medical practices in the us我們晚餐不是來自屠夫釀酒師或者面包師善心而是他們

HealthcareandMedicalPracticesintheUS( -Group SenJi,MD,PhD,StaffCardiacSouthernCaliforniaPermanenteMedicalGroupAssociatedClinicalProfessorofMedicineGaffenSchoolofMedicineatUCLAWhenevertheartofmedicineisloved,thereisalsoaloveofHippocrates,460–370Itisnotfromthebenevolenceofthebutcher,thebrewer,orthebakerthatweexpectourdinner,butfromtheirregardtotheirownAdamSmith,1723-1790HealthcareintheUS Thebestandtheworstintheworld(世界上最好 Highestspendingpercapita每個國民花銷最高Acomprehensive/European2007studyfoundthefive-yearcancersurvivalratewassignificantlyhigherintheU.S.thaninall21Europeannationsstudied 3%vs47.3% and62.9%versus52.8%forwomen(２００７年歐洲研究顯示５年 NobelistsinMedicineandphysiologythantherestoftheworldcombined( morethan80%ofinnovativetherapiesintheworld(世界８０％以上的新醫(yī)療 Thebestequippedhospitalsintheworld有世界上裝備最好的醫(yī)院ButtheuninsuredrateamongU.S.adults11.9%forthefirstquarterof2015截至２０１５年一季度，１１．９％的人沒有醫(yī)療)A2004OECDreportstated:“WiththeexceptionofMexico,Turkey,andtheUnitedallOECDcountrieshadachieveduniversalornear-universal(atleast98.4%insured)cogeoftheirpopulationsby1990(到１９９０年，經合組織中，除了墨西哥，土耳其和，HealthcareExpenditureintheWorldandtheUS( ２０１０ 人均醫(yī)療支出是$8,233.是經合組織平均的2.5倍HealthcareExpenditureandGDPinUS Consecutiveannualincreaseover50yearsuntil2010,reaching2.9billionor17.8%oftotalInthepast3years,thepercentageofannualincreaseinhealthcareexpenditurewasthesameastheincreaseinGDP(連續(xù)50年增長，在2010達到 過去3年的增長率和GDP的增長率持平HowtoLookatHealthcareExpendituresItoncewas,stillisandcontinuouslywillbenationaldebate.(曾經，現(xiàn)在，和將來繼續(xù)是個Agoodorbadthing?(好事還是壞事Ashiftingparadigmoftheeconomy一個變化中Matchesthefundamentalgoalsofeconomicdevelopment,makepeoplehealthierandlivelonger(符合經濟發(fā)展的最終目的，讓人類更健 careproducesmostnewjobs.(醫(yī)療創(chuàng)造 HealthcareExpendituresinUS In2013,thetotalexpenditurewas2.9trillion(2013的總支出是2.9 $9,255percapita(平均每人是 Mostadvancedandoldesttypesco-exist最現(xiàn)代和最Startedasapprentice/solopracticein1700’sSolopractitioners,downto18.8%in2013from32%in2008Bestregardedacademicpractice最好的學術醫(yī)療)Net-worked/integratedgroup )AcademicmedicalcentersareviewedasthecrownjewelsofAmericanhealthcare(學術醫(yī)療中心是 Tertiaryreferralcenterformostadvancedcare最先進的三級診療中心Mostadvancedandtransformationalresearch(最先進的 High-profilemedicalfaculty Mesmerizinginpatientandambulatoryfacilities/equipments令人羨慕的設Inanessence,itisgrouppractice(但在本質上， Physiciansworkasemployees,orarenowforminggroupstocontractwithmedicalcenters(醫(yī)生是雇員,但是現(xiàn)在醫(yī)生也形成 Group ≥25professionalsinthesamegroupbyCMSdefinitionin2012(根據(jù)CMS的定義，≥25個醫(yī)生以上是 Buttophysicians,≥3physiciansinaformalaffiliationwhosharee,expenses,facilities,equipmentandsupportstaff但對醫(yī)生來講，員，即算 行醫(yī)。Why?(為什 行醫(yī)Professionalneed專業(yè)的需要Marketpower市場力量Economiesofscale規(guī)模經濟Betterqualityofcare更高質量的醫(yī)療Ever-expandingMedicalFields（ Ever-expandingmedicalknowledge(不斷擴展的醫(yī)學知識Atotalof8.1millionjournalarticleswerepublishedinMEDLINEbetween1978and2001,andfromanav geof272,344to442,756peryear.(從 Increasingmedicalspecializations(不斷增加的醫(yī)學專業(yè)Nearly>50specialtiesfromtheoriginaltwomedicineandsurgery目前有50多個臨FirstgrouppracticewasformedasMayoClinic.(第一 Proliferationof (不斷發(fā)展的診療技術Fromlaboratorymedicine,radiology…togenetics( ，放射，… Thepowerofafirm/institutiontoset/raisethepriceofagoodorserviceabovethemarginalcostandearnapositiveprofit.(市場 Amarketparticipantsuchasolopractionerhasnomarketpower一個市場參與者，Togainthemarketpoweroneneedstohavethemass,controlofresourcesincreasingreturnstoscaletechnologicalsuperiorityandbarrierscreatedtoentry要取得這種能應的回報，技術優(yōu)勢，和對新加入者所設置的。)In1980-1990’s,themovementofHMO(Healthmaintenanceorganization) loweringphysicianpays.(在1980-1990‘s，健康 Thegrouppracticestartedtoflourishtoincreasemass,controltheresource,increasereturn,andimprove theyuse.( EconomiesofScale規(guī)模經濟學Formationofmedicalpracticegroups,however,didnotshowsignificantbenefitsintermsofphysicianspay,untilthegroupisgreaterthan8-20physiciansorexceptcertainspecialties,suchasorthopedicsandanesthesiology.(除了個別專業(yè)，像麻醉和骨科，大部分 Economiesofscaleworkswhenthecapitalperunitofproductionisfixed.However,theoverheadcostofformingagroupincreases,ortheincreaseininputsisgreaterthantheoneinoutputs,leadingtothesocalleddecreasedreturnstoscale.(但是，一個 Themedica oupistrendingtobelargertogainincreasedreturntoscale. SuccessfulMedicalGroups,2015(成功的醫(yī) SuccessfulMedicalGroups,2015(成功的醫(yī) FactorsDefiningSuccessfulMedicalGroupDecreaseoperatingcost減低運營成本FactorsDefiningSuccessfulMedicalGroupFactorsDefiningSuccessfulMedicalGroupFactorsDefiningSuccessfulMedicalGroup FactorsDefiningSuccessfulMedicalGroupUtilizationof FactorsDefiningSuccessfulMedicalGroup Decreasesoverhead減低開Decreaseserrors降低錯誤Increasescorrectcoding/)KaiserPermanente Firstfoundedin1945byindustrialistHenryJ.KaiserandphysicianDr.SidneyGarfield,althoughtwohaveworkedonprovidinghealthcaretoKaiserindustryworkerssince1933.(于1945由工業(yè)家HenryJ.Kaiser和SidneyGarfield醫(yī)生共同建立。他們兩人的合作始于1933。)Consists2interdependentstructures:(由2個相互獨立，但又合作的機構KaiserFoundation ns(KFHP): offerprepaidhealth nsandinsura stoemployers,employeesandindividualmembers(給雇主，雇員或個人提供預付的 ProvideinfrastructuresforandinvestinKaiserFoundationHospitalsandClinics(給 ContractsexclusivelywithPermanenteMedicalGroup(只和Permanente醫(yī) KaiserFoundationHospitalsandClinics ProvidesthesitesforPermanenteMedicalGroups(給Permanente醫(yī) 提供行醫(yī)場所Managesnursing/supportstaff(管理護理和附屬人員 ProvidesmedicalcaresexclusivelyforKFHPmembers只給KFHP成員提供醫(yī)療NegotiatesabudgetwithKFHPforphysicianssalariesbenefitsandprofits和KFHP商定預算，KaiserPermanenteModel The2structuresareinterdependent,collaborativeandinclusive(2個機構相互依賴,作，和包容TheKFHPandHospitalsarenot-for-profit(KFHP和醫(yī)院是非營利性的In2014,9.6millionmembers(to7/2015,10.1million),$3.1billioninneteon56.4operatingrevenues(到2015年七月，有一千零十萬會員。在2014年，營運額564億，億38medicalcentersand>700medicaloffices(38個醫(yī)療中心，>700多個門診部Decreases/eliminatestheintermediatemechanismsbetweentheKFHPandphysicians,reducingoverhead(減少/消除了KFHP和醫(yī)生間的中間環(huán)節(jié)，所以減少了開銷)Emphasizesonthepreventivemedicine(強調預防醫(yī)療Providescomprehensivemedicalcarefortotalhealth(提供全面的醫(yī)療以保證全面健康Formsanet-workedhealthcaresystemsinageographicregion(在一個地理區(qū)域內形成 medicalcentersemphasizingonbasiccares tertiaryreferralmedicalcenters基本醫(yī)療中 三級轉診醫(yī)療中心Reducingduplicationsinaregion(減少區(qū)域內的重復KaiserPermanenteModel Apioneerintheutilizationofelectronicmedicalrecordsystem電子StartedinvestinginEMRasearlyasbeforetheendoflastcentury在20世紀Invested4billion到目前，花費達4千萬Benefitsallphysicianand nmembers(醫(yī)生 均受益Improvescodingandbilling(改進了診斷編碼 KaiserPermanenteModel ThePermanentemedicalgroups(Permanente醫(yī) Consistsof17,800physiciansnationwidein2014 7,300physiciansinCalifornia加州７，３００名醫(yī)生ContractsexclusivelywiththeKFHP只和ＫＦＨＰ簽約Forprofit是贏利性的NegotiatesbudgetwithKFHP和ＫＦＨＰ協(xié)商預算Salaryisnotthebest,but70-80thpercentileint