政府规制与医疗卫生服务供给的有效性
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摘要
医疗体制改革曾经是许多国家面临的难题。政府在医疗供给层面的规制措施，一是致力于控制医疗服务的价格，二是致力于保证医疗供给的公平性。我国的规制措施在这两方面是否有效?本文选取了医疗服务的递送体系作为主要研究对象，结合我国80年代中期以来进行的医疗体制改革实践，对政府在医疗卫生市场进行规制的必要性、规制措施及其有效性进行了分析，在此基础上进一步研究了政府在医疗服务提供中应当承担的职责，并对我国的医疗体制改革提出了建议。
本文认为，在价格规制方面，我国对于基本医疗服务价格和大型设备检查／药品价格的分别规制，使得作为代理人的医生／医院行为出现扭曲，导致价格规制不仅无助于控制医疗费用的上涨，反而可能作为一种对医院的间接补偿手段产生更大的医疗支出。这种激励的扭曲会为患者带来比只存在医生道德风险和有限责任的次优状态时更大的福利损失，也会降低整个社会的福利。
在公平性方面，以“商业化、市场化”为导向的改革被证明无法解决市场化供给与普遍服务的矛盾，“看病难”的出现正是这一矛盾的集中表现。本文证明，如果将医疗服务完全交由市场提供，由于医疗产品一定程度上自然垄断的特性，一是会导致一部分低收入的消费者被排除在市场之外，二是会使得医疗资源在递送体系的层次上会跟随消费者偏好流入等级较高的医疗机构，在空间布局上会向高收入社区和城市集中。
本文的分析为上述两个问题提供了一个可能的解决之道。本文证明，在竞争的市场条件下，消费者通过观察医生／医院的市场份额与设定的价格来对医生／医院进行选择，医生不提供诱导性消费的均衡状态是可以存在的，因此，在私人消费品属性占优的领域，政府大可放手鼓励私有制医院的进入和竞争，仅实行一定的必要规制保证其竞争秩序；另一方面，在公共品领域，例如公共卫生服务，政府提供是责无旁贷的，特别的，由于市场本身无法实现医疗服务的“普遍服务”功能，政府需要动用力量为一些欠发达地区以及低收入人群提供必要的基本医疗服务，以保障公平性的实现，这时，公有制医院是一项较为适合的选择。
The reform of Medical Care System bothers a lot of governments of the countries in this world. To ensure the medical care services efficiently and equitably supplied, the governments make great efforts regulating on the delivery system of medical care (and also others). These efforts are mainly two fold: first, to control the prices or total expenditure of medical care; second, to make medical care services equitably available to every consumer. As for the on-going reform in China, do these efforts pay off? Based on the 30 years' reform of Medical Care System in China, this dissertation analysis's the effectiveness and influence of government regulation on the delivery system of medical care. The results contain:
First, the price regulation, which aims at controlling medical expenditure, proves to be a failure, since per capita medical expenditure in China is rising quickly over recent years. Our model, using incentive theory, explains how the current price regulation policy affects expenditure controlling through its influence on the efforts of physicians. Under current regulation policies, doctors' skills are underpaid, while the prices of drugs and examinations are allowed to be 15% higher than their costs. Such asymmetric price regulation leads physicians to make less effort than under the second best, and also the effort is distributed on different tasks asymmetrically. This helps the raise of expenditure and causes loss in both patients' welfare and social welfare as a whole.
Second, it has been proved that there is always contradiction between market supply of health services and its obligation of "universal service", as long as there exists monopolistic issues in this market. The market failure to provide universal services leads to two results: consumers of lowest incomes out of service, and medical resources converging to medical institutions with higher hierarchy or to areas with higher purchasing power.
This dissertation also offered a potential resolution to the problems above. Since health services are private goods (with externality) as well as quasi-public goods, the resolution could be taken in two parts: In the private sector, the focus of regulation should be asymmetric information, which provides physicians incentive and opportunities to induce excessive expenditure. Our analysis suggests that, the market mechanism may induce non-fraudulent physician behavior. From the observation of market data such as prices, market shares and so on, consumers can infer the sellers' incentives. The model shows that market equilibria resulting in non-fraudulent behavior do indeed exist. Hence, private providers could be encouraged in this sector. In the public sector, and also to provide supplement to where the market supply could not cover, the government should take responsibility of providing medical care to the poors and to the less developed areas. The model suggests that public hospitals would be a better choice here.
本文认为，在价格规制方面，我国对于基本医疗服务价格和大型设备检查／药品价格的分别规制，使得作为代理人的医生／医院行为出现扭曲，导致价格规制不仅无助于控制医疗费用的上涨，反而可能作为一种对医院的间接补偿手段产生更大的医疗支出。这种激励的扭曲会为患者带来比只存在医生道德风险和有限责任的次优状态时更大的福利损失，也会降低整个社会的福利。
在公平性方面，以“商业化、市场化”为导向的改革被证明无法解决市场化供给与普遍服务的矛盾，“看病难”的出现正是这一矛盾的集中表现。本文证明，如果将医疗服务完全交由市场提供，由于医疗产品一定程度上自然垄断的特性，一是会导致一部分低收入的消费者被排除在市场之外，二是会使得医疗资源在递送体系的层次上会跟随消费者偏好流入等级较高的医疗机构，在空间布局上会向高收入社区和城市集中。
本文的分析为上述两个问题提供了一个可能的解决之道。本文证明，在竞争的市场条件下，消费者通过观察医生／医院的市场份额与设定的价格来对医生／医院进行选择，医生不提供诱导性消费的均衡状态是可以存在的，因此，在私人消费品属性占优的领域，政府大可放手鼓励私有制医院的进入和竞争，仅实行一定的必要规制保证其竞争秩序；另一方面，在公共品领域，例如公共卫生服务，政府提供是责无旁贷的，特别的，由于市场本身无法实现医疗服务的“普遍服务”功能，政府需要动用力量为一些欠发达地区以及低收入人群提供必要的基本医疗服务，以保障公平性的实现，这时，公有制医院是一项较为适合的选择。
The reform of Medical Care System bothers a lot of governments of the countries in this world. To ensure the medical care services efficiently and equitably supplied, the governments make great efforts regulating on the delivery system of medical care (and also others). These efforts are mainly two fold: first, to control the prices or total expenditure of medical care; second, to make medical care services equitably available to every consumer. As for the on-going reform in China, do these efforts pay off? Based on the 30 years' reform of Medical Care System in China, this dissertation analysis's the effectiveness and influence of government regulation on the delivery system of medical care. The results contain:
First, the price regulation, which aims at controlling medical expenditure, proves to be a failure, since per capita medical expenditure in China is rising quickly over recent years. Our model, using incentive theory, explains how the current price regulation policy affects expenditure controlling through its influence on the efforts of physicians. Under current regulation policies, doctors' skills are underpaid, while the prices of drugs and examinations are allowed to be 15% higher than their costs. Such asymmetric price regulation leads physicians to make less effort than under the second best, and also the effort is distributed on different tasks asymmetrically. This helps the raise of expenditure and causes loss in both patients' welfare and social welfare as a whole.
Second, it has been proved that there is always contradiction between market supply of health services and its obligation of "universal service", as long as there exists monopolistic issues in this market. The market failure to provide universal services leads to two results: consumers of lowest incomes out of service, and medical resources converging to medical institutions with higher hierarchy or to areas with higher purchasing power.
This dissertation also offered a potential resolution to the problems above. Since health services are private goods (with externality) as well as quasi-public goods, the resolution could be taken in two parts: In the private sector, the focus of regulation should be asymmetric information, which provides physicians incentive and opportunities to induce excessive expenditure. Our analysis suggests that, the market mechanism may induce non-fraudulent physician behavior. From the observation of market data such as prices, market shares and so on, consumers can infer the sellers' incentives. The model shows that market equilibria resulting in non-fraudulent behavior do indeed exist. Hence, private providers could be encouraged in this sector. In the public sector, and also to provide supplement to where the market supply could not cover, the government should take responsibility of providing medical care to the poors and to the less developed areas. The model suggests that public hospitals would be a better choice here.
引文
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