摘 要 医疗卫生体制改革是当前社会各界最为关注的热点话题之一。对于一个社会来说，合理的医疗卫生政策，不仅仅是社会公正的直接体现，而且关系着一国公民之健康，进而决定了一国未来发展的基础。今天之中国，正在努力建设和谐社会，公平的医疗制度，和谐的医疗市场环境是医疗体制改革的目标。它们应该直接体现社会经济发展的成果，并应该使其惠及全体民众。但是，目前医疗卫生体制改革的推进异常艰难，可以说已经到了一个进退维谷的十字路口，其涉及的问题是多方面的，医疗服务机构、医药流通市场、医疗保障制度和卫生资源配置制度中存在的问题互相交织。为了深入研究卫生体制改革当中的理论问题，为了推进我国医疗卫生体制改革，本文从医疗卫生体制改革的主要矛盾入手，采用适合的理论对这些矛盾加以剖析，以期找到解决问题的路径。 医疗服务市场的矛盾千头万绪，“看病难、看病贵”是各界学者对我国医疗服务市场各种矛盾做的总结。本文通过对医疗服务市场的分析，总结出激励及代理问题在医疗服务市场当中具有突出的地位，在接下来的篇幅中，笔者运用信息经济学、委托代理理论、激励理论、契约理论等现代经济学分析工具，对医疗服务市场的代理与激励问题进行了比较深入的讨论和分析，并建立了一个医疗服务市场供方激励机制的分析框架。本文把医疗服务市场中的三大类代理问题（医患之间代理问题、医疗服务提供方和支付方之间代理问题、医疗服务提供者内部代理问题）置于委托代理与激励理论之下展开讨论，认为医疗服务提供方具有“不完美代理人”特征、“多个委托人的代理人”特征、“多重任务代理人”特征，将会产生“供给诱导需求”或“风险选择”形式的道德风险。此时，作为显性激励性契约的供方支付激励由于涉及到提供方的经济利益，可以对医生的行为产生直接影响。 但是由于经济人的有限理性和市场的交易费用，契约是不完备的，因而激励性支付契约的效果有限，必须辅以其他的激励机制。笔者引入了不完全契约理论、关系型契约理论对医疗服务市场的多重激励机制进行了深入地讨论。当医生考虑自身的长期收益时，声誉机制可以作为隐性激励机制对医生的行为产生影响。同时，医患之间长期和谐的关系、政府的有效规制亦能够对医生行为形成有效的激励机制。医疗市场组织结构的变化如医疗服务提供方和医疗保险商的纵向一体化亦能够改变医生所面临的激励环境。 总的来说，笔者认为由于医疗服务市场的信息不对称和治疗效果的不确定性，医疗服务提供方在医疗服务市场中处于主导地位。医生既是医疗服务的提供者，又是患者的代理人。在这种情况下，如果没有适当的激励机制，很容易产生服务质量和效率低下，医疗费用较高，以及卫生服务可及性缺乏公平等现象。作为经济激励的支付激励机制可以对医生的行为产生显著影响，是医疗服务市场激励机制的核心。但是由于经济激励和支付契约的局限性，医疗服务市场需要建立包括声誉等隐性激励机制在内的多重激励机制。 为了更好地在政策层面上提出解决问题的方案，本文还深入分析了我国医疗服务市场的不良现状及其形成缘由。作为医疗服务市场重要角色的公立医院的发展与生存环境如何呢？就此笔者全面检索了相关文献，系统回顾了中国公立医院补偿与支付制度的演变与现行政策体制，并借此具体分析了中国公立医院医护人员的激励机制。这种政策性的文献回顾是一项具有开创性的工作，同时，笔者认为在整个医疗服务市场的改革中，对医护人员构建全方位、多角度的多重激励机制具有重要地位。 目前，我国医疗体制改革的方案被设定为医院内部管理、医药市场、医疗保障制度、医疗卫生资源配置四个方面，而委托代理与激励则始终是贯穿于以上四个方面的核心问题，因此，在医疗卫生体制改革的重大历史关头，本文作者对医疗服务市场中的委托代理与激励问题的探讨与分析虽然只能起抛砖引玉之效，但这引起的对医疗服务市场中的委托代理与激励问题的研究，将会对整个医疗体制改革产生深远的影响。 关键词：医疗服务市场；激励机制；支付方式；声誉机制 Abstract It’s the reform of the health care system that has become a hot point in our society. For a country, a good health care institution not only affects the social justice, but also determines the people’s welfare in health. And then it will determine the future development for a country. Today, China is devoting herself to building a harmonious society. The establishment of reasonable health care system is the badge of national efficiency and equity. However, the current reform of our health care system is at its difficult position to sustain. The vast contradictions are centering upon the following four fields: the internal hospital management, health care market, health insurance system and health resource allocation .In order to push forward the reform of our health care system deeply, the author analyzes the principal contradictions of the health care system, utilizes the economic theory to discuss these contradictions and finds the solutions to the basic problems in the health care market. The scholars summarize the healthcare market as inaccessible and expensive. Inaccessibility and high expenditure are the peculiarity of all contradictions in this market. The author establishes an analytical framework of supply-side incentives in the health care market with the theories of information economics, the principal-agent theory, the incentive theory, the contract theory. This dissertation analyzes three topics in agency problems in the health care market (agency relationship between the doctor and the patient, agency relationship between the provider and the payer, agency relationship within the health care providers), and it illustrates that there are three characteristics belong to the providers in these agency relationships: imperfect agency, multi-principal agency and multitask agency, which will induce supplier-induced demand or risk selection. Under this circumstances, the provider payment incentive as an explicit incentive contract can effectively influence the doctor’s behavior. Because of the bounded rationality of the principal and the transaction cost in the market, the explicit incentive contract is incomplete and its role is limited. Therefore, other incentive mechanisms are absolutely necessary. The doctor should consider his long-term returns, so reputation can affect the doctor’s behavior as implicit incentive mechanism. At the same time, harmonious relations between doctors and patients, and government's effective regulation can be effective incentive mechanisms to the doctor’s behavior. In addition, the change of market structure such as the integration of the provider and the payer influence the market environment. Overall, the author points out the information asymmetry and the uncertainty in the health care market put the provider at a dominant position. The doctor not only is the provider of health care, but also is the agent of the patient. Under this condition, the absence of appropriate incentive mechanisms can easily lead to high medical cost, low market efficiency and a lack of fairness. The payment incentive as an explicit incentive mechanism can make a significant impact on the behavior of the doctor. However, due to the limitations of economic incentives and payment contract, the health care market should build the multiple incentive mechanisms including implicit incentive mechanisms such as the reputation mechanism. For putting forward the effective reform proposals, we should investigate into the key problems of present health care market. This dissertation reviews relevant literature and summarizes the progress of the reimbursement system for public hospitals. On the basis of the foregoing study, the author conducts a detailed analysis of the incentive mechanisms of Chinese medical staff in public hospitals. Such a comprehensive review of the reform policies is a pioneering work, and the author concludes that in the whole health care system reform, the construction of the multiple incentive mechanisms of the medical staff will play an important role. At present, the reform of China's health care system is set to internal hospital management, health care and medicine market, health insurance system and health resource allocation. The agency and incentive problems always run through the above four core issues. Therefore, it is greatly important to seriously analyze and properly handle the principal-agent and incentive problems, which will have a profoundly impact on the reform of the entire health care system. Key words: Health care market; Incentive mechanism; Payment incentive; Reputation effect. 目录 0.导言 1 0.1选题背景 1 0.2问题的提出及研究思路 2 0.3 本文的结构安排 5 1.中国医疗服务市场的内在矛盾及困境 7 1.1医疗服务市场内在矛盾描述 7 1.2医疗服务市场内在矛盾起因分析 8 1.3过去的解决思路及其争议 16 1.4 目前医疗体制改革的焦点 22 2.医疗服务市场的性质 24 2.1医疗服务市场的行为主体及其特征 24 2.2医疗服务市场的信息结构与行为主体的关系 26 2.3医疗服务市场的多重委托代理关系 30 2.4小结 33 3. 医疗服务市场中委托代理与激励机制 35 3.1相关研究介绍 35 3.2信息不对称与医疗服务市场中的道德风险 41 3.3医疗服务市场中的激励机制——供方支付激励 46 4．医疗服务市场中供方支付激励的理论及模式选择 55 4.1供方支付激励的主要模式 55 4.2 不同支付模式的激励效果分析 59 4.3 支付模式选择的影响因素 66 4.4供方支付制度设计的深层次思考 69 ５．医疗服务市场中激励机制的扩展分析 72 5.1 医疗服务市场激励性契约的纵向扩展分析——声誉激励 72 5.2医疗服务市场激励机制的横向扩展分析 73 5.3 医疗服务市场的多重激励机制 79 6．中国公立医院的激励机制分析 80 6.1 中国公立医院改革的历史回顾 80 6.2中国公立医院支付制度的演变 86 6.3 中国公立医院支付制度的现状分析 90 7.中国公立医院医护人员激励机制分析 93 7.1公立医院分配制度的政策演变 94 7.2现行医护人员收入分配制度的主要内容 97 7.3我国医疗服务市场中多重激励的机制创新与探索 99 7.4医护人员激励现状评价及改革建议 101 8. 结论和展望 106 8.1 主要结论 106 8.2 未来的研究问题 107 参考文献 110 后记 119