US and China Health Reform Paths中美医疗改革之路

1、Presented by Jackson Tung, Ph.D.董晓侬博士December 15, 2010Total health care spending in 2008 was 2.5 trillion US$ (6.9% increase over 2007).（2008年美国医疗卫生事业投入总额为2万5000亿美金（较2007年增长6.9%）The 2008 figure represented 17% of GDP（占2008年GDP总值的17%）$8,000 per person per year of health care cost.（人均每年医疗卫生费用为8000美金）H

2、ealth care spending accounted for 10.9 percent of the GDP in Switzerland, 10.7 percent in Germany, 9.7 percent in Canada and 9.5 percent in France. （医疗卫生经费总额占瑞士GDP总额的10.9%，德国GDP总额的10.7%，加拿大GDP总额的9.7%，法国GDP总额的9.5%）According to government analysts, the nations total health care bill by 2015 will be mo

3、re than $4 trillion, and it will be split about equally between consumers and the government. （据政府分析人士称，国家医疗卫生投入总额至2015年将超过40000亿美金，并把消费者与政府等分开来。）Payer支付方Service Provider服务提供方Patient/people患者/人 Family doctors: maintain one-to-one relationship with patients. Mostly through outpatient office visits. 家

4、庭医生：与患者保持一对一联系。主要通过门诊看诊。 Specialists: provide specialty care. 专科医生：提供专业医治 Hospitals: provide inpatient and emergency care. 医院：提供住院服务和急诊。 Drug stores: fill drug prescriptions. 药店：提供处方药物 Pharmaceutical companies: provide drugs under a “formulary” arrangement with payers. 制药商：与支付方商定后，提供药物。Choose health

5、 insurance programs.（选择医疗保险项目）lMost programs are associated with employers. （多数项目与雇主合作）People over 65 are covered by Medicare.（超过65岁的公民均享受医疗保险）lConsider Medicare supplement insurance.（考虑医疗保险的补贴保险项目） People under a certain poverty line are covered by Medicaid.（在一定贫困线以下的人们享受医疗补助） Enroll annually (with

6、 some exceptions). 年度登记（有一些例外）Still left 15% of the population “uninsured.” （还是有15%的人没有保险。） Uninsured: seek emergency care or Medicaid（无保险者：寻求急诊治疗或医疗补助） Insured:（有保险者）o Choose a family doctor from the list given by payers. 从支付方提供的清单中，选择一位家庭医生。o Family doctor becomes the “care manager” for the patien

7、t. 家庭医生变成了此位患者的“医疗管理者”。o Family doctor must make referral to specialists or hospitals. 家庭医生必须转介专业医师或医院。o Make co-pay as defined by payers (office visits, generic / brand name drug, out-of-pocket maximums, etc.) 以支付标准为依据的共付制度（就诊、非专利/品牌药物、现款支付的最高额度及其他） Government: Medicare and state Medicaid programs（

8、政府：医疗保险制度和州级公共医疗补助项目） Health insurance programs / Health Maintenance Organizations (HMO). (医疗保险项目及卫生维护组织)o Indemnity Plans (fee for service) 补偿计划（服务费用）o Preferred Provider Organizations (PPO) 优先选择医疗服务 提供者组织（PPO）o Staff model HMOs(拥有医院和受薪医师的卫生维护组织）o Employer sponsored programs（雇主资助项目） Patients（患者） Pa

9、y claims submitted by providers. 支付服务提供方提交的费用 Establish “reasonable and customary” fee schedule. 建立“合理及常规的”收费率表 Provider contracting based on price and quality. 以价格和质量为基础，与服务供应方订立合同 Manage care through pre-authorization, referrals, case management, and preventive care. 通过授权、转介案例管理和预防保健，而进行的管理工作。 Wha

10、t benefits health insurance companies:（对医疗保险公司最有利的事）o People stay healthy (prenatal care)人们保持健康（产前保健）o Diseases are diagnosed early (mammogram)早期诊断病情（乳房X光照片）o Minimize disease complications (diabetes)减少并发症-糖尿病 Physician contracting（医生契约） Hospital contracting（医院契约） Pharmaceutical company contracting

11、(formulary)药品制造商契约（处方）This removes all “extra benefits” from providers and allow health insurance companies to, in theory, pass the benefits to consumers.这排除了服务提供方的“额外收益”，而将此利益让渡给医疗保险公司，理论上说，是消费者受益。A Private Third Party Payer is the key to keep US Health Care System in Balance 私营的第三支付方是平衡美国医疗卫生体系的关键

12、Payer支付方Service Provider服务提供方Patient/people患者/人 Providers must compete for Payer business.（为争取支付方，服务提供方间的竞争） Payers must compete for Patient business.（为争取患者，支付方间的竞争） Each market must have multiple Payers (A, B, and C insurance companies)（每一市场必须有多个支付者-ABC保险公司） Each market must have multiple Provider

13、networks.（每个市场必须有多个服务提供者网络体系） Compete on both price and quality（价格与质量的竞争）Federal Government is by far the largest payer through Medicare and Medicaid.（通过医疗保险和公共医疗补助，联邦政府尤其成为最大的支付方）Medicare is for people 65 years of age and older. （医疗保险惠及65岁及以上人群）Medicare spending will more than double in the next de

14、cade, from $309 billion in 2004 to $792 billion in 2015. It will grow from 13% to 21% of the federal budget. （十年间医疗保险投入将翻一番，从2004年的3090亿美元增至2015年的7920亿美元。财政预算将从13%增至21%）o Population Ageing（人口老龄化）o High cost of medical technology（高额的医疗科技费用）Medicaid spending is expected to increase from $293 billion t

15、o $670 billion during the same period（同一时期，公共医疗补助投入有望从2930亿美金增至6700亿美金） Health insurance companies are private business with P&L responsibilities（医疗保险公司作为私营企业，有损益平衡责任）o Adverse selection（逆向选择）o Pre-existing condition（已有疾病）o Investment in health improvement（为提高健康状况而进行的投资） National Health Plan is an e

16、ntitlement program not subject to above concerns and should be lower cost to implement.（全民医保是一项权益性项目，没有以上的顾虑，而应该在项目实施中降低费用） Re-alignment of stakeholders and their benefits.（利益持有者和利益的重新分割） A good reform makes stakeholders interests match peoples interests.（好的改革使利益持有者的利益与人民的利益吻合） Chinas reform effort

17、must have “built-in” anti-corruption component.（中国医疗改革须纳入反腐败部分）Current US Status 美国现状 High cost (GDP and per capita) 高消费(GDP和人均消费） High quality for the rich 高收入人群的高品质医疗 15% uninsured 15%的人没有医疗保障National Health Care全民医疗Proponents 赞成方 People 人民 Businesses 商家 Government 政府Obstacles 阻碍方 Current stakehol

18、ders who stand to lose 既得利益者遭受损失 People under 26 can be covered by parents 26岁以下群众的医疗通过其父母 得以覆盖 No pre-existing condition for children 不以儿童的病史而拒绝接受投保 Life time / annual limits removed 无终生或年度最高赔付标准 No policy cancellation after a person gets ill 罹患疾病后不得撤消保险Health plans must offer electronic records 保险

19、公司必须提供电子病历No pre-existing conditions, health status, nor gender 不因其病史、健康状况和性别而拒绝接受投保Citizens pay fine for not joining health insurance 未投保者将被处以罚款Employers pay fine for not offering health insurance 未为雇员提供医疗保险的公司将被处以罚款2010 - 20112013 - 2014 China had government paid health care for most people prior

20、to first round of heath reform in 1985.（在1985年第一次医疗改革之前，中国是公费医疗） Since 1985, China took a step backward in providing health care for all.（1985年开始，是全民医疗的倒退） National health care is one of the basic service a nation should provide its citizens.（全民医保，是一个国家应提供给公民的基本服务） The detour through market economy

21、involved several failed reform attempts.（与市场经济相关的几种改革尝试是绕弯路）Current Status in China 中国现状 Low level of coverage 覆盖面低 Constrained by providers 医疗服务不足 Runaway cost 成本控制失灵National Health Care全民医疗Proponents 赞成方 People 人民 Government 政府Obstacles: 阻碍方： Corruption 腐败 Privatization of providers to improve eff

22、iciency（服务提供方私营化以提高效率） Price control of common drugs to reduce drug cost（常用药物价格控制以减少药品费用） Established prescription drug system to improve drug safety（建立药物处方系统以提高药品安全） Providers increase charges to patients（服务提供者提价） Pharmaceutical companies stopped producing price controlled drugs.（制药商不生产控价药品） Prescription drug system became the basis for drug kickback to ho