改革医疗体系和服务-石磊玉-2017.6-88页.pdf

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1、报告吧w w w.b a o g a o b a.x y z 收集 w w w.b a o g a o b a.x y z 独家收集 不断更新REFORMING HEALTH CARE SYSTEM AND DELIVERY改革医改革医疗疗体系和服体系和服务务Leiyu Shi（石磊玉）（石磊玉）,Dr.PH,MBA,MPAProfessor of Health Policy&Management Director of Johns Hopkins Primary Care Policy Center 约翰霍普金斯大学公共卫生学院卫生政策与管理系约翰霍普金斯大学公共卫生学院卫生政策与管理系 教

2、授教授约翰霍普金斯大学基本医疗政策研究中心约翰霍普金斯大学基本医疗政策研究中心 主任主任2017年年6月月(2017 Copyrighted)报告吧w w w.b a o g a o b a.x y z 收集 w w w.b a o g a o b a.x y z 独家收集 不断更新Background 背景背景 Reforming health care is a key challenge for almost every nation.几乎每个国家都面临医疗改革的挑战。Low-income countries:provide basic health care across as muc

3、h of the population as possible,for little money and limited resources.低收入国家：以有限的资金和资源有限的资金和资源为尽可能多的人提供基本医疗服务。Emerging economies:deliver high-quality care at a price affordable to their new middle classes under available resources.新兴经济体：以可负担的价格和可用资源可负担的价格和可用资源为中产阶级提供高质量的医疗服务。Developed nations:mainta

4、in equitable access to care and quality while controlling costs(efficiency)and balancing resources(distribution).发达国家：控制成本和平衡资源控制成本和平衡资源的同时保持获得医疗服务的公平和医疗质量。Despite differences in priorities,containing cost and Despite differences in priorities,containing cost and maximizing limited resources are com

5、mon challenges for all maximizing limited resources are common challenges for all nations.nations.尽管优先级不同，控制成本和最大化利用有限资源是所有国家的共同挑战。尽管优先级不同，控制成本和最大化利用有限资源是所有国家的共同挑战。报告吧w w w.b a o g a o b a.x y z 收集 w w w.b a o g a o b a.x y z 独家收集 不断更新Healthcare Reform Is Particularly Challenging for US and China医医疗

6、疗改革改革对对美国和中国尤其具有挑美国和中国尤其具有挑战战性性The Uneven Development Within China 中国中国发发展不均衡展不均衡 Adapting to Chinas Situation 适适应应中国的情况中国的情况 Most populous(1.3 billion),increasing aging population and chronically ill 人口最多（13亿）老龄化、慢性病 Ranked as the 2ndlargest economy,but 93rdin GDP per capita 第二大经济体，但人均GDP仅第93名Incre

7、asing disparities(rich&poor,urban&rural,regional)日益严重的不均等（贫富、城市&农村、区域）Healthcare:expensive and difficult to access 看病难，看病贵3High Cost,Average Outcome,and Low Equity Within USA 美国医美国医疗疗成本高，效果一般、公平性低成本高，效果一般、公平性低 Most costly healthcare system in the world(specialization,medical technology,multi-stakeho

8、lders,and inefficiency)世界上最昂贵的医疗体系（专业化，医疗技术，多方利益相关者和低效率）Large elderly population and chronically ill 老龄化、慢性病 Disparities in access,quality,and outcome across racial/income/insurance groups:an increasing social problem不同种族/收入/保险群体间在医疗可及性、质量和结果方面存在差距：越来越严重的社会问题Evolution of U.S.Healthcare Reform美国医疗改革的

9、演变Strategies to Improve US Healthcare Delivery提升美国医疗服务的策略3.Discussion:Implications for China讨论：对中国之借鉴Roadmap1.Evolution of US Healthcare Reform美国医疗改革的演变5Evolution of US Healthcare Reform美国医疗改革的演变Healthcare reform vs.health insurance expansion医疗改革与医疗保险扩张Forces behind health insurance in the US:美国医疗保险

10、背后的力量-Technology(advanced treatments became available,but they were expensive)技术（先进的治疗方法成为可能，但是昂贵）-Social(desirability of medical treatments)社会（医疗的可取性）-Economic(unpredictability of medical needs and costs of treatment)经济（医疗需求和治疗费用的不可预测性）Rise of private insurance 私人保险的崛起-1929 Modern health insurance

11、was born(Baylor Plan for school teachers,at Baylor University hospital Texas,a prepaid plan,the model for Blue Cross1929年-现代医疗保险诞生了（在得克萨斯州贝勒大学医院的贝勒保险计划为学校教师提供，一个预付费制保险，是蓝十字保险的模型）-1939 The California Medical Association started the Blue Shield plan to cover physician services 1939年-加州医学协会启动了蓝盾保险计划，覆盖

12、医师服务 Private health insurance became employment based 私人医疗保险变为基于雇用-1948 Supreme Court decision legitimized health insurance as a negotiable item in union-management bargaining 1948年基于最高法院的决定，医疗保险合法成为工会管理谈判中可交涉的项目-1954 tax ruling:employer contributions for health insurance became exempt from taxable

13、income for the employee 1954年税收裁定：雇主对医疗保险的缴款可作为该雇员的应纳税收入的免税额度Evolution of US Healthcare Reform(Cont.)美国医疗改革的演变 Rise of public insurance 公共保险的崛起-Politicians believed there would be less opposition for programs targeted at the underprivileged 政治家认为针对弱势群体的方案将会得到较少反对-Social Security Amendments,1965 crea

14、ted Medicare for the elderly and Medicaid for the poor1965年的社会保障修正案建立了老年人医疗保险和穷人医疗补助保险-The 1997 State Childrens Health Insurance Program(SCHIP)for children1997年建立儿童医疗保险计划 Failed actions on national health insurance 未成功的全国医疗保险法案-1935-1940s F.Roosevelts new deal and failed national health insurance bi

15、lls1935-40年代罗斯福的新协议和失败的国家医疗保险法案-1940s:Harry Truman:First US President to propose national health insurance20世纪40年代：哈里 杜鲁门：在美国由总统提出的第一个全国医疗保险-1990s:Clinton and Bush proposals 1990年代：克林顿和布什的提案-Reasons for Defeated NHI Proposals in the United States:Political Inexpediency(no threat to political stabili

16、ty),Stakeholders Opposition(medical,insurance,pharmaceutical,hospital),Ideological Differences(individualism and distrust of government),Tax Aversion(middle class not willing to pay increased taxes to pay for the poor)美国全国医疗保险建议失败的原因：政治失策（不威胁政治稳定），利益相关者反对（医疗、保险、药厂、医院），意识差异（个人主义和不信任政府），避税（中产阶级不愿意增加缴税

17、、为穷人付钱）Evolution of US Healthcare Reform(Cont.)美国医疗改革的演变The ACA or Obama Care 奥巴马医改-Patient Protection and Affordable Care Act,2010 患者保护与平价医疗法案 2010-Not a single Republican voted in favor,President Obama united his own party behind the legislation;Backroom deals were made with waffling members and i

18、nterest groups;The AMA reversed its historic stance in supporting the legislation 没有一个共和党投票赞成，奥巴马总统团结民主党促成立法；与摇摆成员和利益团体达成幕后交易；美国医学会改变一贯立场支持立法-The American public was kept in the dark about the details 美国公众对细节并不了解-Legal challenges pushed the legislation before the Supreme Court 法律挑战将立法推向最高法院-The majo

19、rity of ACA provisions were ruled constitutional under the Congress power to tax(the individual mandate)大部分条款通过议会对于税收的权利被宪法裁定（个人强制）Key Differences between ACA(Obama Care)and AHCA(Trump Care)奥巴马医改与特朗普医改的主要区别-Individual Mandate(ACA:individuals are required to obtain ACA-compliant health insurance or f

20、ace an annual tax penalty;AHCA:Tax penalty will be dropped.Instead,individuals who go for more than two months without health insurance will face a“continuous coverage”surcharge of 30%when they buy a new insurance plan)个人强制（ACA：个人需要获得符合标准的医疗保险或面临年度税款罚款;AHCA：税款罚款条款被取消，取而代之的是对两个月以上没有保险的个人购买新保险计划时将收取附加

21、费30）-Employer Mandate(ACA:Large companies are required to provide health insurance to their employees or face financial penalties;AHCA:This provision is repealed.)雇主强制（ACA：大公司需要为员工提供医疗保险否则将面临经济处罚;AHCA：此项规定被废除。）-Medicaid Expansion(ACA:States may expand Medicaid coverage for low-income individuals by

22、expanding the eligibility cutoff to 138%of the poverty level.The federal government has taken on almost all of the cost of this expansion.AHCA:Medicaid expansion is discontinued in 2020.)医疗补助保险扩大（ACA：各州可以通过将资格限制扩大到贫困线的138来扩大对低收入人群的医疗保险覆盖率。联邦政府已经承担了扩张的几乎所有费用。AHCA：医疗补助保险扩张将在2020年停止）The ACA(Obama Care)

23、was passed in 2010 and starts in 2014奥巴马医改法案在奥巴马医改法案在20102010年通过年通过,从从20142014年起开始生效年起开始生效Key Underlying Goals of Obama Care美国医疗改革的重要目标美国医疗改革的重要目标Cover the Uninsured 覆盖没有保险的Contain Costs 控制花费Improve Quality/Equity 提高质量/公平性Digitize&Modernize 数字化/现代化医疗改革时间表小企业税收抵免提早退休者再保险项目对投保前已存在疾病者投保的保障26岁以下成年人可参加父母

24、保险医疗保险交易市场立法保险公司须支付费用比例交易市场开始认证符合条件的保险卫生部认证符合条件的保险医疗保险交易市场开始使用医疗补助保险扩大各州对扩大的豁免或设计本州计划Other Health Reform Activities:Quality/Equity/Modernization其他医疗改革行动其他医疗改革行动:质量质量/公平公平/现代化现代化Obtaining evidence on what technology is best -Comparative Effectiveness Research(CER)取得何为最佳医疗技术的证据比较效益研究Primary care“Medic

25、al Homes”基本医疗“医疗之家”Huge investment($30B)in electronic health records(EHRs)/Health IT(HIT)for doctors and hospitals 为医生和医院在电子医疗记录/医疗信息技术方面的巨大投资（300亿美元）Accountable Care Organizations(ACOs)责任医疗组织2.Strategies to Improve on US Healthcare Delivery提升美国医疗服务的策略Doctor&Team医生和团队Patient&Family患者和家庭1.Accessibili

26、ty可及性可及性2.Continuity 持持续续性性3.Comprehensiveness 全全面性面性4.Coordination协调协调性性C.Technology-based intervention 基于科技的干基于科技的干预预B.Practice-based intervention基于基于诊疗诊疗的干的干预预A.System-based intervention基于系统的干预Interventions to Improve Health Care Performance提升基本医疗绩效的干预措施提升基本医疗绩效的干预措施1.Implementing the Healthy Peo

27、ple Initiative by Focusing on the Determinants of Health通过关注健康的决定因素实施健康人群行动通过关注健康的决定因素实施健康人群行动Individual个人个人1.Increase skills.提高技术提高技术2.Reduce hazards.降低危险降低危险.3.Increase resources.提升资源提升资源.Hazards危险危险17健康人群的发展过程减少死亡：婴儿-成人提高老年人独立性总体目标涉及方面目标/指标提升健康生活跨度减少健康差异为所有人提供预防服务提高健康生活的质量和年限消灭健康差异免于可预防疾病健康公平社会和环

28、境健康健康生活行为目标年Source:http:/www.healthypeople.gov/hp2020/advisory/PhaseI/PhaseI.pdf.达到健康人群达到健康人群2020目目标标的行的行动动模型模型干预结果测量、监测、评估、传播贯穿生命过程个人个人社交、家庭和社区网络社交、家庭和社区网络生活、工作环境生活、工作环境社会、经济、文化社会、经济、文化健康的决定因素12 Topic Areas for Leading Indicators1912个优先领域医疗服务可及临床预防服务环境质量伤害和暴力母婴和儿童健康生殖和性健康精神健康社会决定因素营养、运动和肥胖药物滥用口腔健康吸

29、烟Healthy People 2020 Focus Areas健康人群健康人群2020关注关注领领域域1.Access to health services 医疗服务可及性2.Adolescent health 青少年健康青少年健康3.Arthritis,osteoporosis,and chronic back conditions关节炎，骨质疏松症和慢性背部疾病4.Blood Disorders and blood safety 血液病和血液安全血液病和血液安全5.Cancer 癌症6.Chronic kidney disease 慢性肾病7.Dementias,including Al

30、zheimer s Disease老年痴呆症，包括阿老年痴呆症，包括阿尔尔茨海默氏病茨海默氏病8.Diabetes 糖尿病9.Disability and health 残疾与健康10.Early and middle childhood 早期和中期儿童早期和中期儿童时时期期11.Educational and community-based programs教育和社区为基础的项目12.Environmental health 环境卫生13.Family planning 计划生育14.Food safety 食品安全15.Health communication 健康沟通16.Heart d

31、isease and stroke 心脏病和中风17.HIV 艾滋病18.Immunization and infectious diseases 免疫和传染病19.Injury and violence prevention 伤害和暴力预防20.Lesbian,gay,bisexual,and transgender health同性恋，双性恋和同性恋，双性恋和变变性者健康性者健康21.Maternal,infant,and child health 孕产妇，婴儿和儿童健康22.Medical product safety 医疗产品安全23.Mental health and mental

32、disorders 心理健康和精神障碍24.Nutrition and weight status 营养和体重状况25.Occupational safety and health 职业安全与卫生26.Older adults 老年人老年人27.Oral health 口腔健康28.Physical activity 体育运动29.Preparedness 准准备备30.Public health infrastructure 公共卫生基础设施31.Respiratory diseases 呼吸系统疾病32.Sexually transmitted diseases 性传播疾病33.Socia

33、l determinants of health 健康的社会决定因素健康的社会决定因素34.Substance abuse 药物滥用35.Tobacco use 烟草使用36.Vision 视力Source:Healthy People 2020,USDHHS,2011.风险转风险转移移时间时间吸烟吸烟缺乏运缺乏运动动、超重、超重城市空气城市空气质质量、交通安全、量、交通安全、职业风险职业风险营营养不良、室内空气养不良、室内空气污污染、染、水、水、卫卫生生风险风险当前当前风险风险传统风险传统风险健康的社会决定因素医疗服务健康行为环境社会经济因素医疗服务的三个目标人群健康服务质量人均花费From

34、 Determinants of Health to Healthcare Delivery从健康的决定因素到医从健康的决定因素到医疗疗服服务务2.Focusing on Primary Care and Integrated Care Delivery重视重视基本医疗及整合的医疗服务基本医疗及整合的医疗服务“我相信一个以基本医疗为基础的医疗体系将更加健全。”25Primary Care and Life Expectancy基基本医疗本医疗与预期寿命与预期寿命Source:Shi et al,JFP 199971727374757677784.004.505.005.506.006.507.

35、007.50Primary Care Physicians/10,000 PopulationLife Expectancy.LASC.GA.NV.MS.AL.WV.DE.NC.KY.KS.TN.ID.MI.TX.IA.UT.NY.CA.MD.ND.WI.NM.AZ.NE.MA.CT.HI.MN.AK.IL.VA.PA.FL.MT.OR.NJME.NH.SD.ID.AR.WA.RIR=.54P.0526Proportion of Practicing Physicians Who Are Generalists,2009医师比例谁是全科医师,2009General practitioners,

36、specialists and other doctors as a share of total doctors,2009(or nearest year)1.Specialists include pediatricians,obstetricians/gynacologists,psychiatrists,medical specialists and surgical specialists.2.Other doctors include interns/residents if not reported in the field in which they are training,

37、and doctors not elsewhere classified.Source:OECD Health Data 2011.Header/Full Bleed ImageName/Subject Subhead Title/captionTitle/caption 2016/2017,Johns Hopkins University.All rights reserved.Delivery System Redesign医疗服务体系重新设计Need to invert the Resource Allocation Triangle需要反转资源分配三角形Prevention Activ

38、ities must be funded and widely deployed需要为疾病预防疾病预防提供资金支持并广泛开展Primary Care must become a desirable occupation and基本医疗基本医疗须成为一个理想的职业Decrease Demand in the Specialtyand Acute Care Systems减少减少对专科专科和急救和急救的需求These are dramatic shifts that will not magically take place这些转变是巨大的，不会自发不会自发27Acute CareSpecialt

39、y CarePrevention,Primary CareCurrent Resource AllocationPrevention&Primary CareSpecialty CareAcute CareNeeded Resource Allocation当前资源分配理想的资源分配Integration of Health Care Delivery Functions through Managed Care通过管理医疗来整合医疗服务的功能通过管理医疗来整合医疗服务的功能MCO 管理医疗组织管理医疗组织PaymentPayment付款付款DeliveryDelivery服务服务Insura

40、nceInsurance保险保险PaymentDiscount feesLimited fee forService付费付费折扣、有限的折扣、有限的按服务付费按服务付费Providers提供者提供者PaymentSalaries andbonusesCapitated fees付费付费工资工资和奖金和奖金按按人头付费人头付费Providers提供者提供者FinancingCapitatedPremiums提供资金提供资金按人头保费按人头保费Delivery ofMedical care提供医疗提供医疗服务服务Delivery ofMedical care提供医疗提供医疗照顾照顾Enrollee

41、s加入者加入者Employer雇主雇主Enrollees加入者加入者Before services are delivered提供服务前提供服务前After services are delivered提供服务后提供服务后MCO Enrollees管理医疗参保人管理医疗参保人Primary care delivery基本医疗首诊基本医疗首诊Secondary care referrals专科转诊专科转诊Care Coordination and Utilization Control through Gatekeeping用“守用“守门门人”的方法来人”的方法来协调协调，制，制约约医医疗疗使用

42、使用医院入院医院入院个案管理个案管理诊疗测验诊疗测验The Core Values,Principles,and Elements in a PHC-Based Health System基于基本医基于基本医疗疗服服务务的的卫卫生系生系统统的核心价的核心价值值、原、原则则和要素和要素Source:Pan American Health Organization/World Health Organization.Renewing Primary Health Care in the Americas.http:/www.paho.org/English/AD/THS/OS/PHC_brochu

43、re_eng.pdf.Accessed 11/12/07.实现最高健康层次的权利公平性一致对人群健康的反应有效的政策、法律框架31Primary Care Approach to Health Care基基本医疗本医疗之方式之方式 illnesswellness从疾病到健康 acute carepreventive care从急诊到预防 inpatientoutpatient从住院到门诊 individual healthcommunity well-being从个人到社区健康 fragmented caremanaged care从片断化到管理医疗 independent instituti

44、onsintegrated systems从独立机构到整合体系 service duplicationcontinuum of services从重复到连续32The Road to“Accountable Care”-Transforming Health Care Will Require Paradigm Shifts通往“责任医疗”通往“责任医疗”-转变医疗服务将需要范式转变转变医疗服务将需要范式转变TRANSFORMED 转变转变后后CURRENT 当前当前Coordinated/Integrated Care 协调协调/整合整合Fragmented Care 碎片化服务碎片化服务P

45、atient/Population Focused 关注病人关注病人Provider Centric 以医务人员为中心以医务人员为中心Payment for Value /Outcome按价值支付按价值支付Payment for Volume/Units 按服务量支付按服务量支付Care System Focused 关注服务系统关注服务系统Individual Facility Focused 关注独立机构关注独立机构Care Team Accountability 团队责任团队责任Physician Accountability 医师责任医师责任Transparency 透明透明Opaqu

46、e rules and systems不透明的规则和系统不透明的规则和系统Wellness/Chronic co-morbidities健康健康/慢性病慢性病Disease oriented/Acute Illness疾病导向疾病导向/急性急性Evidence-Based Care/Learning Organiz.循证循证/学习型组织学习型组织Limited Basis for Clinical Action有限的行动基础有限的行动基础Patient-Centered Medical Home(PCMH)以患者为中心的医疗之家以患者为中心的医疗之家“The Patient-Centered

47、Medical Home(PCMH)is a model of primary care delivery in which patients receive well-coordinated services,evidence based care,and enhanced access to a clinical team.”以团队为患者提供充分协调的、循证的、可及的医疗服务。Improved Access Health care for all Same-day appointments After-hours access coverage Lab results highly acc

48、essible Online patient services e-Visits Group visitsPractice Management Disciplined financial management Cost-Benefit decision-making Revenue enhancement Optimized coding&billing Personnel/HR management Facilities management Optimized office design/redesign Change managementComp.Services Comprehens

49、ive care for both acute and chronic conditions Prevention screening and services Surgical procedures Ancillary therapeutic&support services Ancillary diagnostic servicesCare Management Population management Wellness promotion Disease prevention Chronic disease management Care coordination Patient en

50、gagement and education Leverages automated technologiesContinuity of Care Community-based services Collaborative relationshipsHospital careBehavioral health careMaternity careSpecialist carePharmacyPhysical TherapyCase ManagementPractice-Based Care Team Provider leadership Shared mission and vision