臺灣博碩士論文加值系統

本研究旨在探討醫療產業中參與者間的行為互動，及其所構成的市場競爭特徵。除了第一章為文獻回顧，本研究討論主題分成三大部分: 首先，第二章探討醫療消費面的特性如何影響醫療市場競爭。本文設定一個具有二維度的垂直差異偏好特徵，其中包含消費者風險類型，以此討論需求具備不確定性時，如何影響醫療供給者間的競爭行為，特別是在具有垂直差異的醫療服務供給者間。本文發現醫療需求具有不確定性時，特別是當風險小時，則不確定性提高可能使服務為垂直差異市場有較激烈的價格競爭，但此時醫療品質也會下降；而當風險相對高時，則此時不確定性增加，則會使價格競爭激烈，且品質也因為競爭而提高；而當風險足夠高時，則此時醫療需求的不確定性會使醫療價格與品質都提高。本章的貢獻在於，首度建立一個從效用內生的不確定性於垂直差異型的偏好中，並以此應用在醫療產業競爭模型。
第三章與第四章則將討論加入醫療保險制度的一個特性，即保險公司對消費者的引導行為。在醫療保險三方互動體系內，談判決定醫療價格是一重要機制。實證上影響此機制的重要因素是規模效果(size effect)、彈性與轉介效果(channeling effect)。轉介效果在理論上討論甚少，Ma & McGuire (2002)以限制數量的方式來解釋管理行照護組織選擇「網路型」醫療供給者的原因，而限制數量的懲罰機制就是轉介效果。在第三章，本文討論保險公司的轉介效果，但從對消費者提供財務誘因的角度出發，而有別其他文獻。本文證明，不考慮懲罰機制、規模效果與需求彈性，轉介效果透過改變消費者行為就足以誘發醫療供給者競爭行為的改變。而這些行為包含醫療經濟實證上所謂的病人驅使競爭(patient-driven competition)與付款者驅使競爭現象(payer-driven competition)。從而在一個模型架構裡同時解釋此二種現象並存的實證結果，是為本文貢獻所在。
傳統上討論跨期醫療需求的轉換是以品質不確定性為基礎來討論。這解釋市場因為資訊租而使醫療品質可能有投入不足或過度的無效率現象。實證上，醫療價格與品質除了受供給者之間競爭影響，也受到醫療保險公司影響甚鉅。如前所述，保險公司與供給者的互動理論主要建立在談判機制上，實證結果顯示轉介效果在醫療市場裡是一個重要因素。然以轉介效果解釋跨期醫療需求變動，以及引申的醫療價格與品質的影響文章甚少，故本文第四章即基於此，建立一個價格與品質的跨期競爭模型。本文發現價格變動與品質調整方向確實有可能不一致，亦即醫療給付價格提高(降低)，並不隱含醫療品質必然會提高(降低)。這為Kaestner & Guardado (2008) 的實證結果提出一個可能的解釋。另外本文也為Wu (2009) 與Sorensen (2003)在實證上顯示有時轉介效果會比規模效果更顯著提供解釋空間。

1 醫療產業競爭與醫療品質:部分均衡理論與實證文獻回顧 1
1.1 介紹 1
1.2 文獻回顧 4
1.2.1 疾病:醫療服務需求的本質 4
1.2.2 醫療市場的三方互動 14
1.2.3 醫療產業競爭與醫療品質相關實證 32
1.3 結論 36
2 為什麼人們要去大醫院: 病人觀點的醫療需求再探 37
2.1 介紹 37
2.2 異質醫療服務,不確定性與異質PTS偏好 40
2.2.1 醫療服務的差異化本質 40
2.2.2 異質性偏好的本質: 疾病與生病的狀態 43
2.2.3 不確定性 50
2.3 模型 53
2.3.1 環境 53
2.3.2 偏好與效用 55
2.3.3 需求 59
2.3.4 分配:重症的可能性 71
2.4 均勻分配與固定成本為例:風險,需求與品質 80
2.5 結論與後續研究 87
3 轉介效果,轉介誘因與醫院競爭行為 89
3.1 介紹 90
3.2 模型 95
3.2.1 對稱轉介誘因效果與社會最適服務品質水準 100
3.2.2 比較對稱轉介效果均衡 103
3.2.3 非對稱的轉介效果均衡 105
3.3 比較靜態分析 112
3.3.1 比較靜態分析:運輸費率/消費者偏好的忠誠度 113
3.3.2 比較靜態分析:轉介評價 119
3.4 結論與後續研究 127
4 轉換需求,醫院競爭與轉介效果 135
4.1 介紹 136
4.2 模型 140
4.2.1 效用 140
4.2.2 跨期需求 143
4.3 均衡 146
4.4 比較靜態 157
4.4.1 運輸費率的比較靜態 157
4.4.2 轉介評價的比較靜態 159
4.5 結論與後續研究 164
文獻 177
中文部分 177
英文部分 179
附錄 189

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