多元利益团体合作视角的公立医院补偿机制改革策略研究

In the past 30 years, under multiple interest groups gaming and influenced by twisted hospital payment mechanism, the behavior of Chinese public hospital has significantly deviated from that original expectation and edge further from the goal. Appropriate hospital payment mechanism is the foundation of behavior regulation and safeguard social public hospital value realization. Research on health insurance payment method is mature. There are also quite a lot of studies in public hospital payment mechanism. But there is rare systematical research on the logical relationship between the strategic goals, objectives and measures of payment mechanism and accordingly reactions. Furthermore, in the light of recent literature, the study of public hospitals payment mechanism reform should be added to the view of multiple interest groups cooperation, while there is short of corresponding methodology systems in practice. The main purposes of this study is promoting public hospital social value realization. First, based on precious studies, in the view of multiple interest groups cooperation, this study will build the multiple interest groups cooperation behavior model and comprehensively estimate the social roles and action of public hospital by using multi-subject study method. Next, according to the logical relationship between the strategic goals, objectives and measures of payment mechanism and accordingly reactions, this study will discuss on how to form the methodology and process of draw up the plan of public hospital payment mechanism. Then, analyze and optimize the plan by using evidence-based policymaking method. Finally, this study will summary the methodology system for public hospital payment mechanism development which is worth popularizing in China. In addition, this study would provide theoretical support and strategy advice for policy makers of the reform of public hospital.

30余年来，扭曲的补偿机制和多方博弈互动下，我国公立医院行为与预期渐行渐远。适宜的补偿机制是规范行为，保障公立医院社会价值实现的基础。 目前国内外涉及支付方式研究已成熟，关于公立医院补偿机制也进行了大量探索，但针对补偿机制"目的-目标-措施-行为"间逻辑关系的系统研究较为缺乏。且理论和实践研究一再提示该逻辑关系的构建须基于多元利益团体合作视角，但实践中缺乏一整套从多元利益团体合作视角构建公立医院补偿机制的方法学体系。 课题组在前期研究基础上，集成多学科研究方法，以促进公立医院社会价值实现为目的，从多元利益团体合作视角出发，构建多元利益团体合作模型，对公立医院角色定位与行为进行综合评估，研制遵照"目的-目标-措施-行为"逻辑关系的公立医院补偿机制的思路、步骤和方法；并采用循证决策方法通过实证干预进行完善优化，形成具有一定推广价值的公立医院补偿机制方案研制方法学体系。为深化公立医院改革提供理论

公立医院是各国政府确保医疗卫生服务可及性、公平性，增加国民健康的重要制度安排。30余年来，我国公立医院在扭曲的补偿机制和多方博弈互动下，其行为始终与社会预期相距甚远。适宜的补偿机制是规范公立医院行为、保障其社会价值实现的基础。为促进公立医院社会价值实现，本探究从多元利益团体合作视角出发，构建适宜的政策框架，对公立医院的角色定位与行为进行诊断分析，研制具备鲜明“目的-目标-措施”逻辑关系的公立医院补偿机制改革策略，形成具有一定推广价值的公立医院补偿机制改革策略研制的方法学体系。.本研究综合运用理论研究、规范研究、实证研究等多种研究范式，首先，针对国内外尚未形成清晰的公立医院社会价值内涵界定及因此引起的公立医院行为迷失问题，系统分析212篇相关文献后，运用文献内容归纳和逻辑推演方法，界定了我国现阶段公立医院社会价值内涵，其中“基本医疗服务提供者”、“基本医疗保障的支撑和网底”和“国家和社会安全的稳定器”应为所有公立医院均具备的核心价值功能。而围绕上述核心价值功能，回归公立医院的本质，实现公立医院的社会价值，是世界各国各时期公立医院改革的最终目的。然后，构建了“以社会价值实现为目标导向的公立医院角色定位评价体系”和“公立医院的角色定位的行为诊断评价体系”。选择WX市S院为样本机构，通过个案研究的方式，展开不同医保政策作用下公立医院角色定位与行为的诊断分析。在此基础上，从多元利益团体合作视角出发，构建内部结构逻辑合理、满足多层次目标要求的公立医院补偿机制改革策略思路。最后，基于“目标-措施-策略-方案”的研制思路，形成优化公立医院补偿机制改革策略方案的方法学体系。本研究结果再次提示：公立医院的基本利益并未得到合理补偿，导致采取非合作行为，形成了“补偿不足-浪费性行为增加-补偿更不足”的恶性循环，最终导致政策效果不显著。本研究为深化公立医院改革提供理论和方法学支撑。