公立医院“取消编制”的政策建构:渊源、经验与展望

On the policy construction of “Cancelling Budgeted Posts”in the public hospital: Origination,experience and expectation

我国公立医院编制管理的制度渊源是前苏联的国民经济预算管理制度,现实渊源则是建国以来医院管理的现实制度需求。两者的变革及其经验表明,当前公立医院"取消编制"的改革并不简单源于编制内外的"同工不同酬",而是源于编制管理所固有的弊端,包括产权主体与责任主体的分离、医院决策能力的瓶颈、人才流动的实质性羁绊、与支付制度的分离等。"取消编制"仅仅是去行政化的改革策略,并不能认为是以推进公立医院全面市场化为目标。基于此,"取消编制"将成为推进医院法人化治理、医疗保障制度、政府补偿机制等系统改革的前奏。完善医疗服务成本补偿方式的具体设计将成为"取消编制"后改革的重点,而依据域外经验和改革实践,医疗保险支付和政府购买服务应成为主要补偿方式。然而,目前"取消编制"的改革面临各地经济发展不平衡、相关系统改革难以共同推进、编制制度惯性带来的改革效果不佳等重大障碍,应全面规划,慎重进行。

The institutional origin of Chinese public hospitals＇ management system of the budgeted post is the former Soviet Union＇s national economic budget management system,and the realistic origin is the realistic requirements since 1949. The reform experiece of both above suggests that the reform policy about ＂cancelling budgeted posts＂in the public hospitals was not the result of ＂the different pay,the same work＂dependeds on whether the budgeted post or not,but rooted in defects in management system of the budgeted post,which include the fracture of the ownership and the responsibility subject,the bottleneck of hospital decision-making ability,the obstacles of the talent flowing and separation of the payment system. This policy is only reform strategy of de-administration,rather than promoting the comprehensive marketization of public hospital. so the policy about ＂cancelling budgeted posts＂is the beginning of comprehensive reforms about hospital corporate governance,medical security system,and medical service compensation. The specific methods of the medical service compensation will become the focus of the further reform. According to the foreign reform experiences and our reform practices,Policymakers would get health insurance and government purchase as the main compensation methods in future. However,because of the imbalance of economic development,the diffcult of systematic reform,inertia obstacles of the old management system of the budgeted post,we should make the comprehensive plans and cautiously advance the measures.