhuzhou city, a reform pilot point, from2013to2017by use ofthe data processing system (DPS). The prediction shows that the4counties’total demand for medical services and the suitability of hospital scale development in HunanProvinceare generally consistent with the previous forecast. From2013to2017, the total patient number of the4county hospitals will be479,756、510,716、582,331、664,058and757,312. 4Researches on Financial Compensation of Public Hospitals under the Context of the New Medical ReformGenerally, lack of financial investment in public hospitals and unreasonable"drug-maintaining-medicine"compensation mechanism are considered to be important reasons of the contradiction between medical services and supply. This unreasonable system can be traced back to wrong understanding. At the beginning of reform and opening up, our country’s concept of financial investment in public hospital is "efficiency is priority and the justice should also be taken into consideration"(at this time, justice equals equality), however, the contradiction between service and supply have not been solved even under the guidance of this concept. There is still a lot of difficulty in satisfying Chinese medical demands and hinderthe sustainable developmentof public hospitaland achievement of fair medical care. Through the philosophy analysis on the relationship among fairness、 equality and efficiency (equity and efficiency are required to and able to achieve the high degree of unity in philosophy, while, if we try to achieve the high unity of fairness and efficiency in philosophy, we will realize that it’s only our moral ideal. Sincethere is a hugegapbetweensubjective and objective in reality), combined with the analysis on our government’s financial investment concept of "Efficiency is priority and the justice should also be taken into consideration" in public hospital, this study comes up with a new concept of financial investment in public hospital: justice is priority and the fairness should also be taken into consideration.Under the guidance of the above concept, this research makes a sample survey of financial investment of572comprehensive public hospitals of Hunan Province; with the help of time seriesanalysis andDEAsuper-efficiency slack-based evaluation model and according to the positioning of the social function of public hospitals and the current country’s project of financial compensation to public hospital, takingthe amount of medical services in hospital, namely, the volume of Outpatient, emergency and hospital, as the dependent variable and taking the expense of manufacturing and providing public medical service goods(The so-called Policy expenditure)as the independent variable, this essay estimates the compensation amount of the so-called policy loss of public medical hospital in Hunan Province. Besides, take the retirees fees and expense on hospital infrastructure and large-scale investment in equipment purchase and input in the construction of key disciplines、 the public health grants which hospitals undertake、the fee onEmergency treatment, foreign aid, agriculture aid and frontier aid, etc which government prescribed, this essay calculates that the total amount of financial compensation in public hospitals of Hunan Province in2013will likely reach10billion Yuan.Conclusions1. Holding public hospital is government’s responsibilities, and to fix on the periphery of government’s accountability is of vital importance to improve benefit of government held hospitals.2. The value of public hospital exists in its social function, and classifying of public hospitals’social function is one of the important elements to keep up public hospitals’public benefit.3. In the next five years, the suitable scale of tertiary public hospital in Hunan Province should be controlled about at1200beds, which is300-500beds concerning with secondary public hospital.4. The concept of justice is priority and the fairness should be the new guidance of financial investment in public hospital of Hunan Province.5. The total amount of financial compensation in public hospitals of Hunan Province in2013will likely reach10billion Yuan, so the local government should strengthen financial investment to public hospital.更多还原