US and China Health Reform Paths中美醫(yī)療改革之路

USandChinaHealthReformPaths

中美醫(yī)療改革之路PresentedbyJacksonTung,Ph.D.董曉儂博士December15,2010USHealthCareSpending

美國(guó)醫(yī)療衛(wèi)生投入Totalhealthcarespendingin2008was2.5trillionUS$(6.9%increaseover2007).（2008年美國(guó)醫(yī)療衛(wèi)生事業(yè)投入總額為2萬5000億美金（較2007年增長(zhǎng)6.9%）The2008figurerepresented17%ofGDP（占2008年GDP總值的17%）$8,000perpersonperyearofhealthcarecost.（人均每年醫(yī)療衛(wèi)生費(fèi)用為8000美金）Healthcarespendingaccountedfor10.9percentoftheGDPinSwitzerland,10.7percentinGermany,9.7percentinCanadaand9.5percentinFrance.（醫(yī)療衛(wèi)生經(jīng)費(fèi)總額占瑞士GDP總額的10.9%，德國(guó)GDP總額的10.7%，加拿大GDP總額的9.7%，法國(guó)GDP總額的9.5%）Accordingtogovernmentanalysts,thenation‘stotalhealthcarebillby2015willbemorethan$4trillion,anditwillbesplitaboutequallybetweenconsumersandthegovernment.（據(jù)政府分析人士稱，國(guó)家醫(yī)療衛(wèi)生投入總額至2015年將超過40000億美金，并把消費(fèi)者與政府等分開來。）Payer支付方ServiceProvider服務(wù)提供方Patient/people患者/人ThreeMainPartiesinHealthCare醫(yī)療衛(wèi)生中的三方主體Providers

服務(wù)提供方Doctors（醫(yī)生）Hospitals（醫(yī)院）Laboratories（實(shí)驗(yàn)室）Pharmacies（藥店）PharmaceuticalCompanies(formularies)制藥商（處方）Homecareandotherspecialtycare（家庭保健和其他專業(yè)保?。￤hatDoProvidersDo?

服務(wù)提供者的工作Familydoctors:maintainone-to-onerelationshipwithpatients.Mostlythroughoutpatientofficevisits.

家庭醫(yī)生：與患者保持一對(duì)一聯(lián)系。主要通過門診看診。Specialists:providespecialtycare.

專科醫(yī)生：提供專業(yè)醫(yī)治Hospitals:provideinpatientandemergencycare.

醫(yī)院：提供住院服務(wù)和急診。Drugstores:filldrugprescriptions.

藥店：提供處方藥物Pharmaceuticalcompanies:providedrugsundera“formulary”arrangementwithpayers.

制藥商：與支付方商定后，提供藥物。Patient/people（患者/人民）Choosehealthinsuranceprograms.（選擇醫(yī)療保險(xiǎn)項(xiàng)目）Mostprogramsareassociatedwithemployers.（多數(shù)項(xiàng)目與雇主合作）Peopleover65arecoveredbyMedicare.（超過65歲的公民均享受醫(yī)療保險(xiǎn)）ConsiderMedicaresupplementinsurance.（考慮醫(yī)療保險(xiǎn)的補(bǔ)貼保險(xiǎn)項(xiàng)目）PeopleunderacertainpovertylinearecoveredbyMedicaid.（在一定貧困線以下的人們享受醫(yī)療補(bǔ)助）Enrollannually(withsomeexceptions).年度登記（有一些例外）Stillleft15%ofthepopulation“uninsured.”（還是有15%的人沒有保險(xiǎn)。）WhatDoPeople/PatientsDo?

人民/患者的工作Uninsured:seekemergencycareorMedicaid（無保險(xiǎn)者：尋求急診治療或醫(yī)療補(bǔ)助）Insured:（有保險(xiǎn)者）Chooseafamilydoctorfromthelistgivenbypayers.

從支付方提供的清單中，選擇一位家庭醫(yī)生。Familydoctorbecomesthe“caremanager”forthepatient.

家庭醫(yī)生變成了此位患者的“醫(yī)療管理者”。Familydoctormustmakereferraltospecialistsorhospitals.

家庭醫(yī)生必須轉(zhuǎn)介專業(yè)醫(yī)師或醫(yī)院。Makeco-payasdefinedbypayers(officevisits,generic/brandnamedrug,out-of-pocketmaximums,etc.)

以支付標(biāo)準(zhǔn)為依據(jù)的共付制度（就診、非專利/品牌藥物、現(xiàn)款支付的最高額度及其他）Payers（支付者）Government:MedicareandstateMedicaidprograms（政府：醫(yī)療保險(xiǎn)制度和州級(jí)公共醫(yī)療補(bǔ)助項(xiàng)目）Healthinsuranceprograms/HealthMaintenanceOrganizations(HMO).(醫(yī)療保險(xiǎn)項(xiàng)目及衛(wèi)生維護(hù)組織)IndemnityPlans(feeforservice)

補(bǔ)償計(jì)劃（服務(wù)費(fèi)用）PreferredProviderOrganizations(PPO)

優(yōu)先選擇醫(yī)療服務(wù)提供者組織（PPO）StaffmodelHMOs(擁有醫(yī)院和受薪醫(yī)師的衛(wèi)生維護(hù)組織）Employersponsoredprograms（雇主資助項(xiàng)目）Patients（患者）WhatDoPayersDo?

支付方的工作Payclaimssubmittedbyproviders.

支付服務(wù)提供方提交的費(fèi)用Establish“reasonableandcustomary”feeschedule.

建立“合理及常規(guī)的”收費(fèi)率表Providercontractingbasedonpriceandquality.

以價(jià)格和質(zhì)量為基礎(chǔ)，與服務(wù)供應(yīng)方訂立合同Managecarethroughpre-authorization,referrals,casemanagement,andpreventivecare.

通過授權(quán)、轉(zhuǎn)介案例管理和預(yù)防保健，而進(jìn)行的管理工作。WhenHealthInsuranceCompaniesCompete–People/patientBenefit

醫(yī)療保險(xiǎn)公司的競(jìng)爭(zhēng)-人/患者利益Whatbenefitshealthinsurancecompanies:（對(duì)醫(yī)療保險(xiǎn)公司最有利的事）Peoplestayhealthy(prenatalcare)人們保持健康（產(chǎn)前保?。〥iseasesarediagnosedearly(mammogram)早期診斷病情（乳房X光照片）Minimizediseasecomplications(diabetes)減少并發(fā)癥-糖尿病HealthInsuranceCompaniesKeepProviderCostsDown

醫(yī)療保險(xiǎn)公司把服務(wù)提供方的費(fèi)用降到最低Physiciancontracting（醫(yī)生契約）Hospitalcontracting（醫(yī)院契約）Pharmaceuticalcompanycontracting(formulary)藥品制造商契約（處方）Thisremovesall“extrabenefits”fromprovidersandallowhealthinsurancecompaniesto,intheory,passthebenefitstoconsumers.這排除了服務(wù)提供方的“額外收益”，而將此利益讓渡給醫(yī)療保險(xiǎn)公司，理論上說，是消費(fèi)者受益。APrivateThirdPartyPayeristhekeytokeepUSHealthCareSysteminBalance私營(yíng)的第三支付方是平衡美國(guó)醫(yī)療衛(wèi)生體系的關(guān)鍵Payer支付方ServiceProvider服務(wù)提供方Patient/people患者/人ThreeMainPartiesinHealthCare醫(yī)療衛(wèi)生中的三方主體CompetitionafterPrivatization

私營(yíng)下的競(jìng)爭(zhēng)ProvidersmustcompeteforPayerbusiness.（為爭(zhēng)取支付方，服務(wù)提供方間的競(jìng)爭(zhēng)）PayersmustcompeteforPatientbusiness.（為爭(zhēng)取患者，支付方間的競(jìng)爭(zhēng)）EachmarketmusthavemultiplePayers(A,B,andCinsurancecompanies)（每一市場(chǎng)必須有多個(gè)支付者-A\B\C保險(xiǎn)公司）EachmarketmusthavemultipleProvidernetworks.（每個(gè)市場(chǎng)必須有多個(gè)服務(wù)提供者網(wǎng)絡(luò)體系）Competeonbothpriceandquality（價(jià)格與質(zhì)量的競(jìng)爭(zhēng)）MedicareandMedicaid

醫(yī)療保險(xiǎn)和公共醫(yī)療補(bǔ)助FederalGovernmentisbyfarthelargestpayerthroughMedicareandMedicaid.（通過醫(yī)療保險(xiǎn)和公共醫(yī)療補(bǔ)助，聯(lián)邦政府尤其成為最大的支付方）Medicareisforpeople65yearsofageandolder.（醫(yī)療保險(xiǎn)惠及65歲及以上人群）Medicarespendingwillmorethandoubleinthenextdecade,from$309billionin2004to$792billionin2015.Itwillgrowfrom13%to21%ofthefederalbudget.（十年間醫(yī)療保險(xiǎn)投入將翻一番，從2004年的3090億美元增至2015年的7920億美元。財(cái)政預(yù)算將從13%增至21%）PopulationAgeing（人口老齡化）Highcostofmedicaltechnology（高額的醫(yī)療科技費(fèi)用）Medicaidspendingisexpectedtoincreasefrom$293billionto$670billionduringthesameperiod（同一時(shí)期，公共醫(yī)療補(bǔ)助投入有望從2930億美金增至6700億美金）DifferencesbetweenHealthInsuranceandNationalHealthPlan

醫(yī)療保險(xiǎn)和全民醫(yī)保的差異HealthinsurancecompaniesareprivatebusinesswithP&Lresponsibilities（醫(yī)療保險(xiǎn)公司作為私營(yíng)企業(yè)，有損益平衡責(zé)任）Adverseselection（逆向選擇）Pre-existingcondition（已有疾?。㊣nvestmentinhealthimprovement（為提高健康狀況而進(jìn)行的投資）NationalHealthPlanisanentitlementprogramnotsubjecttoaboveconcernsandshouldbelowercosttoimplement.（全民醫(yī)保是一項(xiàng)權(quán)益性項(xiàng)目，沒有以上的顧慮，而應(yīng)該在項(xiàng)目實(shí)施中降低費(fèi)用）WhyDoWeNeedHealthInsurance?

為什么我們需要醫(yī)療保險(xiǎn)？Highcostatunpredictablefrequency–spreadriskoveralargepopulation.（不可預(yù)測(cè)的頻率下產(chǎn)生的高費(fèi)用-大眾分?jǐn)傦L(fēng)險(xiǎn)）80-20rule–80%ofthehealthexpenseoccurduring20%oftheagespan(oldage).（八二開原則：在20%的時(shí)間中耗費(fèi)了80%的醫(yī)療支出）Currentmoney(insurancepremium)forcurrentneeds–notalongitudinalsavingsconcept.（當(dāng)前需求由當(dāng)前的錢（保險(xiǎn)金）支付-不是存款的理念）WhatisaReform?

改革是什么？Re-alignmentofstakeholdersandtheirbenefits.（利益持有者和利益的重新分割）Agoodreformmakesstakeholders’interestsmatchpeoples’interests.（好的改革使利益持有者的利益與人民的利益吻合）China’sreformeffortmusthave“built-in”anti-corruptioncomponent.（中國(guó)醫(yī)療改革須納入反腐敗部分）USHealthCareReformMap

美國(guó)醫(yī)療改革圖CurrentUSStatus美國(guó)現(xiàn)狀Highcost(GDPandpercapita)高消費(fèi)(GDP和人均消費(fèi)）Highqualityfortherich高收入人群的高品質(zhì)醫(yī)療15%uninsured

15%的人沒有醫(yī)療保障NationalHealthCare全民醫(yī)療Proponents贊成方People人民Businesses商家Government政府Obstacles阻礙方Currentstakeholderswhostandtolose既得利益者遭受損失TimelineofObamaCare

奧巴馬醫(yī)療改革的時(shí)間表Peopleunder26canbecoveredbyparents

26歲以下群眾的醫(yī)療通過其父母得以覆蓋Nopre-existingconditionforchildren不以兒童的病史而拒絕接受投保Lifetime/annuallimitsremoved無終生或年度最高賠付標(biāo)準(zhǔn)Nopolicycancellationafterapersongetsill罹患疾病后不得撤消保險(xiǎn)Healthplansmustofferelectronicrecords保險(xiǎn)公司必須提供電子病歷Nopre-existingconditions,healthstatus,norgender不因其病史、健康狀況和性別而拒絕接受投保Citizenspayfinefornotjoininghealthinsurance未投保者將被處以罰款Employerspayfinefornotofferinghealthinsurance未為雇員提供醫(yī)療保險(xiǎn)的公司將被處以罰款2010-20112013-2014China’sHealthReformEfforts

中國(guó)醫(yī)療改革的過程Chinahadgovernmentpaidhealthcareformostpeoplepriortofirstroundofheathreformin1985.（在1985年第一次醫(yī)療改革之前，中國(guó)是公費(fèi)醫(yī)療）Since1985,Chinatookastepbackwardinprovidinghealthcareforall.（1985年開始，是全民醫(yī)療的倒退）Nationalhealthcareisoneofthebasicserviceanationshouldprovideitscitizens.（全民醫(yī)保，是一個(gè)國(guó)家應(yīng)提供給公民的基本服務(wù)）Thedetourthroughmarketeconomyinvolvedseveralfailedreformattempts.（與市場(chǎng)經(jīng)濟(jì)相關(guān)的幾種改革嘗試是繞彎路）ChineseHealthCareReformMap

中國(guó)醫(yī)療改革圖CurrentStatusinChina中國(guó)現(xiàn)狀Lowlevelofcoverage覆蓋面低Constrainedbyproviders醫(yī)療服務(wù)不足Runawaycost成本控制失靈NationalHealthCare全民醫(yī)療Proponents贊成方People人民Government政府Obstacles:阻礙方：Corruption

腐敗DesiredVSActualOutcomes

期望vs實(shí)際結(jié)果Privatizationofproviderstoimproveefficiency（服務(wù)提供方私營(yíng)化以提高效率）Pricecontrolofcommondrugstoreducedrugcost（常用藥物價(jià)格控制以減少藥品費(fèi)用）Establishedprescriptiondrugsystemtoimprovedrugsafety（建立藥物處方系統(tǒng)以提高藥品安全）Providersincreasechargestopatients（服務(wù)提供者提價(jià)）Pharmaceuticalcompaniesstoppedproducingpricecontr