经济学人商业 || 美国医疗体系

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American health care

美国医疗体系

英文部分选自经济学人20191123期Business版块

美国医疗体系

Diagnosis: opaque

诊断：不透明

The Trump administration wants hospitals to be more upfront about prices. They demand a second opinion

特朗普政府要求医院公开医疗费用，而医院希望征求更多的意见。

“I don’t know if the hospitals are going to like me too much any more with this,” quipped President Donald Trump on November 15th. He was referring to two bold initiatives unveiled earlier that day by Alex Azar, his health secretary, to rein in America’s soaring health-care costs. The administration finalised a rule, to take effect in 2021, which will double down on its effort to bring price transparency to hospital care. And it put forward a new proposal, open for 60 days of public comment, that would force health-insurance firms to reveal confidential details of negotiated discounts with hospitals and doctors. It is the biggest shake-up of America’s $3.5trn health-care industry in years. And no, hospital operators are not happy.

11月15日，美国总统唐纳德·特朗普打趣地说：“我不知道签了这个行政令之后医院还会不会继续爱我。”他指的是，卫生与公共服务部长亚历克斯·阿扎尔（Alex Azar）早先提出的两项大刀阔斧的改革方案，旨在控制不断飙升的医疗费用。政府最终确定了一项规则，将于2021年生效，旨在加大力度推进医疗行业价格透明化。新规中有一项提案强制要求医疗保险公司披露与医院和医生协商价格的保密细节，并公开征询公众意见，为期60天。对市场规模高达3.5万亿美元的美国医疗业来说，这是近年来最大的一次变革。而对此医院运营者并不开心。

注：

1.美国医生，保险公司和医院的关系

http://blog.sina.com.cn/s/blog_5cebbb3b0102v2we.html

2.特朗普签署行政令，要求医疗价格透明化，将会带来行业深远的变化!

http://med.china.com.cn/content/pid/151966/tid/1026

3.美国两党医改再斗

http://www.xinhuanet.com//globe/2019-07/31/c_138247736.htm

4.一文读懂2019美国医保大变革(超链)

5.美国总统行政令是个啥?
https://www.bbc.com/zhongwen/simp/indepth-38813996

Mr Trump’s first round of hospital reform required hospitals to make public the full list of costs billable to patients or their insurers. Hospitals previously held these so-called “chargemasters” close to their chest. Since January, when the reform came into force, they have taken to releasing convoluted spreadsheets with theoretical list prices for thousands of procedures, all couched in impenetrable medical jargon—transparent in theory but “useless” in practice, says George Nation of Lehigh University in Pennsylvania.

在首轮医改中，特朗普政府规定医院需向患者或其保险公司公布全部医疗费用明细。过去，医院把内部价目明细表捂得紧紧的，生怕被人看到。宾夕法尼亚州里海大学(Lehigh University)的乔治•内森(George Nation)表示，今年一月实施医改以来，医院开始公示医疗服务价目明细表，数目多达几千项，纷繁复杂。明细表上的数字基本上是摆设，充斥着晦涩难懂的医学术语。形式上看起来公开透明，实际上却云遮雾绕毫无用处。

注：

1.Chargemaster:

In the United States, the chargemaster, also known as charge master, or charge description master (CDM), is a comprehensive listing of items billable to a hospital patient or a patient's health insurance provider. In practice, it usually contains highly inflated prices at several times that of actual costs to the hospital.（选自维基百科）

2.在美国看病到底有多贵(超链)

3. 医改新规公布价目表(超链)

4. 国内外医保制度给我国商业健康险启示：增长空间大 科技创新提供支持

https://www.zhitongcaijing.com/content/detail/246914.htmlhttps://www.zhitongcaijing.com/content/detail/246914.html （可能需要网络支持）

In need of radical surgery

医改亟需治本（不仅要治标，更要治本）

The new rule goes further. It requires hospitals to disclose and update details, including gross charges, cash prices and negotiated rates, for thousands of services. They must also explain in plain English how much a basket of 300 common services (things like  MRIscans or hip replacements) will cost, including any extras and hidden charges.

新规则更进一步，要求医院公示并定时更新数千项医疗服务的详细信息，包括总费用，现金价格以及医院与保险公司协商后的价格。新规还要求医院必须用简明的英语公示300种常见服务的价格，如核磁共振MRI、髋关节置换等。若有任何额外费用和隐性费用，必须给予说明。

In setting his sights on hospitals, Mr Trump is taking on a colossus. They accounted for nearly a third of America’s health-care costs in 2017, far more than the share of much-maligned drugmakers (see chart 1). The country has over 6,000 hospitals. Only 1,300 or so are private for-profit institutions; the rest are non-profit or government-run. The lack of an overt profit motive has done little to rein in prices, however. Hospital costs have risen at an annual rate of close to 5%, compared with below 1% for drug prices. Nor has a charitable mission dampened the ambition of bosses at big hospital chains; seven-figure salaries are not unheard of at those with revenues exceeding $500m a year. They have also been on an acquisition binge. The number of deals has jumped from around 55 a year between 2002 and 2009 to 90 or more these days. Since 2018 non-profit hospitals have been the acquirers in three-quarters of the transactions.

特朗普对医院开刀，实际上是在挑战一个巨人。究其原因，2017年，医院诊疗费用占据美国医疗费用的近三分之一，远超备受诟病的制药商的份额。美国有6000多家医院，其中仅有大约1300家为私立营利性机构，其余的要么是非营利性机构，要么由政府运营。然而，正因为缺乏明显的盈利动机，控制价格上涨的动力也微乎其微。相比年增长率不足1%的药品价格，医院费用的年增长率接近5%。慈善的使命并未降低大型连锁医院老板们赚钱的雄心。对年收入超5亿美元的大型连锁医院而言，七位数年薪并不稀奇。此外，医院还在大举收购，年均交易数已从2002至2009年间的55宗左右跃升至如今的90宗，甚至更多。自2018年以来，四分之三的医院收购案都出自非营利性医院之手。

Early on, consolidation was fuelled by the passage in 2010 of the Affordable Care Act. Barack Obama’s health reform imposed red tape, such as a switch to electronic medical records, that some smaller hospitals found onerous. Moody’s, a ratings agency, thinks economies of scale and gaining leverage in negotiations with insurers are now the chief motive.

早些时候，2010年出台的《平价医疗法案》推动了行业整合。巴拉克·奥巴马（Barack Obama）的医疗改革要求繁琐，比如改用电子病历，给规模较小的医院带来麻烦。评级机构穆迪（Moody’s）认为，就目前而言，实现规模经济在与保险公司的谈判中占据上风是行业整合的主要动机。

注：

red tape: (disapproving) official rules that seem more complicated than necessary and prevent things from being done quickly 繁文缛节；官僚作风 (选自《牛津高阶英汉双解词典》

The merger wave has increased concentration and pricing power. Brent Fulton of the University of California, Berkeley, found that 90% of America’s hospital markets, representing a population of over 200m, were highly concentrated (see chart 2). Zack Cooper of Yale University, whose team looked at insurance claims covering over a quarter of Americans with employer-provided health insurance, discovered that prices at hospitals with a local monopoly were 12% higher than in markets with four or more rivals. A study by an insurance-industry body concluded that consolidation cut costs by 15-30% at acquired hospitals, but average prices for hospital services still rose by between 6% and 18%.

这股并购浪潮增强了医院的集中度和定价权。加州大学伯克利分校的布伦特·富尔顿（Brent Fulton）研究发现，90%的美国医院市场（覆盖逾2亿人口）高度集中。耶鲁大学（Yale University）的扎克·库珀（Zack Cooper）团队分析了四分之一以上美国人的保险索赔案例（由雇主提供的医疗保险），发现当地垄断医院的诊疗价格比市场（至少有四家医院）上的高出12%。一家保险机构的研究结论表明，合并降低了被收购医院成本的15%-30%，但医院的平均诊疗价格仍上涨6%-18%。

According to the American Hospital Association, a lobby group, operating margins in the industry rose from 4.4% in 2007 to 6.4% in 2017. But many hospitals in rural areas, which suffer from undercapacity, and in poor urban areas, which have lots of uninsured patients, barely break even or lose money. Big for-profit chains like HCA Healthcare, with around 180 hospitals, can enjoy high (if volatile) margins. Non-profit institutions often plough those gains into expansion or salaries.

据游说团体美国医院协会（AHA）调查，医疗业年营业利润从2007年的4.4%上升至2017年的6.4%。但许多农村医院仍然产能不足，贫困城镇地区的不少医院又会面对很多没有医疗保险的患者。这些医院只能勉强维持盈亏甚至已陷入亏损。诸如HCA（旗下拥有近180家医院）等全球大型营利性连锁医院运营商，营业利润率却十分可观（即便时常波动）。非盈利机构往往将盈余用于连锁扩张或提高员工薪酬。

Given this concentration, many experts are sceptical that transparency alone can rein in prices. Sherry Gleid of New York University observes that patients are often not price-sensitive. They are either in need of urgent care, with no time to shop around, or have insurance, and so pay a fraction of the full cost (often nothing beyond an annual out-of-pocket limit).

集中度如此之高，许多专家对仅凭监管透明就能有效限价表示怀疑。纽约大学谢里·格莱德（Sherry Gleid）研究表明，患者对价格因素通常并不敏感。他们要么因为急需治疗没空货比三家，要么因享受医保而满足于支付全额费用的一小部分（通常不会超过年度免赔额上限）。

Insurers, for their part, care less about prices because they now make more money by managing health plans for self-insured employers than by managing risk. They may even like to see inflation rise, since they can take a bigger cut from a bigger base. A well-intentioned Obamacare rule forces insurers to pay out at least 80% of their revenue from premiums. But by capping margins, it encourages raising revenue, not efficiency—and higher costs can be used to justify higher premiums.

就保险公司而言，他们更不在乎价格。因为现在为自保型雇主提供医疗计划比风险管理更赚钱。他们甚至更希望看到诊疗价格上涨，基数更高，他们能分得的提成也就越高。用心良苦的奥巴马医改要求保险公司的理赔支出必须至少占到保费收入的80%。但奥巴马医改限定了利润率，这也就变相鼓励提升收入而非提高效率；而医疗费用的增加又成了保费涨价的正当理由。

Others are more hopeful. Marty Makary of Johns Hopkins University, author of “The Price We Pay”, a new book about America’s health-care system, thinks that a small number of “proxy shoppers” can bring about powerful change once prices are revealed, even if most patients remain insensitive to prices. Dr Makary points out that in elective procedures like LASIK eye surgery, cosmetic surgery or in vitro fertilisation, which enjoy full transparency, “prices fall and quality rises each year just like in every normal market.”

其他人则对监管透明满怀希望。约翰·霍普金斯大学（Johns Hopkins University）教授，讲述美国医保体系的新书《我们所付出的代价》（”The Price We Pay”）的作者马蒂·马卡里（Marty Makary）认为，尽管大部分患者对医院诊疗价格仍不敏感，但哪怕只有很小一部分患者感知到价格透明的影响，就能给医疗业带来巨大的变革。医学博士马卡里还指出，诸如眼部激光、整容或体外人工受孕这类选择性手术的价格高度透明化，像其他正常市场一样运转，价格逐年下降，质量不断提高。

It is possible that prices may initially rise in some places as cheaper hospitals raise theirs once they realise how much peers in similar markets or pricier local rivals are earning. The Federal Trade Commission (FTC) has raised that troubling prospect—and hospitals have (self-servingly) echoed it. Hospital lobbyists report their clients are likely to sue the government over the new rules.

一旦那些价格较低的医院意识到其它医院或当地收费较高的竞争对手收入不菲时，他们也会开始提价。联邦贸易委员会（FTC）指出前景令人不安，医院（出于自身利益考量）也表达了同样的担扰。医疗游说团体报道称，医院很可能就医疗新规起诉政府。

Larry Levitt of the Kaiser Family Foundation, a health-care think-tank, worries that many hospitals will ignore the paltry $300 daily penalty for scofflaws as a cost of doing business. But, he says, Mr Azar’s second proposal, to force disclosure of prices insurers actually pay, may prove potent.

医疗智库凯撒家庭基金会（Kaiser Family Foundation）的拉里·莱维特（Larry Levitt）担心，很多医院为了牟利愿意支付每日300美元的违规罚金。但是他表示，阿扎尔的第二项提案——强制保险公司披露实际支付的金额，也许会奏效。

The cost of insurance is growing unbearable for many. Nearly 180m Americans, more than half the population, are covered by employer-provided health insurance. The average family’s premiums have shot up by 54% over the past decade, far outpacing wage growth, and employers are shifting more costs onto workers through ever higher out-of-pocket payments and deductibles. Reformers hope that by making real prices and out-of-pocket costs available upfront in simple language, patients can shop for non-emergency services. PWC, a consultancy, reckons these make up about half of all medical services by volume (though less by value).

日益增长的保险费用让许多人不堪重负。美国有近1.8亿人由雇主提供医疗保险，占总人口一半以上。在过去十年中，平均每个家庭的保险开支增长54%，远超工资增速。此外，雇主在不断提高员工的保险自费额度和免赔额上限，把更多的成本转嫁给员工。改革者希望，医院能以简明语言公示实际的医疗服务价格和自费费用，以便患者提前了解相关费用，选择非急诊类的服务。据咨询公司普华永道估算，从数量上来说，这种服务在所有医疗服务中约占二分之一，但从经济收益而言，其占比不到一半。

注：

Over-the-pocket: In the health care financing sector, this represents the share of the expenses that the insured party must pay directly to the health care provider, without a third-party (insurer, or government).

Why should hospital and insurance prices remain taboo, asks Dr Makary, when a corner of the health industry is already subject to strict transparency regulation? The Funeral Rule, enacted by theFTC in 1985, requires undertakers to provide itemised and detailed price data. What is good for the dead is surely good for the living.

医学博士马卡里医生质疑，医疗产业已有一个角落处于严格透明的监管之下，为何医疗服务价格和保险费用却依旧是禁区？1985年，美国联邦贸易委员会实施的《葬礼规则》规定，殡葬承办机构必须公示各项服务的价格明细。这种对逝者有益之举当更惠及生者。

翻译组：

Celine，女，英专，外应MA已录取

Emily，女，金融民工，经济学人粉丝

Hikali，女，英语小粉头，人生路口徘徊中

Elle, 女， 靠着土豆腿前行的small potato

校对组：

Humi，女，CATer，Catti二笔

Monica，女，第一名骨子里的理想主义者

Megan, 女，外事民工，热爱是唯一的信仰

Li Xia, 女， 我视英语为初恋，英语瞧我像备胎

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