US and China Health Reform Paths
中美医疗改革之路
Presented by
Jackson Tung, Ph.D.
董晓侬博士
December 15, 2010
US Health Care Spending
美国医疗卫生投入
• Total 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）
• Health 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 nation‘s total health
care bill by 2015 will be more 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。）
Three Main Parties in Health Care
医疗卫生中的三方主体
Payer
支付方
Service
Provider
服务提供方
Patient/
people
患者/人
Providers
服务提供方
•
•
•
•
•
Doctors（医生）
Hospitals（医院）
Laboratories（实验室）
Pharmacies（药店）
Pharmaceutical Companies
(formularies)制药商（处方）
• Home care and other specialty
care（家庭保健和其他专业保健）
What Do Providers Do?
服务提供者的工作
• Family doctors: maintain one-to-one relationship
with patients. Mostly through outpatient office visits.
家庭医生：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。
Patient/people（患者/人民）
Choose health insurance programs.（选择医疗保险项目）
 Most 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）
 Consider 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 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。）
What Do People/Patients Do?
人民/患者的工作
• 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
patient.
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）
Payers（支付者）
• Government: Medicare and state Medicaid
programs（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）
What Do Payers Do?
支付方的工作
• Pay 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。
When Health Insurance Companies
Compete – People/patient Benefit
医疗保险公司的竞争-人/患者利益
• What 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
Health Insurance Companies Keep
Provider Costs Down
医疗保险公司把服务提供方的费用降到最低
• Physician contracting（医生契约）
• Hospital contracting（医院契约）
• Pharmaceutical company contracting
(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
Three Main Parties in Health Care
医疗卫生中的三方主体
Payer
支付方
Service
Provider
服务提供方
Patient/
people
患者/人
Competition after Privatization
私营下的竞争
• 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A\B\C保险公司）
• Each market must have multiple Provider 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）
Medicare and Medicaid
医疗保险和公共医疗补助
• 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 decade,
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
to $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）
Differences between Health Insurance
and National Health Plan
医疗保险和全民医保的差异
• 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 entitlement
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）
Why Do We Need Health Insurance?
为什么我们需要医疗保险？
High cost at unpredictable
frequency – spread risk
over a large population.
（不可预测的频率下产生的
高费用-大众分摊风险）
80-20 rule – 80% of the health
expense occur during 20% of
the age span (old age).（八二
开原则：在20%的时间中耗费
了80%的医疗支出）
Current money (insurance premium) for current needs – not a
longitudinal savings concept.（当前需求由当前的钱（保险金）
支付-不是存款的理念）
What is a Reform?
改革是什么？
• 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）
• China’s reform effort must have “built-in”
anti-corruption component.（中国医疗改革须
纳入反腐败部分）
US Health Care Reform Map
美国医疗改革图
National Health Care
Proponents 赞成方
• People
全民医疗
人民
• Businesses 商家
• Government 政府
Obstacles 阻碍方
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
• Current stakeholders
who stand to lose
既得利益者遭受损失
Timeline of Obama Care
奥巴马医疗改革的时间表
2013 - 2014
2010 - 2011
• 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
China’s Health Reform Efforts
中国医疗改革的过程
• China had government paid health care for most
people prior 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 involved
several failed reform attempts.（与市场经济相关的几
种改革尝试是绕弯路）
Chinese Health Care Reform Map
中国医疗改革图
National Health Care
全民医疗
Obstacles: 阻碍方：
• Corruption
腐败
Proponents
• People
• Government
赞成方
人民
政府
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
Desired VS Actual Outcomes
期望vs实际结果
Desired期望
Actual结果
• Privatization of
• Providers increase
providers to improve
charges to patients（服
efficiency（服务提供方
务提供者提价）
私营化以提高效率）
• Pharmaceutical
• Price control of
companies stopped
common drugs to
producing price
reduce drug cost（常用
controlled drugs.（制药
商不生产控价药品）
药物价格控制以减少药品
费用）
• Prescription drug
• Established prescription
system became the
drug system to improve
basis for drug kickback
to hospitals or doctors.
drug safety（建立药物处
方系统以提高药品安全）
（药物处方系统成了医院
或医生拿回扣的根据）
Bottom-line Issues
最基本的问题
• Is the USA’s 3rd party payer system a good
corruption fighter for China’s health reform?
（对于中国医疗改革，美国的三方制衡体系是否
能有力地打击腐败？)
• If yes. Is it worth the price (adding 10 to 15%
of the health care cost) to pay?如果是，增加
投入是否划算（增加了10%至15%的医疗投入）
• Should we ignore the corruption issue and
model after Canada or an European system?
（我们是否应该忽略腐败问题，而建立加拿大或
者欧洲模式？）
Government Regulations
政府政策法规
• Insurance business must be highly regulated
(reserves and profits).（保险业务必须高度管制-储
量和利润）
• Standardize quality measures.（质量检验标准化）
• Standardize reporting measures.（报告评估标准
化）
• Prohibition of “corporate management of
medicine.”（“行政不干涉医疗”的禁令）
• Administer public health and other social
medicine projects.（推行公共健康与其他社会医疗
项目）
Thank you.
Jackson Tung, Ph.D.
tungjackson@gmail.com