说到医疗费用，这期纽约客上有篇 Atul Gawande写的文章分析医疗费用和医疗质量的关系。拿德州一个小镇做解刨，写的很好。这个小镇人均医疗费用从十五年前开始暴涨，现在是明州mayo clinic 那边的三倍，他从各种可能的原因入手，找有可比性的例子来对照，一条条排除“人群特别不健康”，“医疗设备先进”，“保险公司消耗大“，等想当然的原因，找到医疗费用高的原因是医生更倾向于用更多不必要的诊断技术而不是多想多看。但是为什么这里的医生比别处更爱滥用诊断技术呢？他又深入挖掘下去，指出社会学上有anchor 效应，一个anchor 容易带动整个地方的风气。然后分析了弊端。再拿mayo clinic 的运作模式来比较，指出现在的医疗体系弊端是大家各自为政，保险按量付钱而不是由总体协调按质付费，就象你修房子，如果你不是雇一个工头调度付钱给他，而是雇一个电工，一个水工，一个泥瓦匠分别付钱，电工按他装的插头个数给钱，水工按他装的管子付钱，泥瓦匠按他砌的墙数付钱，你最后房子很可能会有一千个插头，一千个管子，一千个房间，还不是个好房子。而谁写支票不重要。雇再好的电工水工泥瓦匠也不管用。所以不管公共医疗还是私营医疗都不治本。mayo clinic 是医院里付工资，医生之间协调合作以期找到最好的医疗方案，而不是按带进来的病人能产生多少利润付工资。
作者我以前见他跟依丽莎白爱德华兹谈话提过，是个医生，兼职写作，也参与很多医疗政策的建议，是克林顿政府时期的advisor.
http://www.fabvalley.org/bbs/viewtopic.php?t=3707
强烈推荐该文。观点很新鲜，从来没听说过。（不过我不大读这些东西的，所以可能是流行的观点我完全不知道。我经常这样落伍，寒）。分析的很扎实，是科学青年喜欢看见的有数据，有对照组，前因后果抽丝拔茧很严密的文章，又很生动，一点不枯燥。非常好看。
http://www.newyorker.com/reporting/2009 ... ct_gawande
推荐一篇关于医疗费用的文章
Atul Gawande
嗯,Knowing 讲的是现在政府要推行的在医疗费用支付时"Pay for Performance"和 "Bundle Payment" 政策的理论基础.
恰好手边有一本Atul Gawande的书. "Better: A surgeon's notes on performance", 讲有关美国医疗系统目前的困境和医疗质量提高的种种观点. 很有趣. 作者是一个外科医生,同时是哈佛医学院的Associate Professor.观点清晰,文字流利,深入浅出,值得推荐.
http://www.amazon.com/Better-Surgeons-P ... 604&sr=1-1
恰好手边有一本Atul Gawande的书. "Better: A surgeon's notes on performance", 讲有关美国医疗系统目前的困境和医疗质量提高的种种观点. 很有趣. 作者是一个外科医生,同时是哈佛医学院的Associate Professor.观点清晰,文字流利,深入浅出,值得推荐.
http://www.amazon.com/Better-Surgeons-P ... 604&sr=1-1
I've read both Complications and Better.
Obviously he has done a lot of research on the health care system and understands it deeply and has many good insights. However, I must say I disagree with some of his ideas for medicine in "Better". I'm afraid his view of health care is a bit too ... elitist. Not every institution and every practitioner can be made "better", and the cost of health care may not go down if the quality gets better. People do not necessarily want to pay to get better or even know the difference between better and worse.
The problem of the US health care system goes far beyond medicine and what medicine can fix by being more dilligent and efficient. It's a lot more complicated. If you don't take into account the "darker" nature of human behaviors and tendencies, you are bound to fail in the pursuit. This is what economists do far better. Medical people tend to have a rosier view of reality and humanity.
Anyway, whatever, I guess I'd rather have an optimist working on the system than I, a pessimist.
Obviously he has done a lot of research on the health care system and understands it deeply and has many good insights. However, I must say I disagree with some of his ideas for medicine in "Better". I'm afraid his view of health care is a bit too ... elitist. Not every institution and every practitioner can be made "better", and the cost of health care may not go down if the quality gets better. People do not necessarily want to pay to get better or even know the difference between better and worse.
The problem of the US health care system goes far beyond medicine and what medicine can fix by being more dilligent and efficient. It's a lot more complicated. If you don't take into account the "darker" nature of human behaviors and tendencies, you are bound to fail in the pursuit. This is what economists do far better. Medical people tend to have a rosier view of reality and humanity.
Anyway, whatever, I guess I'd rather have an optimist working on the system than I, a pessimist.
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I did not read Better. But I think his point in this article is we need to design the reward system in a way that One entity oversees the healthcare of each patient and remove the incentive for individual doctors to maximize revnue out of this patient, precisely because of 'weekness' of human nature when it comes to profit.
I like the article because it really pointed out what is wrong with the existing system. Not because he has the solution. I have doubts about his solution too. Designing a reward system that's greed-proof is hard. I am not sure how Mayo Clinic as whole can resist the temptation to see patients as revnue source. An organization can be as greedy as individual. I understand why you think he is an elitist....mayo clinic model is based on a small group of "good individuals" affecting the rest of the majority "normal individuals". but on the other hand, anchor effects matters, and good individuals can set the tone for at least that small area, and benefit the locals. So, I don't know, maybe it is worth a try.
I like the article because it really pointed out what is wrong with the existing system. Not because he has the solution. I have doubts about his solution too. Designing a reward system that's greed-proof is hard. I am not sure how Mayo Clinic as whole can resist the temptation to see patients as revnue source. An organization can be as greedy as individual. I understand why you think he is an elitist....mayo clinic model is based on a small group of "good individuals" affecting the rest of the majority "normal individuals". but on the other hand, anchor effects matters, and good individuals can set the tone for at least that small area, and benefit the locals. So, I don't know, maybe it is worth a try.
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When medical care is provided by a single payer and is centrally administered, the quality is actually not bad at all --- the example is the Veterans Affairs health care system. Despite the Walter Reed scandal, the health care services at most VA facilities are better, less expensively provided, and far more efficient than the private insurance/free market health care we get. For most of the past several decades, VA has been doing a pretty good job for the people they service. And medical personnel are generally pretty satisfied with their work condition -- they're paid less but not emotionally exhausted and sucked dry.
So, why the scandal and deterioration recently? First, they are overwhelmed with the massive number of soldiers who need medical service. It's a tsunami in the past 7 years and the previous infrastructure is not able to handle it (and it will get worse). Second, the leadership sent down from the military leadership was just awful, with a deadly combination of incompetence, arrogance, and indifference, under the past administration. But then that phenomenon was hardly limited to VA, was it?
In a way that may be a risk for single-payer, government-managed health care. You could end up with a bunch of mean and corrupt people running the show and wreck it. Politicians who don't know much about medicine or science, and don't care, but have too much power to interfere can pose a threat to the system.
So, why the scandal and deterioration recently? First, they are overwhelmed with the massive number of soldiers who need medical service. It's a tsunami in the past 7 years and the previous infrastructure is not able to handle it (and it will get worse). Second, the leadership sent down from the military leadership was just awful, with a deadly combination of incompetence, arrogance, and indifference, under the past administration. But then that phenomenon was hardly limited to VA, was it?
In a way that may be a risk for single-payer, government-managed health care. You could end up with a bunch of mean and corrupt people running the show and wreck it. Politicians who don't know much about medicine or science, and don't care, but have too much power to interfere can pose a threat to the system.
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