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2. ???????. ????(S). . ??(C). ????(P). . ???????????????????????????????. ?????????. ??( Cost )??( Quality). 3. ???????. ????????????????????????????(Entry Barrier)?????(GO)????(NPO-NGO)???. 4. ????????. ????????????????????????????????(??????????????). 5. ??????????. ??????????

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    1. 1 ???????? ????:??????????? ????:????????????? ?????????

    2. 2 ???????

    3. 3 ??????? ???????? ????? ????????? ??????(Entry Barrier) ?????(GO)????(NPO-NGO)???

    4. 4 ???????? ????????????? ?????? ???????? ?????(??????????????)

    5. 5 ?????????? ?????????????????????:????????????????? ?????????????????,????????????????: ???????????????:????;???????????:?????? ? ?????????,???????????????????

    6. 6 ???????????? Gaynor and Vogt(2000)?????,???????????,???????????????: ???????????????:???????????????????????????????,????????????? ?????????????????????? ???????????????????? ?????????????????? ???????????? ????????(supplier-induced demand) ?????

    7. 7 ???????????????? ???? ???? ?????? ?????????????? ??????????? ?? ???????????????????????; ???????,???????????,????????????

    8. 8 ????????? ?????????,???????????????????,?????????????,?????????????????? ???????,???????????????,?????: ?????????; ????,?????????????????; ??????????????? ?????????????????????

    9. 9 Why Not-for profit (NPO)? ?????????????????? ?Arrow(1963)?????????????,???????????????????:???????????????,???????????????,????????????? ???????????????????? ?Bays(1983)?????????,????????????????,?????????????,??????????????

    10. 10 ???????(GO)? ?????????noncontractible???,????? ?Hart et al. (1997)?????????????????,?????????????????????????? ?????????,???????????????noncontractible quality??????? ???????????????????? Gertler(1998)?????:???????????,????????????????????

    11. 11 ?????????? ???????? ???????,??????????????????,????????????Pauly and Redisch(1973)????????????? ???????? Duggan(2000)?????,????????????????????,???????????????,????????????????????????

    12. 12 ?????? ????????????? ????????? ????????? ????????????

    13. 13 ????????????? 1. ????????????????????,???????? 2. ???????????????????????(Hoeger, 1991) ? 3. ???????????????,???? ???????????????;?????????,????????????????(Lynk, 1995) ? 4. ?????????????????????????????????,????????????(Duggan, 2000) ?

    14. 14 ???????? ??????????,??????????? ?????????????????????,???????????? ???,????????????????,???????????????

    15. 15 ????????? ??????????? ???????(patient-driven competition): ????? ????????(payer-driven competition):???? ?????????????

    16. 16 Patient-Driven Competition ???????????????????,?????????????????“good shoppers”???: 1.??????????,???????????? 2.????????????????? ??????,?????????????,???????(????primary care physicians)?????(agent)???,??????????? ??????,????????????,??????????????????(??)?????????Dranove??(1993)???????“???????”(patient-driven competition)?

    17. 17 Patient-driven Competition????? ??????????,??????????????????,???????????,?????????? ?????????????????(medical arms race) ?

    18. 18 The Medical Arms Race(MAR) ??????????,?????????????????????,?????????? ?????????????????????????,???? Medicare?Medicaid????? ?????????????????????????????????????????????,?????????????,??????????

    19. 19 MAR??? ????,MAR?????????????,?????????????????:“In the MAR, hospitals compete for physicians and their patients by providing the latest technology, excessive staffing, and lavish amenities.” Enthoven(1978)???????:MAR?????????,??????????“social optimum”? ?????????????????????????(practice makes perfect),?MAR??????????????,????????????

    20. 20 ??MAR??????? ????????????????(reduced form): Y= f (H, X) Y ?????????; H ???????,???????? ?; X ?????????

    21. 21 ????? ??????????(concentration ratio)??????????? ????????????: 1)???????:????????????? 2)????(Herfindahl-Hirschman Index): ????50????????????????? ?????????,??????????;???????,???????????

    22. 22 ????????? ??????:HHI=100 × 100=10,000 ??????:HHI=0.12 × 50 =0.5 ? 0 (??50???,????????0.1%) ??,????????0,???10,000 ??????????: ????:HHI<1,000 ????:1,000<HHI<1,800 ????:HHI>1,800

    23. 23 MAR??????? Robinson & Luft (1985):???????????,??????????,??MAR??? Zwanziger & Melnick (1988):???????????????,??????????:1983??????????MAR???,1985??????????? Dranove et al. (1992):???????????????????,????MAR???????

    24. 24 Patient-driven competition??? Arrow(1963)?????,?????????????: ???:???????????????; ???:?????????? Arrow?????????(???)???????,?????????: ???:?? ???:???????(??????)? ????????????????????????????????????????????????(??)????????,????provider?????????????,??????????,??????????????,?????????????

    25. 25 Payer-driven competition?????1 ???????Medicare?Medicaid programs??????????payers,???????????,??payer??????bargaining power,???????????:1.?1983??????PPS;2.?1992????????RBRVS? ??????????????“???”,???????????????,??????????????????,??????????????,????????????:Preferred Provider Organizations(PPOs)?

    26. 26 Payer-driven competition????2 PPOs???payer????????,??????????(discounted price),?payer?????????????????(preferred providers)?????Payer???????????????:?????????,????????????????? PPO????????????(selective contracting),?????payer????,?????PPO???HMO????????? ????PPO?HMO??,????????????????payers? Payer?????????,????????????;payer???????????????,??????????????,????????????????,???????????????

    27. 27 Payer-driven competition????3 PPO?????????? 1.Larger purchasers obtain bigger discounts. (Melnick et al.,1992) 2.???????PPO??,???????????(???????),?????????????????HMO?PPO??,??????????????? 3.?patient-driven competition??,??????????????????,???????????,?????????????????,?PPO???????????????????,???????????

    28. 28 Payer-driven competition?????4 ?PPO???,??????????????,?????????????? PPO????,?????????????????(player),?????????,?????????????????Dranove??(1993)?????payer-driven competition?

    29. 29 Payer-driven competition????? ??????????????,???????????(price per day)???????(price per discharge)? ????????????,???????????????????: 1.??????? 2.?????????????? 3.???????????????? 4.The hospital’s price/cost margin

    30. 30 PPO????????? ???,????????????????????????????,???????????????????(????),???????????????????(?p)? ?PPO??????????, ?p????????offer(??)?PPO??????PPO?????????????,????????PPO????????,???????????????????PPO??,???????????????????????

    31. 31 PPO????????? ???,????????????????,???,??????????????????? ?????,PPO?????????????????????????????????????????????,????????????????PPO?????????????????????? ??patient-driven competition????,?????????????,??PPO??????????????;?????????????,?PPO??????????????????????? ???,PPO?????????????????????????????????PPO???????????????????????,?????????????????

    32. 32 PPO??????? ???,PPO???????????????????:????????????????PPO??primary care physicians,??????????????? ????,PPO?????????????:??????????????????????????

    33. 33 Payer-driven competition ????? 1.??PPO(?managed care)??????? 2.?????????????

    34. 34 ??PPO??????? Dranove??(1998)?????:PPO????????????????????excess capacity???????????,Dranove?????:???????????????????,???????????????? ???????????,??????:????????????????????:1.????? 2.???? 3.???????? ???????:?Patient-driven competition??,??MAR???,?????????????????(??????????,???????,????);??Payer-driven competition??,????????????????:???????(?????),selective contracting???,?????

    35. 35 Dranove et al. (1993)??? ???????1980?????,?????????????? 1983??????,???????????????,?1988??????????????????? ??????,???????1980?????patient-driven competition,??1980?????managed care??????,????payer-driven competition?

    36. 36 ?????1 Payer-driving competition???????,???????????????????????,????????????? ???????,??:1.???????,??????????? 2.??????????,?????????????? ???????,???????????????????????????????????????????,??: 1.??????,?????????????,??????? 2.????????payer???????????????,??????????????

    37. 37 ?????2 ??PPO?????,??????????,????????????? Dranove and Satterthwaite (2000)??:???????????,?????????PPO????????????????,???????????????????????,????????????

    38. 38 ????????????? ?????????????,???????????????: ?????:????????????,????????????????? ?????:???????,????,??????????????????????????

    39. 39 ?????????????? ??????????????: ????????????,?????????????,???????????????????????????,??????????????????????,???????????????? ????????,?????????? ????????????,????????????? ??????????????,???????????????????????????????????

    40. 40 ?????????????? MAR??,??????????????,??????????????? MAR?????????,??managed care???????????????????,??????MAR????????????? ??managed care plan??????????????????????,?managed care????????????????,??????? (cost-effective)??????

    41. 41 ????????????????? ????????????????,???????????????,????????????? ?????(Pro competition) ?????????????????? (????),??????????????????? (????????),??????? ????(Anti competition)

    42. 42 ??????????? ????????????????????? ???????????,????????: 1.????1980???????????:???????????????????????????patient-driven competition????,?????????????????? 2.????????????????:????????????????????,??????????payer-driven competition????,???????????????? 3.???????:?????????,??????????????

    43. 43 ????????? ??????????????????????????????,??????????????????????????,?????????????,?????????«??????»???,???????????,???????????????? ??????????????????,?????????????????????????????????????????,???????????

    44. 44 Kessler and McClellan (2000) ??1985??1994???,4????Medicare??????,????????????????? ?????AMI????????,??travel distances????????,?????managed care????????????????????????????????????,????????????????????

    45. 45 Kessler and McClellan (2000) ????????????????expenditures on treatment (social cost) and patient health outcomes (social benefits). ??????:???????1980?????,????????????,?1990?????????,??????????????:?????????,??????????(????),?????(????)???HMO?????(???managed care?????)?????????????????????

    46. 46 ????????????????1 ????????????????,??????????????????? ???????,??????????????? ???????????,?????????????????:????????????????,????????? ????????????,???????????????,?????????????,?????????????

    47. 47 ?????????????2 ????????????,??????????????,??????????????? Kessler and McClellan(2000)?????:???????????????????,?????AMI???????,??????????????,????????????????

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