【作者】 周毅；

【导师】 李兰娟；

【作者基本信息】 浙江大学 ， 劳动卫生与环境卫生学， 2015， 博士

【摘要】 与世界发达国家及发展中国家相比,中国医疗资源稀缺性和失衡性问题尤其突出。“新医改”实施方案摸石过河,成效甚微。一是医疗资源布局、配置及结构不合理问题尚未根治,医疗资源地域、城乡和人群差别失衡局面依旧,国民健康不确定因素增多,人均医疗资源占有量居于世界下游水平,医疗资源约束性不断增强,难以维持中等发达国家的健康水平。二是银发浪潮压力巨大,财政投入不足,“泛市场化”取向的“旧医改”产生恶果,“看病难看病贵看不好病”等问题普遍存在。三是外部效应导致利益外溢性现象,中央与地方政府之间协同整合效果差,供需双方利益集团内外摩擦,引发各类矛盾,加剧原本紧张的医患供需矛盾,由可为社会所承受到难以承受,市场机制、政策调控、法规契约三法失灵,后续发展空间难以为继。因此,如何调整完善“新医改”实施方案,实现医疗资源均衡发展,是理论与实践都亟待解答的重大课题。在深入探讨医改理论及其相关性辨析基础上,比较分析了中外主要发达国家“新医改”经验教训,与其他相关研究比较,本文主要贡献是：1.揭示医疗体制改革发展一定要适应健康生产力发展矛盾运动规律。比较分析发现,医疗体制改革与健康生产力发展二者之间的关系表现为“基本适应→基本不适应→基本适应”的矛盾运动,健康生产力发展决定医疗体制改革发展,居支配地位,是医疗体制改革发展动力源泉和物质基础,在一定条件下,医疗体制改革发展对健康生产力发展的反作用尤为突出。医疗体制改革发展是健康生产力发展的产物,只有提供足够医疗体制改革成果,健康生产力才能可持续发展。成功经验是根据医疗体制改革一定要适应健康生产力发展规律,实现医疗服务福利均衡化；失败教训是违背医疗体制改革一定要适应健康生产力发展规律,加大医疗布局、资源分配、患者待遇及病种医疗差距,致使医疗体制改革发展失衡。描述中国医疗体制改革轨迹,从建国初期“统包统揽”到改革开放后“旧医改”时期“过度市场化”,再到目前“新医改”时期可能“过度公立化”趋势,致使医疗资源使用效率全球最低、医疗费用全球较高。探讨其从一个极端似乎走向另一个极端的深刻历史背景和纷繁复杂的现实国情。揭示中国“旧医改”“基本不成功”主因是违背医疗体制改革一定要适应健康生产力发展规律,忽视医患之间天然权力关系,违背医疗卫生“反市场化”公益天性；解剖公立医院改革的不彻底性、不完整性及形式主义猖獗,究其“医殇”根源,在于财政约束、路径依赖和特殊利益集团关系盘根错节,强权弱法,传统体制机制根基未根本动摇,加剧医患关系紧张,致使患者灾难波及广大民众,城门失火,殃及池鱼。2.分析公立医院与私立医院改革发展相互作用的辩证关系,论证公立医院和私立医院存在的历史必然性和现实可能性。基于主要矛盾和次要矛盾辩证关系及矛盾发展不平衡性原理,运用全面性视角的两点论及重点论分析,在医疗体制多元化矛盾中,公立医院是主要矛盾,起主导、支配和决定作用。私立医院是次要矛盾,处于从属地位。公立医院与私立医院如鸟之双翼,车之双轮,相辅相成,形影相随,缺一不平,缺一不飞,二者在一定条件下相互转化。阐释私立医院改革发展的开放性、创新性、突破性、竞争性与公立医院改革发展的相对稳定性、保守性、封闭性、约束性矛盾的运动规律。根据强制性公益、强制性私益、志愿性公益和志愿性私益等四种历史必然选择,公立医院、私立“非营利”医院与私立营利医院三驾马车竟相发展是市场配置资源决定性作用的必然结果。私立医院供需双方以市场为主,政府为辅,在市场失灵情况下实行政府干预,通过管控下的竞争提供医疗服务；而公立医院供需双方以政府为主,市场为辅,在政府失灵后引入市场机制提高效率。公立医院志愿选择非营利性公益服务,具有纠正政府和市场双重失灵功能。研究发现,私立非营利医院体现的非分配约束、平等竞争、透明信任和社会参与等组织特性,不仅可协同政府调控和市场机制进行医疗体制结构和功能优化,又能有效降低交易的隐性成本,防止道德风险,在提供多层次和多样化优质服务,尤其是满足低收入人群的医疗需求方面优势明显。3.探寻治理医疗体制“市场失灵”和“政府失灵”有效途径。围绕“钱从哪里来?钱到哪里去?如何用好钱?”议题,针对垄断性、外部性、信息不对称、公共产品供给短缺等问题,对症下药,科学的宏观调控与适度自由的市场调节双轮驱动,协调政府主导资源配置与市场公平竞争关系,医改政策导向性与医疗立法强制性统一,理顺患者就医和医师行医两种行为关系,建立完善社会事业新型法入治理结构和激励约束机制,树立医院品牌,建立健全筹资、付费、医院管理及全科医师“守门人”核心制度,构造“全覆盖多层次低标准”的基本医疗保障体系及弱势群体医疗救助机制,立法确保患者知情权、自愿权、保密权和选择权。坚持医疗文明人道性、公益性、公平性、专业性、预防性、可及性、多样性,提出“新医改”实施方案从特殊性、稀缺性、垄断性向法制化、标准化、均衡化、人性化转型新思路。更多还原

【Abstract】 Compared with most developed and developing countries in the world, China has to deal with the obvious problems of medical system such as medical resources scarcity and unbalanced medical allocation. It is agreed that the previous medical reform scheme for implementation with the character of "touch stone across the river", proved not so successful and needs further reforms with new notions.First, the problems of Chinese medical system have not been properly solved, especially in the fields as follows:the unreasonable problems of the distribution of medical resources, configuration and structure; the radical imbalances among regional, urban and rural medical resources and the population who can obtain the medical services; the increased uncertainty of national health status. In addition, the per capita possession of medical resources in China is in a lower level than those of in many other countries, with medical resources constraint increased and is difficult to maintain the similar healthy level of moderately developed countries.Second, the "grey hair wave" pressure to the medical system is enormous, in addition to the comparatively lack of financial investment on medical industries; the so-called market-orientated of previous medical reform in China did not proceed as expected, resulting in the major problems of difficult and expensive medical treatment in China.Third, it is the major task need to be answered in theory and practice on how to adjust and improve the implementation of "new medical reform", so as to realize the balanced development of medical resources, under the situation that there are external effects leading to the spillover benefits of medical market, and the poor collaboration and integration between the central and local governments. Moreover, the insufficient supply of medical services resulting in internal and external frictions between different interest groups, has caused all kinds of contradictions, exacerbated the already tense of doctor-patient relationship, which may be too cost for the society to bear. So it is important to combine the market, policy regulations and social contracts to obtain sustainable medical development. The dissertation discusses the theories relative to medical reforms based on the comparative analysis of "experience and lessons of the current medical reform" in China and main developed countries. Compared to other relevant studies, the main contributions of this dissertation are:First, reveals the development of medical system reform must adapt to the law of contradictive movement and the productive forces of the medical market. Comparative analysis found that, the reform of the medical system and the productive forces of medical market should keep the rational relations. On the one hand, the healthy development of productivity of medical market determines the development of medical system reform; on the other hand, the medical system reform is the power source and institutional basis, which, under certain conditions, have great effects on the sustainable development of medical market. Description of China’s medical system reform path, from the "turnkey" medical system after the foundation of the People’s Republic of China, to the "old reform "period which laid too heavily on the solely market-oriented system, and then to the current "new medical reform "period which government changed to shoulder more responsibilities, showed that China has been taken great efforts to combat the inefficient, expensive medical systems, and the unbalanced medical resources allocation all over the country. International experiences indicate that it is vital yet difficult to design the good medical systems to keep the balance of the market forces and the public goods nature of medical services.Second, the dissertation discusses the structure of the medical services suppliers who laid the foundation of sustainable medical system. It is the historical necessity and practical possibility that requires the proper allocation between the public and private hospitals to realize the development of new reform. While China has tried to ensure that the in the medical system, public hospital play dominant and decisive role to offer public goods, private hospital, in a subordinate position, will be more market driven to offer the variety of the medical services besides what the public hospitals has offered. In a way, public and private hospitals are as the two wings of a bird, or wheels of the car, to be complementary with each other. In the market condition, the private hospitals try to provide medical services according to the rule of market competition. And the public hospitals supported by the government primarily, should meet the public’s basic health requirements and gradually adapt to certain market mechanisms to improve the efficiency. The study found that many countries’reform experiences can be useful for China to improve medical systems with characteristics of non-distribution constraint, equal competition, transparent and social participation. The new reform aims to promote the private hospitals to work together with the public hospitals by providing multi-level medical services with quality and diversification, and especially have obvious advantages to meet the needs of low-income people’s medical demand. Furthermore, it should not only optimize the structure and function of medical system which is collaborative with government regulations and market mechanism, but also can effectively reduce the hidden costs of trading and prevent moral hazard.Third, the dissertation explores the governance of medical system of "market failure" and "government failure" in scientific way. The effective medical system reform should resolve the basic problems such as questions of "where does the money come from? Where did the money go? How to make good use of the money?" Based on the efficient medical system, the medical system and mechanism reform should make the map road to prevent monopoly, externalities, asymmetric information, public goods supply shortages and other issues. Under the unified medical reform policy guidance and mandatory medical legislation, Chinese medical systems reform should move towards the coordination of government leading resource allocation and fair market competition, straighten out the relationship between patients and doctors’practice, set up and improve the medical enterprise’s model of corporate governance structure, incentive and restraint mechanism, construct mechanism of the full coverage with multi-levels of the basic medical insurance system and medical assistance to vulnerable groups, adopt legislation to ensure the patients’informed rights, privacy rights and freedom of medical choices. Adhere to the aims of medical civilized humanity, fairness, professionalism, accessibility and diversity, the paper puts forward the new medical reform scheme for implementation of transformation with the new principle of legalization, standardization, equalization and humanization.更多还原