政府财政投入模式对医疗费用的影响

Effects of Public Expenditures on Health Care Cost in China

财政投入能否改善医疗服务质量,降低人民群众医疗负担,是完善我国医疗财政投入制度的核心问题。为此,本文首先构建了一个财政投入、患者就医选择和医院投资及收费行为的理论模型,分析财政投入对医院投入和收费行为的影响。模型预测对供方的财政投入,导致医院规模扩张,进而通过增加住院人次以及患者的均次支付意愿抬高医疗费用。对于需方即医保的补贴也会抬高医疗费用,但和差异化的补供方投入不同,无差异普惠性的医保促进了医院间的竞争,这使得补需方导致的医疗费用增幅低于补供方导致的医疗费用增幅。此外,由于医疗成本差异,对高等级医院的财政补贴使医疗费用的提升效应超过对低等级医院补贴的效应。本文利用13个地市的医院微观数据,衡量了财政投入(补供方)和医保支付(补需方)对医疗费用和服务质量的影响,并分析了财政投入对医疗费用产生影响的各种渠道。结果表明,增加公立医院财政投入会加剧其规模扩张,进而通过提高住院率抬高均次医疗费用,同时增加患者自费费用;医保支付增加亦会抬高均次医疗费用,但能够降低患者自费费用,实证分析结果和理论分析预测一致。

The Chinese government’s health care expenditure has grown significantly over the past several decades and is projected to grow in the future.In 2020,the Chinese government spent about 7.1%of its financial expenditure on health care,increased from 6.8%in 2013.The funding to China’s public health care institutions has increased from CNY 489 billion in 2013 to CNY 755 billion by 2020,which account for 52%of total health care expenditures by then.Government subsidies on China’s public insurance programs were CNY 1.4 trillion in total from 2016 to 2020.The government spending on health care systems was supposed to reduce the burden of people’s health care spending.However,the rapid expansion of government health care spending came with the escalating expenditures of medical care,because of the problems of supplier-induced demand.Therefore,in this paper,we investigated the effects of different types of government health care expenditures on health cost and health care market in China.We first developed a static medical market competition model to investigate the effects of different types of public health care expenditures on patients’hospital choices,and hospitals’decisions of investment and pricing.In the model,we assume that a government can invest in public hospitals or subsidize the public insurance program,given the fixed total health care budget.A fixed number of patients are choosing hospitals by comparing the quality and prices of the hospitals.A primary public hospital,a tertiary public hospital and a private hospital are competing for patients by investing on beds and setting price.In the model,government spending on the supply side or demand side can affect health care cost by affecting the hospitalization rate of each hospital and patients’hospital choices.The model predicts that the government expenditures on supply sides causes hospitals to invest more in medical facilities and beds,which lead to more inpatients and higher average medical payment willingness,and further a higher medical cost.Although the subsidy to the demand side will still increase the investment of hospitals,due to the competitive pressure between hospitals,the increase of patient burden caused by the demand side is lower than that caused by the supply side.In addition,due to the asymmetric competitive characteristics of the medical market,increasing the subsidy ratio of high-level hospitals will lead to high-level hospitals occupying the resources and market share of primary hospitals,thus increasing the average medical expenses.In the empirical part,we constructed a dataset with hospital operation information of 13 Chinese cities from 2008 to2016,which consists of 17,869 hospital-year observations.Using the dataset,we employed a 2 SLS regression method to assess effects of the government’s health care expenditures(supply side)and medical insurance payment(demand side)on medical expenses and hospitals’service quality,and analyzed various channels through which financial expenditure affects medical expenses.The results show that increasing health care expenditures on hospital will increase the average medical service cost.The reason is that increasing the health care expenditure on public hospitals will accelerate their scale expansion,and then increase the average medical expenses by increasing the hospitalization rate,and at the same time increase the self-payment of patients.The increase of medical insurance payment will also increase the average medical expenses,but it can reduce the patients’self-payment.The empirical analysis results are consistent with the theoretical analysis predictions.The empirical results indicate that the average health care spending per visit increased as government funding increased and the expenditure on aggregate public health insurance increased.The raising government funding increased self-payment of patients,while the raising health insurance subsidies had no significant effects on self-payment.The decomposition of the impact of competition shows that government funding will cause hospitals to increase investment on beds,doctors and facilities,which cause a higher price.The results are also proposed that public health care expenditures on the supply side can cause more price changes than that on the demand side through increasing the hospitalization rate and the market share of public hospitals.Additionally,expenditures on public hospitals decrease the market share of private markets;expenditures on tertiary public hospitals will cause more competitive pressure on other hospitals than the expenditure on other hospitals.To conclude,direct government spending on public health care institutions causes the expansion of public hospitals,which raises the total health care expenditures and self-payment of patients,because of the problems of supplier-induced demand in the health care systems in China.The findings facilitate the understanding of the influence of government expenditures on health care market in China.The paper also contributes to the literature by exploring the channels of the influences of public health care expenditures on the efficiency of the health care system and the market structure of health care systems.The conclusion of the paper suggests that increasing medical and health investment is an important means to meet people’s medical needs.However,the health care expenditure to the supply side,especially the allocation of health care expenditures according to administrative levels,has intensified the over-expansion of tertiary hospitals,resulting in the over-growth of medical costs.In order to eliminate this influence,the Chinese government needs to adjust the structure of public health care expenditures to deal with the problems of supplier-induced demand in the public health care institutions.At the same time,the way to supplement the supplier should be to promote competition rather than intensify monopoly,so as to promote the rational and balanced allocation of medical resources.