改革醫(yī)療體系和服務(wù)

ProfessorofHealthPolicy&ManagementDirectorofJohnsHopkinsPrimaryCarePolicyCenter約翰霍普金斯大學(xué)基本醫(yī)療政策研究中心主任2017年6月(2017Copyrighted)?Reforminghealthcareisakeychallengeforalmosteverynation.幾乎每個國家都面臨醫(yī)療改革的挑戰(zhàn)。?Low-incomecountries:providebasichealthcareacrossasmuchofthepopulationaspossible,forlittlemoneyandlimitedresources.低收入國家：以有限的資金和資源為盡可能多的人提供基本醫(yī)療服務(wù)。?Emergingeconomies:deliverhigh-qualitycareatapriceaffordabletotheirnewmiddleclassesunderavailableresources.新興經(jīng)濟體：以可負擔(dān)的價格和可用資源為中產(chǎn)階級提供高質(zhì)量的醫(yī)療服?Developednations:maintainequitableaccesstocareandqualitywhilecontrollingcosts(efficiency)andbalancingresources(distribution).發(fā)達國家：控制成本和平衡資源的同時保持獲得醫(yī)療服務(wù)的公平和醫(yī)療質(zhì)?Despitedifferencesinpriorities,containingcostandmaximizinglimitedresourcesarecommonchallengesforallnations.3HealthcareReformIsParticularl醫(yī)療改革對美國和中國尤其具有挑戰(zhàn)性3HighCost,AverageOutcome,andLowEquityWithinUSA美國醫(yī)療成本高，效果一般、公平性低?Mostcostlyhealthcaresystemintheworld(specialization,medicaltec?Largeelderlypopulationandchronical?Disparitiesinaccess,quality,andoutcomeacrossracia不同種族不同種族/收入/保險群體間在醫(yī)療可及性、質(zhì)量和結(jié)果方面存在差距：越來越嚴(yán)TheUnevenDevelopmentWithi?Mostpopulous(1.3billion),increasingagingpopulationandchr?Healthcare:expensiveanddifficulttoaccess看病難，看病貴1.EvolutionofU.S.H2.StrategiestoImprov3.Discussion:ImplicationsforChina5美國醫(yī)療改革的演變-Technology(advancedtreatmentsbecameavailable,buttheywereexpensive)技術(shù)（先進的治療方法成為可能，但是昂貴）-Social(desirabilityofmedicaltreatments)社會（醫(yī)療的可取性）-Economic(unpredictabilityofmedicalneedsandcostsoftreatment)經(jīng)濟（醫(yī)療需求和治療費用的不可預(yù)測性）-1929–Modernhealthinsurancewasborn(BaylorPlanforschoolteachers,atBaylorUniversityhospitalTexas,aprepaidplan,themodelforBlueCross1929年-現(xiàn)代醫(yī)療保險誕生了（在得克薩斯州貝勒大學(xué)醫(yī)院的貝勒保險計劃為學(xué)-1939–TheCaliforniaMedicalAssociationstartedtheBlueShieldplantocoverphysicianservices1939年-加州醫(yī)學(xué)協(xié)會啟動了藍盾保險計劃，覆蓋醫(yī)師服務(wù)用-1948SupremeCourtdecisionlegitimizedhealthinsuranceasanegotiableiteminunion-managementbargaining1948年基于最高法院的決定，醫(yī)療保險合法成為工會管理談判中可交涉的項目-1954taxruling:employercontributionsforhealthinsurancebecameexemptfromtaxableincomefortheemployee1954年稅收裁定：雇主對醫(yī)療保險的繳款可作為該雇員的應(yīng)納稅收入的免稅額度-Politiciansbelievedtherewouldbelessoppositionforprogramstargetedattheunderprivileged政治家認為針對弱勢群體的方案將會得到較少反對-SocialSecurityAmendments,1965createdMedicarefortheelderlyand正案建立了老年人醫(yī)療保險和窮人醫(yī)療補助保險-The1997StateChildren?sHealthInsuranceProgram(SCHIP)forchildren1997年建立兒童醫(yī)療保險計劃-1935-1940sF.Roosevelt?snewdealandfailednationalhealthinsurancebills1935-40年代羅斯福的新協(xié)議和失敗的國家醫(yī)療保險法案-1940s:HarryTruman:FirstUSPresidenttoproposenationalhealthinsurance20世紀(jì)40年代：哈里·杜魯門：在美國由總統(tǒng)提出的第一個全國醫(yī)療保險-1990s:ClintonandBushproposals1990年代：克林頓和布什的提案-ReasonsforDefeatedNHIProposalsintheUnitedStates:PoliticalInexpediency(nothreattopoliticalstability),StakeholdersOpposition(medical,insurance,pharmaceutical,hospital),IdeologicalDifferences(individualismanddistrustofgovernment),TaxAversion(middleclassnotwillingtopayincreasedtaxestopayforthepoor)美國全國醫(yī)療保險建議失敗的原因：政治失策（不威脅政治穩(wěn)定），利益相關(guān)者反對（醫(yī)療、保險、藥廠、醫(yī)院），意識差異（個人主義和不信任政府），避稅（中產(chǎn)階級不愿意增加繳稅、為窮人付錢）-TheAmericanpublic-Legalchallengespushedthelegislamandate)大部分條款通過議會對個人強制（ACA：個人需要獲得符合標(biāo)準(zhǔn)的醫(yī)療保險或面臨年度稅款罰款;AHCA：稅款罰款條款被取消，取而代之的是對兩個月以上沒有保險的個人購買新保險計劃時將收取附加費30%)facefinancialpenalties;AHCA:Thisprovisio雇主強制（ACA：大公司需要為員工提供醫(yī)療保險否則將面臨經(jīng)濟處罰;AHCA：此項規(guī)定被廢除。）通過將資格限制擴大到貧困線的138％來擴大對低收入人群的醫(yī)療保險覆蓋率。聯(lián)邦政府已經(jīng)承擔(dān)了擴張的幾奧巴馬醫(yī)改法案在2010年通過,從2014年起開始生效KeyUnderlyingGoalsofObamaCare美國醫(yī)療改革的重要目標(biāo)?CovertheUninsured覆蓋沒有保險的?ContainCosts控制花費?ImproveQuality/Equity提高質(zhì)量/公平性?Digitize&Modernize數(shù)字化/現(xiàn)代化其他醫(yī)療改革行動:質(zhì)量/公平/現(xiàn)代化?Primarycare“MedicalHomes”基本醫(yī)療“醫(yī)療之家”nA.nA.System-basedintervention提升基本醫(yī)療績效的干預(yù)措施 Doctor&TeamPatient&FamilyDoctor&Team1.ImplementingtheHealthyPeopleInitiativebyFocusingontheDeterminantsofHealth通過關(guān)注健康的決定因素實施健康人群行動提高健康生活的質(zhì)提高健康生活的質(zhì)量和年限消滅健康差異總體目標(biāo)減少死亡：嬰兒總體目標(biāo)人提升健康生活跨度提高老年人獨立性提升健康生活跨度提高老年人獨立性減少健康差異為所有人提供預(yù)為所有人提供預(yù)防服務(wù)涉及方面達到健康人群2020目標(biāo)的行動模型干預(yù)干預(yù)貫穿生命過程測量、監(jiān)測、評估、傳播Source:/hp2020/advisory/PhaseI/Phas臨床預(yù)防服務(wù)臨床預(yù)防服務(wù)環(huán)境質(zhì)量傷害和健康人群2020關(guān)注領(lǐng)域2.Adolescenthealth青少年健康3.Arthritis,osteoporosis,andchronicbackcon4.BloodDisordersandbloodsafety血液病和血液7.Dementias,includingAlzheimer’sDi9.Disabi10.Earlyandmiddlechildhood11.Educatio20.Lesbian,gay,21.Maternal,infant,andchi23.Mentalhealthandmentaldisord25.Occupat30.Publicheal32.Sexuallytrans33.Socialdeterminantsofhealth健康的社會決定因素Source:HealthyPeople2020,USDHHS,2011.城市空氣質(zhì)量、交通安全、職業(yè)風(fēng)險健康的社會決定因素FromDeterminantsofHealthtoHealthcareDelivery從健康的決定因素到醫(yī)療服務(wù)重視基本醫(yī)療及整合的醫(yī)療服務(wù)“我相信一個以基本醫(yī)療為基礎(chǔ)的醫(yī)療體系將更加健全?！盠ifeLifeExpectancy基本醫(yī)療與預(yù)期壽命..HI.NDESD..OR.ME.NH.AZRI.NM..MT..NJ.FLWIKS.PANC.VA..MN.WA.CA ..TNWVARTXALGASC..AKR=.54P<.05醫(yī)療服務(wù)體系重新設(shè)計 AllocationTriangleAcuteCare?PreventionActivitiesmustbefundedandwidelydeployed需要為疾病預(yù)防提供資金支持并廣泛Special?PrimaryCaremustbecomeaPndesirableoccupationandCareCare基本醫(yī)療須成為一個理想的職業(yè)?DecreaseDemandintheSpecialtySpecialtyCareandAcuteCareSystems減少對?？?ThesearedramaticshiftsthatwillnotPrevention&magicallytakeplacePrimaryCare2727?2016/2017,JohnsHopkinsUniversity.AllrightsreseDeliveryDeliveryof提供醫(yī)療照顧Financing提供資金Payment付費Payment付費折扣、有限的按服務(wù)付費Payment付費Payment付費折扣、有限的按服務(wù)付費Deliveryof提供醫(yī)療服務(wù)Delivery服務(wù)用“守門人”的方法來協(xié)調(diào)，制約醫(yī)療使用MCOEnrollees管理醫(yī)療參保人基于基本醫(yī)療服務(wù)的衛(wèi)生系統(tǒng)的核心價值、原則和要素對人群健康的反應(yīng)實現(xiàn)最高健康層次的權(quán)利公平性一致Source:PanAmericanHealthOrganization/WorldHealthOrganization.RenewingPrimaryHealthCareintheAmericas. 有效的政策、法律框架/English/AD/THS/OS/PHC_brochu 有效的政策、法律框架re_eng.pdfre_eng.pdfPrimaryCareApproachtoHealthCare基本醫(yī)療之方式?illnesswellnes診到預(yù)防?inpatientoutpatient從住院到門診?individualhealthco到社區(qū)健康?fragmentedcare化到管理醫(yī)療?independentinstitutionsintegrated構(gòu)到整合體系?serviceduplicationcontinuumofservices從重復(fù)到連續(xù)通往“責(zé)任醫(yī)療”-轉(zhuǎn)變醫(yī)療服務(wù)將需要范式轉(zhuǎn)變 Wellness/Chronicco-morbidities健康/慢性病“ThePatient-Centered的醫(yī)療服務(wù)。?Healthcareforall提高可及性?Same-dayappointments?After-hoursaccesscoverage?Labresultshighlyaccessible?Onlinepatientservices?e-Visits?Groupvisits?Cost-Benefitdecision-making?Revenueenhancement?Optimizedcoding&billing?Personnel/HRmanagement?Facilitiesmanagement?Optimizedofficedesign/redesign?Changemanagement?Comprehensivecareforbothacuteandchronicconditions?Preventionscreeningandservices?Surgicalprocedures?Ancillarytherapeutic&supportservices?Ancillarydiagnosticservices?Electronicmedicalrecord?Electronicordersandreporting?Electronicprescribing?Evidence-baseddecisionsupport?Populationmanagementregistry?PracticeWebsite?Patientportal??Populationmanagement?Wellnesspromotion?Diseaseprevention?Chronicdiseasemanagement?Carecoordination?Patientengagementandeducation?Leveragesautomatedtechnologies?Providerleadership?Sharedmissionandvision?Effectivecommunication?Taskdesignationbyskillset?NursePractitioner/PhysicianAssistant?Patientparticipation?Familyinvolvementoptions?Evidence-basedbestpractices?Medicationmanagement?Patientsatisfactionfeedback?Clinicaloutcomesanalysis?Qualityimprovement?Riskmanagement?Regulatorycompliance?Community-basedservices?CollaborativerelationshipsHospitalcareBehavioralhealthcareMaternitycareSpecialistcarePharmacyPhysicalTherapyCaseManagementAppointmentAccess預(yù)約可及性;24/7AccesstoClinicalAdvice全天候臨床咨詢;ElectronicAccess電子信息訪問的可及性?PCMH2:Team-BasedCare團隊醫(yī)療Continuity連續(xù)性;MedicalHomeResponsibilities醫(yī)療之家責(zé)任;CulturallyandLinguisticallyAppropriateServices適當(dāng)?shù)奈幕驼Z言服務(wù);ThePracticeTeam診療團隊PCMH3:PopulationHealthManagement人群健康管理PatientInformation患者信息;ClinicalData臨床數(shù)據(jù);ComprehensiveHealthAssessment綜合健康評估;UseDataforPopulationManagement使用數(shù)據(jù)進行人口管理;ImplementEvidence-BasedDecisionSupport實施循證決策支持以患者為中心的醫(yī)療之家的認證標(biāo)準(zhǔn)?PCMH4:CareManagementandSupport醫(yī)療管理和支持?PCMH5:CareCoordinationandCareTransitions醫(yī)療服務(wù)協(xié)調(diào)和服務(wù)轉(zhuǎn)換?PCMH6:PerformanceMeasurementandQualityImprovement績效測量和質(zhì)量改進WHODeclaration世衛(wèi)組織宣言督促各國強化基本醫(yī)療體系，并通過基本醫(yī)療提供公JohnsHopkinsPrimaryCarePolicyCenter PCAT(PrimaryCareAsses.PCATVersions版本.PCATLanguage語言.English,Spanish,Chinese,K.KlaC表的論文：100+ImpactofChronicDisease-US?Treatmentofpatientswithchroniaccountsforaboutthreequartersofall?Reducingtheimpactofchronicillnessisthekeytocontrollinghealthcarecosts減少慢性病ObesityintheUnitedStates美國的肥胖問題2010年美國20歲及以上成年人超重和肥胖.正常Normalweightorunderweight(BMIunder24.9):31.2%.超重Overweight(BMIof25to29.9):33.1%.肥胖Obesity(BMIof30+):35.7%.嚴(yán)重肥胖Extremeobesity(BMIof40+):6.3%Source:NationalHealthandNutritionExaminationSurveyPrevalenceofOverweightandObesityAmongAdults我國成人超重和肥胖情況RisingCostsofManagingNCDs:UnitedStatesSeverityofProblemintheUnitedStates美國嚴(yán)重的問題良好的營養(yǎng)和健康的體重可以抑制潛在的健康問基本醫(yī)療團隊提供醫(yī)療服務(wù)/()ThePrimaryCareTeamApproachtoCare基本醫(yī)療團隊提供醫(yī)療服務(wù)/()ThePrimaryCareTeamApproachtoCare Visit藥師門診Coordinatewithspecialists,hospitalists Visit藥師門診Coordinatewithspecialists,hospitalists健康教練門診30-minuteMDvisit30分鐘醫(yī)生門診Adherenceisamajorproblem!AdherenceBreakdown堅持是一個重大問題！堅持分解怎樣改變行為？密切關(guān)注他們提供的信息；將其觀察加入病人制低高eating健康飲食Monitoringmedicationeating健康飲食Monitoringmedicationcoping應(yīng)對健康促進7項自我照顧行為：BeingBeingactive更加積極運動Problem-Problem-solving解決問題ReducingReducing減少風(fēng)險Ambulatorycarecenters門診醫(yī)療中心Ambulatorycarecenters門診醫(yī)療中心整合式的服務(wù)提供模型InformationSystems信息系統(tǒng)55?2016/2017,JohnsHopkinsUniversity.55?2016/2017,JohnsHopkinsUniversity.Allrightsrese理解醫(yī)療管理模式的發(fā)展方向?IntegratedHealthcareSystem整合的醫(yī)療系統(tǒng)IntegratedHealthCareSystemClinicSpecialtyClinicsClinicMedicalClinicHospitalsHospitalsMedicalMedicalClinicHospitalsHospitalsSpecialtyClinicsSpecialtyClinicsDecreasingHealthcareCostThroughPaymentReform通過支付改革減少醫(yī)療服務(wù)成本FeeforServiceDiscountedBundling/EpisodesCapitationSchemeReimbursementModelVSPaymentPaymentlinkedtoqualityandcostforaspecifiedepisodeofcare支付基于特定疾病Examples:治療質(zhì)量和花費ElectiveprocedureepisodesHospitaladmissionepisodesDiagnosis---basedepisodes(e.g.,pregnancy,backpain)Chronicdiseaseepisodes(e.g.,CHF,cancer)AGlobalPerspectiveofSystemIntegration整和式醫(yī)療體系全球性模式NationalHealthSystemizationPatient-PCPRelationship病人-基本醫(yī)療醫(yī)生的關(guān)系Patient-PCPRelationship病人-基本醫(yī)療醫(yī)生的關(guān)系?？萍捌渌t(yī)療服務(wù)5.FOCUSINGON‘LOW-TECH’ENHANCEEFFICENCYAND重點關(guān)注“簡單科技”應(yīng)用于醫(yī)療服務(wù)以提補差距50醫(yī)生供給與人口增長和老齡化的預(yù)測需求：人口增長/老齡化生20002005201020152020-M-health移動醫(yī)療-TabletPCs平板電腦-E-health電子醫(yī)療-Patientportals患者客戶端-Telemedicine遠程醫(yī)療-Mobilehomehealthcare-Mobilelearning移動學(xué)習(xí)-Genome-basedpersonalized-Nanomedicine納米醫(yī)學(xué)-VirtualClinics/Kiosk-Clinicaldecisionsupport(CDS)-ApplicationinGeographical事件總結(jié)個人健康管理復(fù)雜醫(yī)療管理technologiestoprovideandtheparticipants.應(yīng)用電子信息系統(tǒng)和通訊科技手段遠程提供和輔助醫(yī)療服務(wù)。Robotics機器人RemoteSurgery遠程手LiveLiveMonitoringviaCellPhones手機在線監(jiān)測個體指導(dǎo)服務(wù)視頻直播診療異步存儲&發(fā)送個體指導(dǎo)服務(wù)遠程監(jiān)控Source:KaiserPermanente監(jiān)測早期出院病人監(jiān)測早期出院病人急診和創(chuàng)傷監(jiān)測高風(fēng)險病人用診療中：付費、病歷監(jiān)測慢性病患者After-care:prescription監(jiān)測慢性病患者診療后：處方、依從、隨訪移動醫(yī)療在醫(yī)院的潛在應(yīng)用移動醫(yī)療在醫(yī)院的潛在應(yīng)用點：住院和急診入院，死亡。次要端點：生活質(zhì)量、滿意度?Biomarkersensing標(biāo)志物檢測time實時傳感器采樣未來醫(yī)療的發(fā)展方向IntegratedIntegrated提升醫(yī)療信息技術(shù)是提供整合的醫(yī)療服務(wù)的關(guān)鍵ResearchInstitute研究機構(gòu)ResearchInstitute研究機構(gòu)公共衛(wèi)生部門CHC社區(qū)醫(yī)療社區(qū)醫(yī)療中心Agencies政府機構(gòu)Community社區(qū)RegionalHealthInformationRegionalHealthInformationDeliverySystem整合的醫(yī)療服務(wù)體系HealthCenterSystem整合的醫(yī)療服務(wù)體系HealthCenterNetwork醫(yī)療中心網(wǎng)絡(luò)Community/Public/SocialHealth社區(qū)/公眾/社會健康ClinicalCareCommunity/Public/SocialHealth社區(qū)/公眾/社會健康ClinicalCare以人群健康為核心的醫(yī)療服務(wù)PopHealthCentricDenominatorBasedFinance/Admin以人群為核心的財務(wù)/管理ConsumerConsumerWellness消費者健康CareCareManagement基于多數(shù)人的醫(yī)療管理MonitoringMonitoring/LearningSystems檢測/質(zhì)量提升/學(xué)習(xí)體系PopulationHealth,PublicHealthandClinicalInformatics（人群，公衛(wèi)，臨床醫(yī)療信息學(xué)）Source:JHUCPHIT–SeeKharrazietalJAMIAat:/pubmed/270182644V：數(shù)據(jù)量，來源，速度，真實度VarietyVeracity132Demographics;Diagnosis;PopulationHealthDataCost;Mort.;ER-admit;PredictHospitalization; Medications;CostReadmit;Warehouseandetc.64132Demographics;Diagnosis;PopulationHealthD