中国农村居民医疗服务需求研究
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摘要
长期以来,医疗卫生和居民健康问题是政府、学者和民众最为关心的问题之一。保持优良的健康状况和获得基本的医疗服务是人的一项基本权利,政府在其中有重要作用。医疗市场的外部性、信息不对称和不确定性特征导致了医疗卫生服务领域存在市场失灵,政府必然要充当家长式的角色对医疗卫生服务事业进行管理,其具体责任在于确保居民医疗服务需求得到满足,疾病经济负担不致过高,并逐步提高国民的健康状况。
新中国建国后,农村医疗卫生事业发展迅速,政府致力于构建几乎覆盖整个农村的三级卫生服务网,在改善国民健康方面取得了举世瞩目的成就,被世界卫生组织誉为发展中国家卫生服务系统的典范。80年代后,农村卫生服务领域经历了重大变化,农村医疗事业发展缓慢,乡镇卫生院人才流失、资金短缺、合作医疗失去了集体经济的支撑和由于自身管理的问题而逐渐衰退,农村居民丧失了医疗保障的覆盖。多方面的证据表明,农村居民疾病经济负担加重,特别是低收入农户疾病经济负担更为严重,医疗服务供需双方之间的矛盾集中表现为“看病难、看病贵”,因病致贫和因病返贫问题也日益突出。根据国家三次卫生服务调查的数据,90年代以来,农村居民的医疗服务需要增加,但医疗服务的利用却在下降,居民的医疗服务需要难以转化为现实的需求。本文认为,导致这一问题的原因可能来自于主观和客观两个方面,主观方面是居民认为前去正规医疗服务机构的机会成本太高,或者他们本已具备自我医疗的能力而主动放弃了进入正规医疗服务市场,这是居民的理性选择;客观方面的因素可能来自于经济原因、看病不方便、对医疗机构的服务质量不信任等,这部分由于客观原因导致必要的医疗服务需求得不到满足的居民是政策应帮助的对象,也是研究者关注的对象。
近30年来,国内外学者对医疗改革问题给予了较多关注,现有研究在宏观层面侧重于在更好地实现公民优良健康条件下如何控制卫生总费用和实现医疗服务的公司利用,微观层面聚焦于探讨家庭或个体医疗消费的研究,得出了很多有益的结论。需求研究是卫生经济学研究的核心范畴,本文进行需求研究的目的,就是要讨论社会和个人如何分配有限的医疗资源用于医疗服务的使用,分析农村居民医疗服务需求的特征,探讨居民对医疗卫生服务的可及性、可得性问题,并重点考察经济因素在其中的作用,包括居民收入状况、医疗服务价格和医疗保险状况如何影响到农村居民对医疗服务的需求,最终是要寻找居民医疗服务需要转化为现实需求的障碍因素。当前,农村医疗卫生改革的核心问题之一是医疗保障制度的改革,医疗保障制度改革的目标一要控制医疗费用的上涨,其二是要满足居民基本医疗服务的需要,特别是确保低收入农户和中低收入农户基本医疗服务的获得和医疗保险的覆盖,减轻居民的疾病经济负担。本文的研究可以更好地解释不同特征的人口医疗服务利用的变化,有助于政策制定者理解不同的经济干预手段将如何影响到居民的医疗服务需求,医疗保险对医疗服务需求影响的相关研究结论也可以为当前农村医疗改革和新型农村合作医疗政策的全面推进提供科学依据。
在健康经济学领域,严格经济学意义上的医疗产品或服务的需求量很难测度,现有文献一般将是否使用医疗服务、使用的频率或费用作为需求变量的代理变量,这实际上是居民的医疗服务需求行为。一般来说,人们患病后寻求医疗服务面临一系列选择行为:一是根据自己病情的需要和经济能力、机会成本多种因素的权衡决定是否就医;二是决定就医的方式,即到什么地方就医;三是就医后根据医生治疗方案的建议决定就医的类型和医疗支出。这三个方面的需求分析是本文实证部分的核心内容。出于研究的完整性和研究方法同质性的考虑,本文将居民是否就医、就医服务类型的选择和医疗服务支出水平统称为居民医疗服务利用来展开分析,将居民就诊单位选择行为作为需求分析的另一项内容进行论证。本文共分为八章,主要研究内容和结论陈述如下:
研究内容一:对中国农村医疗服务市场进行供需分析,构建中国农村医疗服务需求模型,测算农村医疗服务需求的收入弹性和价格弹性。
人口增长,收入增加和老龄化速度加快促进了社会对医疗服务需求的快速增加,需求的增加推动了医疗服务的价格上涨,从而导致卫生费用的增长。本文利用三次国家卫生服务调查的相关数据和结论阐明研究的背景,勾画农村医疗服务市场的面貌,揭示中国农村医疗卫生存在的问题及原因,深入描述近年来中国农村医疗市场的供给、需求和价格的变化及根源,并构建了农村医疗服务需求模型,测算出中国农村医疗服务需求的收入弹性为1.31,价格弹性为-0.76。可以得出,农村居民医疗服务需求对收入的变动较敏感,对价格的变动较不敏感,因此,居民收入的增加能显著地促进医疗服务需求的增加,而医疗服务价格的变化只能导致其需求量很小幅度的变化。
研究内容二:利用四部模型法(Four-Part Model),对中国农村居民医疗服务利用的影响因素进行实证分析。
本部分首先考察调查地区样本医疗支出分布的数据特征,讨论医疗支出变量的正态性分布问题,零医疗支出与样本选择问题,在此基础上,提出选择四部模型法进行回归分析的计量依据和适用性。利用该模型,分别考察农村居民是否就诊、医疗服务类型选择行为的影响因素,以及医疗支出的决定因素,并详细分析了收入、价格和医疗保险在其中的作用,得出了以下三个有意义的结论:
第一,由于医疗服务具有稀缺性和不可替代性,疾病的严重程度直接决定了居民对医疗服务的需求;医疗服务价格对居民是否就诊有显著影响,也是门诊支出和住院支出的重要决定因素;当患者进入医疗市场后,选择门诊医疗服务还是住院医疗服务类型与收入水平密切相关。此外,医疗服务质量、看病时间成本、居民生活方式、年龄、家庭规模对居民医疗服务需求也有一定影响。
第二,本文比较了门诊支出模型和住院支出模型中医疗需求的收入弹性和价格弹性,结果显示,收入在门诊支出模型中比在住院支出模型中更缺乏弹性,价格在住院支出模型中比门诊支出模型中更缺乏弹性。因此,在既要保证患者因为经济困难不致于放弃原本必要的医疗卫生服务需求,又要防止因价格降低导致过度使用医疗服务的双重目标下,相应的医疗保险政策必然是优先发展住院医疗服务。
第三,保险对居民医疗服务的使用有促进作用,但由于弹性值较小,其促进作用很有限;拥有医疗保险的患者更倾向于选择使用住院服务;保险对居民住院服务利用的影响还与居民收入水平密切相关,拥有保险的中等收入居民更倾向于选择住院服务,而高收入组居民未呈现出类似的趋势;另外,医疗支出水平与保险共付率无明显关系。医疗保险对居民医疗服务需求的作用在于一定程度上减少了居民医疗服务的价格,理论上有助于居民疾病经济负担的缓解,但是,由于道德风险和供给诱导需求现象的存在,价格降低可能会导致过度医疗需求,医疗保险不一定能最终减轻居民疾病经济负担。因此,必须规范医患双方的行为,严格控制供给诱导需求的现象。
研究内容三:农村居民就诊单位选择行为的影响分析。
在既定的收入水平和疾病特征下,人们总会期望去医疗服务质量更高的机构就诊。分析结果显示,家庭经济状况好的患者由于就诊的机会成本较高,要么选择自我医疗,要么选择县及以上医院就诊;医疗保险一方面通过降低医疗服务价格促进了患者对更高一级医疗服务的利用,另一方面,医疗保险规定的定点医疗机构和严格的转诊制度导致了参加医疗保险的患者更倾向于在村诊所和县及以上医院就诊,这一定程度上限制了居民对医疗服务的过度利用。加强农村医疗卫生服务和基本公共卫生服务的建设,提高农村基层医生的素质,提高医疗服务质量,能使农村居民能更方便地获得可靠的医疗服务。
Medical care and people's health is one of the issues that the government, scholars and the public concern most for a long time. The characteristics of externality, asymmetric information and uncertainty have lead to market failure of the medical care market. And being a quasi-public product, the rural medical care service determines that government is of vital importance in the medical care system. The government must play the role of guardians to carry on the management of the rural public medical care service, which includes to ensure the satisfaction of residents' demand in this service, the low level of economic burden of medical treatment and the improvement of people's health.
Since the founding of China, the undertaking of rural medical care has developed rapidly and the government has been dedicated to construct a service network of three levels that almost cover the whole countryside. Accomplishments have been made in improving our people's health, which has been regarded as a model among developing countries by WHO. However, rural medical service has undergone great changes since 1980's. The undertaking of rural medical care developed slowly, the public health centers in towns encountered brain drain and fund shortage. The Cooperative Medical System lost its support from collective economy and gradually deteriorated because of management problems. Rural villagers were no longer covered by medical insurance. Especially since the 1990's, the phenomena of becoming poor and falling into poverty again were prominent. The contradictions between medical service's supply and demand were mainly "the great difficulty and the expensive cost of receiving medical treatment". According to the other evidence, the disease burden of rural resident has been increase, especially, the burden of the low income resident is very heavy. And the result of national health service survey reveal that the need of the medical care has been increased, but the utilization of them has been decreased since the 1990's.
In recent 30 years, scholars in China and abroad paid attention to the issue of medical treatment reform and focused their researches on how to control total medical cost and fairness while better realizing the maintenance of people's health and the behavior of family's or individual's medical treatment consumption, respectively at the macroeconomic and microeconomic level, which brought useful conclusions. Research on demand is the essence of health economics researches. The purpose of demand analysis in this paper is to discuss how should our society and individual allocate the limited medical treatment resources for the usage of medical treatment service, to analyze the characteristics of rural residents' behavior in the demand of medical treatment service and the issues of medical treatment service's availability and residents' obtainment. It also focuses on the role of economic factors in the issues above, including people's income, medical service price and how medical insurance influences people's demand. All of these researches offer explanations to how the utilization of medical service changes and how different health demand is among people with different characteristics, which helps policy-makers understand how can different means of intervention affect people's demand of medical service and their state of health. What's more, the research conclusions of medical insurance's influence on medical demand in this paper provide scientific basis for the current rural medical treatment reform and New Rural Cooperative Medical System promotion.
It is very difficult to measure the demand for the medical care, the literature make the utilization、frequncy and the expendicture as the demand. Generally speaking, people face a series of choices when they look for medical service: the first is to weigh emergency of the disease, economic ability of the family, opportunity cost and many other factors before making the decision of whether to go to the hospital; the second is to decide the way of receiving treatment, such as which hospital to choose; the third is to choose what kind of treatment to receive and the expenditure according to the doctor's suggestion. These three aspects of demand behavior constitute the positive analysis of this paper. Considering the process interity and homogenesis of research method, this paper entitles the three aspects of demand behavior covering whether to receive treatment, type of medical service and expenditure level as residents' utilization of medical service. On the other hand, it regards residents' choice of medical service unit as anther aspect of demand behavior. This paper is divided into eight chapters and the main contents and conclusions are as follows:
Part 1: the supply-demand analysis of the medical service market, the model construction of medical service demand and the calculation of income and price elasticity of medical service demand.
The growth of population, income and the speeding up of aging process accelerated the increasing demand in medical treatment demand, which promoted the rising of medical service price. As a result, the cost of medical service increased.Based on the data collected from national health service investigation which has been carried out for three times, this paper elaborates the background of research, limns China's urban and suburban medical service market and describes the outlook of rural medical service market, illustrates the existing problems of China's rural medical treatment and causes of such problems and incisively depicts the changes of supply, demand as well as price of China's rural medical market in recent years and the sources of these changes. The dissertation also constructs the model of rural medical service demand and calculates the income elasticity of medical service demand is 1.31 and the price elasticity is -0.76 based on the overall data of medical market, which indicates medical service demand is sensitive to residents' income changes but not to price fluctuations. Thus, the increment of residents' income can significantly improve demand in medical service while price fluctuations can only lead to small changes in demand.
Part 2: the positive analysis of influence factors of Chinese rural residents' medical service utilization based on Four-Part Model.
This part first analyzes the statistical characteristics of medical expenditure distribution, discusses the questions of medical expenditure variable's normal distribution, zero medical expenditure and choices of sample. Based on these foundations, this dissertation illustrates the econometric basis and adaptability of doing regression with Four-Part Model. This model helps us figure out factors which influence whether rural residents receive medical treatment, their choice of the type of medical service, the determinants of medical expenditure and the role that income, price and medical insurance have played in it as well. The conclusions are as follows:
Firstly, because of the scarcity and irreplaceability of medical treatment service, the seriousness of the disease directly determinates residents' demand in medical service. The price of medical service has a significant influence on whether people choose to receive medical treatment and it's also an important determinant of outpatient service disbursement and hospitalization disbursement. When a patient enters the medical market, his or her choice of outpatient medical service or hospitalization disbursement is related to personal income level. Besides, the quality of medical service, cost of time, people's way of living, their age, scale of family also have influence on behavior of demand in medical service.
Secondly, the results of positive analysis show that income factor lacks elasticity in outpatient medical service compared with that in hospitalization service while the price factor lacks elasticity relatively in hospitalization service in comparison with that in outpatient medical service. Since medical treatment expenditure is determined by the two aspects of quantity and price, the conclusions above can also be interpreted as: the effect that the increment of income has in improving the utilization of hospitalization service for residents is greater than that of outpatient medical service while the effect that the reduction of medical treatment service price has in improving the utilization of outpatient medical service for residents is larger than that of hospitalization service. Therefore, in pursuing the dual goals of guaranteeing that our patients don't give up their rights of receiving necessary medical treatment when facing economic difficulty while preventing excessive utilization of medical treatment service due to price cut, our corresponding medical treatment insurance policy should give priority to the development of hospitalization service.
Thirdly, insurance can enhance residents' utilization of medical service. But because of its low elasticity value, the improvement is limited. Patients who enjoy medical insurance tend to choose hospitalization medical service. The influence insurance has on residents' utilization of hospitalization service is also related to their income. People with medium income level and insurance tend to choose hospitalization medical service while in the group with high level of income, insurance doesn't take on similar tendency any more. What's more, medical expenditure and the coinsurance rate don't have a close relation between each other. The effect that medical insurance has on medical service demand is it reduces medical service costs for the residents to some extent and theoretically it helps alleviate residents' economic burden. However, because of the existence of moral hazard and the phenomenon of supply inducing demand in medical insurance, price cut may lead to excessive demand of medical service, as a result, medical insurance may not alleviate people's economic burden eventually. Thus, we have to regulate the behavior of doctors and patients, strictly control the phenomenon of supply inducing demand, otherwise, the implement of medical insurance will exacerbate people's economic burden.
Part3 : the analysis of people's choice of medical treatment unit.
Facing income constraints and same disease characteristics, people are more willing to go to institution with high level of medical service quality. Analysis shows that patients with good economic status will either choose self-cure or at least go to the county hospital because of high opportunity cost; on one hand, medical insurance has improved patients' utilization of medical service at a higher level; on the other hand, the regulations of fixed medical treatment institutions and strict medical treatment transfer institutions in medical insurance have constrained people's excessive utilization of medical service, resulting that patients with medical insurance tend to receive treatment in the village clinic or county hospital. Strengthening the construction of rural medical service and fundamental public health service, raising the quality of doctors who are at grass root level and that of medical service so as to make it more convenient for villagers to get reliable medical service and alleviate the issue of "the great difficulty and the expensive cost of receiving medical treatment".
新中国建国后,农村医疗卫生事业发展迅速,政府致力于构建几乎覆盖整个农村的三级卫生服务网,在改善国民健康方面取得了举世瞩目的成就,被世界卫生组织誉为发展中国家卫生服务系统的典范。80年代后,农村卫生服务领域经历了重大变化,农村医疗事业发展缓慢,乡镇卫生院人才流失、资金短缺、合作医疗失去了集体经济的支撑和由于自身管理的问题而逐渐衰退,农村居民丧失了医疗保障的覆盖。多方面的证据表明,农村居民疾病经济负担加重,特别是低收入农户疾病经济负担更为严重,医疗服务供需双方之间的矛盾集中表现为“看病难、看病贵”,因病致贫和因病返贫问题也日益突出。根据国家三次卫生服务调查的数据,90年代以来,农村居民的医疗服务需要增加,但医疗服务的利用却在下降,居民的医疗服务需要难以转化为现实的需求。本文认为,导致这一问题的原因可能来自于主观和客观两个方面,主观方面是居民认为前去正规医疗服务机构的机会成本太高,或者他们本已具备自我医疗的能力而主动放弃了进入正规医疗服务市场,这是居民的理性选择;客观方面的因素可能来自于经济原因、看病不方便、对医疗机构的服务质量不信任等,这部分由于客观原因导致必要的医疗服务需求得不到满足的居民是政策应帮助的对象,也是研究者关注的对象。
近30年来,国内外学者对医疗改革问题给予了较多关注,现有研究在宏观层面侧重于在更好地实现公民优良健康条件下如何控制卫生总费用和实现医疗服务的公司利用,微观层面聚焦于探讨家庭或个体医疗消费的研究,得出了很多有益的结论。需求研究是卫生经济学研究的核心范畴,本文进行需求研究的目的,就是要讨论社会和个人如何分配有限的医疗资源用于医疗服务的使用,分析农村居民医疗服务需求的特征,探讨居民对医疗卫生服务的可及性、可得性问题,并重点考察经济因素在其中的作用,包括居民收入状况、医疗服务价格和医疗保险状况如何影响到农村居民对医疗服务的需求,最终是要寻找居民医疗服务需要转化为现实需求的障碍因素。当前,农村医疗卫生改革的核心问题之一是医疗保障制度的改革,医疗保障制度改革的目标一要控制医疗费用的上涨,其二是要满足居民基本医疗服务的需要,特别是确保低收入农户和中低收入农户基本医疗服务的获得和医疗保险的覆盖,减轻居民的疾病经济负担。本文的研究可以更好地解释不同特征的人口医疗服务利用的变化,有助于政策制定者理解不同的经济干预手段将如何影响到居民的医疗服务需求,医疗保险对医疗服务需求影响的相关研究结论也可以为当前农村医疗改革和新型农村合作医疗政策的全面推进提供科学依据。
在健康经济学领域,严格经济学意义上的医疗产品或服务的需求量很难测度,现有文献一般将是否使用医疗服务、使用的频率或费用作为需求变量的代理变量,这实际上是居民的医疗服务需求行为。一般来说,人们患病后寻求医疗服务面临一系列选择行为:一是根据自己病情的需要和经济能力、机会成本多种因素的权衡决定是否就医;二是决定就医的方式,即到什么地方就医;三是就医后根据医生治疗方案的建议决定就医的类型和医疗支出。这三个方面的需求分析是本文实证部分的核心内容。出于研究的完整性和研究方法同质性的考虑,本文将居民是否就医、就医服务类型的选择和医疗服务支出水平统称为居民医疗服务利用来展开分析,将居民就诊单位选择行为作为需求分析的另一项内容进行论证。本文共分为八章,主要研究内容和结论陈述如下:
研究内容一:对中国农村医疗服务市场进行供需分析,构建中国农村医疗服务需求模型,测算农村医疗服务需求的收入弹性和价格弹性。
人口增长,收入增加和老龄化速度加快促进了社会对医疗服务需求的快速增加,需求的增加推动了医疗服务的价格上涨,从而导致卫生费用的增长。本文利用三次国家卫生服务调查的相关数据和结论阐明研究的背景,勾画农村医疗服务市场的面貌,揭示中国农村医疗卫生存在的问题及原因,深入描述近年来中国农村医疗市场的供给、需求和价格的变化及根源,并构建了农村医疗服务需求模型,测算出中国农村医疗服务需求的收入弹性为1.31,价格弹性为-0.76。可以得出,农村居民医疗服务需求对收入的变动较敏感,对价格的变动较不敏感,因此,居民收入的增加能显著地促进医疗服务需求的增加,而医疗服务价格的变化只能导致其需求量很小幅度的变化。
研究内容二:利用四部模型法(Four-Part Model),对中国农村居民医疗服务利用的影响因素进行实证分析。
本部分首先考察调查地区样本医疗支出分布的数据特征,讨论医疗支出变量的正态性分布问题,零医疗支出与样本选择问题,在此基础上,提出选择四部模型法进行回归分析的计量依据和适用性。利用该模型,分别考察农村居民是否就诊、医疗服务类型选择行为的影响因素,以及医疗支出的决定因素,并详细分析了收入、价格和医疗保险在其中的作用,得出了以下三个有意义的结论:
第一,由于医疗服务具有稀缺性和不可替代性,疾病的严重程度直接决定了居民对医疗服务的需求;医疗服务价格对居民是否就诊有显著影响,也是门诊支出和住院支出的重要决定因素;当患者进入医疗市场后,选择门诊医疗服务还是住院医疗服务类型与收入水平密切相关。此外,医疗服务质量、看病时间成本、居民生活方式、年龄、家庭规模对居民医疗服务需求也有一定影响。
第二,本文比较了门诊支出模型和住院支出模型中医疗需求的收入弹性和价格弹性,结果显示,收入在门诊支出模型中比在住院支出模型中更缺乏弹性,价格在住院支出模型中比门诊支出模型中更缺乏弹性。因此,在既要保证患者因为经济困难不致于放弃原本必要的医疗卫生服务需求,又要防止因价格降低导致过度使用医疗服务的双重目标下,相应的医疗保险政策必然是优先发展住院医疗服务。
第三,保险对居民医疗服务的使用有促进作用,但由于弹性值较小,其促进作用很有限;拥有医疗保险的患者更倾向于选择使用住院服务;保险对居民住院服务利用的影响还与居民收入水平密切相关,拥有保险的中等收入居民更倾向于选择住院服务,而高收入组居民未呈现出类似的趋势;另外,医疗支出水平与保险共付率无明显关系。医疗保险对居民医疗服务需求的作用在于一定程度上减少了居民医疗服务的价格,理论上有助于居民疾病经济负担的缓解,但是,由于道德风险和供给诱导需求现象的存在,价格降低可能会导致过度医疗需求,医疗保险不一定能最终减轻居民疾病经济负担。因此,必须规范医患双方的行为,严格控制供给诱导需求的现象。
研究内容三:农村居民就诊单位选择行为的影响分析。
在既定的收入水平和疾病特征下,人们总会期望去医疗服务质量更高的机构就诊。分析结果显示,家庭经济状况好的患者由于就诊的机会成本较高,要么选择自我医疗,要么选择县及以上医院就诊;医疗保险一方面通过降低医疗服务价格促进了患者对更高一级医疗服务的利用,另一方面,医疗保险规定的定点医疗机构和严格的转诊制度导致了参加医疗保险的患者更倾向于在村诊所和县及以上医院就诊,这一定程度上限制了居民对医疗服务的过度利用。加强农村医疗卫生服务和基本公共卫生服务的建设,提高农村基层医生的素质,提高医疗服务质量,能使农村居民能更方便地获得可靠的医疗服务。
Medical care and people's health is one of the issues that the government, scholars and the public concern most for a long time. The characteristics of externality, asymmetric information and uncertainty have lead to market failure of the medical care market. And being a quasi-public product, the rural medical care service determines that government is of vital importance in the medical care system. The government must play the role of guardians to carry on the management of the rural public medical care service, which includes to ensure the satisfaction of residents' demand in this service, the low level of economic burden of medical treatment and the improvement of people's health.
Since the founding of China, the undertaking of rural medical care has developed rapidly and the government has been dedicated to construct a service network of three levels that almost cover the whole countryside. Accomplishments have been made in improving our people's health, which has been regarded as a model among developing countries by WHO. However, rural medical service has undergone great changes since 1980's. The undertaking of rural medical care developed slowly, the public health centers in towns encountered brain drain and fund shortage. The Cooperative Medical System lost its support from collective economy and gradually deteriorated because of management problems. Rural villagers were no longer covered by medical insurance. Especially since the 1990's, the phenomena of becoming poor and falling into poverty again were prominent. The contradictions between medical service's supply and demand were mainly "the great difficulty and the expensive cost of receiving medical treatment". According to the other evidence, the disease burden of rural resident has been increase, especially, the burden of the low income resident is very heavy. And the result of national health service survey reveal that the need of the medical care has been increased, but the utilization of them has been decreased since the 1990's.
In recent 30 years, scholars in China and abroad paid attention to the issue of medical treatment reform and focused their researches on how to control total medical cost and fairness while better realizing the maintenance of people's health and the behavior of family's or individual's medical treatment consumption, respectively at the macroeconomic and microeconomic level, which brought useful conclusions. Research on demand is the essence of health economics researches. The purpose of demand analysis in this paper is to discuss how should our society and individual allocate the limited medical treatment resources for the usage of medical treatment service, to analyze the characteristics of rural residents' behavior in the demand of medical treatment service and the issues of medical treatment service's availability and residents' obtainment. It also focuses on the role of economic factors in the issues above, including people's income, medical service price and how medical insurance influences people's demand. All of these researches offer explanations to how the utilization of medical service changes and how different health demand is among people with different characteristics, which helps policy-makers understand how can different means of intervention affect people's demand of medical service and their state of health. What's more, the research conclusions of medical insurance's influence on medical demand in this paper provide scientific basis for the current rural medical treatment reform and New Rural Cooperative Medical System promotion.
It is very difficult to measure the demand for the medical care, the literature make the utilization、frequncy and the expendicture as the demand. Generally speaking, people face a series of choices when they look for medical service: the first is to weigh emergency of the disease, economic ability of the family, opportunity cost and many other factors before making the decision of whether to go to the hospital; the second is to decide the way of receiving treatment, such as which hospital to choose; the third is to choose what kind of treatment to receive and the expenditure according to the doctor's suggestion. These three aspects of demand behavior constitute the positive analysis of this paper. Considering the process interity and homogenesis of research method, this paper entitles the three aspects of demand behavior covering whether to receive treatment, type of medical service and expenditure level as residents' utilization of medical service. On the other hand, it regards residents' choice of medical service unit as anther aspect of demand behavior. This paper is divided into eight chapters and the main contents and conclusions are as follows:
Part 1: the supply-demand analysis of the medical service market, the model construction of medical service demand and the calculation of income and price elasticity of medical service demand.
The growth of population, income and the speeding up of aging process accelerated the increasing demand in medical treatment demand, which promoted the rising of medical service price. As a result, the cost of medical service increased.Based on the data collected from national health service investigation which has been carried out for three times, this paper elaborates the background of research, limns China's urban and suburban medical service market and describes the outlook of rural medical service market, illustrates the existing problems of China's rural medical treatment and causes of such problems and incisively depicts the changes of supply, demand as well as price of China's rural medical market in recent years and the sources of these changes. The dissertation also constructs the model of rural medical service demand and calculates the income elasticity of medical service demand is 1.31 and the price elasticity is -0.76 based on the overall data of medical market, which indicates medical service demand is sensitive to residents' income changes but not to price fluctuations. Thus, the increment of residents' income can significantly improve demand in medical service while price fluctuations can only lead to small changes in demand.
Part 2: the positive analysis of influence factors of Chinese rural residents' medical service utilization based on Four-Part Model.
This part first analyzes the statistical characteristics of medical expenditure distribution, discusses the questions of medical expenditure variable's normal distribution, zero medical expenditure and choices of sample. Based on these foundations, this dissertation illustrates the econometric basis and adaptability of doing regression with Four-Part Model. This model helps us figure out factors which influence whether rural residents receive medical treatment, their choice of the type of medical service, the determinants of medical expenditure and the role that income, price and medical insurance have played in it as well. The conclusions are as follows:
Firstly, because of the scarcity and irreplaceability of medical treatment service, the seriousness of the disease directly determinates residents' demand in medical service. The price of medical service has a significant influence on whether people choose to receive medical treatment and it's also an important determinant of outpatient service disbursement and hospitalization disbursement. When a patient enters the medical market, his or her choice of outpatient medical service or hospitalization disbursement is related to personal income level. Besides, the quality of medical service, cost of time, people's way of living, their age, scale of family also have influence on behavior of demand in medical service.
Secondly, the results of positive analysis show that income factor lacks elasticity in outpatient medical service compared with that in hospitalization service while the price factor lacks elasticity relatively in hospitalization service in comparison with that in outpatient medical service. Since medical treatment expenditure is determined by the two aspects of quantity and price, the conclusions above can also be interpreted as: the effect that the increment of income has in improving the utilization of hospitalization service for residents is greater than that of outpatient medical service while the effect that the reduction of medical treatment service price has in improving the utilization of outpatient medical service for residents is larger than that of hospitalization service. Therefore, in pursuing the dual goals of guaranteeing that our patients don't give up their rights of receiving necessary medical treatment when facing economic difficulty while preventing excessive utilization of medical treatment service due to price cut, our corresponding medical treatment insurance policy should give priority to the development of hospitalization service.
Thirdly, insurance can enhance residents' utilization of medical service. But because of its low elasticity value, the improvement is limited. Patients who enjoy medical insurance tend to choose hospitalization medical service. The influence insurance has on residents' utilization of hospitalization service is also related to their income. People with medium income level and insurance tend to choose hospitalization medical service while in the group with high level of income, insurance doesn't take on similar tendency any more. What's more, medical expenditure and the coinsurance rate don't have a close relation between each other. The effect that medical insurance has on medical service demand is it reduces medical service costs for the residents to some extent and theoretically it helps alleviate residents' economic burden. However, because of the existence of moral hazard and the phenomenon of supply inducing demand in medical insurance, price cut may lead to excessive demand of medical service, as a result, medical insurance may not alleviate people's economic burden eventually. Thus, we have to regulate the behavior of doctors and patients, strictly control the phenomenon of supply inducing demand, otherwise, the implement of medical insurance will exacerbate people's economic burden.
Part3 : the analysis of people's choice of medical treatment unit.
Facing income constraints and same disease characteristics, people are more willing to go to institution with high level of medical service quality. Analysis shows that patients with good economic status will either choose self-cure or at least go to the county hospital because of high opportunity cost; on one hand, medical insurance has improved patients' utilization of medical service at a higher level; on the other hand, the regulations of fixed medical treatment institutions and strict medical treatment transfer institutions in medical insurance have constrained people's excessive utilization of medical service, resulting that patients with medical insurance tend to receive treatment in the village clinic or county hospital. Strengthening the construction of rural medical service and fundamental public health service, raising the quality of doctors who are at grass root level and that of medical service so as to make it more convenient for villagers to get reliable medical service and alleviate the issue of "the great difficulty and the expensive cost of receiving medical treatment".
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