What is different about the market for health care?
What is different about the market for health care?
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医疗保健市场有何不同？
DOI：
10.1001/jama.298.23.2785
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发表时间：
2007
期刊：
影响因子：
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通讯作者：
A. Detsky
中科院分区：
文献类型：
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作者：
D. Wells;Joseph S. Ross;A. Detsky
经济学是一门社会科学，描述社会如何生产和消费商品和服务。它既涉及效率（从固定数量的资源中获得最大收益），也涉及分配（谁受益，谁损失）。自亚当·斯密时代以来，大多数经济学家一直在吹捧自由市场作为提高效率的机制。他的理论是，在自由市场中，每个追求自身利益的人都会受到某种“看不见的手”的引导，产生一种使社会效用最大化的分配。然而，自由市场要实现有效的分配，需要某些条件。第一种是完全竞争，也就是说，在这个市场中，没有一个单独的买方或卖方可以通过他或她的行为影响价格。没有这一条件，就会出现结构缺陷或市场扭曲，导致分配效率低下。例如，石油市场被扭曲，因为石油输出国组织（欧佩克）自1970年代以来通过限制石油供应对石油价格施加影响。医疗服务市场存在诸多扭曲，包括医患信息不对称、医生作为患者代理人和独立企业主的双重角色等（通过订购或提供某些医疗服务获利）;保险在降低患者医疗保健服务表观成本方面的作用（由于医疗保健的全部费用不向病人收取，也称为“价格楔子”扭曲）;对消费者购买保险的决定有类似影响的税收补贴;垄断权力赋予某些行业，在一些国家，还赋予医疗保险计划，从而限制了竞争。在过去的40年里，卫生经济学家对这些扭曲对卫生保健市场的影响给予了相当大的关注。费尔德斯坦是最早提出医疗保险税收补贴对市场效率的扭曲效应的人之一。Detsky描述了信息的不对称和临床医生作为代理人的影响。阿罗指出，当市场失灵时，公共政策往往是用来改善后果的。在这篇评论中，我们回顾了3个经典的努力来描述，量化，并提出解决方案，市场扭曲的医疗保健。这些努力构成了过去40年的政策倡议，对今天的卫生政策辩论仍然具有现实意义。
ECONOMICS IS A SOCIAL SCIENCE THAT DESCRIBES HOW society produces and consumes goods and services. It is concerned with both efficiency (getting the most out of a fixed amount of resources) and distribution (who gains and who loses). The use of free markets as a mechanism of promoting efficiency has been touted by the majority of economists since the time of Adam Smith. His theory was that in free markets each individual, pursuing his or her own self-interests, will be led, as if by some “invisible hand,” to produce an allocation that maximizes society’s utility. However, certain conditions are required for free markets to result in efficient allocations. First among these is perfect competition, ie, a market in which no individual buyer or seller can affect the price by his or her actions. Without this condition, structural imperfections or market distortions arise and result in inefficient allocations. For example, the oil market is distorted because the Organization of the Petroleum Exporting Countries (OPEC) has exerted influence on the price of oil by restricting its supply since the 1970s. The market for health care contains many distortions, including asymmetry of information between clinicians and patients; clinicians’ dual roles as patient agent and independent business owner (profiting by ordering or providing certain medical services); the effect of insurance in reducing the apparent cost of health care services to patients (since the full cost of health care is not charged to patients, also known as the “price-wedge” distortion); tax subsidies that have a similar effect on consumers’ decisions to purchase insurance; and monopoly power bestowed on certain professions and, in some countries, health insurance plans, thereby limiting competition. Over the last 40 years, health economists have devoted considerable attention to the impact of these distortions on the market for health care. Feldstein was one of the first to write about the distorting effect of health insurance tax subsidies on market efficiency. Detsky described asymmetry of information and impact of clinician as agent. Arrow noted that when markets fail, public policies are often derived to ameliorate the consequences. In this Commentary we review 3 classic efforts to describe, to quantify, and to propose solutions to market distortions in health care. These efforts framed policy initiatives over the last 40 years and remain relevant to health policy debates today.