民营化、混合竞争与卫生系统绩效--经验证据及其对中国医改的启示

Privatization,Mixed Competition and Performance of Healthcare System——Empirical Evidence and Its Enlightenment for China’s Medical Reform

鼓励社会办医是中国近年来医疗服务供给侧改革的重要举措。然而,随之而来的卫生系统民营化是否有利于促进居民的健康保障并提高其就医满意度?既有研究聚焦公立和民营医疗机构之间绩效比较,而相对忽略民营化在社会层面的溢出效应。文章从混合医疗服务体系的竞争视角入手,在"结构-行为-绩效"分析框架的基础上,利用嵌套数据的多层次模型进行研究发现:民营医院数量占比和市场份额的增加并没有对居民的自评健康水平和就医条件满意度产生显著影响,但与住院费用、自付住院费用显著地负相关。民营化很可能促进了医疗服务的价格竞争,却未能增强其质量竞争。进一步的分析指出,中国公立和民营医疗机构在医疗服务定价、质量监管和人才流通等方面存在多重制度分割,从而制约了民营化产生的市场效应。在深化医疗卫生体制改革的过程中,政府应同时注重公私结构上价格竞争和质量竞争,完善治理结构,消除竞争壁垒,以进一步提高卫生系统的微观健康绩效和消费者满意度。

It has been an important policy in recent years to encourage social resources to run medical establishment in China as part of the supply-side reform of the medical service.However,we will wonder whether the subsequent privatization of the healthcare system can help promote residents’health protection and increase their satisfaction with medical treatment?Existing researches focus on the performance comparison between public and private medical institutions,while relatively ignoring the spillover effect of privatization at the social level.This article starts from the competitive perspective of the mixed medical service system.Based on the"structure-behavior-performance"analysis framework,we use a multi-level model of embedded data for the research.It is found that the rising number of private hospitals and their market share show no significant impact on residents’self-assessed health level and satisfaction with medical service conditions,but are significantly and negatively related to hospitalization costs and out-of-pocket hospitalization costs.Privatization is likely to encourage the price competition of medical services,but fails to enhance its quality competition.Further analysis reveals that there are multiple institutional divisions in China’s public and private medical institutions in terms of medical service pricing,quality supervision and talent circulation,which restricts the market effect of privatization.In the process of deepening the reform of the medical and health system,the government should also pay attention to price competition and quality competition on the public and private structures,improve the governance structure,and eliminate competition barriers to further improve the micro-health performance and consumer satisfaction of the healthcare system.