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1、我国医疗费用增长的影响因素与控制研究 4 摘 要摘 要 自从二十世纪八十年代以来，伴随着医疗卫生制度改革的不断深入，我国医疗费用一直处于快速增长阶段， “看病贵、看病难”问题愈显突出。2005 年国务院发展研究中心提出的“医改总体上不成功”的报告更是在全社会掀起了一场关于医疗卫生制度如何改革的大讨论。我国医疗费用增长的深层次原因是什么？医方诱导需求存在与否？如何抑制医疗费用的过快增长？如何设计一种公平和效率兼顾的医疗卫生制度？这不仅是一个经济问题，也是一个社会问题。 本文从合理增长因素和不合理增长因素两个方面研究了我国医疗费用增长的影响因素，区分了医疗费用合理增长和不合理增长，并从对医疗费用不
2、合理增长的抑制和合理增长的支持两个方面分析了医疗费用的控制策略。 首先，提出了我国医疗市场中医方诱导需求理论模型，并选择政府卫生事业投入占整个财政预算比例来表示我国医方诱导需求并进行了协整分析，解决了医方诱导需求识别问题。研究表明，政府卫生事业投入比例不断减少对医方收入形成的巨大冲击、以药养医政策以及医方天然信息优势共同促成了我国医方诱导需求的实现。医方诱导需求是我国医疗费用长期稳定增长因素，但这种因素导致的医疗费用增长是不合理的增长，必须在制度设计上加以抑制。 其次，采用计量经济学协整和误差修正模型等方法，实证分析我国医疗费用增长的各种可能因素，剔除虚假因素，避免虚假回归。结果表明：经济增长
3、、人口老龄化和城市化水平提高，也是我国医疗费用长期稳定增长因素。这些因素导致的医疗费用增长实际上是社会进步和居民生活质量提高的表现，因而是正常合理的增长因素，应该扩大医疗服务的供给来保证其得到满足。医疗技术的进步和医疗保险制度的引入并不是我国医疗费用长期稳定增长因素。 再次，为消除医方诱导需求，抑制医疗费用的不合理增长，本文通过一个博弈模型比较了国内外主要医疗费用支付方式的优缺点，并运用博弈论和信息经济学有关知识，在分析医疗服务的需方、供方和第三方各自行为特征和目标函数的基础上，以按人头支付为例，提出了一种既可以抑制医方自选择又能激励医方提高效率降低医疗费用的支付方式，该方式既具有预付制支付方
4、式的优点，又避免了其缺点，且依据的是日常管理信息，因而管理费用低，可操作行强，特别适于行政效率不高的国家和地区。 最后，为确保我国居民合理的医疗需求得到满足，提出了我国医疗卫生制度总体安排的原则：公平优先，兼顾效率；政府和市场并重。并分别从卫生供给制度、健康保障制度和卫生筹资制度三个方面分析了我国医疗卫生总体制度的具体安排。 关键词： 医疗费用， 医疗保险，增长因素，总体制度安排，委托-代理理论，博弈论， 医疗费用支付方式。 南京航空航天大学博士学位论文 5Abstract With the development of medical systems reform the health ca
5、re expenditure (HCE) in our country is increasing faster and faster since 1980. Health care service is getting more and more expensive and difficult to obtain for our residents. The report provided by the centre of development and research of Chinese government in 2005 has said that the medical syst
6、ems reform was not successful as a whole in our country. This has brought a hot discuss about how to reform our health system. What has brought the rise of HCE in our country? How to choke back the unreasonable increase of HCE? How to design a health system which can give the same attention to the t
7、wo thingsequity and efficiency? All the questions are not only an economy issue but also a social one. The determinants of HCE in China are divided into reasonable parts and unreasonable parts. Therefore, the rise of HCE has included reasonable parts and unreasonable parts. The control of HCE accord
8、ingly includes the support of reasonable parts and the choking back of unreasonable one. Firstly, a theoretical and empirical analysis about physician-induced demand (PID) in our medical market has been provided. The analysis indicates that it is the reduction of government finance to hospital, the
9、policy of supporting hospital by medicine overpricing and the doctors information predominance that has caused PID. PID is one of the most important long-term and steady-going factors which raised HCE in our country. Because PID leads to unreasonable and irrational rising of HCE, we should reform an
10、d redesign our medical system to control it. Secondly, the multi-factors empirical analysis about the rise of HCE has been brought forward. The economic growth, population aging and urbanization level are also the long-term and steady-going factors which raised HCE in our country. However, the rise
11、brought by these factors is the embodiment of our society advancement and living quality improvement. So the rise of HCE brought by these factors is reasonable and rational and we should support it by extending health care supply. This dissertation has distinguished reasonable rise from unreasonable
12、 rise of HCE. And this is different to the general and total research. Moreover, both the progress of medical technology and medical insurance are not the long-term and steady-going factors. Thirdly, in order to choking back the unreasonable rise of HCE brought by PID， the main health care payment s
13、ystems has been compared in one game model. Then, on the basis of the utility functions of the demand side, the supply side and third party, a first best payment system has been 我国医疗费用增长的影响因素与控制研究 6 provided to eliminate moral hazard and self-selection from doctors by game theory and principal-agent
14、 theory. The payment system , acting on routine information available , is very simple and suitable for those inefficient country and region. At last , in order to support of reasonable rising of HCE and meet the reasonable demand , we should insist the principle of our health care system reform whi
15、ch includes “equity first” and paying equal attention to the government and market. Then, some advices about how to adjust our micro-health-system have been provided. Keyword: health care expenditure , medical insurance , increase factor , total system arrangement, game theory , principal-agent theo
16、ry , payment system of HCE. 南京航空航天大学博士学位论文 3承诺书 本人声明所呈交的博士学位论文是本人在导师指导下进行的研究工作及取得的研究成果。 除了文中特别加以标注和致谢的地方外， 论文中不包含其他人已经发表或撰写过的研究成果， 也不包含为获得南京航空航天大学或其他教育机构的学位或证书而使用过的材料。 本人授权南京航空航天大学可以将学位论文的全部或部分内容编入有关数据库进行检索，可以采用影印、缩印或扫描等复制手段保存、汇编学位论文。 （保密的学位论文在解密后适用本承诺书） 作者签名： 日期： 年 月 南京航空航天大学博士学位论文 1第一章 绪论第一章 绪论 1.1 研究背景和研究意义 1.1 研究背景和研究意义 改革开放以来，我国经济建设取得了举世瞩目的成绩：国民收入持续快速增长，居民人均收入稳步提高。据 2007 年中国统计年鉴,我国人均名义 GDP 由 1978 年的 381.00 元增加到2006 年的 16084.00 元，年平均增长率达到了 14.8%,这直接推动了我国医疗卫生
