政府公立医院财政专项补助对居民医疗费用负担的影响——基于某市23家三级医疗机构的分析

以基本建设或设备购置等方式注入公立医院的财政专项补助,能够在一定程度上分担公立医院发展投入方面的资金压力,减轻患者的医疗费用负担.为验证上述假设,基于某市23家三级医疗机构的数据,建立面板数据模型.实证研究发现:财政专项补助的增加会降低患者的医疗费用负担,相比之下,门诊医疗费用负担受财政专项补助的影响更为明显.财政专项补助通过分担公立医院部分成本而影响医院提供服务的行为,进而有利于降低患者的医疗费用负担.     

社会医疗保险制度下公立医院财政补助机制

我国医疗卫生体制已从公共融合向公共契约模式转变，社会医疗保险的迅速推进使基本医疗需方投入为主成为实际的政策选择。在社会医疗保险制度框架下，公立医院仍有部分支出不能由社会医疗保险支付，需要财政补助予以保障。政府财政补助应与公立医院绩效评估机制相联系，以对公立医院经营者形成有效的激励约束机制。     

The Current and Projected Taxpayer Shares of US Health Costs

Objectives. We estimated taxpayers’ current and projected share of US health expenditures, including government payments for public employees’ health benefits as well as tax subsidies to private health spending.Methods. We tabulated official Centers for Medicare and Medicaid Services figures on direct government spending for health programs and public employees’ health benefits for 2013, and projected figures through 2024. We calculated the value of tax subsidies for private spending from official federal budget documents and figures for state and local tax collections.Results. Tax-funded health expenditures totaled $1.877 trillion in 2013 and are projected to increase to $3.642 trillion in 2024. Government’s share of overall health spending was 64.3% of national health expenditures in 2013 and will rise to 67.1% in 2024. Government health expenditures in the United States account for a larger share of gross domestic product (11.2% in 2013) than do total health expenditures in any other nation.Conclusions. Contrary to public perceptions and official Centers for Medicare and Medicaid Services estimates, government funds most health care in the United States. Appreciation of government’s predominant role in health funding might encourage more appropriate and equitable targeting of health expenditures.The United States has the world’s highest per capita health care costs—about double those of other wealthy nations.1 According to both official figures and public perception, most health care funding in the United States comes from private payers. For instance, the Centers for Medicare and Medicaid Services (CMS) estimates that federal, state, and local governments accounted for 43% of health expenditures in 2013.2These official figures reflect an accounting framework based on who wrote the final check as money flowed from households or employers to health care providers, and exclude many indirect government health expenditures. Thus, when government pays for veterans’ care, CMS classifies it as a public expenditure because government writes the checks that fund the Veterans Health Administration. But CMS classifies government-paid health benefits for senators or Federal Bureau of Investigation agents as “private” expenditures because a private insurer pays the claims. Moreover, the tax subsidies that fund a significant share of private health expenditures (e.g., private-employer spending) are not counted by CMS as government health spending, although the Office of Management and Budget (OMB) tabulates these subsidies as “tax expenditures” in official budget documents.3In a previous study, we estimated that the public share of US health spending—after inclusion of these tax subsidies and government payments for public employees’ health benefits—amounted to 59.8% of the total in 1999, nearly double the 1965 figure.4 The current study provides detailed estimates of direct and indirect government health spending in 2013, as well as projected figures through 2024.     

Hospital sector choice and support for public hospital care in New Zealand: Results from a labeled discrete choice survey

This study uses a discrete choice experiment (DCE) to measure patients’ preferences for public and private hospital care in New Zealand. A labeled DCE was administered to 583 members of the general public, with the choice between a public and private hospital for a non-urgent surgery. The results suggest that cost of surgery, waiting times for surgery, option to select a surgeon, convenience, and conditions of the hospital ward are important considerations for patients. The most important determinant of hospital choice was whether it was a public or private hospital, with respondents far more likely to choose a public hospital than a private hospital. The results have implications for government policy toward using private hospitals to clear waiting lists in public hospitals, with these results suggesting the public might not be indifferent to policies that treat private hospitals as substitutes for public hospitals.     

Health Services Pricing in Turkey

Abstract

One of the most important and complex decisions that public services managers have to make is pricing. This is especially difficult within public health care because pricing decisions are influenced by a myriad of ideological, political, economic and professional arguments. In Turkey the majority of health care services are provided under public auspice; however, recent changes in governmental policy have led to increased competition among hospitals in both the public and private sector. Therefore, all institutions are being watched and remain open to government scrutiny and regulation. The aim of the study is to analyze how the private and governmental hospitals determine pricing or the actual cost of services in Turkey. Also, comparisons are made between health services expenditures and the Consumer Price Index with suggestions provided for public and private hospital managers in regard to the general cost of health services.     

Health services pricing in Turkey

One of the most important and complex decisions that public services managers have to make is pricing. This is especially difficult within public health care because pricing decisions are influenced by a myriad of ideological, political, economic and professional arguments. In Turkey the majority of health care services are provided under public auspice; however, recent changes in governmental policy have led to increased competition among hospitals in both the public and private sector. Therefore, all institutions are being watched and remain open to government scrutiny and regulation. The aim of the study is to analyze how the private and governmental hospitals determine pricing or the actual cost of services in Turkey. Also, comparisons are made between health services expenditures and the Consumer Price Index with suggestions provided for public and private hospital managers in regard to the general cost of health services.     

The Canadian health care system: an overview

Although health care is a provincial responsibility in Canada, universal hospital insurance was fully adopted by 1961; universal medical insurance followed 10 years later. Each province enacted universal insurance after the federal government offered to pay 50% of provincial hospital and medical care costs. Hospital insurance had wide public and provider support but universal medical care insurance was opposed by organized medicine. The federal government soon realized that it had no control over total expenditures and no mechanisms for controlling costs. In 1977 it enacted Bill C-37 which limited total federal contributions and made those contributions independent of provincial health care expenditures so that increased costs had to be met by the provinces. Since private health care insurance for universal benefits is prohibited by the federal terms of reference for health insurance, the provinces must raise the money by taxes and (in some provinces) premiums. Although prohibited by the terms of reference of the universal program, some provinces have adopted hospital user fees and are allowing their physicians to bill patients in excess of provincial fee schedules. The 1980s have seen increased confrontations between the federal and provincial governments and between the provinces and their providers. The issues are cost containment and control of the system. The provinces have two broad options. The first is more private funding through private insurance and user fees. The proposed new Canada Health Act will probably prohibit such charges. A second option involves greater control and management of the system by the provinces; this has already occurred in Quebec. Greater control is vigorously opposed by physicians and hospitals. The Canadian solution to health insurance problems in the past has been moderation. Extreme moves in either direction would represent a break with tradition, but they may prove to be unavoidable.     

THE DETERMINANTS OF HEALTH CARE EXPENDITURE TOWARD THE END OF LIFE: EVIDENCE FROM TAIWAN

This paper empirically investigates the relationship between the health care expenditure of end‐of‐life patients and hospital characteristics in Taiwan where (i) hospitals of different ownership differ in their financial incentives; (ii) patients are free to choose their providers; and (iii) health care services are paid for by a single public payer on a fee‐for‐services basis with a global budget cap. Utilizing insurance claims for 11 863 individuals who died during 2005–2007, we trace their hospital expenditures over the last 24 months of their lives. We find that end‐of‐life patients who are treated by private hospitals in general are associated with higher inpatient expenditures than those treated by public hospitals, while there is no significant difference in days of hospital stay. This finding is consistent with the difference in financial incentives between public and private hospitals in Taiwan. Nevertheless, we also find that the public–private differences vary across accreditation levels. Copyright © 2013 John Wiley & Sons, Ltd.     

青岛市市属公立医院财政补助收入与公立医院运行情况的相关性分析

目的:探索财政补助收入与公立医院运行情况的相关关系。方法:以青岛市市属13家公立医院为研究对象,以财政补助收入与公立医院运行情况指标为分析对象,对公立医院补偿情况进行描述性分析,对财政补助收入与公立医院运行相关指标进行相关性分析,探究财政补助收入与公立医院运行之间的相关性。结果:青岛市市属公立医院财政补助收入呈逐年增长趋势,但占比却呈逐年下降趋势;公立医院收入构成欠合理,药占比虽呈下降趋势,但比重依然偏高;财政补偿收入与公立医院运行的每职工平均业务收入、每职工平均住院床日、出院者平均医药费用、管理费用率、百元医疗收入消耗卫生材料、在职职工人均工资性收入几项指标产生正相关或负相关影响。结论:应完善顶层设计,明晰政府投入边界,完善政府投入机制,以信息化为支撑,实行精细化全成本核算。     

PATTERNS OF PRIVATE HOSPITAL OWNERSHIP IN VICTORIA

A study has been conducted into the pattern of ownership of “for-profit” private hospitals in Victoria. Private companies were found to dominate the acute care private hospital business in Victoria; the company structures were sophisticated, involving numerous individuals and the business was rapidly expanding. Victorian Health Commission registration requirements were inadequate and, in particular, the definition of “Proprietor” in the Victorian Health Act was seen to be imprecise. It is proposed that all individuals holding a financial interest in private hospitals should be required to be registered publicly, together with their occupations. More than one-third of the hospitals had doctors or their relatives as directors or shareholders, although bed utilization figures for these doctors in their hospitals were not obtainable. The conflict between commercial practice and professional practice of medicine is briefly discussed. The influence of business costs on profit-motivated hospitals is briefly examined, leading to questions about the use of Commonwealth subsidies as “health-investor subsidies” and “commercial subsidies”. These observations are presented with attention to the current encouragement of greater use of private enterprise in Australian hospital resources.     

我国公立医院债务融资的现状、成因和治理策略

公立医院债务融资是当前深化公立医院管理体制改革中一个迫切需要研究的问题.本文根据债务融资理论与原理,分析我国公立医院债务融资的现状,在讨论其产生原因的基础上上,从完善对公立医院的投入和监管机制、控制负债规模、保持合理的负债结构、拓宽公立医院投融资渠道、实施对外业绩信息发布制度、建立明晰的领导任期内经济责任制等方面提出了完善公立医院债务融资的政策建议.     

Public versus private hospital maternity length of stay: a gamma mixture modelling approach.

Application of a gamma mixture model to obstetrical diagnosis-related groups (DRGs) revealed heterogeneity of maternity length of stay (LOS). The proportion of long-stay subgroups identified, which can account for 30% of admissions, varied between DRGs. The burden of long-stay patients borne was estimated to be much higher in private hospitals than public hospitals for normal delivery, but vice versa for Caesarean section. Such differences highlights the impact of DRG-based casemix funding on inpatient LOS and have significant implications for health insurance companies to integrate casemix funding across the public and private sectors. The analysis also benefits hospital administrators and managers to budget expenditures accordingly.     

The impact of China's retail drug price control policy on hospital expenditures: a case study in two Shandong hospitals

In China, 44.4% of total health expenditures in 2001 were for pharmaceuticals. Containment of pharmaceutical expenditures is a top priority for policy intervention. Control of drug retail prices was adopted by the Chinese government for this purpose. This study aims to examine the impact of this policy on the containment of hospital drug expenditures, and to analyze contributing factors. This is a retrospective pre/post-reform case study in two public hospitals. Financial records were reviewed to analyze changes in drug expenditures for all patients. A tracer condition, cerebral infarction, was selected for in-depth examination of changes in prices, utilization, expenditures and rationality of drugs. In the two hospitals, a total of 104 and 109 cerebral infarction cases, hospitalized respectively before and after the reform, were selected. Prescribed daily dose (PDD) was used for measuring drug utilization, and the contribution of price and utilization to changes in drug expenditures were decomposed. Rationality of drug use post-reform was reviewed based on published literature. Drug expenditures for all patients still increased rapidly in the two hospitals after implementation of the pricing policy. In the provincial hospital, drug expenditures per patient for cerebral infarction cases declined, but not significantly. This was mainly attributable to reduced utilization. In the municipal hospital, drug expenditure per patient increased by 50.1% after the reform, mainly due to greater drug utilization. Three to five fold higher drug expenditure per inpatient day in the provincial hospital was due to use of more expensive drugs. Of the top 15 drugs for treating cerebral infarction cases after the reform, 19.5% and 46.5% of the expenditures, in the provincial and municipal hospitals, respectively, were spent on drugs with prices set by the government. A large proportion of expenditures for the top 15 drugs, at least 65% and 41% in the provincial and municipal hospitals, respectively, was spent on allopathic drugs without an adequate evidence base of safety and efficacy supporting use for cerebral infarction. Control of retail prices, implemented in isolation, was not effective in containing hospital drug expenditures in these two Chinese hospitals. Utilization, more than price, determined drug expenditures. Improvement of rational use of drugs and correcting the present incentive structure for hospitals and drug prescribers may be important additional strategies for achieving containment of drug expenditures.     

Public insurance substituting for private insurance: new evidence regarding public hospitals, uncompensated care funds, and Medicaid

This paper examines the impact of public health insurance programs, whether structured as subsidies to health care providers (public hospitals and uncompensated care reimbursement funds) or as direct insurance (Medicaid), on the purchase of private health insurance. The presence of a public hospital is associated with a lower likelihood of private insurance for those with incomes between 100-200% and 200-400% of the poverty level. Uncompensated care reimbursement funds were associated with less purchase of private health insurance and a higher likelihood of being uninsured across all income groups. More generous Medicaid programs showed both safety-net and crowd out effects.     

Private medicine and the privatisation of health care in South Africa

Health services in the Republic of South Africa (RSA) are provided by a mixture of public and private providers and institutions. Estimates of total health-related expenditure for 1985 range between 5.3% and 5.9% of gross national product (GNP), divided on approximately a 55:45 basis between public and private sectors. Basic preventive and curative services are provided by a hospital- and clinic-based public system. The public system does not adequately serve the rural areas and African tribal bantustans, and racial discrimination and/or segregation are obvious in its organisation and funding. The public sector's strength is the provision of state-subsidised care to many citizens who are unable to afford private medicine. The vast majority of hospitals are operated on a non-profit basis by government, industries, and voluntary agencies. Excluding hospitals that receive state subsidies, private investor-owned hospitals control about 10% of all hospital beds in the RSA. One-third of these investor-owned beds are held by state-dependent contractors providing long-term care. Two-thirds are wholly independent. Growth has been rapid in the independent hospital sector, and major corporations have entered the market. In 1985, over 85% of the white population was privately insured by a variety of prepayment programmes, including those organised through parastatal corporations and government departments. Despite major enrollment growth in the preceding decade, only 8% of blacks held private insurance by 1985; their coverage also tended to be less comprehensive. Faced with deficit financing, a sluggish economy, complaints from its white constituency about taxation levels, and pressure from private sector interest groups, the Nationalist government has endorsed the concept of privatisation of health care. Exponents of privatisation claim that it will permit differentiation by income to supplant discrimination by race. However, the direct links between disposable income and race, the rapidly rising costs of private insurance, and the still-limited extent of private coverage among the black majority, indicate that privatisation is likely to co-opt a comparatively small proportion of the total black population. It may exacerbate the urban-rural imbalance in health status and health services, promote growth of hospital-intensive curative services rather than needed expansion of community-centred preventive and primary care, and create financial barriers to access for low-income patients.(ABSTRACT TRUNCATED AT 400 WORDS)     

仪征市公立医院新医药价格综合改革初探

2013年3月15日起,仪征市所有二级以上公立医院同步实施新医药价格改革。将医院补偿由医疗服务收费、药品加成收入和政府补助三个渠道改为医疗服务收费和政府补助两个渠道;破除公立医院＂以药养医＂机制,建立新型医疗服务价格定价机制和管理机制;健全医疗服务补偿机制,缓解医疗服务价格结构性矛盾,有效遏制医药费用增长,促进公立医院健康良性发展。     

不同举办主体的两家非营利性医疗机构历史和现状的比较

目的 :比较两家不同举办主体的医疗机构在发展历程、规模、服务能力的差异,揭示社会资本办医之困境。方法 :通过深度访谈和问卷调查,对两家医院历史和运营数据进行描述性分析。结果 :两家不同举办主体的医疗机构,在发展演变、医院规模、医疗服务能力等方面存在差异。结论 :管理创新是促进民营医院发展的重要因素;人才短缺是制约民营医院发展的重要因素;政府扶持是保证民营医院发展的重要因素。     

On the efficiency of public, welfare and private hospitals in Germany over time: a sectoral data envelopment analysis study.

This paper examines the efficiency of the German hospital sector over time and the relative efficiency of public, welfare (both nonprofit) and private (for-profit) hospital sectors using data from the Federal Statistics Office of German hospitals. Efficiency scores were computed using data envelopment analysis. The absolute efficiency of the hospital sector as a whole was found to have improved between 1991 and 1996. In this comparison, the empirical results showed that the hospitals in the public and welfare sector are relatively more efficient than private hospitals. Our results suggest that public, welfare and private hospital sectors have different best-practice frontiers; and that public and welfare hospital sectors appear to use relatively fewer resources than private hospitals. These results suggest differences in quality of care arising from ownership.