我国公立医院制度性诱导需求遏制政策评价研究

A synergistic interrelation among insufficient government financial inputs, undervalued labor pricing and profitable overdosing leads to supplier-induced demand in China’s public hospitals, which causes waste of medical resources. This phenomena can be called supplier-induced demand with institutional roots (SIDIR), meaning it is resulted from unreasonable institutions and should be tackled through institutional adjustments. Since China’s healthcare reform in 2009, government financial inputs into public hospitals have been greatly increased, health service pricing has been adjusted upward for several times, and drug markup has been scrapped across the country. It is urgent to know to what extent the SIDIR has been curbed, how many medical resources have been saved through this process, and how to uproot the SIDIR in China. Therefore, the applicant intends to (1) build both a qualitative and a quantitative models of the SIDIR for China’s public hospitals; (2) collect data from 1999 to 2018 through large-scale field research in sample areas in China’s eastern, central and western regions; (3) analyze the overall layout and crisscrossing relations among government financial inputs into public hospitals, hospital income from provision of health services and medical examinations and prescription of medicines and medical consumables, personnel expenditures, and expenditure for hospital development; (4) follow the change of the SIDIR before and after the 2009 healthcare reform, compare the differences of any waste of health resources in the same period, and identify reasons for whether the SIDIR has been curbed; and (5) propose holistic suggestions at national level to adjust fiscal policies, medical insurance mechanisms, health service pricing system, and drug administration policies, and predict their effects. The research will provide evidence for improving the financing system of public hospitals in China.

财政投入不足、劳务价格过低、药品耗材检查有利可图等因素共同作用下，医生不得不诱导需求以满足薪酬诉求，造成资源浪费。这类诱导需求，称之为制度性诱导需求，它因制度不合理而产生，应当通过制度调整来消除。新医改以来，财政投入加强，劳务价格多次调整，药品零差率政策在全国各地普遍推行。目前迫切需要知道，制度性诱导服务遏制程度如何，节省了多少资源，如何根除制度性诱导服务。为此，申请项目拟构建制度性诱导需求概念模型和定量模型，结合我国东-中-西样本地区大规模调研所得数据，分析1999-2018年公立医院财政投入、劳务收入、药品耗材检查收益、人员薪酬支出、医院发展支出的基本情况和联动关系，比较新医改前后制度性诱导需求及资源浪费的变化情况，明确制度性诱导需求得到遏制或未能遏制的原因，综合提出国家层面财政、医保、物价、药政相关政策调整的建议，并预测其效果。研究成果将为完善我国公立医院经济补偿制度提供证据支持。

背景 控制医疗费用不合理增长，是深化医改的主要任务之一。新医改以来，我国公立医疗机构的财政投入普遍加强，医疗服务价格多次调整，药品零差率政策普遍推行。目前需要知道上述政策实施之后，制度性诱导需求的遏制程度如何，如何进一步根除制度性诱导需求。目的 本研究旨在甄别公立医院医疗费用增长中制度性诱导需求带来的医疗费用浪费。分析取消药品加成政策、调整物价政策、政府投入政策对公立医院制度性诱导费用的遏制机制、遏制效果。内容 建立公立医院制度性诱导需求的资金流转模型；实证样本地区制度性诱导需求下公立医院资金的流转；评价制度性诱导需求遏制政策实施效果，提出政策优化建议。方法：基于系统动力学和仿真方法学，建立公立医院制度性诱导需求的资金流转模型。收集了样本地区上海市2010-2019年公立医院费用投入和支出明细数据，公立医院人力投入数据。结果 2019年样本地区公立医院中诱导费用约为425亿元，当年诱导费用占公立医院总资金的24%。以2010年为基准年，到2019年十年间，样本地区公立医院总资金增长了1143亿元。总资金增长中87%是由公立医院业务增长带来的费用增长，其中外因导致的增长占51%，诱导导致的增长占36%；其余约13%的资金增长属于由于财政投入增加带来的总资金增长。政策评价上看，取消药品加成政策不会引起公立医院资金总量变化，也不会增加诱导费用变化，但资金流量分配会发生变化。医疗服务价格调整政策，一定程度上遏制诱导费用，缓解公立医院医疗费用总量增长。2019年公立医院制度性诱导费用从474亿元下降到414亿元，诱导费用降低13%。加大财政投入政策，一定程度上遏制诱导费用，但由于财政补贴劳务效率低，财政投入增加额反而超过遏制的诱导费用，公立医院总费用上升。2019年，公立医院财政投入增加105亿元，制度性诱导费用降低了84亿元，诱导费用降低17%。政策比较上看，取消药品加成政策单独实施不能直接遏制公立医院诱导费用。加大财政投入政策相比医疗服务价格调整政策对公立医院制度性诱导费用的遏制效果更好。