是什么讓美國(guó)的醫(yī)療體系如此昂貴?
What makes the US healthcare system so expensive?譯文簡(jiǎn)介
網(wǎng)友:美國(guó)的醫(yī)療費(fèi)用為何遠(yuǎn)高于其他國(guó)家,尤其是考慮到其他國(guó)家提供的醫(yī)療服務(wù)質(zhì)量相當(dāng)甚至更好?這里有很多原因,以下是一些主要的解釋......
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What makes the US healthcare system so expensive?
是什么讓美國(guó)的醫(yī)療體系如此昂貴?
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Why is healthcare in the United States so expensive when compared to other countries which provide treatment of comparable or better quality?
There is a long list of reasons but here's a start.
美國(guó)的醫(yī)療費(fèi)用為何遠(yuǎn)高于其他國(guó)家,尤其是考慮到其他國(guó)家提供的醫(yī)療服務(wù)質(zhì)量相當(dāng)甚至更好?這里有很多原因,以下是一些主要的解釋?zhuān)?/b>
Walk through any ICU and you'll routinely see some people in vegetative conditions with virtually no chance of getting better. Yet they are receiving a full court press with anything and everything that can be done from the standpoint of medical technology.
美國(guó)人通常不接受醫(yī)療服務(wù)的配給制度。美國(guó)人在生命最后6個(gè)月的醫(yī)療費(fèi)用比其他任何國(guó)家都要高,高出好多。
走過(guò)任何一個(gè)重癥監(jiān)護(hù)室,你都會(huì)經(jīng)常看到一些人處于植物人狀態(tài),幾乎沒(méi)有好轉(zhuǎn)的機(jī)會(huì),但他們?nèi)匀辉诮邮茚t(yī)療技術(shù)所允許的一切手段,進(jìn)行全面而竭盡全力的治療。
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這種對(duì)治療的堅(jiān)持部分源自那些堅(jiān)決反對(duì)減少或停止治療的家庭成員。同時(shí),醫(yī)生們也難辭其咎,他們有時(shí)會(huì)過(guò)度治療。我們都聽(tīng)說(shuō)過(guò)一些醫(yī)生,他們堅(jiān)信在重癥監(jiān)護(hù)室里,不管情況多么絕望,總有奇跡發(fā)生。
這筆開(kāi)銷(xiāo)極為龐大,美國(guó)家庭卻往往與之脫節(jié)。若患者未投保,相關(guān)費(fèi)用便由治療醫(yī)院和醫(yī)生承擔(dān)。若患者已投保,一旦滿(mǎn)足了免賠額,剩余費(fèi)用便由保險(xiǎn)公司承擔(dān),或者通過(guò)納稅人資金支付。
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在其他國(guó)家的國(guó)家衛(wèi)生服務(wù)體系中,你不會(huì)見(jiàn)到這樣的做法。例如,在英國(guó)的國(guó)家衛(wèi)生服務(wù)(NHS)中,老年患者通常不會(huì)開(kāi)始接受透析治療,而是會(huì)因腎功能衰竭而去世。同樣,你也不會(huì)看到七八十歲的老人接受四重搭橋手術(shù)。在加拿大和英國(guó),癌癥患者通常無(wú)法獲得每月高達(dá)1萬(wàn)美元、平均只能延長(zhǎng)幾個(gè)月生命的昂貴抗癌藥物。這些藥物在加拿大可能根本無(wú)從獲得(因?yàn)橛行┛拱┧幬飶奈传@得批準(zhǔn)),或者在英國(guó),它們通過(guò)一種抽簽制度幾乎變得不可及。
美國(guó)在藥品上的花費(fèi)遠(yuǎn)高于世界其他國(guó)家。在美國(guó)政府受到大型制藥業(yè)游說(shuō)團(tuán)體的影響下,拒絕為聯(lián)邦醫(yī)療保險(xiǎn)(Medicare)提供折扣價(jià)格談判。因此,美國(guó)人為同樣的藥物支付的費(fèi)用比加拿大人高出30%至300%——盡管這些藥物可能是在新澤西或加利福尼亞制造的。
在美國(guó)聯(lián)邦醫(yī)療保險(xiǎn)(Medicare)和 聯(lián)邦醫(yī)療補(bǔ)助(Medicaid)項(xiàng)目中,存在著巨大的浪費(fèi)和欺詐問(wèn)題。賬單是電子化的,支付是自動(dòng)完成的。審計(jì)過(guò)程不僅成本高昂,而且顯然很少執(zhí)行。由于通過(guò)欺詐手段從這些計(jì)劃中騙取數(shù)億美元的收益巨大且操作簡(jiǎn)單,現(xiàn)在連有組織的犯罪集團(tuán)也參與其中。
據(jù)合理估算,每年的欺詐金額在1200億到1800億美元之間,這是一個(gè)天文數(shù)字。
人們經(jīng)常稱(chēng)贊聯(lián)邦醫(yī)療保險(xiǎn)(Medicare)和 聯(lián)邦醫(yī)療補(bǔ)助(Medicaid)的效率,因?yàn)榕c保險(xiǎn)公司相比,它們的行政成本要低得多。(要從保險(xiǎn)公司那里騙取大量資金相當(dāng)困難。)但是,Medicare/Medicare的行政管理不僅涉及衛(wèi)生及公共服務(wù)部(HHS),還包括聯(lián)邦政府的多個(gè)執(zhí)法機(jī)構(gòu)。這并不便宜,而且顯然效果也不盡人意。
美國(guó)民眾期望能夠即刻獲得技術(shù)資源。他們希望能夠迅速預(yù)約到磁共振成像,或者是在美國(guó)有線電視新聞網(wǎng)上看到的最新診斷測(cè)試和治療方法。這種即時(shí)獲取技術(shù)的能力,其代價(jià)極為昂貴,不僅包括建設(shè)醫(yī)療設(shè)施和購(gòu)置昂貴設(shè)備的成本,還有執(zhí)行這些程序所需的費(fèi)用。
即使有時(shí)候這些檢查對(duì)于維持健康并非必要,美國(guó)人仍然希望進(jìn)行這些檢查。我們請(qǐng)求醫(yī)生排除那些極小概率的事件。追求最新最好的一切是人類(lèi)的本能。但它從來(lái)不是免費(fèi)的,這種醫(yī)療服務(wù)需要花費(fèi)大量的錢(qián)。
I've seen estimates of $600+ billion a year in unneeded tests and procedures done primarily to avoid litigation. That's a lot of money that could otherwise go to insuring the uninsured. Opponents to tort reform quote very small numbers because they only use the cost of defending lawsuits in their equation. But that's a drop in the bucket compared to what doctors in America waste so that no one will accuse them of "missing something."
美國(guó)存在一種防御性醫(yī)療的浪費(fèi)做法。醫(yī)生們?yōu)榱吮苊饪赡艿脑V訟,會(huì)進(jìn)行大量不必要的檢測(cè)和掃描,這種做法造成了巨大的資源浪費(fèi)。在美國(guó),醫(yī)生在執(zhí)業(yè)時(shí)無(wú)法忽視訴訟的威脅,我以及每一位坦率的醫(yī)生都會(huì)承認(rèn)曾經(jīng)開(kāi)具過(guò)出于防御目的的檢查單。
我見(jiàn)過(guò)估算顯示,每年因不必要的檢測(cè)和手術(shù)而浪費(fèi)的金額超過(guò)6000億美元,這些檢測(cè)和手術(shù)主要是出于避免訴訟的考慮。這筆巨額資金本可以用于為未投保人群提供醫(yī)療保險(xiǎn)。反對(duì)醫(yī)療事故改革的人在他們的論據(jù)中只提到了很小的數(shù)字,因?yàn)樗麄儍H考慮了應(yīng)對(duì)訴訟的費(fèi)用。然而,與美國(guó)醫(yī)生為了避免被控告“漏診”而浪費(fèi)的資金相比,這僅僅是滄海一粟。
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監(jiān)管和認(rèn)證。
對(duì)于醫(yī)院、診所和醫(yī)生來(lái)說(shuō),美國(guó)的監(jiān)管程序已經(jīng)變得如此繁重,以至于為了達(dá)到合規(guī)標(biāo)準(zhǔn),需要一小群管理人員和律師來(lái)通過(guò)這些程序?!镀絻r(jià)醫(yī)療法案》實(shí)施之后,為了適應(yīng)新的規(guī)章制度,許多醫(yī)生選擇加入了大型醫(yī)療系統(tǒng)。在過(guò)去十年里,我們?cè)\所的行政管理人員數(shù)量翻了不止一番。醫(yī)院同樣擴(kuò)充了行政團(tuán)隊(duì),以確保符合各項(xiàng)規(guī)定并通過(guò)必要的各項(xiàng)檢查。醫(yī)療行業(yè)如今需要處理大量的費(fèi)用和許可證問(wèn)題。這些相關(guān)的財(cái)務(wù)開(kāi)銷(xiāo)最終會(huì)轉(zhuǎn)嫁到保險(xiǎn)公司,由它們支付。
I notice that you don't explain why for a given simple procedure, an American hospital might charge 10X more than the same procedure in the UK.
我注意到你沒(méi)有解釋為什么在美國(guó),相同簡(jiǎn)單的醫(yī)療程序,醫(yī)院的收費(fèi)可能是英國(guó)的10倍。
An American hospital, for a simple procedure, might charge 40x more than the same procedure done in another hospital in the US. 10X is nothing.
The costing and billing procedures used here are insane.
Data Reveal Hospital Charges Vary Widely for Same Procedure
在美國(guó),即使是簡(jiǎn)單的醫(yī)療程序,一個(gè)醫(yī)院的收費(fèi)可能比美國(guó)國(guó)內(nèi)其他醫(yī)院高出40倍。相比之下,10倍根本不算什么。這里的成本計(jì)算和賬單程序簡(jiǎn)直荒謬。數(shù)據(jù)顯示,即便是同一醫(yī)療程序,不同醫(yī)院的收費(fèi)也存在巨大差異。
I believe this is largely driven by using people who can pay to subsidize people who cannot pay.
In the US, hospitals are required to treat all patients in the emergency department regardless of whether the patient can pay. So, the hospital passes that charge along to the next guy who can pay.
Also hospitals typically have far more overhead than smaller ambulatory surgery centers and clinics. Simply being larger leads to more bureaucracy and complexity which needs staff. Example of complexity: academic medical center has PET scan, MRI, CT. Small community hospital only has CT. So staff at the academic center need to be either more competent or else have more staff to ensure all the systems are operated correctly.
我認(rèn)為這主要是因?yàn)橛心芰χЦ兜娜嗽谘a(bǔ)貼那些無(wú)力支付的人。
在美國(guó),醫(yī)院必須依法治療急診室的所有病人,不管他們是否有支付能力。因此,醫(yī)院將這些成本轉(zhuǎn)嫁給下一個(gè)有能力支付的病人身上。
此外,醫(yī)院通常比小型的門(mén)診手術(shù)中心和診所有更高的運(yùn)營(yíng)成本。規(guī)模的擴(kuò)大導(dǎo)致了更多的官僚機(jī)構(gòu)和復(fù)雜性,這就需要更多的員工。例如,一個(gè)學(xué)術(shù)醫(yī)療中心可能擁有PET掃描、MRI、CT等設(shè)備,而小型社區(qū)醫(yī)院可能只有CT。因此,學(xué)術(shù)中心的工作人員要么需要更有能力,要么需要更多的工作人員來(lái)確保所有系統(tǒng)的正確運(yùn)行。
這主要是因?yàn)橛心芰χЦ兜娜嗽谘a(bǔ)貼那些無(wú)力支付的人。這正是保險(xiǎn)的作用,但有了(國(guó)家)保險(xiǎn),保費(fèi)合理,貢獻(xiàn)者眾多,醫(yī)院和醫(yī)生不能隨意制定高得離譜的賬單。
1) there is more rationing which I read to mean more smaller community hospitals vs large academic centers
2) the hospitals aren't worried about patients not being able to pay, so costs are "true" per patient as opposed to including a subsidy for someone else.
相比之下,英國(guó)的情況似乎是:
實(shí)行了更多的配給制度,我理解為這指的是相比大型學(xué)術(shù)醫(yī)療中心,有更多小型的社區(qū)醫(yī)院。
醫(yī)院不必?fù)?dān)心病人無(wú)力支付醫(yī)療費(fèi)用,因此每個(gè)病人的成本是“真實(shí)”的,并不包括對(duì)其他病人的補(bǔ)貼。
I believe this is largely driven by using people who can pay to subsidize people who cannot pay. Well that’s exactly what insurance is, except with (national) insurance the premiums are reasonable, the pool of contributors is huge and the hospitals and doctors can’t just make up ridiculously high bills on an ad hoc basis.
我認(rèn)為這種情況主要是由于有能力支付的人群在資助那些無(wú)力支付的人。這實(shí)際上就是保險(xiǎn)的工作原理,但國(guó)民保險(xiǎn)的特點(diǎn)是保費(fèi)合理,參與的人數(shù)眾多,醫(yī)院和醫(yī)生不能隨意制定過(guò)高的醫(yī)療費(fèi)用。
As Glyn Williams indicates, the hospital system also deserves a big chunk of the blame: they are wildly lacking in price transparency (hospitals within a few miles of each other charge 5-10x the price of others), which doesn't introduce anything resembling competition or efficient pricing into the marketplace.
Additionally, I absolutely feel that doctors are underpaid relative to their time, effort and monetary investment; but the magnitude of investment in the first place is due to several runaway costs and poor incentive systems in place (rampant rise in tuition due to high demand for medical professionals, compounded by the number and amount of student loans administered). Someone has to pay for this and it's passed along from the doctors, then to the hospitals, then to the insurance companies and ultimately to the payers (whether consumers or government, and the latter then passes it on to the taxpayers anyway).
格倫·威廉姆斯指出,醫(yī)院體系本身也應(yīng)負(fù)有重要責(zé)任:它們?cè)趦r(jià)格上缺乏透明度(彼此僅幾英里的醫(yī)院對(duì)相同服務(wù)的收費(fèi)可能相差5到10倍),這并沒(méi)有在市場(chǎng)上形成任何競(jìng)爭(zhēng)或有效定價(jià)的機(jī)制。
此外,我堅(jiān)信,相較于醫(yī)生們的投入——包括時(shí)間、努力和經(jīng)濟(jì)投資——他們的收入是偏低的。這種高額投資的根源在于一些失控的成本和不良的激勵(lì)機(jī)制,比如由于對(duì)醫(yī)療專(zhuān)業(yè)人員的高需求導(dǎo)致的學(xué)費(fèi)激增,以及學(xué)生貸款的數(shù)量和金額的增加。這些成本最終需要有人承擔(dān),它們從醫(yī)生傳遞到醫(yī)院,再到保險(xiǎn)公司,最后落到支付者身上——無(wú)論是消費(fèi)者還是政府,而政府最終會(huì)將這些成本轉(zhuǎn)嫁給納稅人。
I would love to see the cost/expense breakdown that justifies a $13 per pill Tylenol bill levied by hospitals. Everything that is given you as treatment in a US hospital is a form of financial rape.
我很想知道,醫(yī)院如何解釋將泰諾林每粒藥片的價(jià)格定為13美元的成本和費(fèi)用明細(xì)。在美國(guó)醫(yī)院接受的任何治療都感覺(jué)像是在被金融掠奪。
Where do you think facilities get the money to pay for the uninsured?
你認(rèn)為醫(yī)院從哪里獲得資金來(lái)支付未參與保險(xiǎn)的病人的費(fèi)用?
I would add one more comment to your thoughtful, complete and compelling answer. In many other countries, primary care physicians are more plentiful, they are paid better, and they are the gatekeepers to more expensive specialists. In America, we do a poor job controlling the way Americans access healthcare. Many patients go straight to specialists, who prescribe expensive and intensive treatments. Closely related to this is the fact that we have allowed health records to be kept in separate provider silos, which means that no physician has a complete record of the patient’s care elsewhere. We allow duplicative and dysfunctional care because of a poorly-designed health record system.
我對(duì)你的深入、全面且有說(shuō)服力的回答還有一點(diǎn)補(bǔ)充。在許多其他國(guó)家,基層醫(yī)療的醫(yī)生數(shù)量更充足,收入也更高,他們充當(dāng)著通往更昂貴專(zhuān)科服務(wù)的守門(mén)人角色。然而在美國(guó),我們對(duì)民眾獲取醫(yī)療服務(wù)的方式控制不嚴(yán)。許多患者直接求助于專(zhuān)科醫(yī)生,而這些醫(yī)生往往會(huì)推薦費(fèi)用較高且復(fù)雜的治療方案。與此緊密相關(guān)的是,我們?cè)试S健康檔案分散在不同的醫(yī)療服務(wù)提供者手中,導(dǎo)致沒(méi)有一位醫(yī)生能夠全面掌握患者在其他地方接受的治療情況。由于健康檔案系統(tǒng)設(shè)計(jì)不佳,我們?nèi)萑塘酥貜?fù)和效果不佳的醫(yī)療服務(wù)。
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My PCP is essentially useless for all but the most basic of problems. One time he prescribed me an ointment, but otherwise, he has always directed me to a specialist. Skin problem? Dermatologist. Low libedo? Endocrinologist. Again and again. I hardly bother him anymore and if I have a problem with [body part] I just make an appointment with a [body part]ologist.
我的家庭醫(yī)生對(duì)于除了最基本問(wèn)題之外的事情基本上沒(méi)什么用。有一次他給我開(kāi)了一種藥膏,但除此之外,他總是把我轉(zhuǎn)給專(zhuān)科醫(yī)生。皮膚問(wèn)題?看皮膚科醫(yī)生。性欲低下?看內(nèi)分泌科醫(yī)生。一次又一次。我現(xiàn)在很少麻煩他了,如果我身體的某個(gè)部位有問(wèn)題,我就直接預(yù)約那個(gè)方面的專(zhuān)科醫(yī)生。
That’s his job, weed out the bumps and bruises and direct to the appropriate specialist. Do you know weather you need and oncologist or a proctologist, no you don’t
他的職責(zé)是分辨出輕微的外傷,并將患者指引到合適的專(zhuān)科醫(yī)生那里。你自己怎么能確定是需要腫瘤科醫(yī)生還是肛腸科醫(yī)生呢?你并不清楚。
I was discharged from a VA hospital the end of Feb. after a vicious bout with the flu, and on continuous oxygen. The tech told me to make an appointment with my PCP. I walked to her office and was told the first available appointment was June 21. I called back, and, well, May 15. I called the patient advocate and made it in April 20. I was discharged Feb 27. Had I not been a nurse, I may have ended up dead. They rolled me out to the door, no instructions, no emergency number and a lot of unanswered questions.
二月底,我在一場(chǎng)劇烈的流感后從退伍軍人醫(yī)院出院,需要持續(xù)使用氧氣治療。技術(shù)人員建議我預(yù)約我的家庭醫(yī)生。我走到她的診所,卻被告知最早的可預(yù)約時(shí)間是6月21日。我再次打電話,預(yù)約時(shí)間提前到了5月15日。通過(guò)聯(lián)系患者權(quán)益倡導(dǎo)者,我最終在4月20日得到了預(yù)約。我是2月27日出院的。如果我不是一名護(hù)士,我可能已經(jīng)不幸去世了。出院時(shí),他們沒(méi)有給我任何具體指導(dǎo),沒(méi)有緊急聯(lián)系電話,卻留下了許多未解答的問(wèn)題。
I resonate with your comment so much, however, now it’s 2022 and I think this has started to improve right? I’m from Texas, and I’ve been in both corporate and on the end floor while being employed with more than one provider. This was the absolute most frustrating thing to me that EHR (at least) wasn’t accessible across the board using an NPN based system. Why are medical records still such a hassle when we transitioned from paper charting to electronic over a decade ago?
我非常理解你的評(píng)論,但現(xiàn)在已經(jīng)是2022年了,我想這種情況應(yīng)該有所改善了吧?我住在德克薩斯,曾在不止一家醫(yī)療機(jī)構(gòu)工作過(guò),既有在公司層面,也有在臨床一線。最讓我感到沮喪的是,電子健康記錄(EHR)系統(tǒng)本應(yīng)提高醫(yī)療信息的可訪問(wèn)性,但令我極其懊惱的是,這一系統(tǒng)并沒(méi)有實(shí)現(xiàn)全國(guó)性提供者編號(hào)(NPN)下的普遍接入。既然我們?cè)谑嗄昵熬屯瓿闪藦募堎|(zhì)記錄到電子記錄的轉(zhuǎn)變,為何如今獲取醫(yī)療檔案依舊如此不便呢?