习近平总书记在被人们称为“就职演说”的讲话里面说到：“人民对美好生活的向往就是我们的奋斗目标”。那么，具体到“民生改善”上面，在中国老龄化社会这一历史阶段来临，又进入中等收入阶段的情况下，实际上“民生改善”中有种种新的矛盾和挑战。从人本立场来看，说到源头，人的美好生活是和医疗保障不能够分开的，而且在这个“中等收入”加“老龄化”的特定阶段上我们“医疗的改进”会合乎逻辑地成为“民生的改进”之重中之重。同时，还要意识到全民医疗保障体系的建立以及它的可持续的高质量———这个质量还应该是处于不断优化提升过程中———这样一个结合，所涉及的医改问题，是全世界的难题。据我的了解，现在还找不到一个可以稳定地、持续地得到高度评价的先例。

Xi jinping in general secretary was called"Inaugural address"In the speech said:"People's yearning for a better life is our goal".so,Specific to"To improve the livelihood of the people"above,In China's aging society this historical phase is coming soon,And to enter into middle-income stage of the case,In fact"To improve the livelihood of the people"In a variety of new problems and challenges.From the humanistic standpoint,Said to source,The good life is and medical security can't separate,And in the"middle-income"add"aging"The specific stage we"Medical improvement"Will become logical"The improvement of people's livelihood"Most of.At the same time,To realize the medical security system is established and its sustainable high quality - the quality also should be in a continuous optimization of the process of ascension -- such a combination,Medical problems involved,Is the problem of the world.According to my understanding,Still can't find a can steadily/Continue to get highly precedent.

　　那么，在中国，怎么样把这个事情处理好？我调研不够全面，只能作为研究者提出一些要领，谈谈对于“中国社会经济发展中的公立医院改革”这个题目的一些考虑。

so,In China,How to deal with this matter?My research is not comprehensive enough,Only as the researchers put forward some main point,Talk about for"China's social and economic development of the reform of public hospitals"The subject of some consideration.

　　从现在已经推进的新医改来看，基层的“收支两条线”的机制已经建立，我们不再展开评价它了。但是，我想比较直率地谈一点，这样的一种机制恐怕只能适合于基层。“收支两条线”就是把基层的医疗单位实际上看作和公检法一样或相类似的公权单位，对它的约束、规则这方面的控制，由此可能比较容易到位。但是，它的内部激励机制却很难能够合乎理想。在基层已有了这样一个制度框架之后，我们今天讨论的公立医院的改革，则是绝对不可能照搬基层经验的。公立医院改革需要更多地考虑在提高民众对于医疗保障覆盖面的满意度的同时，必须得到一个可持续的支撑机制，使医疗服务水平不断提高。那么，内在激励机制非常重要，它必须是面对公立医院这个概念下这些医疗供给主体怎么改革，实际上还有社会主义市场经济进一步发展进程中非公立的主体也必然要进入医疗卫生领域这些因素，结合在一起实现良性互动。我的理解，谈公立医院改革，实际上就是谈整个医疗领域里的这些要提供医疗服务的主体的通盘改革。这样的改革，我认为需要在由政府牵头提供的“托底”的医保基础之上，形成一种全局性健康竞争的机制，它应该是多层次、多样化地提供出能够最大限度地满足社会成员“改善民生”所需要的多样化的医疗服务。

From now has propelled the new medical reform to see,grassroots"Balance two lines"Mechanism has been established,We no longer evaluation on it.but,I would like to compare freely talking about a little,Such a mechanism I'm afraid only suitable for base."Balance two lines"Is the base of medical unit in fact as public security organs and the same or similar male power unit,To its constraints/The control rules,This may be relatively easy to put in place.but,It is very difficult to internal incentive mechanism to ideal.In the basic unit has such a system after framework,Today we discuss the reform of public hospital,It is absolutely impossible to copy the grass-roots experience.Public hospital reform need more consideration in improving public health care coverage for satisfaction at the same time,Must be a sustainable support mechanism,The medical service level continuously improve.so,Internal incentive mechanism is very important,It must be in the face of public hospital under the concept of the medical supply subject how to reform,In fact and the socialist market economy further development process central African public subject also must enter the medical and health fields these factors,Work together to achieve a virtuous interaction.I understand,Talk about public hospital reform,Is actually about the medical field these to provide medical service main body overall reform.This reform,I think that need to be in the lead by the government provide"TuoDe"Based on the medical insurance,Formed a global health competition mechanism,It should be a multi-level/To provide a diversified to maximize meet members of society"Improve the livelihood of the people"The diversity of the need of medical service.

　　那么，这里我们现在已碰到的问题是什么？是不是可以作为一个我们考虑通盘设计的切入点？这个通盘设计千头万绪，我无力对它的一些细节发表评论，但是作为研究者的探讨性观点，我感觉现在人们所说的“看病贵”“看病难”问题，认识深度还明显不够。其实，“贵”和“难”都是在不同的特定约束条件下相对而言的。比如说“看病贵”，现在大家最不满意的就是一般头疼脑热的小病也贵；“看病难”是大家都想进最高水平的大医院得到专家治疗，而要得到这种治疗太难；等等。我们还需要在更深入的层面揭示问题。我认为至少可提出下面这三个较大的问题：

so,Here we have now met what's the problem?If we can as a starting point we consider overall design?The overall design how to deal,I am unable to comment on some of its details,But as the researchers study viewpoint,I feel now what people say"The doctor your""Difficulties in getting"problems,Understanding depth is also obviously not enough.In fact,"your"and"difficult"Are in different specific constraints relative.For instance"The doctor your",Now everybody's most not satisfied is generally slight illness of the ailment is expensive;"Difficulties in getting"Is everyone want to get into the highest level of large hospital treatment for experts,And if you want to get this kind of therapy too hard;etc.We also need to be in deeper level out.I think at least can put forward the following three large problems:

　　市场化竞争对诊疗对象可带来选择性的好处的同时，也隐含着信息不对称带来的偏向“创收第一”的问题。

Market competition on diagnosis and treatment can bring the benefits of selective object at the same time,Also implied the information asymmetries bias"Earned the first"problem.

　　一个是我们已经注意到的所谓“过度市场化”的问题。前些年，在创收这方面我们看到了已带上、或者说已比较严重的唯利是图色彩的这样一些行为。在信息不对称的情况下，医疗机构如要创收那是很容易的。我个人就有体验，比如说我曾经去治牙，这个过程中病人是很痛苦的，拖了很长时间。快到春节了，最后一个步骤———关键性的把牙植好这一步，医生表示要拖到春节以后，他建议(实际上对于我来说，我必须服从)在春节之前他给我开始其他方面的、我认为不太重要的治疗，他认为应该一揽子把我口腔里面的问题都给处理好。那么，我就想到，我春节期间自己的生活质量要受到严重的影响。实际上我选择的是什么呢？我了解到别的医院可以继续把植牙这一步完成，我就脱离开这个医院另找别家解决了问题。在这种竞争环境里的可选择性，解决了我个人关心的这样的一个治牙的问题。我个人认为，我是走了市场竞争渠道，也享受到了它带来的好处，但是再想一下，如果按照原医院的思路，对具体的“供方”来说，创收可以进一步地提升，而不少患病人士未必会像我一样“改换门庭”。我这是一个小例子，说明在市场化竞争对诊疗对象可带来选择性的好处的同时，也隐含着信息不对称带来的偏向“创收第一”的问题。

One is we have noticed the so-called"Excessive marketization"problem.Before some year,In the revenue in this we see already take/Or has serious venality colorific such behavior.In case of asymmetric information,Medical institutions such as it has to earn that is very easy.I personally have experience,For instance I once went to dental treatment,The process of patients is very painful,Drag for a long time.Fast to the Spring Festival,The last step - key to dental planting good this step,Doctors say the delay after the Spring Festival,He suggested that(Actually for me,I must obey)Before Spring Festival he gave me began to other aspects/I think not too important treatment,He thinks I should package in oral problems to deal with.so,I thought of,During the Spring Festival I their quality of life will have been seriously affected.In fact I choose what is it?I know to other hospital can continue to implant the complete this step,I will open the hospital from other find another solved the problem.In this competitive environment of the selectivity,I solved the personal care about such a dental treatment problem.Personally, I think,I am go market competition channel,Also enjoyed the benefits of it,But to think about,If in accordance with the original idea of the hospital,The specific"The supplier"for,Revenue can further improve,And many sick people may not like me"Turin switch".I here is a small sample,In the market competition that for diagnosis and treatment can bring the benefits of selective object at the same time,Also implied the information asymmetries bias"Earned the first"problem.

　　“不行，有现金就办，没现金就不行，这是制度。”这是过度市场化造成的吗？我绝不认可。

"no,Have the cash to do,No cash is no,This is the system."This is caused by the excessive market?I never approved.

　　第二，我们还有另外一个重要的问题叫“过度官场化”。中国的传统体制遗留的很多东西在医疗领域里边仍然存在，不能回避。比如说，我们医疗机构在公立医院概念之下，仍然有衙门作风，它特别讲究“我这里有规定”。我们看到这样的案例，有人出了车祸需要急救了，这一包血要输下去，命就可能抢救过来。这时候已经是夜间，值班的人告诉伤者亲友：“你要先交钱。”他说：“对不起，我身上没有现金，现在又没有银行能取，我把手表、手机押在这里，希望你们先把血给伤者输进去。”但回答是：“不行，有现金就办，没现金就不行，这是制度。”这是过度市场化造成的吗？我绝不认可。这是衙门作风啊。要是市场化的话，他应有的反应是：“好，反正你有抵押物，明天这个钱就能收进来了，我就增加收入了。”市场化恰恰是有动力更多地做这种事。但是，这里碰到的是衙门作风，可就是这样的反应了：“我这是有规定的”———规定不给现金就不能输血。

The second,We have another important question that"Excessive officialdom change".Chinese traditional system left a lot of things in the medical field inside still exist,Can't avoid.For instance,Our medical institutions in the public hospital under the concept,There are still yamen style,It is especially pay attention to"I have provisions".We see this case,Someone had an accident the need first aid,This a pack of blood to lose it,Life may come to the rescue.This time is the night,Watch people tell the relatives and friends:"You'll have to pay."He said:"I'm sorry,I have no cash on me,Now, again have no bank can take,I put the watch/Mobile phones and here,Hope you to lose the first blood in."But the answer is:"no,Have the cash to do,No cash is no,This is the system."This is caused by the excessive market?I never approved.This is the government style ah.If word of marketization,He should have reaction is:"good,Anyway, you have the mortgaged property,Tomorrow the money can accept came in,I will increase the income."The market is a force more to do such a thing.but,Here is with the style of government,But such a reaction:"I this has a regulation"-- shall not give cash is not a blood transfusion.

　　另外，还有一种情况，即医疗待遇三六九等。等级特权的问题，是中国现实存在的。现在仍可见一个人是个什么什么的副部级职务，但是，后边有括弧注明：(正部级医疗待遇)。为什么会这样？医疗待遇已经成了一种与行政职务、社会地位相伴随的特定权利，在某些情况下还可“自成体系”，如“高配一级”以示不同于一般。那么，上行下效，中央和省里既然有，市里、县里都可以有自己规定的特定医疗待遇，到了乡镇里也可比照———有的乡镇居然还设立有“高干病房”。人家问：“你这里有什么高干？”回答说：“我们乡镇级就没有高干了？我们这儿靠上的都是高干。”诸如此类的问题，我觉得在现实生活里边，必须意识到它是不符合现代社会发展方向的，是不符合社会主义市场经济资源配置优化方向的，但它确实存在，它属于医疗领域一种过度的官场化。现在种种的特别待遇、特别护理，也往往是以潜规则的形式、以它自发生长出来的形式在现实中存在的，植根于行政权力和“官场文化”的。

In addition,Still have a kind of situation,That medical treatment such as 369.The problem of privilege level,China is real.It is still visible one is what what deputy ministry class position,but,Behind a brackets indicate:(Is ministry of medical treatment).Why do you?Medical treatment has become a kind of and administrative duties/Social status accompanied by certain rights,In some cases can also"System which has its own",if"With high level"To show different from general.so,ShangHangXiaXiao,The central and province since have,city/County can have its own stated specific medical treatment,The villages and towns can -- in some villages and towns incredibly still have set up"Senior cadre ward".Being asked:"Do you have anything here to senior cadre?"said:"We have no high ranking official the township level?We here by on high ranking official."Such problems,I think in real life there,Must be aware that it is not accord with the modern social development direction,Is not compatible with the socialist market economic resource allocation optimization direction,But it is there,It belongs to medical field a excessive officialdom change.Now all kinds of special treatment/Special care,Also often takes the form of hidden rules/It is ready to grow out in the form of the existing in reality,Rooted in the administrative power and"Officialdom culture"of.

　　它是一种我们现在存在的物质条件上升、但是专业水平没有相伴随上升的一种“非专业化”问题。

It is a kind of now we are rising material conditions/But professional level not accompanied by a rise"Not professional"problems.

　　第三个问题，我称为“医疗服务的非专业化”。有了这么多年的发展之后，这种不符合职业道德的案例仍然还可时常听到。有一种例子，可能属于少数医护人员心术不正，这是个别现象，但它确实存在———即出于某种原因要报复他的服务对象，比如说在媒体报道中听到的“缝肛门”案例，曾经闹过轩然大波。或在医疗处理的过程中给你制造别扭。另外还有一种情况，并不是心术不正，而是职业道德层面相关联的敬业态度和专业水平不到位。比如一个案例，没有死的婴儿给按死婴处理了，好在有一个偶然的原因，人们发现这个孩子没死，又给救回来了。诸如此类的事情合在一起，它是一种我们现在存在的物质条件上升、但是专业水平没有相伴随上升的一种“非专业化”问题。原因何在？和我们的激励、约束、管理，以及我们现代化过程中要追求绩效所伴随的机制问题未解决好，是联系在一起的。

The third question,I called"Medical service is not professional".Have so many years after the development,This is not in conformity with the professional ethics cases still can often hear.There is a example,May belong to the medical staff of sincerity,This is the individual phenomenon,But it is there, that is, for some reason to revenge his service object,For instance in media reports hear"Joint anal"case,Ever make a storm in a teacup.Or in the medical treatment process make you uncomfortable.Another kind of circumstance,And not of sincerity,But professional moral level of the associated professional attitude and professional level does not reach the designated position.Such as a case,Not dead baby give according to the dead baby dealt with,May have an occasional cause,People found the child not dead,And to save back.Such things together,It is a kind of now we are rising material conditions/But professional level not accompanied by a rise"Not professional"problems.why?And our motivation/constraint/management,And our modernization process to the pursuit of the performance of the mechanism that accompany not solve,Is linked together.

　　如果必须正视上述这三个方面的问题，那么，我们要探讨应该怎样对症下药？我想从要领上来说还是可以有所考虑的。前面说到的医保“托底”，以后的远景似乎应该是：全社会成员均有一个社会保障号码，还是他享受全社会统筹的医疗服务的号码(同时也是他个人的纳税号码)。最理想的状态是：这个人无论在哪儿，不论是在出差的状态、还是旅游的状态，有病了，进任何一家医院，提供号码，接受治疗，最后结算。这是一个比较合理的理想的“托底”，它能使所有的公民在我们中华人民共和国的管辖范围之内，有病马上可以得到最便捷的治疗。而在此基础上，还有由大型的高水准的公立医院以及类似的非公立医院在健康竞争的情况下一起形成所谓医疗的选择性“网络”。我注意到，有专家发言所提到的概念是叫“医院联盟”———可理解为横向的联盟和纵向一直往下延伸到社区的联盟，再加上借鉴医药分开的国际经验作必要的机制化的改进。除了有社区医疗，我认为也需要探索发展个性化的“家庭医生”机制。怎样合理转诊？应该是在有选择性的、多样化的健康竞争局面中，凭借医疗机构自己的公信力，使越来越多的服务对象自动地通过先到社区医院，或打电话咨询自己的家庭医生，然后在有必要的情况下再进大医院找顶尖专家。这个过程不应是人为压出来、管制出来的，不是人为设置就可以马上执行的，它需要有一个培育社会公信力的过程，使老百姓认为这是一个对他最合理的医疗流程。另外，应该积极地发展有竞争力、能够促进我们医疗水平不断提升的多样化的医疗机构。高端的一些医疗形式，我认为在中国也同样要重视：低端“托底”的保障是现在的重点，但同时，我们不必讳言，中国一定要发展高端的、能够以后和世界前沿水平大致一比高下的这样一些医疗服务的主体与力量。

If you must face up to the above three aspects of the problem,so,We want to discuss how should suit the remedy to the case?I want to bring from speaking or can have considered.In front of the medical insurance"TuoDe",The prospect of the future is likely to be:The whole society members have a social security number,Or he enjoyed the whole society to plan as a whole medical service number(At the same time also is his personal tax number).The most ideal state is:The man no matter where is it,Both in the state of the business trip/Or the state of tourism,sick,In any hospital,Provide number,treatment,Final settlement.This is a more reasonable ideal"TuoDe",It can make all the citizens of the People's Republic of China in our jurisdiction scope,Sick immediately can get the most convenient treatment.And based on this,And the large high level of public hospitals and similar non public hospital in healthy competition together form the so-called medical selectivity"network".I noticed,Experts speech mentioned concept is called"Hospital alliance"- can be understood as the transverse and longitudinal alliance has been extended to the community to the alliance,Plus reference medicine separate international experience make necessary improvement along.In addition to the medical community,I think also need to explore the development of the individual"Family doctor"mechanism.How reasonable referral?Should be in a selective/The diversity of healthy competition situation,With medical institutions own credibility,To make more and more service object automatically through the first community hospitals,Or call consulting his family doctor,Then in the necessary circumstances again into the hospital looking for top experts.This process should not be artificial pressure out/Control out of the,Not artificial Settings you can instantly execution,It needs a process of cultivating social credibility,Make people think this is a the most reasonable medical process.In addition,Should actively develop competitive/We can promote the level of medical treatment to improve the diversity of the medical institution.Some of the high-end medical form,I think in China also want to pay attention to:low"TuoDe"Now the security is the key,But at the same time,We don't have the truth,China must to develop high-end/After the world's leading level and can be roughly a poirot such medical service main body and power.

　　对应于三大问题，我们应该有三个推进，从财政支持的政策设计来说，前提是至少不能摆脱这三个大的基本取向。

YuSanDa corresponding problems,We should have three propulsion,From the financial support for the policy design,Premise is at least can't get rid of the three big basic orientation.

　　总结一下我的这些想法，对应于三大问题，我们应该有三个推进：

Sum up my ideas,YuSanDa corresponding problems,We should have three propulsion:

　　第一个推进，是“健康的市场化”。公立医院改革和与公立医院改革并生配套的所有医疗机构的这些改革，没有一个健康的竞争环境，我认为是没有出路的。不要设想简单地靠“收支两条线”式的管理或者类似的思维逻辑能够处理好这个问题。

The first push,is"Healthy market".Reform of public hospitals and public hospital reform and life form a complete set of all medical institutions of these reforms,Without a healthy competition environment,I think that is no way out.Don't assume that simply rely on"Balance two lines"Type management or similar thinking logic to deal with this problem.

　　第二个推进，在中国以后要推进实质性的“最低的官场化”的过程。不可能设想一个社会里边在医疗待遇方面不做一些特殊待遇的处理。美国对它的总统也有特殊的医疗人员来护理，来提供特别的服务。但在中国应该是非常明确的：需有降低医疗领域特定的“过度官场化”水平的过程，要使这种带有官场化色彩的医疗服务消减到最低限度，这要结合行政体制和政治体制的改革。

The second advance,In China will promote substantive"The lowest officialdom change"process.Can't imagine a society in the medical treatment inside not do some special treatment processing.Of the U.S. President also have special medical personnel to care,To provide special service.But in China should be very clear:Need to have a lower medical field specific"Excessive officialdom change"Level of process,To make the color change with officialdom medical service cut to the minimum,According to the administrative system and political system reform.

　　第三个推进，应该推进一种“可持续的、有竞争力的专业化”发展过程。这里边需要有很多机制性的设计：怎么样真正调动医护人员提高自己专业水准、服务水平的内在积极性，怎样培养现在基层更多需要的所谓“全科型”的医疗服务人员，怎样鼓励我们每年招收的为数可观的医学本科学生、研究生在毕业以后不是只考虑进大医院，能够服务地方、服务基层，使他们在中心城市工作中有去边远、欠发达区域“挂职”工作一段时间的合理程序？这些激励———兼容机制结合在一起，应该可以形成一种可持续的、有竞争力的专业化趋势，来支撑整个民族的医疗服务水平的提高。

The third propulsion,Should promote a"sustainable/Competitive professional"Development process.There needs a lot of the design of the mechanism continuity:How to real medical personnel to improve their professional level/The service level of the inherent enthusiasm,How to train now base more need of so-called"General type"Medical service personnel,How to encourage each year we recruited a substantial number of medical undergraduate students/Graduate student in after graduation is not only considered in big hospitals,To serve local/Service base,Make them work in the center city to remote/Owes the developed area"credentials"A period of reasonable program?These incentives - compatible mechanism unifies in together,Should be able to form a sustainable/Competitive professional trend,To support the whole nation to raise the level of medical services.

　　最后，财政的支持可以归结到一个简单的概念，就是追求公共资金运用于医疗中的绩效。前述三个推进如果能掌握得好，财政资金的投入支持所带来产出的绩效水平就比较高；没有这些机制方面的优化和提升，财政资金即使是大量使用了，但绩效却会比较低，那就不能给予较高的评价。所以，从财政支持的政策设计来说，我认为前提是至少不能摆脱前面所说的三个大的基本取向。贾康

finally,Financial support boils down to a simple concept,Is the pursuit of public funds used in the performance of the medical treatment.The foregoing three push if you can grasp well,The finance fund's investment support brought about by the performance of the output level is high;Without these mechanisms optimization and promotion,Even if a large number of financial capital is used,But performance is relatively low,It can't give high evaluation.so,From the financial support for the policy design,I think the premise is at least can't get rid of the above three big basic orientation.Jia kang