第五节 结论与启示
由于医学和技术的发展，人口结构的变迁(特别是人口老龄化)，疾病谱的变化，公众预期的提升，以及医疗需求对国民经济的影响，使各国的医疗保健制度面临共同的费用压力，政治回应是必不可少的。但由于价值判断、社会预期和医疗卫生体制的差异，各国在控制医疗卫生费用方面面临不同的选择，所做出的政治回应是不相同的。通过对相关理论的厘清和对发达国家费用控制实践的总结，我们认为有几个基本的价值理念值得遵循和借鉴:
第一，要消除急功近利的思想。因为费用问题的产生有极其复杂的原因，费用变化有周期性，因此，解决费用问题绝对没有简单的或一劳永逸的方案。
第二，政府与市场、管制与竞争是控制费用的两种主要工具，到底谁做得更好很难评说(66)。虽然政府管制越来越不受欢迎，但用自由放任的方法解决医疗问题也是不能容忍的。在激励与管制之间寻求平衡才是最为重要的。
第三，解决费用问题必须要有全局观。70多年前就有人说过，“卫生体制不是可以孤立地研究的一个问题，它是文化的一部分，它的组织安排与整个社会密不可分。”(67)要实现费用的可持续增长，需要消费者、雇主、保险方、医疗方和政府共同行动来控制费用;减小费用变化的幅度，对各方来说都是有利的，同时也是可以接受的，否则会损害各方的利益。面对公共医疗开支或私人医疗开支的快速增长，进行局部的改革是很不幸的(68);历史经验证明，控制整个制度的费用才是值得期待的(69)。
第四，费用控制方案的设计和选择要依各国的具体情况而定，没有统一的模式。
第五，从医疗卫生费用的未来走势来看，技术进步仍将是推动费用上涨最主要的动力，既要鼓励技术创新，又要限制技术应用，这是各国政府面临的两难问题，毕竟在医疗创新和费用控制之间存在冲突。关于技术变革与费用上涨的关系，我们将在下一章详细分析。
【注释】
(1)汽车在20世纪20年代、计算机在20世纪70年代和20世纪80年代的生产和使用都曾急剧增加。
(2)经济学家认为，医疗卫生服务与普通商品的区别至少有两个方面:一是医疗卫生服务的需求取决于个人的健康状况;二是医疗保险市场的特殊性，而保险的盛行又是医疗卫生经济最明显和最不同寻常的特点之一(Mark V.Pauly，“Taxation，Health Insurance，and Market Failure in the Medical Economy”，Journal of Economic Literature，Vol.24，No.2，June 1986:629-675)。
(3)Joseph P.Newhouse，“An Iconoclastic View of Health Cost Containment”，Health Affairs，Supplement 1993:152-171.
(4)David M.Cutler，“Equality，Efficiency，and Market Fundamentals:The Dynamics of International Medical-Care Reform”，Journal of Economic Literature，Vol.40，No.3，Sep.2002:881-906.
(5)David M.Cutler，“The Cost and Financing of Health Care”，American Economic Review，Vol.85，No.2，Papers and Proceedings of the Hundredth and Seventh Annual Meeting of the American Economic Association(May，1995):32-37.
(6)Henry J.Aaron，“Should Public Policy Seek to Control the Growth of Health Care Spending?”Health Affairs，8 January 2003，Web Exclusive:28-36.
(7)Mark V.Pauly，“Taxation，Health Insurance，and Market Failure in the Medical Economy”，Journal of Economic Literature，Vol.24，No.2，June 1986:629-675.
(8)Stuart H.Altman，et al.，“Health Care Spending:An Analytical Forum”，Health Affairs，January/February 2003，Vol.22，No.1:12.
(9)David M.Cutler，“Equality，Efficiency，and Market Fundamentals:The Dynamics of International Medical-Care Reform”，Journal of Economic Literature，Vol.40，No.3，Sep.2002:881-906.
(10)David M.Cutler，and Mark McClellan，“Is Technological Change in Medicine Worth It?”Health Affairs，September/October 2001，Vol.20，No.5:11-29.
(11)Joseph P.Newhouse，“Medical Care Costs:How Much Welfare Loss?”The Journal of Economic Perspectives，Vol.6，No.3，Summer 1992:3-21.
(12)Uwe E.Reinhardt，et al.，“Cross-National Comparisons of Health System Using OECD Date，1999”，Health Affairs，May/June 2002，Vol.21，No.3:169-181.
(13)Michael E.Chernew，et al.，“Increased Spending on Health Care:How Much Can the United States Afford?”Health Affairs，July/August 2003，Vol.22，No.4: 15-25.
(14)Uwe E.Reinhardt，et al.，“US Health Care Spending in An International Context”，Health Affairs，May/June 2004，Vol.23，No.3:10-25.
(15)Henry A.Shenkin，Medical Care Reform:A Guide to Issues and Choices.SantaMonica:Oakvale Press，1994:Xii.
(16)大卫·N·海曼:《公共财政:现代理论在政策中的应用》，章彤译，中国财政经济出版社2001年，第309页。
(17)转引自约翰·F·沃克、哈罗德·G·瓦特:《美国大政府的兴起》，重庆出版社2001年，第264页。
(18)David Mechanic，and David A.Rochefort，Comparative Medical Systems.Annual Review of Sociology，Vol.22，1996:239-270.
(19)Henry J.Aaron，The Unsurprising Surprise of Renewed health Care Cost Inflation.Health Affairs，23 January 2002，Web Exclusive:85-87.
(20)Annetine Gelijns，and Nathan Rosenberg，The Dynamics of Technological Change in Medicine.Health Affairs，Summer 1994:28-46.
(21)The Technological Change in Health Care(TECH)Research Network，Technological Change around the World:Evidence from Heart Attack Care.Health Affairs，May/June 2001，Vol.20，No.3:25-42.
(22)Kennelth J.Arrow，“Uncertainty and the Welfare Economics of Medical Care”，American Economic Review，December 1963，Vol.53，No.3:41-73.
(23)MichaelE.Chernew，PeterD.Jacobson，TimothyP.Hofer，Keith D.Aaronson，and A Mark Fendrick，“Barriers to Constraining Health Care Cost Growth”，Health Affairs，Nov./Dec.2004，Vol.23，No.6:122-128.
(24)Kennelth J.Arrow，“Uncertainty and the Welfare Economics of Medical Care”，American Economic Review，December 1963，Vol.53，No.3:41-73.
(25)Howard L.Smith，Myron D.Fottler，and Borje O.Saxberg，“Cost Containment in Health Care:A Model for Management Research”，The Academy of Management Review，Vol.6，No.3，July 1981，397-407.
(26)医疗卫生领域的管理成本包括四部分:交易成本、利润管理成本、营销成本和规章制度的制定与执行方面的成本。
(27)Joseph P.Newhouse，“Medical Care Costs:How Much Welfare Loss?”TheJournal of Economic Perspectives，Vol.6，No.3，Summer 1992”3-21;and J.P.Newhouse，“An Iconoclastic View of Health Cost Containment”，Health Affaires，Supplement 1993:152-171。其前期的相关研究成果还包括:J.P.Newhouse，The Erosion of the Medical Marketplace，Santa Monica，Calif.:RAND，December，1978; and J.P.Newhouse，“Has the Erosion of the Medical Marketplace Ended?”Journal of Health Politics，Policy and Law，Summer 1988:263-278。
(28)Joseph P.Newhouse，“Medical Care Costs:How Much Welfare Loss?”TheJournal of Economic Perspectives，Vol.6，No.3，Summer 1992:3-21.
(29)Peter J.Neumann等人认为，关于技术推动费用的争论其实是一种误导，因为，技术本身不会提高价格，而是相关的制度在起作用;而且不管制度如何，问题的关键不是费用上升本身，而是在消耗资源的同时社会获得了什么(Peter J.Neumann，et al.，“From Principle to Public Policy:Using Cost-Effectiveness Analysis”，Health Affairs，Summer 1994:206-214);Victor Fuchs则对Newhouse的计算方法提出了质疑，认为他低估了人口老龄化对费用的影响(Joseph P.Newhouse，“Medical Care Costs:How Much Welfare Loss?”The Journal of Economic Perspectives，Vol.6，No.3，Summer 1992:3-21)。
(30)Victor R.Fuchs，“Economics，Values，and Health Care Reform”，AmericaEconomic Review 1996，86(1):1-24.
(31)Edgar A.Peden，and Mark S.Freeland，“A Historical Analysis of Medical Spending Growth，1960-1993”，Health Affairs，Summer 1995:235-247.
(32)Uwe E.Reinhardt，“Health Insurance and Cost-Containment Policies:The Experience Abroad”，American Economic Review，Vol.70，No.2，Papers and Proceedings of the Ninety-Second Annual Meeting of the American Economic Association(May，1980):149-156.
(33)Thomas Bodenheimer，“The Not-So-Sad History of Medicare Cost Containment as Told in One Chart”，Health Affairs，23 January 2002，Web Exclusive:88-90.
(34)Kant Patel and Mark E.Rushefsky.Health Care Politics and Policy in America，2nded.Armonk:M.E.Sharpe，Inc.1999:164-165.
(35)Mark V.Pauly，“Is medical Care Different?”in Warren Greenberg(ed.)，Competition in the Health Care Sector:Past，Present，and Future.Germantown，Maryland:Aspen Systems Corporation，1978:33.
(36)Mark V.Pauly，“Is Medical Care Different?Old Questions，New Answers”，Journal of Health Politics，Policy and Law 13，No.2，Summer 1988:227-237.
(37)Stephen M.Weiner，“On Public Values and Private Regulation:Some Reflections on Cost Containment Strategies”，Milbank Memorial Fund Quarterly/Health and Society，Vol.59，No.2，Spring 1981:269-296.
(38)Joseph P.Newhouse，“Medical Care Costs:How Much Welfare Loss?”TheJournal of Economic Perspectives，Vol.6，No.3，Summer 1992:3-21.
(39)David M.Cutler，“Equality，Efficiency，and Market Fundamentals:The Dynamics of International Medical-Care Reform”，Journal of Economic Literature，Vol.40，No.3，Sep.2002:881-906.
(40)后来，PSRO更名为同行评议组织(PRO)。
(41)Uwe E.Reinhardt，“Health Insurance and Cost-Containment Policies:The Experience Abroad”，American Economic Review，Vol.70，No.2，Papers and Proceedings of the Ninety-Second Annual Meeting of the American Economic Association(May，1980):149-156.
(42)David M.Cutler，“Equality，Efficiency，and Market Fundamentals:The Dynamics of International Medical-Care Reform”，Journal of Economic Literature，Vol.40，No.3，Sep.2002:881-906.
(43)Walter McClure，“Structure and Incentive Problem in Economic Regulation ofMedical Care”，Milbank Memorial Fund Quarterly/Health and Society，Vol.59，No.2，Spring 1981:107-144.
(44)Alain C.Enthoven，“Competition in the Marketplace:Health Care in the 1980s”，in James R.Gay and Barbara J.Sax Jacobs(eds.)，Competition in the Marketplace:Health Care in the 1980s，New York:Spectrum Publication，1982:18-19.
(45)这里并不排除为保证公平竞争而采取的监督和干预措施，如反垄断法等。
(46)Paul Starr，“Changing the Balance of Power in American Medicine”，Milbank Memorial Fund Quarterly/Health and Society，Vol.58，No.1，Winter 1980:170.
(47)Nicholas Barr，“Economic Theory and the Welfare State:A Survey and Interpretation”，Journal of Economic Literature，Vol.30，No.2，June 1992:741-803.
(48)所谓起付线，就是被保险人在享受保险待遇之前，必须支付一定数量的费用，支付标准往往是固定的;所谓共同保险，就是一旦费用超过了起付线，被保险人要按一定比例承担部分医疗费;所谓共付额，就是被保险人对所接受的每项服务都要支付固定数量的费用，而不是按比例出资。
(49)被保险人对费用分担的反应程度可以用其支出的弹性系数来衡量，也就是自费成本每增加1%，被保险人支出下降的比例。Eichner关于这一问题的研究结论是－0.62(Matthew J.Eichner，“The Demand for Medical Care:What People Pay Does Matter”，American Economic Review，Vol.88，No.2，Papers and Proceedings of the Hundredth and Tenth Annual Meeting of the American Economic Association，May 1998:117-121);而其他两项类似的研究得出的弹性系数(绝对值)要小一些，分别是－0.22(Joseph P.Newhouse，Free for All:Lessons from the RAND Health Insurance Experimen，.Cambridge，MA:Harvard University Press.)和－0.22～－0.32之间(Matthew J.Eichner，“Incentives，Price Expectations，and Medical Expenditures:An Analysis of Claims under Employer-Provided Health Insurance”，Mimeo，Massachusetts Institute of Technology，1997.)
(50)Karen Davis，Gerard F.Anderson，Diane Rowland，and Earl P.Steinberg，Health Care Cost Containment.Baltimore:The Johns Hopkins University Press，1990: 126.
(51)Randall P.Ellis，and Thomas G.McGuire，“Supply-Side and Demand-SideCost Sharing in Health Care”，The Journal of Economic Perspectives，Vol.7，No.4，Autumn 1993:135-151.
(52)当然，供方可以通过交叉补贴(cross subsidy)的方式将慈善医疗的费用转嫁给其他收费服务的人群，但这样做会提高医疗服务的价格，对供方而言仍然是有风险的。
(53)Dennis R.Heffley，Thomas J.Miceli，“The Economic of Incentive-Based Health Care Plans”，The Journal of Risk and Insurance，Vol.65，No.3，Sep.1998: 445-465.
(54)Nicholas Barr，“Economic Theory and the Welfare State:A Survey and Interpretation”，Journal of Economic Literature，Vol.30，No.2，June 1992:741-803.
(55)Stuart H.Altman，and Sanford L.Weiner，“Regulation as a Second Best”，inWarren Greenberg(ed.)，Competition in the Health Care Sector:Past，Present，and Future，Germantown，Maryland:Aspen Systems Corporation，1978:339.
(56)美国斯坦福大学经济学教授Alain C.Enthoven是managed competition的积极倡导者和理论创始人。他从20世纪70年代末开始，通过一系列的论著，系统阐述了managed competition的理念和制度设想，是90年代初克林顿医疗改革重要的理论基础。Enthoven的相关著述包括:A.C.Enthoven，Health Plan:The Only Practical Solution to the Soaring Cost of Medical Care.Reading，Mass.:Addison-Wesley，1980;A.C.Enthoven，“Managed Competition in Health Care and the Unfinished Agenda”，Health Care Financing Review，1986 Annual Supplement:105-119; A.C.Enthoven，“Managed Competition:An Agenda for Action”，Health Affairs，Summer 1988:25-47;A.C.Enthoven，Theory and Practice of Managed Competition in Health Care Finance，1987，Professor Dr.F.de Vries Lectures，North-Holland/American Elsevier，1988;A.C.Enthoven and R.Kronick，“A Consumer Choice Health Plan for the 1990s:Universal Health Insurance in a System Designed to Promote Quality and Economy”，The New England Journal of Medicine，5 and 12 January 1989:29-37 and 94-101;A.C.Enthoven and R.Kronick，“Universal Health Insurance through Incentives Reform”，Journal of the American Medical Association，15 May 1991:2532-2536; and A.C.Enthoven，“The History and Principles of Managed Competition”，Health Affairs，Supplement 1993:24-48.
(57)公共医疗保险计划实际上也是一种政府管制的形式。
(58)Henry J.Aaron，Barry P.Bosworth，David M.Cutler，and Mark V.Pauly.“Economic Issues in Reform of Health Care Financing”，Brookings Papers on Economic Activity.Microeconomics，Vol.1994:249-299.
(59)Henry J.Aaron，“Should Public Policy Seek to Control the Growth of Health Care Spending?”Health Affairs，8 January 2003，Web Exclusive:28-36.
(60)加拿大、法国、德国、意大利、英国、日本等国家的费用变化与费用控制情况请参阅David M.Cutler，“Equality，Efficiency，and Market Fundamentals: The Dynamics of International Medical-Care Reform”，Journal of Economic Literature，Vol.40，No.3，Sep.2002:881-906。
(61)Mark V.Pauly，“Should We Be Worried about High Real Medical Spending Growth in the United States?”Health Affairs，8 January 2003，Web Exclusive:15-27.
(62)英国的全民医疗保险制度叫国家卫生服务(National Health Services，NHS)。
(63)参见张奇林:《美国医疗保障制度研究》，人民出版社2005年，第24～29页。
(64)David M.Cutler，and Mark McClellan，“Is Technological Change in Medicine Worth It?”Health Affairs，September/October 2001，Vol.20，No.5:11-29.
(65)Joseph P.Newhouse，“An Iconoclastic View of Health Cost Containment”，Health Affairs，Supplement 1993:152-171.
(66)单纯从费用控制的效果来说，政府管制要好于市场竞争，但从政府管制所带来的后果以及费用变化的周期性来看，政府管制是否真正好于市场竞争就很难说了。
(67)转引自Victor R.Fuchs，“Economics，Values，and Health Care Reform”，America Economic Review 1996，86(1):1-24。
(68)Randall P.Ellis，and Thomas G.McGuire，“Supply-Side and Demand-Side Cost Sharing in Health Care”，The Journal of Economic Perspectives，Vol.7，No.4，Autumn 1993:135-151.
(69)Joseph P.Newhouse，“An Iconoclastic View of Health Cost Containment”，Health Affairs，Supplement 1993:152-171.
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