【作者】 王晓玲；

【导师】 邓大松；

【作者基本信息】 武汉大学 ， 社会保障， 2010， 博士

【摘要】 健康是人全面发展的基础,医疗服务与人的生命健康紧密相关,各国政府均在不同程度上对医疗服务市场进行规制。我国医疗服务领域在向市场经济体制转变的过程中,出现了一系列令人忧心的现象,集中体现在“看病难、看病贵”。针对我国医疗服务市场存在的种种问题,学术界对医疗服务市场是否需要规制、规制什么、怎样进行规制以及如何选择有效的规制方式和提高规制有效性等问题,至今尚未达成一个明确、一致的认识,关于医疗服务领域政府规制的研究也因此而成为社会各界所关注的焦点。基于上述背景,本文以狭义的医疗服务市场(即疾病医疗服务市场,有别于公共卫生服务和特殊医疗服务)为对象,坚持从一般到特殊、从理论到实践的基本分析思路,运用理论构筑与理论应用相结合的分析方法,对医疗服务政府规制的相关问题进行了探究,力图建立一个较为完整的医疗服务规制体系构建的理论框架,为中国医疗服务市场规制改革提供理论和政策参考,这无论在实践上还是理论上都显得十分必要,也是本文研究的动机和归宿。本文由引言、六章和结束语组成。引言提出了选题背景、研究的理论意义和现实意义,对国内外在该领域的相关文献进行归纳,介绍文章的研究思路、研究方法和可能的创新之处和不足之处。对医疗服务市场规制体系的构建进行研究,首先需要回答医疗服务领域是否需要进行规制的问题。第一章在对医疗服务市场规制的内涵、特征及方式进行阐述的基础上,从公共利益、特殊集团利益以及规制者利益的角度对医疗服务规制的动因进行分析。公共利益理论在假设政府是“公共利益的代表”前提下,以市场失灵作为一个主要依据分析政府规制的必要性,并提出了相应的规制政策；而特殊利益集团理论则认为政府也是一个“经济人”,很多时候会被特殊利益集团所“俘获”而使政府规制不是出于公共利益,而是被规制者的利益。站在规制者的角度,规制的供给产生了权利租金,使规制者能够获得经济上的利益。同时,规制所承诺的社会福利的提升也使规制者能够获取选票的支持,从而获得政治上的利益。在医疗市场中,由于各种形式的市场失灵广泛存在,使其偏离于完全竞争市场,对医疗市场进行规制既是纠正市场失灵的客观需要,又是维护公民健康权、平等权的基本要求,同时也要看到存在利益集团俘获和政府规制失灵的情况,因此需要对规制者进行规制,这也是完善政府规制的一个很重要方面。在回答医疗服务市场是否需要规制这一问题之后,在第二、三、四章进一步就“规制什么”、“怎样规制”和“如何提高规制有效性”进行了深入分析。第二章对医疗市场规制体系的构成及运作机理进行了分析。在进入规制方面,分别对直接进入规制和间接进入规制进行了分析。首先界定进入规制的对象,然后对传统经济学理论在理性经济人假设下的过度进入原理提出质疑,从行为经济学视角论述了有限理性是造成过度进入的原因,但这并不是政府实施直接进入规制的充分条件,直接进入规制很可能是低效的。接着,从信息经济学的视角论述了间接进入规制具有替代企业建立基本声誉的作用,比直接进入规制具有更大的优越性。但过度的间接进入规制同样会滋生腐败和寻租,阻碍医疗服务市场的运行。在价格规制方面,首先分析了医疗服务价格的构成,主要价格水平规制模型的特点以及当前医疗服务价格水平规制的发展趋势；其次通过借鉴拉姆赛定价的基本思想,指出考虑到医疗服务价格弹性的差异,政府应该针对不同的医疗服务、不同地区、不同人群制定一定差别的规制价格,从而形成有利于提升社会福利的价格结构。最后,通过分析不同费用支付方式对医疗支出和医疗质量的影响,提出应该将不同支付方式结合使用的方式来调节和规范医疗服务提供者的行为。在社会性规制方面,着重分析以客户满意度为核心的医疗服务质量监督机制、医疗伤害责任制度、医疗信息披露制度、社会医疗制度和医疗救助制度的运作机理。第三章主要论述医疗市场规制方式的选择。这一章首先运用巴泽尔的产权理论分析了公共领域的存在是市场失灵的根源,然后结合医疗服务产品经济属性的分析,将医疗市场的规制边界区分为三个层次的公共领域,并论述了不同层次的公共领域所应该选择的规制方式。在产权界定成本较低的公共领域,可放松直接经济性规制：当产权虽然可以界定,但界定的各种交易成本很高或由于其它原因而使产权模糊不清的区域,在放松直接规制的同时,要完善间接经济性规制；在产权因技术原因或成本的原因而没有界定或无法得到界定的区域,应该由政府提供直接的社会性规制。最后,指出政府规制、市场竞争与规制方式选择的相互关系：缺乏有效竞争的医疗市场难以运转；缺乏有效规制的医疗市场无法持续；规范医疗市场主体行为应该采用能保持有效竞争的间接规制方式；要实现医疗服务公平性、公益性需要强化直接社会性规制。第四章主要回答如何提高医疗市场规制执行有效性的问题。首先,分析规制机构的运行机制。政府规制职能是通过具有独立性的规制机构来施行的,一国的规制机构采取何种设置模式,取决于市场发育及法律的完善程度、政宪制度和行政文化因素的影响以及规制机构的设置成本。由于独立性较高的规制机构一般具有准立法权、准司法权和行政权,为了防止权利的滥用,需要通过其它行政机构从各个渠道对规制权利进行制衡和监督,加强对规制者的规制。接着,阐述了医疗服务市场规制有效性的涵义及分类。规制有效性包括了规制效果和规制效率两个方面,当规制者加强规制时所增加的成本并不高,但是却能对被规制者违规的成本产生很大的影响,此时的规制既有效果,又有效率,实现了最佳规制。最后,分析了影响规制执行有效性的主要因素,分别是规制执行的外部环境、规制参与主体间的博弈、医疗信息化建设等。在对医疗服务市场政府规制的构建进行一般性规范分析之后,第五、六章着重对中国医疗服务市场规制的相关问题进行了应用研究。第五章首先对中国医疗服务规制实践的历史变迁、特点和现行规制体系进行了较为系统的分析。接着,从医疗服务公平性、医疗服务费用控制、医疗服务供给能力、医疗服务效率四个方面对规制绩效进行了分析。改革开放以来,我国已初步建立起了医疗服务的政府规制体系,在保障人民健康、促进社会发展方面取得了一定成效,但也存在不少问题。导致这些问题的成因是政府在医疗领域的行政垄断并未消除、间接规制有待完善、社会性规制不足以及规制机构运行低效。第六章提出了重构中国医疗规制体系的目标、原则和基本思路。医疗规制的目标是保障公平与正义,促进健康和发展,提升医疗资源的利用效率。针对目前我国的实际情况,重构规制体系需要依据规制有据、经济适用、公益性和政府规制和市场竞争相结合的原则。规制重构应该采取以健康为核心的“规制—竞争”模式,基本思路是：消除垄断性规制、完善间接规制、强化社会性规制、加快规制机构改革。更多还原

【Abstract】 Health is a basic condition for the full round development of a personnel. However, medical service, in large extent secures the human’s life and health. So it is regulated in varying degrees by every country in the world. However, the particularity and complexity of medical service market make it a global difficulty in government regulating. Therefore, how to build a scientific regulation framework and regulatory system becomes a deep concern to the public and the policymakers.Accompanying with medical reform in China, the variety of unsatisfactions is encountered, which mainly focuses on the difficulties and high cost to "see a doctor". Although diverse ideas and solutions are proposed, no common consent has been reached on how to, what to regulate medical service and how to ensure its implementation. Therefore, the research on the construction of government regulation system in medical service market attracts the attention of society.Based on the background mentioned above, this article is centered on constructing regulation system for medical service market, more definitely narrow sense medical service market (or the public health and special health service is excluded). Following the analyzing path, from general to special, from theory to practice and focusing on study subject, the theory and methodology of establishing medical regulation system is explored and theoretical basis and policy reference are raised. Its significance is both in theory and in reality.This article is consisted of the introduction and six chapters. In introduction, the significance of the subject is stressed by reviewing published literatures on similar subjects. Also studying methodology, innovation proposed and thesis structure are represented.In chapter one, the necessity for medical care regulation is analyzed theoretically. Based on the definition of related concepts, the causes of regulating are searched by applying the public interest group theory, special interest group theory and regulator interest theory. By using public interest theory regarding the government as the representative of public interest and failure of market function, the necessity for regulation is itemed and corresponding treatment policies are represented. Special interest group theory regards the government as an economic man. It would be captured by the Special interest group which makes the regulation not for the public interest but for those who are regulated. The regulator would gain economic benefit by rent seeking which was generated by the power of providing regulation. At the same time, it would gain political interest by promising the voters to increase the level of medical welfare. While many sorts of market failure exit in medical service market, the regulation is the objective needs to correct market failure. At the same time, the existence of special interest group capture and government failures shall be realized. Therefore there is also an objective need to regulate those who regulates.Chapter 2 analyzes the institutional mechanism of the medical service regulation. By comparing the mechanism between direct and indirect entry regulation, it is indicated direct entry regulation would result in corruption, rent seeking and no activity for innovation. While indirect entry regulation has more advantages over the direct regulation if the appropriate intensity is given. As to the price regulation, firstly the characteristics of different kinds of price level regulation models are summarized and the subject of rational cost imbursement under price level regulation is discussed. Secondly, on the basis of principle of Ramsey Pricing, it is described the government should establish different price system for different medical care service, different region and different patients based on the different demand elasticity. Thirdly, the economic analysis of incentives of different medical care provider payment systems is advanced and indicated diverse payment methods to regulate and standardize the behavior of health care providers shall apply collectively. As to the social regulation, the attention is paid to the mechanism of medical service supervision system, medical injury responsibility system, medical information disclosure system, social medical insurance and medicaid system and it is indicated that the social regulation is increasingly important to the regulation system.Chapter 3 discusses the manner selection of medical service regulation. Firstly we use the Property Rights Theory of Barzel to analyze the root of market failure, and then allowing the economic attributes of medical service, divide the regulation boundary into three parts of public domain, discuss the different selection of regulatory manner according to the different part of public domain. Direct economic regulation may be released in the public domain that the cost is low in the property right demarcations. Indirect economic regulation should be perfect while releasing the direct economic regulation when the cost is high or ambiguous region occurs during the course of property transaction. Direct social regulation should be provided by the government when the property right could not, or difficult to transfer by high transaction cost. Finally the relationships between regulation, competition and the manner selection are expounded.Chapter 4 gives the answers to how to increase the efficiency and effectiveness of regulation. Firstly, the running mechanism of the regulation executing is analyzed. The government regulation function is carried out by the organization that has relevant independence. The setting mode selection of the regulation organization depends on the growing level of market and the law maturity, political system and administration culture, organization setting cost. The independent regulation organization has quasi-legislative power, quasi-judicial power and administrative power, so it should be counterbalanced or supervised so as to avoid power abuse. Then, the intention and the classification of regulation effectiveness are discussed. The effectiveness includes both the regulation effects and regulatory efficiency. The optimal regulation shall be the regulation with less cost for regulating and having strong impact on those who violates the regulation. Finally, the main factors that affect the effectiveness of regulation are analyzed, that is the outside environment of execution, the behavior of regulation participant and the medical information construction.After a general normative analysis of the construction of medical service regulation, the following Chapter 5 and 6 focus research on the related problems of Chinese medical service regulation. Chapter 5 firstly systematic analyzes the history change, its characteristics and existing system of Chinese medical service regulation. Then, from four aspects of medical equity, cost control, supply capacity and running efficiency to evaluate the performance of Chinese medical regulation system. After the open and reform policy, medical service regulation system has been established in China, some effects have been achieved in ensuring human health and promoting economic and social development, but still many problems occurs. The causes of those problems are that the government enables to eliminate the administrative monopoly, further improve the indirect economic regulation, provide sufficient social direct regulation and enhance the systematic running efficiency.Finding the root of the problems, Chapter 6 puts forwards the objectives, principles and some suggestions on the reconstruction of Chinese medical service regulation system. It stresses that the ultimate aim of medical market regulation is to guarantee people’s fairness and justice, promote health and development, and increase the efficiency of medical resource allocation. According to the reality of China, the reconstruction of medical market regulation should follow the principles of accordance with laws and rules, affordable, public welfare and the combination of regulation and market competition, elimination of the monopoly regulation, improvement of indirect economic regulation, strengthening of the social regulation and speeding up the reform of regulatory organization.更多还原