Liu Yu, Saltman Richard B
1 Emory University, Atlanta, GA, USA.
Inquiry. 2019 Jan-Dec;56:46958019872348. doi: 10.1177/0046958019872348.
Physicians play multiple roles in a health system. They typically serve simultaneously as the agent for patients, for insurers, for their own medical practices, and for the hospital facilities where they practice. Theoretical and empirical results have demonstrated that financial relations among these different stakeholders can affect clinical outcomes as well as the efficiency and quality of care. What are the physicians' roles as the agents of Chinese patients? The marketization approach of China's economic reforms since 1978 has made hospitals and physicians profit-driven. Such profit-driven behavior and the financial tie between hospitals and physicians have in turn made physicians more the agents of hospitals rather than of their patients. While this commentary acknowledges physicians' ethics and their dedication to their patients, it argues that the current physician agency relation in China has created barriers to achieving some of the central goals of current provider-side health care reform efforts. In addition to eliminating existing perverse financial incentives for both hospitals and physicians, the need for which is already agreed upon by numerous scholars, we argue that the success of the ongoing Chinese public hospital reform and of overall health care reform also relies on establishing appropriate physician-hospital agency relations. This commentary proposes 2 essential steps to establish such physician-hospital agency relations: (1) minimize financial ties between senior physicians and tertiary-level public hospitals by establishing a separate reimbursement system for senior physicians, and (2) establishing a comprehensive physician professionalism system underwritten by the Chinese government, professional physician associations, and major health care facilities as well as by physician leadership representatives. Neither of these suggestions is addressed adequately in current health care reform activities.
医生在医疗体系中扮演着多重角色。他们通常同时充当患者、保险公司、自身医疗业务以及执业医院机构的代理人。理论和实证结果表明，这些不同利益相关者之间的财务关系会影响临床结果以及医疗服务的效率和质量。在中国，医生作为患者代理人的角色是什么呢？自1978年以来中国经济改革的市场化路径使医院和医生以盈利为导向。这种逐利行为以及医院与医生之间的财务关联，反过来使医生更多地成为医院的代理人，而非患者的代理人。虽然本评论承认医生的职业道德及其对患者的奉献精神，但认为中国目前的医生代理关系为实现当前供方医疗改革努力的一些核心目标设置了障碍。除了消除目前针对医院和医生的不当财务激励措施（众多学者已认同这种需求）之外，我们认为中国正在进行的公立医院改革以及整体医疗改革的成功还依赖于建立适当的医患代理关系。本评论提出了建立这种医患代理关系的两个关键步骤：（1）通过为资深医生建立单独的报销系统，尽量减少资深医生与三级公立医院之间的财务关联；（2）在中国政府、专业医生协会、主要医疗机构以及医生领导代表的支持下，建立一个全面的医生职业精神体系。当前的医疗改革活动中，这两条建议均未得到充分探讨。
