【作者】 陈颖；

【导师】 杨临宏；

【作者基本信息】 云南大学 ， 行政管理， 2021， 博士

【摘要】 党的十九大报告提出“新时代我国社会主要矛盾是人民日益增长的美好生活需要和不平衡不充分的发展之间的矛盾”。我国进入老龄化社会后,老年人的医疗、护理、康复、心理辅导需求与日俱增,但是在医疗服务供需矛盾以及医疗与养老资源互不衔接的背景下,“医养结合”是我国实现健康老龄化的必然选择和理想模式。政府跨部门协同被广泛运用于研究各种跨部门和跨界的由单一公共部门无力解决的公共性事务。本文研究的“初心”是将这一经典理论运用到推进我国医疗卫生服务与养老服务相结合的医养结合发展问题上,探讨如何通过行政管理体制变革和公共政策、服务组织的协同,实现两大社会服务体系从分离割裂走向连接融合。围绕以上问题,本文遵循整体性治理研究的传统路径“碎片化——棘手性问题——协调与整合”,按照“问题溯源——变革实践——协同棘手——协同政策工具与部门网络——域外借鉴——对策建议”的逻辑主线设计论文研究总框架。运用社会调查和多案例研究、政策工具分析、社会网络分析等方法开展研究,研究内容包括我国医养分离生成的行政体制与政策审视、医养结合养老服务的变革实践、医养结合养老服务跨部门协同困境的现状考察、医养结合养老服务跨部门协同的政策工具和协同网络分析、域外代表性国家改革健康行政部门和推行整合照料的经验借鉴以及我国健康领域跨部门协同机制建构六个方面,形成如下的结论和建议:首先,医养结合的难点、痛点在“医”不在“养”。回顾我国近40年的医疗卫生体制改革,就是一场破除医疗、医药、医保“三医”存在的管理体制分化和公共政策碎片化弊端的改革,这些弊端是造成医养分离状况的制度性土壤和环境。在医疗和养老领域迫切需要运用跨部门协同的思维与策略进行一场从行政体制到公共政策的变革。上海、山东青岛等地政府进行的医养结合政策试验,开启了一场打破过去医疗和养老政府部门单项分头推进政策的方式,通过家庭医生签约服务和社区医养结合、长期护理保险等制度整合和创新医疗服务和医疗保障的管理体制、政策体系和运行机制,强化政府在医疗和养老领域的主导作用和保障责任,实现医疗和养老公共政策的协同性,最终促成医养结合从试点上升为国家政策在全国范围内推进。第二,医养结合的类型学分析认为,医养结合不是医疗机构或者养老机构“不分专业”的“大而全”,也不是医疗机构和养老机构被行政化的“拉郎配”,而是从机构到社区再到居家的一个连续、协调、便利的服务递送体系,能够实现长期护理保险资金覆盖全民,失能失智人群精准定位,定点机构全人全责综合服务,国家和个人养老责任合理分担,以及健康管理、慢病、长期护理、社会救助信息服务整合共享的老龄健康服务目标。第三,政府在推动医养结合发展中的跨部门协同失灵表现为行政不作为、自作为、乱作为和难作为四个维度上的职能悬浮、政出多门、权责失范和壁垒、协同乏力、规制受限与缺位五种现象。具体通过卫生健康行政部门内医养结合职能部门权能不匹配、医养结合机构准入行业标准设置过高、享受财政补贴的医养机构存在差异、医养结合地产项目违法、地方政府卫生事权与财权不匹配、地方政府领导分工“医养分管”等一系列事(案)例展现出来。作为医养结合政策的一线执行者,医养结合服务组织同样也面临着来自合作利益、资源依赖和公私合作所有制鸿沟等合作障碍,导致医养签约合作、医内设养、养内设医三大医养结合类型遭遇各具自身不同特点的跨界合作困境。第四,从医疗、医药、医保和社会化养老四个跨部门的管理与服务体系的医养结合政策工具使用情况看,医养结合公共政策的供给存在部门之间严重的不均衡态势,呈现出“过度倚重医疗、各家推进不一、政策空白较多”的局面,说明我国医养结合发展路径尚处于医疗卫生系统内部的服务机构与流程的自我完善阶段,具有一定的部门封闭性。此外,在政策内容上过度依赖规划策略,对基础设施、财政投入、筹资、金融、税收等配套性政策供给不足,医养结合深入推进亟需依靠跨部门的政策协同供给。随后采用社会网络分析法(UCINET软件)构建以政策文本任务分工为依据的政府部门网络和以实际协同过程中协同机制开展情况为依据的政府部门网络,测算两个网络的密度和部门度数中心度并绘制协同网络结构图。研究有助于对政策工具分析的结果进行交互印证。卫生健康部门处于网络中心位置,任务高度集中,与政策工具分析中来自医疗管理与服务体系中的政策供给数量最多相互印证,支持了“当前医养结合发展仍处于卫生健康部门系统内部自我完善的阶段”的基本论断;但是卫生健康部门没有形成明显的协同机制控制力,医养结合的协同活动仍然处于多部门中心的分散状态。医疗保障部门、工信部门虽然在任务分工处于中等规模,但在协同机制中成为活跃行动者,而金融、税收、志愿者服务等支持性部门在任务分工和参与协同行动方面都处于边缘不活跃状态,支持了环境型政策工具过度依赖“规划策略”,金融、税收等配套政策存在供给不足的研究结论。第五,英国、美国、德国、日本通过老年人健康权益保障立法、行政管理组织整合、公共筹资政策整合、整合照料服务机制等一系列改革和制度设计,致力于解决老龄化社会普遍存在的医养分离顽疾,可供借鉴的经验有:组建健康福利大部制和老龄管理部门实职化,实施长期护理保险体现老年失能护理的独立性和综合性,建立医养服务接续性连接组织、多学科服务团队和信息平台。最后,针对医养结合领域存在的跨部门协同失灵,提出改进协同机制的建议:根据部门资源实质化原则,在卫生健康部门和民政部门重新划分医养结合的管理事项职责,实现职能与权能相匹配;根据改革同步性原则,加快医疗、医药、医保“三医联动”,尤其是基本医疗保险和长期护理保险的改革滞后于医养结合的发展实践;根据健康治理大协同原则,建立立法、行政、司法三大机关“链接式”的健康大协同,实现权力的监督制约;根据扁平化分权和中枢型连接组织的原则,提出设立国家健康委员会、国家健康服务质量监管委员会、地方健康和社会福利促进委员会的机构设置设想,提升健康部门的协同领导力。在促进医养服务组织跨界合作方面:围绕“以人为本的整合型卫生服务”目标,构建由医疗资源、康复资源、照护资源、社区服务资源、志愿者资源等组成的整合性服务网络。在协同保障方面:构建一个由法律、行业标准、示范性文本等组成的综合性配套医养结合标准化工具体系,有助于政府跨部门协同具有制度约束力和操作性。本文可能的创新之处在于:第一,通过个案跟踪观察发现政府推动医养结合跨部门协同和服务组织跨界合作中存在两个具有中国情境的现象——“机构改革后的协同棘手内部化”和“医疗养老公私合作所有制鸿沟”,提出根据部门资源实质化原则,在卫生健康部门和民政部门重新划分医养结合的管理事项职责;依据医疗卫生事业公益性原则,政府应当通过跨部门的政策协同供给重点扶持非营利性医养结合机构发展。第二,采用政策工具聚类定量分析,从文本内容的微观视角展现来自“三医”不同部门的政策供给的非均衡状态,揭示医疗、医药、医保“三医”在推动医养结合中政策协同的短板和改进方向。采用社会网络(SNA)结构分析从宏观视角展现医养结合跨部门协同的部门构成、协同任务的紧密程度和协同行动实际开展状态。第三,建立我国健康领域中枢型多部门联席协调部门,其中国务院组建国家健康委员会、国家卫生健康委员会下设国家健康服务质量监管委员会以及地方政府设立健康和社会福利促进委员会的设想为未来我国健康领域的政府机构改革提出前瞻性的建议。更多还原

【Abstract】 The Report to the 19 th National Congress of the Communist Party of China pointed out that the principal contradiction facing Chinese society in the new era is that between unbalanced and inadequate development and the people’s ever-growing needs for a better life.After China entered the aging society,the needs of medical care,nursing care,rehabilitation and psychological counseling for the elderly are increasing with each passing day.However,under the background of contradiction between supply and demand of medical services and non-connection between medical and social care resources,the combination of medical care and nursing is an inevitable choice and ideal model for realizing healthy aging in China.The cross-agency collaboration of government has been widely used in a variety of cross-departmental and cross-boundary public affairs that cannot be solved by a single public sector.The primary purpose of the dissertation is to apply this classical theory in aged care with medical service,and then discuss how to achieve the integration of the two from separation to integration by reforms of administrative management system and collaboration of the public policies of and service organizations.Centering on the above problems,the dissertation follows the traditional research path of Holistic Governance Theory "fragmentation--intractable problem--coordination and integration ",and designs the overall research framework according to the logical main line of " exploration of the problem source--reformation and practice--intractable problems from collaboration--collaboration of policy tools and departmental network--foreign experience--measures and suggestions".The study is based on research methods of social research,case study,policy tool analysis,social network analysis,comparative study etc.It is divided into six parts: administrative system and policy review of separation of medical service and social care,reformation and practice of the aged care and medical care integrated modes in China,intractable problems during collaborative process,governmental policy tools use and different administrative departments collaborative network analysis,the reforms experience on the administrative department of health and integration social care from foreign countries and the cross-agency collaboration mechanisms in the health governance.The following conclusions and recommendations are formed through the above studies:First of all,the key and sore point of combination of medical service and elderly care is the former not the latter.Review the process of China’s medical and health system reform in the past 40 years,China’s medical and health system reform is a reform to get rid of the disadvantages of management system differentiation and public policy fragmentation existing in medical,pharmaceutical and medical insurance.These disadvantages are institutional soil and environment causing the separation of medical and social care.There is an urgent need to use cross-agency strategies to transform the administrative system to public policy in the field of health care and elderly care.The local government in Shanghai,Shandong Qingdao have been carrying on policy experiment which opened up a break in the past health and pension separately promoting policies from government agencies,for example the family doctor service,social nursing care in community and long-term care insurance system which integration and innovation of the medical service and health care management system,policy system and operation mechanism.The practice has strengthened the government’s leading role,guaranteed responsibility in the medical and old-age care fields and realized the synergy of public policies on medical and old-age care,so that ultimately promoted local policy pilot into a national policy.Second,through typological analysis,the aged care with medical service does not mean that medical institutions or gerocomium do not make any distinction,nor is it a compulsory combination of medical institutions and gerocomium by administrative means,but a continuous and coordinated service delivery system from institutions to communities and then to families.This reflects the convenience of service organization reconstruction and one-stop service delivery based on the needs of the elderly which achieve long-term care insurance fund use concentration at the same time,accurately determine the position of the people who lose intelligence or ability,comprehensive service organization,national and personal pension liability reasonable sharing,health management,chronic diseases,long-term care,social assistance information service integration for the elderly health services goals.Third,the failure of cross-agency collaboration in development of the aged care with medical service is manifested in four dimensions: administrative inaction,self-action,disorderly action and difficulty in acting which manifested suspension of functions,multiple policies,anomies and barriers of power and responsibility,lack of coordination,restriction and absence of regulations.Specific things(cases)showed as followed:through the health administrative department function not match,institutional access industry standards setting too high,allocating the financial subsidy agency indiscriminately,real estate project development illegal,local government health authority and financial ability mismatched,local government leadership division unreasonably.As the direct practitioners of the policy,combination of medical and nursing services are faced with obstacles such as cooperative interests,resource dependence and public-private partnership.As a result,medical and gerocomium agreement cooperation shows unilateral enthusiasm,public hospitals lack enthusiasm for setting up nursing institutions,and the medical institutions set up by nursing institutions only serve minority groups.Fourth,policy tools use from the medical treatment,medicine,medicare and social elderly care four cross-department management and service system,public policy supply of the aged care with medical service exits serious imbalance between departments,presents a "excessive reliance on medical,promote differently and policy blanks",shows that development path is still in the medical and health system internal service institutions and self-improvement process with Departmental closure.In addition,it relies too much on planning strategies,and the supply of supporting policies for infrastructure,financial investment,financing,finance,taxation and other policies is insufficient.The the aged care with medical service requires the need of cross-departmental policy coordinated supply.Subsequently,the social network analysis method(UCINET software)was adopted to build a government department network based on the division of policy text tasks and a government department network based on the collaborative mechanism in the actual coordination process,to calculate the density and departmental degree center of the two networks and draw the collaborative network structure map.Research can help to interactively confirm the results of the policy tool analysis.The health department is at the center of the network,with highly concentrated tasks,and the maximum number of policy supply from the medical management and service system,which supports the basic conclusion that "the current development is still in the stage of self-improvement within the health department system",but the health department does not form an obvious coordination mechanism control,the coordination activities of medical and social care are still in the multi-department center dispersion.Medical security department,industry and information department in the division of tasks in the medium scale,but become active actors in the coordination mechanism,and finance,taxation,volunteer services and other supporting departments in task division of labor and collaborative actions in inactive state,support the research conclusion that environmental policy tools rely on "planning strategy",but finance,tax and other supporting policies supply inadequately.Fifth,The United Kingdom,the United States,Germany and Japan have taken a series of measures,including legislation on the protection of the health rights and interests of the elderly,integration of administrative organizations,integration of public financing policies and integration of care service mechanisms,to solve the common problems of separation of medical service and social care in the aging society.The experience for reference is as follows: establishment of a large department of health and welfare and a full-fledged department for the management of the elderly,implement of long-term care insurance to demonstrate the independence and comprehensiveness of the care for the elderly,and establishment of a certain amount of continuous connection organization of medical and social care services,multidisciplinary service teams and information platforms.Finally,suggestions on improving the cross-agency collaboration mechanism of the the aged care with medical were put forward: according to the principle of substantive department resources,the management authority within the health department was redistributed to achieve the matching of responsibilities and powers.In accordance with the principle of synchronization of reform,accelerate the connection between medical treatment,medicine and medical insurance,and improve the backward status of the reform of basic medical insurance and long-term care insurance.In accordance with the principle of great synergy in health governance,the legislative,administrative and judicial organs should cooperate in health to restrict and supervise power.According to the principle of flat decentralization and central connected organization,it is proposed that the institutional setting of National Health Committee,National Health Service Quality Supervision Committee and Local Health and Social Welfare Promotion Committee to improve the collaborative leadership of health departments.In the aspect of cross-boundary coordination,the medical and social care service organizations build a comprehensive service network composed of medical resources,rehabilitation resources,care resources,community service resources and volunteer resources,centering on the goal of "people-oriented integrated health service".In terms of collaborative security,a comprehensive and supporting standardized tool system for the combination of medical care and social care should be built,which is composed of laws,industry standards and demonstration texts,etc.,which can improve the binding force and practicability of cross-agency collaboration.The possible innovations of this thesis are: firstly,the research reveals two phenomena with Chinese context in the aged care with medical service "internalization of collaboration intractable problems after institutional reform" and "ownership gap of public-private collaboration".According to the principle of substantive department resources,to redivide the management responsibilities on the aged care with medical service between health and civil affairs departments.According to the principle of public welfare of medical and health undertakings,the government should support the development of non-profit medical and nursing institutions through cross-agency policy providing synergistically.Secondly,cluster quantitative analysis of policy tools is adopted to reveal the unbalanced state of policy supply from different departments of medical treatment,medicine and medicare from the micro perspective of policy texts content,and reveal the shortcomings and improvement direction of policy coordination from medical treatment,medicine and medical insurance.The structure of social network analysis(SNA)is used to show the composition of departments,the closeness of collaborative tasks and the actual implementation status of collaborative actions in the aged care with medical service from a macro perspective.Thirdly,establishing central joint-department about health affairs in China,including the formation of National Health Committee of the State Council,the National Health Committee consists of the National Health Service Quality Supervision Committee and the local government setting up a council for the promotion of health and social welfare which are the prospective recommendations for institutional reform in the health areas in the the future.更多还原