越评级越失衡?——我国医院等级评定与医生人力资源配置研究

The More Hospital Ratings,The More Geographical Maldistribution of Physicians? A Study on the Relationship between Hospital Rating and Geographical Maldistribution of Physicians in China

本文基于信息不对称理论,研究政府主导的医院等级评定制度对我国城乡医生人力资源非均衡配置的影响。理论分析认为,医院评定等级是政府主导下形成的一种行政型声誉,在信息不对称的医疗服务市场上发挥了信号功能,扭曲了医生的执业地点决策和患者的就医决策,使"三甲"医院具备了强大的"资源虹吸"能力;随着"三甲"医院比重的上升,医院间竞争程度加剧,"三甲"医院的"资源虹吸"动机得到强化,"虹吸效应"将进一步加重。因此,医院等级评定制度是造成我国城乡医生人力资源非均衡配置的主要原因之一。本文利用我国2004—2016年的省际面板数据对理论分析进行了实证检验。研究发现:(1)"三甲"医院"虹吸效应"显著存在,"三甲"医院比重每增加10%,城乡医生人力资源非均衡配置程度将显著扩大16%~21%;(2)"三甲"医院的"虹吸效应"存在明显的区域差异,西部地区最为突出,东部地区相对较小;(3)"三甲"医院的"虹吸效应"在"新医改"实施后有所减弱。本文的启示在于,在加强基层医疗服务体系建设的过程中,应摒弃行政等级化的计划管理思路,弱化政府主导的医院等级制度对患者和医生的扭曲激励,抑制"三甲"医院的资源"虹吸效应",从而促进我国城乡医生人力资源的均衡配置。

a new view on the geographical maldistribution of physicians in China.Based on the theory of asymmetric information,we analyze the effect of government-dominated hospital rating system on the geographical maldistribution of physicians in China.The theoretical analysis shows that the government-sponsored hospital rating acts as an inappropriate“market signal”in the health care market with asymmetric information.This signal distorts the location choices of physicians and health care seeking behaviors of patients.The hospital rating makes the tertiary hospitals in urban areas have strong siphon effect,being more attractive for the qualified physicians in rural grassroot areas.This signal also attracts a lot of patient to seek health care in urban hospitals.By this way,a vicious cycle formed.The higher the hospital rating,the more qualified physicians and the more patients attracted to the tertiary hospitals in urban areas.Therefore,we argue that the government-dominated hospital rating system is a major factor contributing to the geographical maldistribution of physicians in China.We further employ the 2004-2016 provincial panel data from 31 provinces in China to test the theoretical hypothesis.We use the percentage of tertiary hospitals in a province as a proxy for hospital rating.Our model may suffer endogeneity bias which is caused by omitted variable and reverse causality.The omitted variables include time-invariant unobserved provincial heterogeneity and time-variant unobserved provincial heterogeneity.We use Fixed-Effect model(FE)to control for the possible bias caused by time-invariant unobserved provincial heterogeneity and Fixed-Effects Instrumental Variable methods(FE-IV)to control for the bias caused by time-variant unobserved heterogeneity and reverse causality.Our result show that:(1)The tertiary hospitals in urban areas have a significant siphon effect.The 10%increase in the percentage of tertiary hospitals leads to 16%~21%increase in the geographical maldistribution of physicians in China;(2)There are significant regional differences in this effect,which is being most pronounced in the west and least pronounced in the east;(3)The new round of health care reform since 2009 has reduced the siphon effect of tertiary hospitals to some extent.To check the robustness of the results,we first carry out regressions by using Theil T index and Theil L Index as separate dependent variables.Then we run the regression by splitting the sample into two subsamples,one before 2009 and one after 2009.We find that our main results remain unchanged.Based on the theoretical and empirical analysis,we suggest that,in order to achieve the even geographical distribution of physicians,the government should reform the hospital-rating system and reduce its distorted incentives for physicians and patients.The government should abolish the ideology of planned economy and entrust the hospital rating to an independent,third party market institutions.By this way,the market will evolve an objective,transparent and comprehensive hospital rating system.Our study is subject to several limitation.First,due to the data availability,we do not analyze the underlying mechanism and leave it for further research.Second,the maldistribution index should adjust the quality differences of physicians.In this paper,we only include the service capabilities of physicians as quality adjustor.However,quality is a multidimensional concept.The future study should include more quality indicators to adjust the maldistribution index.