| Rapidly rising of health care cost is the challenge of governments in the world,and a over-load burden of residents in many countries.,Its influence is also beyond national borders in the background of economic globalization today.It influened the cost of goods or service supplied to the world market,and it is an important factor of national competitiveness.Indeed,objective factors will lead to increases in health care cost, for example advance in medical technology including advances in disease diagnosis technology,new drug development and clinical application,and an aging population But it is undeniable that the performance of the health system is worrying and is the causes of excessive medical cost rise,such as medical corruption,drug abuse,excessive medical treatment,human medical error and accidents,non-professional hospital managers etc.,Health care institution was the institution root of health performance,and determined the health status of residents. The performance of health system of countries in the world was barely satisfactory on the whole. Its efficiency is low with long waiting time of medical service and high cost of medical service and serious waste of resources. Or it is lack of fairness with poor accessibility of medical service in rural and remote areas. The poor are unavailable to basic medical service.The target of health system is to promote fairness and to raise efficiencies.It is key to devise and implement scientific medical and health regulation system for the target.(A)Purpose of researchEfficient health care institution must be consistent with the characteristics of medical service market.The market of medical service has the trait of information asymmetry、monopoly、externality and so on. The substantive characteristics of medical service market is uncertainties.They include the uncertainty of individual incidence (disease risk)、the uncertainty of treatment effect(medical risk)、the uncertainty of doctor behaviour(doctor moral risk)、the uncertainty of price(price discrimination) and so on.They cover the adverse selection and moral hazard of insurance policy holder if pay mechanism of third party is introduced.Medical market with numerous uncertainties is the most complicated and the most difficult to regulate.The method of resolving one problem leads to another problem.Specificities of medical market resulted in difficulty that we cleared up between market failure and government failure.Common mistake is that let government play a role in the field fitted to market mechanism,and we mistake excessive intervention of the government as market failure and rely on more government intervention.Specificities of medical market ask for coupling market mechanism with government role even if in a certain field.For example,general practitioners institution comprises the mechanism of inspireing free competition of general practitioners and the mechanism of limiting patient rights of free choice.The urgent affairs are distinguish by deep analysis which areas mainly played by market mechanism and which areas mainly played by government role.Government should secede automatically and quickly the field fitted to market mechanism.We should as much as possible make use of market mechanism to better efficiency of medical health service,even if in the field mainly fitted to government role.Efficiency is basis of justice in the long run.Efficiency is vital force of institution and first consideration aim of medical health institution devise.We should adhere to orientation of making the past experiences serving the present and the foreign experiences serving China for devising scientific medical and health institution.It is no doubt important to absorb and mirror foreign advanced institutions.But formal institutions take effect on the condition of its according with domestic informal institution.Informal institution can not be transplanted.So it is important perspective of scientifically devising medical and health institution to take a new view at change trends of domestic medical and health institution,to grasp change laws of medical and health institution and to thoroughly analyze change factors of impact on medical and health institution.Health care institution means that the government introduced a series of norms of health services supply 、distribution、consumption behavior.They are laws、regulation、 rules、policies、norms、standards、guidelines and so on.Many institutions formed institution system,which consists of public health and medical service supply institution、medical security institution、drug distribution institution.Between the various types of institutions and internal are interaction and mutual influence.Chinese current problems in the health institutions,including the three major institution itself,and the synergy between the three institutions.This suggests that the efficiency of our health care institutions with a huge room for improvement.However,the health care institutions toward better efficiency changing does not naturally occur.Only in-depth understanding the impact reasons of health care institutions changing,we can remedy.With the role of government or market mechanisms,we can force or induce health care institutions toward the direction of better efficiency.This paper studies the change of institution since the founding of new China. According to Chninese medical and health institution characteristics of changes from the founding of new China to today, Chninese medical and health institution changes was divided into the following three periods:from 1949 to 1978 major medical and health institution, from 1979 to 2003 major medical and health institution, after 2003 major medical and health institution.Economic system is the foundation of the government medical and health institution. Medical and health institution changes with the economic system change.Emphasis of government on medical health work is also a significant impact on the health care institution change.The way of division is based on economic system.China adopted a planned economic system from 1949 to 1978. Chinese economic system had a gradual transition from a planned system to a market system after 1979. It prompted the central government to re-emphasis on medical health work in 2003 with SARA as a symbol of Chinese public health crisis. The central government increased the effective supply of health care institution,but also changed the willingness and preferences of local government in investment and implementation of health care institution.From the perspectives of institutional change, the research of health care institution has important theoretical and practical significance.Establishment of health services supply organization fitted to characteristics of health services is a source of microeconomic efficiency.For the purposes of more macroeconomic efficiency of health services,we must distinguish what areas are the appropriate stage of private capital and social organization.What is the institutional root that state capital has not yet quit?Which areas that private capital do not want to invest can only play a role by public health institutions of government.What is the cause of government absence.In the medical and health services field,where is the boundaries of government and market and society role. Which institutions are needed to coordinate them to play their functions by forming a joint force.Exploring of these issues,we can enrich and develop regulatory economics> institutional economics^ health economics and other disciplines.The new health care reform task is still in solving the longstanding and hot social issues of difficulty and expensive to see a doctor. In addition to expanding coverage of medical insurance institutions,how to create a new mechanism is the core and difficulty of health care supply institutional reform. To identify the rules of health care institutional change and to build the system of health care institutions related to success or failure of the new health care reform and achievement with the Chinese dream by studying the history of health care institutional change.(B)Methods of researchThe methods of research in this paper include institution analysis method,normative analysis method and empirical analysis method.Institutions are not only behavior norms of market players,but also an important source of efficiency. The basic function of the institution is to reduce the transaction costs in order to look for potential trading partners,to expand the field of future transactions,constantly to increase transaction frequency.It further deepened the division and cooperation of labor,and improved the macro-efficiency of the resources allocation and micro-efficiency of resources utilization.Regarding health care institution as endogenous variables,we analysed the various factors of affecting the health care institution and studied the sources of institution and power of institution change.Through institutional analysis,we clarify reason that inefficient institutions are able to long-term presence and which factors that hindered the supply of the efficient institutions. Application of institution analysis method is the basic method to create a sustainable system of health care institution.Normative analysis method was combined with empirical analysis method.The current health care institutions are not in line with market economy rules and characteristics of health service, and not do meet the requirements of the principle of cost-effectiveness.Which factors determine the supply and demand for medical and health institution.?How many of main parts of medical and health institution and what are their preferences of every main part?In the institution design and implementation process,how is the interaction between the various interest groups?how is the interaction between government regulation agencies and the various interest groups?how to balance the interests of patients and department interests and the interests of vested interest groups for government regulation agencies.In the interests of health care institution against for departments interests and the interests of vested interest group, departments and vested interest group are how to react.Transition period,the phenomenons that are anti-rule of price in China largely emerge,for example, high-priced drugs expulsion of low-priced drugs and "tender death"and high technical examination expulsion routine examination. It is an important task of normative analysis how to explain these phenomenas.From the empirical point of view we analyze the existence of imbalance between supply and demand of current health care institution,and how its manifestations. Whether is current health care institution an important cause of resident medical treatment with difficulty and expensive.(C)Results of researchOur institution change of public health and medical service supply manifested that public health was the best health intervention measure of cost-effictiveness.Public hospital institution is inefficient, public welfare can not be guaranteed by Public hospital.Our institution change of medical security manifested that Chinese medical security institution exacerbated the use of health services inverse equalization and limited the health level of our residents to improve with the characteristics of fragmentations and identity.Our institution changes of drug production and distribution manifested that virtual height of drug price is result of unfair power of drug market players. Artificially high drug prices is an unbearable burden of patient and medical security institution.Drug profit overflowing to public hospitals make medicines innovation fatigue. The system of management tied the setting up of hospital resulting in a public hospital in bilateral monopoly of buying and selling drugs, is the drug prices artificially high institutional roots.Transformation of the health care institution showed that the various interest groups influence the strength of the health institution change unequally. Strong interest groups determine the direction of medical and health institution changing by endowment of resources advantages.But strong interest groups stick to low efficient institution with preference to distributional effort.(D)Conclusion of researchRural cooperative medical institution in Chinese planned economy period is collective welfare and is not a medical insurance institution with its endogenous defects. Although the World Bank and the World Health Organization called Chinese rural cooperative medical care institution "the only model" of raising the health funds in developing countries.But a good performance of China’s medical and health work in the planned economy period came mainly from putting in place and low-cost public health work.Under the legislative framework, all levels of government are required and obliged to carry out investment responsibility of full and comprehensive public health.Chinese medical services market was marketing of demand levels under the control of the executive power.The supply of medical services is still subject to strict government regulation.In public hospitals leading to medical services transactions, the powers of the each market parts in the medical services market is extremely unequal.The transaction is non-voluntary transactions. Establishing a private nonprofit hospitals as the main competitive part of medical service market is foundation of reducing the cost of medical services. The key of new health care reform may not be incremental reform to expand health insurance coverage and enhance security strength.Its more important and difficult stock reform is to promote institutional change of public hospitals.Our current medical security institution resulted in the fact that reverse subsidies to hinder the goal implementation of medical care utilization equalization and to hinder to enhance population health level.Binary three-dimensional medical security institution coexistence phenomenon, essentially unequal power between residents,rooted in the feudal ideology of official standard, professional grade etc. Binary three-dimensional medical security institution, incompatible with the socialist market economic system.Our medical security institution is experiencing the evolution,from the old ternary structure system of free medical institution and labor medical institution and rural cooperative medical institution, to the new ternary system architecture of medical insurance for urban workers and urban residents and the new rural cooperative medical insurance institutions.Government should promote merging three types of medical security institutions, to build a unified national universal medical security institutions.Finally, further changing to the national health insurance institution to adapt to the concept of disease treatment transformation to the concept of disease prevention.With the traditional and universal ideas of more health care costs by the burden of government differently, this paper considers that individual should shoulder more responsibility for their health risks behaviors in addition to the poor.Pharmaceutical market with depth intervention by the authority. These powers include the direct drugs management rights in public hospitals and almost free from laws of doctor prescription derived from the rights of administrative examination and approval and the tube management system. Pharmaceutical market with intervene of power became the rent-seeking games.Powerful interest groups do everything possible for interests by the sector power and the maximum power rent. The key of institutional change of drug prices lies in establishing the pharmaceutical market without authority to intervene. Major drug-related interest groups have government health authorities, other government departments, public hospitals, non-public medical institutions,doctors, drug manufacturers and distributors,patients etc.The government health authorities and public hospitals are the most powerful interest groups, their behaviors have an important impact on other interest groups.For drug prices institution change toward the efficient direction, the government must do to get rid of the public hospital management system, establishing social organization of patient associations, to counterbalance the market power of medical institutions. Various interest groups involved in drug only with equal rights, they become profit-seeking group instead of dividend group, focusing on improving the efficiency of production and distribution of drugs, focusing on improving corporate governance to pursue legitimate profits,pharmaceutical production and circulation institution is efficient.(E)OthersIn Chinese current system of decision-making, executive dominates. From the central down to the town, the main leaders have a major impact on construction and implementation of health care institution. Key government leaders recognize the extent of the importance of health care work depending on the medical and public health crisis,personal life experiences of key government leaders, such as personal or family members experiencing a health crisis or misfortune etc;also depending on the heads of government health department developing the capacity of local Party and government leaders,through health reports and conferences and public health achievements and so on.Quantitative study of government leaders recognization extent of the health care importance, is worthy of further study.Moral hazard of doctors in public hospitals is a major source of medical corruption. The key of curbbing excessive medical practices is to establish evaluation mechanism of incentive and restraint compatibly, so that the doctor’s medical decisions based on need of illness rather than target revenue of doctors. Currently the price of medical services and drug prices and the price of high-tech equipment and routine equipment inspection items are extremely unreasonable.The doctor’s behavior for benefits resulted in the selection of high prices of drugs and high-tech equipment inspection items.This is not only a waste of scarce health resources, resulting in iatrogenic disease, but also generating doubly effects of economic burden of patients. If by the number of relationships between the net income and gross income of medical institutions is 1:4 to 1:5, by the implementation of the excessive medical practices, hospitals have only got one yuan from the patient with five yuan payment.Changing the behavior of doctors is key to enhance the performance of the health system, also the important issue of new health care reform.Scientific and rational physician compensation institution is an important challenge we face in further research. Fixed wage system must suppress the enthusiasm of the doctor’s work, with formation of supply bottlenecks, such as difficulty seeing a doctor and difficulty for being hospitalized and difficulty for operation.With revenues linked wage system,doctors will be induced with excessive medical services implemented. Under the premise of the disease and the patient heterogeneity, basing on the number and quality of work of doctors who have completed, we should design the new pay institution.It is one of the difficulties of reform of public hospitals.In a word, sustainability of medical and health institution is severe challenge that we face in the institution design.In the course of devising medical and health institution, we are possible to attain the goal of both justice and efficiency in medical and health service only with coupling government effect with market mechanism. |
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