摘要
研究目的分析医疗费用控制过程中政府、医院、患者的行为特点及其对医疗费用增长的影响,建立行为模型;理论上构建医疗费用控制中政府、医院、患者间层次委托代理体系,并提供相应的政策解释,探索政府、医院、患者和谐互动机制,为政府解决医疗费用增长过快问题提供决策依据和新的政策思路,从而为实现社会和谐发展提供政策依据。
研究方法
文献研究法:查阅大量国内外关于医疗费用发展情况及控制,政府、医院和患者博弈方面的公开文献和研究成果。
深入访谈法:本研究在医疗费用相关主体的行为、行为对医疗费用的影响、调查内容等方面进行了反复的访谈和严格的论证,在同济医学院医管学院、医院院长、卫生局管理人员等专家的参与下完成。
问卷调查法:采用规范的、标准化问卷调查,针对政府代表、医院管理者和患者分别设计问卷,以获得三方在控费过程中行为特征及其影响因素的相关信息。数据统计分析方法:单因素分析:计数资料的卡方检验;多因素分析:非条件Logistic回归分析。调查问卷采用Microsoft Office Excel2003录入数据,采用SPSS11.5处理所有数据。
研究结果
1.医疗费用控制相关主体政府行为的经济学分析
政府行为的理论分析结果显示:政府的价值在于维护和发展社会公共利益,其行为的目标取向是保持社会的和谐与稳定的发展。但是在现实生活中,政府利益除了可以代表公共利益,同时也可以代表政府自身权力的利益,这就容易形成政府行为两难困境,当政府利益超越了公共利益,政府行为就表现为政府功能缺位或功能限度。
政府在医疗卫生体制改革中的行为实证分析结果显示:在市场经济体制改革时期,对政府来说,一方面要采用在计划经济体制下的“万能政府”的做法和相关的医疗卫生政策以维持政府作为卫生事业发展与改革的主导地位,另一方面,政府的财政能力却很难满足卫生事业迅速发展和人民群众卫生服务需求不断提高的要求。政府在医疗费用控制过程中的行为分析结果显示:政府也陷入利益困境之中——既要考虑自身经济财力又要考虑解决患者看病贵的问题。
2.医疗费用控制相关主体医院行为的经济学分析
医院行为的分析结果显示:医院的行为价值取向往往具有双重性,一是追求经济效益;二是体现社会效益。
医院实证研究结果显示:1998-2005年卫生部综合医院总收入与总支出是同步增加的,并且其业务支出与业务收入几乎重合。医院服务提供数量增加不多,速度也不快,明显低于医院收入速度的增加。每个医生的工作负荷增长速度逐年下降,甚至不再增长的同时,他们的年业务收入却快速增长。每门诊人次医疗费用和出院者日床位费用以及出院者平均医疗费用在逐年上升,即单位服务费用在上升。出院者人均医疗费用构成中药品和检查费用占医疗费用的比例增长缓慢,有下降的趋势。
3、医疗费用控制相关主体患者行为的分析
门诊患者控费意识在年龄、收入分布上的差异有统计学意义。住院患者控费意识在文化、收入户口分布上的差异有统计学意义。门诊和住院患者的控费意识在性别、职业、居住地和医保形式分布方面的差异没有统计学意义。门诊和住院患者控费意识在治疗情况分布方面的差异有统计学意义。
门诊患者和住院患者关注医疗费用信息在医保方面分布上的差异没有统计学意义,并且均关注医疗费用信息。住院患者看病时选择医生的情况在控费意识分布方面的差异有统计学意义。
门诊患者检查情况在控费意识方面上的差异没有统计学意义,但是在医保形式方面上差异有统计学上意义。住院患者检查情况在控费意识分布情况方面的差异有统计学意义。在对检查的态度方面,门诊患者在医保方面上和控费意识方面的差异没有统计学意义。
门诊患者要求医生开便宜药在控费意识分布方面的差异有统计学意义。门诊和住院患者选药情况在控费意识分布方面的差异均有统计学意义。门诊和住院患者在就诊医院药房买药情况在控费意识分布方面的差异均有统计学意义。住院患者选择医疗耗材在控费意识分布方面的差异没有统计学意义。
非条件Logistic回归分析结果显示影响门诊患者控费意识的因素与月收入、关注医疗费用信息及药品选择有关;影响住院患者控费意识的因素与月收入和在就诊医院买药有关。
研究结论
1.提出了医疗费用控制中政府行为的特点,即政府是医疗费用控制政策供给的主体;政府是宏观调控的主体;医疗费用控制中政府行为具有公益性。并根据其行为特点构建了政府控制医疗费用增长模型。
2.医院在响应我国医疗费用控制政策自觉采取措施降低药品和检查费用的同时,医院年业务收入的增加是依靠次均费用的提高而增加的。根据上述结论提出了医院控制医疗费用模型和医院增长医疗费用模型。
3.提出患者在医疗费用控制中的特点即主动性和被动性。在关注医疗费用信息方面,两者的选择是一致的——门诊和住院患者均主动关注医疗费用。而在选择检查方面、选择药物方面和看病后在就诊医院购买药品的情况,具有控费意识的两者选择也是一样的,均为听从医生安排,都表现出控费的被动性。这在非条件Logistic回归分析中也得到验证。这个结果一方面证实了患者因为健康刚性需求而导致药品和检查的选择的被动性;另一方面说明医生具有信息优势,有出现道德风险的动机因素。根据上述研究构建了患者增长医疗费用的行为模型。
4.医疗费用控制中政府、医院、患者和谐互动机制研究
结合理论研究与实证的分析结果的探讨,本文最后总结了医疗费用控制患者、政府及医院的委托代理关系体系。这一委托代理体系存在着如下几组委托代理关系:医疗保险机构与患者;医疗保险机构与医院;患者与医疗服务提供者;患者与政府;政府与医院以及与医疗保险机构。然后根据这一委托代理关系体系,从系统的角度,研究三者之间的相互之间的关系,探讨博弈行为背后的深层次问题,构建三方的医疗费用控制和谐互动机制。这一互动机制考虑了不同关系与具体的策略之间的交互关系,同时能够反映随着相关主体的变化,控制医疗费用策略发生的变化。
5.构建了医院自我激励约束机制的框架,概括为建立和完善医院内部的制度、市场竞争机制的引入、构建和谐的医院文化、医生品质的鉴别四个方面。具体来说,医疗机构激励与约束机制的建设包括以下几方面:改进医疗机构内部治理结构;设计管理者报酬机制;营造竞争的市场环境,强化市场竞争约束;建立管理者的职业风险机制,加强职业风险约束;建立科学的医院文化;加强医生的道德品质鉴别。
6.根据委托代理关系以及互动机制构建政府医疗费用控制政策框架。其价值取向“以民为本,政府主导,系统控制,制度创新,道德培育”。政策框架内容包括:政府决策维度有加强政府投入,体现政府职责;建构政府管制的法律体系;进一步深入改革药品集中招标制度;尽快建立社区卫生服务体系的配套制度。医院决策维度有建立医院自我激励约束机制;改进对医疗单位的支付制度;强化对医疗服务提供方的制约和调控制度建设;建立缩小医疗信息不对称的制度;建立治理商业贿赂工作机制;设立资格处罚制,从制度上约束、规范医疗机构及医生的行为。患者决策维度有建立科学的医疗救助工作机制,保障弱势人群的基本医疗服务需求;建构各阶层平等参与的制度平台,扶持患者权利保障组织的利益调节机制;加强居民的健康教育与促进;建立约束需方道德风险的制度。
Objectives:
Analyzing the behavior characteristic of the government, the hospital, and the public in the process of medical expense control and its influence to medical expense increase, establishing the behavior model; Theoretically constructing the entrusting and the agent system of the government, the hospital, the public in the medical expense control, and providing the corresponding policy to explain, exploration the harmonious interaction mechanism in the government, the hospital and the public, to provide the policy-making basis and the new policy mentality in solving the excessively quickly growing of medical expense for the government, thus providing the policy basis for the realization society harmonious development.
Methods:
Literature methodology: Consulting massive domestic and foreign public literature and the research results about the medical expense development situation and the control, also the government, the hospital and the public gambles.
Thorough interview methodology: This research has carried on repeatedly interview and strict proof in the medical expense correlation main body behavior, the influence of the behavior to medical expense and investigation content. completing in participation of experts of Tongji Medical college, hospital chief, sanitation bureau administrative personnel.
Questionnaire survey methodology: Using the standardized questionnaire survey, in view of the government representatives, the hospital superintendent and the patient separately designs the questionnaire, to obtain the related information on the tripartite behavior characteristic and its the influence factor in the process of controlling expense. Statistical Analysis methods:Univariate Analysis:Chi-square for variable data; Multivariate Analysis:Unconditional Logistic Regression; All data are input by using Microsoft Office Excel 2003 and processed by SPSS for Windows 11.5.
Results:
1.The economic analysis of the government behavior in medical expenses control The theoretical analysis result of the government behavior showed that, Government's value lies in the maintenance and the development society public interest,its behavior goal orientation is maintenance harmonious and stable development. But in real life, the government benefit may be the public interest which the government represents, also may be the benefit from the government authority. This is easy to form the government behavior to be in a dilemma, when the government benefit has surmounted the public interest, the government behavior is on performance for government function vacancy or function limit.
Government's behavior analysis in the medical health organizational reform demonstrated that, In the market economy organizational reform period, to the government,On the one hand the government must use the measures under the planned economy system "the multi-purpose government" and the correlative health policies and measures to maintain oneself is the public health main policy-maker and the investment, on the other hand, government's financial resource satisfy the request with difficulty which the public health rapid development and the people health service demand unceasingly enhances.
The government's behavioral analysis result in the process medical expense controlled demonstrated that, The government also falls into in the benefit difficult position - both to have to consider own economical financial resource and to have to consider solving the patient to see a doctor with much money.
2. The economic analysis of the hospital behavior in medical expenses control The hospital behavior analysis result showed that, The hospital behavior value orientation often has the ambiguity, one is pursuing the economic benefit; The other is the public benefit.
The research on hospital showed that, in 1998-2005 year the gross income and the gross expense in the general hospitals of ministry of health is synchronized increasing, and its service disbursement and the service income nearly superposed. The quantity increase of the hospital service providing are not many, the speed is not quick, obviously is lower than the speed of the hospital income increase. Each doctor's working load rate of rise drops year by year, even at the same time no longer grows, their year service income actually fast grows. The medical expense of each outpatient service, the everyday bed expense of leaving the hospital as well as the average medical expense of leaving the hospital is rising year by year, namely the unit service expense is rising. In the leaving the hospital average medical expense constitution per person, the proportion of Chinese native medicine and the inspection expense account for the medical expense grows slowly, has the tendency to drop.
3. The economic analysis of the patient behavior in medical expenses control The outpatient’s consciousness of controlling spending has statistical significance in the difference of age and income. The inpatient’s consciousness of controlling spending has statistical significance in the difference of culture, income and registered permanent address. But in sex, occupation, inhabited area and the form of medicare, the difference of the outpatient’s and inpatient’s consciousness of controlling spending have no statistical significance. The difference of the outpatient’s and inpatient’s consciousness of controlling spending have statistical significance in treatment situation.
The outpatient and inpatient paying attention to the medical expense information has no statistical difference in the aspect of medicare, and both pay attention to the medical expense information. The difference of the inpatient’s consciousness of controlling spending has statistical significance when they choose a doctor.
The check-up of outpatient has no statistical difference in consciousness of controlling spending, but has statistical difference in the form of medicare. The check-up of inpatient has statistical difference in consciousness of controlling spending. In the attitude to check-up, the inpatient participating in medicare and having consciousness of controlling spending have no statistical difference.
The outpatient requesting doctors to prescribe cheap medicine has statistical difference in consciousness of controlling spending. The outpatient and inpatient to choose the medicine have statistical difference in consciousness of controlling spending. The outpatient and inpatient to buy the medicine in the hospital pharmacy have in statistical difference in consciousness of controlling spending. Inpatient to choose the medical consuming material has no statistical difference in consciousness of controlling spending. Unconditional Logistic regression analysis result showed that the factor that influence outpatient’s consciousness of controlling spending has related to concerning medical expense and choosing drug; the factor that influence outpatient’s consciousness of controlling spending has related to the month income and buy the medicine in the hospital pharmacy.
Conclusions:
1. Proposed the government behavior characteristic in the medical expense control, namely the government is the supplying main body in medical expense control policy; The government is the main body of macroeconomic regulation and control; The public welfare of government behavior in medical expense control. And construct the government control medical expense growth model acted according to its behavior characteristic to.
2. Responding to our country medical expense control policy ,the hospital has its own initiative to take measures to reduce the expense of drugs and checking-up, at the same time, the increase of hospital service income is actually depending on enhancing the unit service expense, and unit service expense enhancement is through increasing service intensity. Proposed the hospital control medical expense model and the hospital medical expense growth model according to the above conclusion.
3. Proposed patient's characteristic in medical expense control, go-aheadism and passivity. In the aspect of attention to medical expense information, two choices are consistent - the outpatient and inpatient having control spending consciousness both initiative pay attention to medical expense. But in the aspect of selecting checking-up, the choice of medicine and purchasing the drugs in the hospital after seeing a doctor, two choices is also the same in having control spending consciousness, both obeys doctor to arrange, both displays the passivity in controlling spending. This also obtains the confirmation in the multi-factor analysis. This result on the one hand confirmed that the patient causes the drugs and the inspection choice passivity because of the healthy rigid demand; On the other hand explained doctor has the information superiority, has appears the moral risk to induce the factor. Constructed the behavior model of patient growing the medical expense according to the above research.
4. The harmoniously interacting mechanism research of the government, the hospital and the patient in medical expenses control
United the fundamental research and the demonstration analysis result discussion, this article finally summarized the entrusting and the agent system of the government, the hospital, the public in the medical expense control. The entrusting and the agent system at least have the following several groups relationships, Medicare organization and patient; Medicare organization and hospital; Patient and medical service provider; Patient and government; Government and hospital as well as with medicare organization.Then according to the entrusting and the agent system, from the system angle, studies the relationships between the three aspect, discussing the deep level questions behind the gambling behavior, constructs the tripartite harmonious interaction mechanism in medical expense control. This interaction mechanism had considered the alternately relations between the different relationships and the concrete strategy, simultaneously can reflect along with the change of the correlation main body, the change which the control medical expense strategy occurs.
5. Constructed the frame of hospital self-encouragement restraint mechanism, summarizes for four aspects such as establishing and consummating the hospital interior system, the market competition mechanism introduction, constructing the harmonious hospital culture, the doctors’quality distinguishing. Concretely said, the inspirit and restraint mechanism construction of medical organization including the following several aspects: Improvement medical organization interior structure; Designing the superintendent reward mechanism; Building the competition the market environment, strengthens the market competition restraint; Establishing superintendent's professional risk mechanism, strengthening the professional risk restraint; Establishing scientific hospital culture; Strengthening doctors’moral cultivation .
6. According to the entrusting and the agent relations as well as the interaction mechanism construct the government medical expense control policy frame. Its value orientation is "take the people as the basic, the government leads, systemically control, system innovation, moral cultivation". The content of policy frame includes: In the government decision-making aspect, strengthening the government invest, manifests the government responsibility; Constructing the legal framework of government regulation; Further thorough reforming drugs inviting public bidding system; Establishing the necessary system of the community health service system as soon as possible; In the hospital decision-making aspect, Establishing the hospital self-encouragement restraint mechanism; Improvement the payment system to medical organization; Strengthening the restriction to the medical service supplier and the construction of regulative system; Establishment the system reducing the medical information asymmetry; Establishment the work mechanism fathering commercial bribe; Establishment qualifications punishment system, restraining and standardizing the behavior of medical organization and doctors from the system; In the patient decision-making aspect, Establishment scientific medical rescue work mechanism, safeguard the basic medical service demand of weak crowd; Constructing the system platform that various social strata can equality participate, supporting the benefit adjustment mechanism of the patient right safeguard organization; Strengthening inhabitants’health education and promotion; Establishment the system of restraining consumer moral risk.
引文
[1]Yanzhong Huang. The Paradox of State Power: Political Institutions, Policy Process, and Public Health in Post-Mao China (A PhD Dissertation). The University of Chicago. Chicago, Illinois. Dec, 2000
[2]卫生部统计信息中心.中国卫生服务调查研究第三次国家卫生服务调查分析报告.北京:中国协和医科大学出版社,2004.
[3]李郁芳.政府规制过程的行为主体及其相互关系的理论分析.福建论坛·经济版.2002,11:24-27
[4]邹东涛,席涛.制度变迁中个人、企业和政府行为主体的经济分析.北京大学学报(哲学社会科学版).2002,39{2}:5-14
[5]Evans,R.(1974),“Supplier-induceddemand:someempiricalevidenceandimplications”,in:M.Perlman,ed,TheEconomicsofHealthandMedicalCare162-173.
[6]Pauly,M.V. Doctors and Their Work shops :Economic Models of Physician Behavior (University of Chicago Press, Chicago).
[7]Cromwell,J,and J.B.Mitchell(1986),“Physician-induced demand for surgery”, Journal of Health Economics293-313.
[8]张勇.三医联动之改革政策问题的关系研究篇.世界临床物.2003.2:124-127
[9]张勇.三医联动之改革政策问题的内部机制研究篇.世界临床药物.2003.158-62
[10]李玮.我国城镇职工基本医疗保险制度改革中若干关键问题研究(博士论文).上海交通大学, 2003年10月
[11]张亚东,马剑.控制医疗费用的主体与方式研究.卫生经济研究理.2003.11:18-21
[12]吴忠民.“和谐社会”释义.前线.2005,1:28-29
[13]郝模.社会互动:医院补偿机制恶性循环模型逻辑推论.中华医院管理杂志.1998,14:6-2
[14]张维迎.博弈论与信息经济学.上海:上海人民出版社.1996
[15]Macho-Stadler,I. Perez-Castrillo,D. An Introduction to the Theory of Information:Incentives and Contracts. Oxford University Press,Oxford,1997
[16]贺琼,王磊.不完全信息条件下委托代理问题博弈分析.当代经济.2006,9:91-92
[17]周业勤.当代卫生改革的利益结构分析.中国卫生经济,2002,(9):28-29.
[18]周成红,汤质如,吴方.医疗机构实行“双轨制”收费的寻租经济分析.卫生经济研究,2003,6:14-15
[19]Arrow K J . Uncertainty and the welfare economics of medical care . The American Economic Review,1963,53 (5) :941-973.
[20]Eggleston K. Risk selection and optimal health insurance provider payment systems. The Journal of Risk and Insurance,2000,67(2) :173-196.
[21]Pauly M V. The economics of moral hazard: comment. The American Economic Review,1968,58 ( 3) :531-537.
[22]高志明.制度公正与博弈均衡:一种关于法律制度的博弈论分析.理论与改革.2004,1:137-139
[23]马占稳.博弈论对创建和谐社会的启示.领导科学.2005,22:42
[24]臧乃康.政府利益论.理论研讨.1999,1:18-21
[25]陈卉敏.谭学锋.政府行为困境解析——从政府利益谈起.当代经理人.2006,21:659
[26]杨丽丽.我国公共政策制定过程中的政府利益分析.天水行政学院学报.2005,4:31-34
[27]杨超.政治的功能分析:利益关系的视角.南京政治学院学报.2007,23(1):54-58
[28]王臻荣,常轶军.论政府利益与“改革困境”.经济社会体制比较.2005,6:97-103
[29]HerbertA.Simon.,Models of Man., Social and Rational (New York: Wiley , 1957).
[30]麻宝斌.公共利益与政府职能.公共管理学报.2004,2:86-73
[31]崔斌.对我国医改中四大矛盾的再认识.中国药物经济学.2006,2:52-60
[32]唐涛.中国医改履历:续写争议.中国卫生产业.2005,12:51-52
[33]邵卫东,牛思聪.医改大事记.当代医学2005,12:38-53
[34]梁中堂.宏观视野下的我国医疗卫生体制改革.经济问题.2006,3:12-17
[35]杜乐勋等主编.中国医疗卫生发展报告.北京.社会科学文献出版社.2006.5
[36]中国医改20年.南方周末2005.
[37]陈立今.医疗卫生产业范畴界定和策略研究(博士后论文).复旦大学,2004年4月
[38]吴娆.我国医疗卫生费用控制浅谈.发展,2004,8:27-29
[39]许妈银.关于当前药品集中招标采购存在问题及对策研究.国际医药卫生导报,2003,23:97-106
[40]Feldman, R,Dowd,B,A new estimate of the welfare loss of excess health insurance, The American Economic Review,March 1991,297-301.
[41]Feenberg,D,Skinner,J,The risk and duration of catastrophic health care expenditures,Review of Economics and Statistics,1994(76),333-347.
[42]Nyman,J. A.,The economics of moral hazard revisited,Journal of Health Economics,1999(18),811-824.
[43]Jacob,J,Lundin,D. A median voter model of health insurance with ex post moral hazard,SSE/EFI Working Paper Series in Economics and Finance,No.409,October 2000.
[44]Crew,M.,Coinsurance and the welfare economics of medical care, The American Economic Review,1969(59),906-908.
[45]Yip W,Eggleston K..Addressing Government and Market Failures with Payment Incentives: Hospital Reimbursement Reform in Hainan,China. Social Science & Medicine,2004,58: 267-277
[46]Yip W,Hsiao W. Medical Savings Accounts: Lessons from China. Health Affairs, 1997,16: 244-251
[47]金春林,王锦福.卫生改革谈医院药品收支两条线管理.卫生经济研究,2002,4:31
[48]王俊华.医疗服务机构要强化其社会责任.中华医院管理杂志.2005,21{3}:205-207
[49]李军,杜丹琳,任华康.探讨医疗保险机构和医疗机构在控制医疗费用中的作用.中华现代医院管理杂志.2004,11:33-35
[50]徐斌.从医药业的寻租行为看制度创新的必要性.中国软科学.1998,10:22-25
[51]苏红.过度医疗的经济学分析.卫生经济研究,2004,9:38-39
[52]陈少敏,邱强.医疗行业中的过度治疗行为的经济学分析.医学与哲学.2005,7:54-55
[53]方东荔.有效遏制“过度医疗”.赤峰学院学报.2006,5:82-84
[54]李传良.法视野下的过度医疗行为分析.法律与医学杂志.2006,13(2):98-103
[55]陈晓阳,杨同卫.关于过度医疗的经济学分析与伦理.医学与哲学.2003,9:13-14
[56]李德玲.过度医疗的成因与对策.医学与哲学.2003,9:5-9
[57]李军,杜丹琳,任华康.探讨医疗保险机构和医疗机构在控制医疗费用中的作用.中华现代医院管理杂志.2004,11:33-35
[58]于德志.我国医疗费用增长与控制策略分析(博士论文).华中科技大学,2005年5月
[59]弓宪文.信息不对称下医患关系博弈分析重庆大学学报,2004, 4(27):4-7
[60]Qingyue Meng, The impact of urban health insurance reform on hospital charges a case study from two cities in China. Health Policy. 2004, 68:197–209
[61]Darrell J. Gaskin .Altruism or moral hazard: The impact of hospital uncompensated care Pools. Journal of Health Economics.1997,16: 397-416
[62]Evan Doran.Moral hazard and prescription medicine use in Australia—the patient perspective. Social Science & Medicine .2005,60 :1437–1443
[63]Pierre-Andre,Chiappori. Moral hazard and the demand for physician services:First lessons from a French natural experiment. European Economic Review.1998, 42: 499-511
[64]陈永升.医疗保险中医疗供方道德风险行为分析.新疆财经学院学报.2002,4:35-37
[65]李宜军.中国政府实现“医药分家”政策目标的难点分析.广东药学,2001,11(4):1-5
[66]赵军.医疗费用过快增长的动力机制和控制策略谫论.中华医院管理杂志.2003.19(8):449-450
[67]Peter,C. S,et al,Principal-agent problems in health care systems: an internationalperspective,Health Policy,1997(41), 37-60.
[68]Mooney, G,Ryan,M,Agency in health care: getting beyond first principles, Journal of Health Economics,1993(44), 125-135.
[69]Rasell,E,Cost sharing in health insurance—a reexamination,The New England Journal of Medicine,1995(17),164-168.
[70]Eisenhardt,K,Agency Theory: an assessment and review,Academy of Management Review,1989(14),67-74.
[71]Jones,A,Zanola,R.,Agency and health care,Center for health economics, University of York,1995.
[72]胡苏云,医疗保险中的道德风险分析,《中国卫生资源》,2000年第3期.
[73]Beazoglou,T,Dennis,H,Optimal market structures in an insured health care market: some implications for Health Care Reform,Society,Economy,and Health,1995(4), 5-30.
[74]Beazoglou,T. et al. Efficiency in insured health care markets,Journal of Health Care Sciences,1993(2),3-18.
[75]Gaynor,M,Gertler,P. Moral hazard and risk spreading in partnerships,Rand Journal of Economics,1995(26),591-613.
[76]Gaynor,M,Haas-Wilson,D. and Vogt,W. B. Are invisible hands good hands? Moral hazard,competition and the second best in health care markets, NBER Working Paper No.6865,December,1998.
[77]Randall P. Ellis. Hospital response to prospective payment: Moral hazard,selection, and practice-style effects. Journal of Health Economics.1996,3:257-277
[78]Newhouse,J. P,et al,Free for all Lessons from the Rand Health Insurance Experiment,Harvard University Press,Cambridge,MA,1993.
[79]Keeler,E. B,J. E. Rolph,The demand for episodes of treatment in the health insurance experiment,Journal of Health Economics,1988(7),337-367.
[80]Manning,W. G. et al,Health insurance and the demand for medical care: evidencefrom a randomized experiment,The American Economic Review,1987(77), 251-277.
[81]Manning,W. G,Marquis,M.,Health insurance: the tradeoff between risk pooling and moral hazard,Journal of Health Economics,1996(15),609-640.
[82]Buchanan,J. L. et al,Simulating health expenditures under alternative insurance plans, Management Science,1991(37),1067-1090.
[83]Douglas Lundin. Moral hazard in physician prescription behavior. Journal of Health Economics.2000,19: 639–662
[84]Blomqvist,A. The doctor as double agent: information asymmetry,health insurance, and medical care. Journal of Health Economics1991,10: 411–432.
[85]Coscelli,A,1998. Are market shares in drug markets affected by doctors’and patients’preferences forbrands? Discussion Paper 98-01,University College London.
[86]耿嘉川.利益主体下的中国医疗体制改革博弈.东岳论丛.2006,27(1):81-84
[87]张文生,毛正中,阎正民.我国政府对国有医院管理的委托代理结构分析.卫生软科学. 2003,17( 6):6-8
[88]周业勤.利益冲突的调节机制.医学与哲学.2004,25(10):69-70
[89]黄成礼,马进等.供方支付方式研究及政策建议.中国卫生经济[J],2000,19(1):8-10
[90]张亚东.我国控制医疗费用的现状.经济论坛[J],2003.10:8-10
[91]毛孟凯.我国医疗费用高涨的原因和对策分析.广西社会科学[J],2005.2:58-60
[92]左宏.医疗市场博弈分析与医疗体系结构优化初探.卫生经济研究.2005,8:13-15
[93]赵贺春.企业内部约束与激励机制研究.冶金经济与管理.2006,3:6-8
[94]杨红炳.委托代理理论与国有企业激励约束机制的建构.边疆经济与文化.2006,8:36-38
[95]郝海,张双德,张庆云.公立医疗机构激励与约束机制研究.卫生软科学.2005,3:161-164
[96]赵文华等,一个新的委托代理问题-共谋行为,《西北大学学报(哲学社会科学版)》1998年第3期.
[97]Tirole,J,Hierarchies and bureaucracies: on the role of collusion in organizations, Journal of Law,Economics,and Organizations,1986,2(2): 181-214.
[98]Albert Ma C,McGuire T. G,Optimal health insurance and provider payment,The American Economic Review,1997(87),685-704.
[99]Kofman,F,Lawarree, J,On the optimality of allowing collusion,Journal of Public Economics,1996,61(3): 383-407.
[100]Tirole,J,A theory of collective reputation with applications to the persistence of corruption and to firm quality,Review of Economic Studies,1996,63(1): 1-22.
[101]张文生,毛正中,阎正民.我国政府对国有医院管理的委托代理结构分析.卫生软科学. 2003,17( 6):6-8
[102]钟东波.我国医疗行业政府管制的制度框架.中国卫生经济.2003,1:14-18
[103]南京辉,张亮,张翔.药品集中招标采购存在问题研究.医学与社会.2005,18(5):49-51
[104]陈爱云.医疗费用控制的国际比较及对我国的启示.国际医药卫生导报.2005,23:9-11
[105]赵曼.社会医疗保险费用约束机制与道德风险规避.财贸经济.2003,2:54-57
[106]张宗利.医疗机构必须从“以药养医”转为“以医养医”.中国药业.2002.1:4-5
[107]王前强.利益集团博弈与公立医院产权改革的挫败.2005,09,13. http://xz.bokee.com/print.php?id=35028
[1]张奇林,论美国的医疗卫生费用控制,《美国研究》,2002年第1期.
[2]莫京梁,医疗保健成本及其控制的理论研究和实证分析,上海交通大学博士学位论文,1996.
[3]王敏,日本:强制性医疗保险制度,《中国保险》,2001年第6期.
[4]王耕晨,肖湘泉.医疗费用在医疗制度改革中的变化趋势及政策取向.医学与哲学.2000,21(1):20-22
[5]卫生部,2001年中国卫生统计提要,2002/6/17.
[6]卫生部卫生统计信息中心,2001年全国卫生事业发展情况统计公报,2002/4/10.
[7]饶克勤,深化卫生改革的几点思考,2002.
[8]王海明.医疗卫生费用控制探讨.江苏卫生事业管理.2004.6(15):58-60
[9]雷海潮.中国卫生总费用的未来趋势及相关政策思考.中国卫生事业管理. 1999. 3:137- 140
[10]胡善联、龚向光,如何正确评价医药费用的增长,《中国卫生经济》,1999年第6期.
[11] Newhouse,J. P,Medical care costs: how much welfare loss? Journal of Economic Perspectives,1992(6),3-21.
[12]张侃.谈医疗费用的控制目标.解放军医院管理杂志.2003.10(6):527-528
[13]郑树忠.关于卫生事业发展与费用控制的探讨.中国卫生资源.2000.9(3):203-205
[14]吴娆.我国医疗卫生费用控制浅谈.发展.2004.8:27-29
[15]苏红.过度医疗的经济学分析.卫生经济研究.2004.9:38-39
[16]赵军.医疗费用过快增长的动力机制和控制策略谫论.中华医院管理杂志.2003. 19 (8): 449-450
[17]毛孟凯.我国医疗费用高涨的原因和对策分析.广西社会科学.2005.2:58-60
[18]国家统计局,迎接十六大系列分析报告,2002.
[19]国家统计局,《中国统计年鉴2001》.
[20]朱毅,医疗费用过度增长的成因与思考,《卫生经济研究》,2000年第2期.
[21]饶克勤等,中国居民健康转型、卫生服务需求变化及其对经济、社会发展的影响(之一),《中国卫生经济》,2000年第9期.
[22] Davis,Karen,Gerard F,Anderson,Diane Rowland,and Earl P. Steinberg: Health Care Cost Containment,Baltimore: The Johns Hopkins University Press,1999
[23]黄成礼,马进等.供方支付方式研究及政策建议.中国卫生经济[J],2000,19(1):8-10
[24]李秀娟、吴洋,医疗费用增长的原因及对策思考,《卫生软科学》,2002年第3期.
[25]左学金等,中国城市医疗保险体制改革:建立成本制约机制和组织创新,中国社会保障和保险论坛,1997-1998.
[26]王延中,中国医疗保险制度改革研究,《经济工作者学习资料》,1999年第17期.
[27]康永军,张洪彬,徐昌青.当前医疗费用上升的原因和对策.中华医院管理杂志.2005,21(4):220-223
[28] Yip W,Eggleston K. Addressing Government and Market Failures with Payment Incentives: Hospital Reimbursement Reform in Hainan,China. Social Science & Medicine,2004,58: 267-277
[29] Yip W,Hsiao W. Medical Savings Accounts: Lessons from China. Health Affairs, 1997,16: 244-251
[30]吴娆.美国医疗卫生费用控制政策分析.社会.2003.9:31-33
[31]仲秋.欧盟各国费用控制及卫生改革.国外医学卫生经济分册.1997.14(4):156-164
[32]马宏坤,吴玉华,张福利.美国医疗费用控制策略.国际医药卫生导报.2004,11:26-27
[33]杨明亮.浅谈德国医疗费用的控制及借鉴作用.事业财会.1998.5:36-37
[34]高大林.德国医疗设备管理及费用控制.国外医学卫生经济分册.2000.17(1):4-10
[35] Yanzhong Huang. The Paradox of State Power: Political Institutions, Policy Process, and Public Health in Post-Mao China (A PhD Dissertation). The University of Chicago. Chicago,Illinois. Dec,2000
[36]卫生部统计信息中心.中国卫生服务调查研究第三次国家卫生服务调查分析报告.北京:中国协和医科大学出版社,2004.
[37]阎玉霞.住院病人“病例组合”统计分类方法研究(博士论文).第四军医大学,成都, 2001年6月
[38]李云良.医疗保险费用支出的经济学分析.卫生经济研究.2005.3:21-22
[39]丁继红,朱铭来.试论我国医疗保险制度改革与医疗费用增长的有效控制.南开经济研究.2004.4:96-99
[40]胡苏云.医疗保险中的道德风险分析.中国卫生资源,2000.5, 3(3)
[41] Thorpe,Kenneth E: Inside the Black Box of Administrative Costs. Health Afairs,Summer 1992: 41-55
[42]首届中国商业医疗保险论坛,保险研究,2002,11
[43]劳动和社会保障部医疗保险司中国医疗保险制度改革政策与管理中国劳动社会保障出版社,1999,10
[44] Kauer,R.T. The Effect of Fixed Payment on Hospital Costs. Journal of Health, Politics Policy and Law,1995,20: 303-327
[45] Mougeot M,Naegelen F. Hospital Price Regulation and Expenditure Cap Policy. Journal of Health Economics,2005,24: 55-72
[46] Boadway R,Marchand M,Sato M. An Optimal Contract Approach to Hospital Financing. Journal of Health Economics,2004,23: 85-110
[47] Evans,R.(1974),“Supplier-induceddemand:someempiricalevidenceandimplications”,in:M.Perlman,ed,TheEconomicsofHealthandMedicalCare162-173.
[48] Pauly,M.V. Doctors and Their Work shops :Economic Models of Physician Behavior (University of Chicago Press,Chicago).
[49] Cromwell,J,and J.B.Mitchell(1986),“Physician-induced demand for surgery”, Journal of Health Economics293-313.
[50]张勇.三医联动之改革政策问题的关系研究篇.世界临床药物.2003.2:124-127
[51]张勇.三医联动之改革政策问题的内部机制研究篇.世界临床药物.2003.158-62
[52]李玮.我国城镇职工基本医疗保险制度改革中若干关键问题研究(博士论文).上海交通大学,2003年10月
[53]张亚东,马剑.控制医疗费用的主体与方式研究.卫生经济研究理.2003.11:18-21
[54]苏红.医疗费用控制的制约因素及变化趋势分析.卫生经济研究.2005,5:11-12
[55]吴忠民.“和谐社会”释义.前线.2005,1:28-29
[56]郝模.社会互动:医院补偿机制恶性循环模型逻辑推论.中华医院管理杂志.1998,14:6-2
[57]张维迎.博弈论与信息经济学.上海:上海人民出版社.1996
[58] Macho-Stadler,I. Perez-Castrillo,D. An Introduction to the Theory of Information: Incentives and Contracts. Oxford University Press,Oxford,1997