公立医院改革--历史演进、制度困境与路径选择

摘要

From the Government’s fully guarantee stage to the stage of independent organization of medicine, then to the market-oriented reforms and the new health care reform exploration stages, the public hospitals reform fol-lows different institutional logics, but the institutional dilemma have emerged at all stages including the little coupling between the institutional arrangements and environment, the public welfare and benefit wandering, the management system instability, and the breakdown of the financial investment and control costs mechanisms. The Government should elaborate conditions for the spontaneous public hospitals reform on the institutional environment in order to em-bed intrinsic motivation of the induced institutional change into the imposed institutional change. There should be positive interaction between the government and the market in order to form a reasonable and orderly competitive land-scape to the market of medical services. Payment should be reformed which has significant influence on internal medi-cal service system incentives.%从政府全面保障阶段到自主化办医阶段，再到市场化改革阶段与新医改探索阶段，公立医院改革遵循不一样的制度逻辑，但都出现了制度困境：制度安排与制度环境耦合性弱，公益性与效益性徘徊，管理体制失衡，财政投入机制与控费机制错位失位等。建议在制度环境上为公立医院的自发改革创造条件，使诱致性制度变迁的内在动力嵌入强制性变迁中；政府与市场良性互动，形成医疗服务市场合理有序的竞争格局；改革对医疗服务体系内部激励有重要影响的支付方式等将是公立医院改革的可选路径。