What if we paid doctors to keep people healthy? | Matthias Müllenbeck

Prevoditelj: Izidora Zganjer Recezent: Sanda L

It's 4am in the morning.

Četiri su sata ujutro.

I'm waking up in a Boston hotel room

Budim se u bostonskoj hotelskoj sobi

and can only think of one thing:

i mogu razmišljati o samo jednoj stvari:

tooth pain.

zubobolji.

One of my ceramic inlays fell off the evening before.

Keramički umetak mi je ispao noć prije.

Five hours later, I'm sitting in a dentist's chair.

Pet sati kasnije, sjedim u zubarskoj stolici.

But instead of having a repair of my inlay so that I can get rid of my pain,

Ali, umjesto da mi popravi umetak tako da me prestane boljeti,

the dentist pitches me on the advantages of a titanium implant surgery.

zubar me informira o prednostima ugradnje titanskih implantata.

Ever heard of that?

Jeste li ikada čuli za to?

(Laughter)

(Smijeh)

It essentially means to replace a damaged tooth

To u praksi znači zamjenu oštećenog zuba

by an artificial one,

umjetnim zubom,

that is screwed into your jaw.

koji se učvršćuje u vašu čeljust.

Estimated costs for the implant surgery may add up to 10,000 US dollars.

Procijenjeni trošak operacije ugradnje može doseći do 10.000 US dolara.

Replacing the ceramic inlay I had before

Zamjena keramičkog umetka kakvog sam imao

would come in at 100 US dollars.

bi bila do 100 US dolara.

Was it my health or the money that could be earned with me

Je li moje zdravlje ili novac koji bi mogao zaraditi na meni

that was the biggest concern for my dentist?

bilo ono što je brinulo moga zubara?

As it turned out, my experience wasn't an isolated case.

Ali, ispada da moje iskustvo nije iznimka.

A study by a US national newspaper estimated that in the United States,

Istraživanje jednih američkih novina je procijenilo da je u SAD-u

up to 30 percent of all surgical procedures --

do 30 posto svih operacija,

including stent and pacemaker implantations,

uključujući ugradnje stenta i pacemakera,

hip replacements and uterus removals --

zamjene kuka i odstranjenja maternice,

were conducted

izvedeno

although other nonsurgical treatment options had not been fully exploited

iako drugi nekirurški tretmani nisu bili do kraja iskorišteni

by the physician in charge.

od strane odgovornog liječnika.

Isn't that figure shocking?

Zar nije taj postotak šokantan?

Numbers may be slightly different in other countries,

Brojevi se mogu malo razlikovati u drugim zemljama,

but what it means is that if you go to a doctor in the US,

ali to znači da ako idete liječniku u SAD-u,

you have a not-insignificant chance to be subjected to a surgical intervention

velike su šanse da će vam se nuditi operacija,

without there being an immediate need for it.

iako ne postoji nasušna potreba za time.

Why is this?

Zašto je to tako?

Why are some practitioners incentivized to run such unnecessary procedures?

Zašto se neke liječnike potiče na nepotrebne operacije?

Well, perhaps it is because health care systems themselves

Možda se radi o tome da sam zdravstveni sustav

incentivize in a nonideal way

potiče, na neidealan način,

towards applying or not applying certain procedures or treatments.

primjenu ili neprimjenu određenih postupaka ili tretmana.

As most health care systems reimburse practitioners

Kako većina zdravstvenih sustava nagrađuje liječnike

in a fee-for-service-based fashion

u smislu naknade za uslugu,

on the number and kind of treatments performed,

baziranu na broju i vrsti izvedenih zahvata,

it may be this economic incentive that tempts some practitioners

možda taj ekonomski poticaj dovodi u napast neke liječnike

to rather perform high-profit surgical treatments

da radije provode visoko profitne kirurške tretmane,

instead of exploring other treatment options.

umjesto da istražuju neke druge opcije.

Although certain countries started to implement

Iako su neke zemlje počele uvoditi

performance-based reimbursement,

naknadu prema izvedbi,

anchored on a quality and efficacy matrix,

koja se temelji na kvaliteti i učinkovitosti,

overall, there's very little in today's health care systems' architecture

zapravo, malo toga u današnjem zdravstvenom sustavu

to incentivize practitioners broadly

zaista potiče liječnike

to actively prevent the appearance of a disease in the first place

da prvenstveno aktivno sprečavaju pojavu bolesti

and to limit the procedures applied to a patient

i ograniče zahvate koje će primjenjivati na pacijentu,

to the most effective options.

koristeći najučinkovitije opcije.

So how do we fix this?

Kako ćemo to popraviti?

What it may take is a fundamental redesign

Potrebna je temeljita reforma

of our health care system's architecture --

strukture našeg zdravstvenog sustava -

a complete rethinking of the incentive structure.

potpuna promjena razmišljanja u strukturi naknada.

What we may need is a health care system

Ono što nam treba je zdravstveni sustav

that reimburses practitioners for keeping their customers healthy

koji daje naknadu liječnicima koji održavaju svoje pacijente zdravima,

instead of almost only paying for services once people are already sick.

umjesto plaćanja njihove usluge kada se ljudi razbole.

What we may need is a transformation

Potrebna nam je promjena

from today's system that largely cares for the sick,

današnjeg sustava koji se najviše brine za bolesne,

to a system that cares for the healthy.

ka sustavu koji se brine za zdrave.

To change our current "sick care" approach

Promijeniti sadašnji "bolesni" pristup

into a true "health care" approach.

u istinski "zdravstveni" pristup.

It is a paradigm shift from treating people once they have become sick

To je promjena paradigme od liječenja ljudi kada postanu bolesni,

to preserving the health of the healthy before they get sick.

u očuvanje zdravlja zdrave osobe prije nego oboli.

This shift may move the focus of all those involved --

Ta promjena će pomaknuti fokus svih sudionika,

from doctors, to hospitals, to pharmaceutical and medical companies --

od liječnika do bolnica, farmaceutskih i medicinskih kompanija,

on the product that this industry ultimately sells:

na proizvod koji ta industrija zapravo prodaje:

health.

zdravlje.

Imagine the following.

Zamislite sljedeće.

What if we redesign our health care system

Što ako reformiramo naš zdravstveni sustav

into one that does not reimburse practitioners

u takav koji ne nagrađuje liječnike

for the actual procedures performed on a patient

za operacije provedene na pacijentima,

but rather reimburses doctors, hospitals,

nego nagrađuje liječnike, bolnice,

pharmaceutical and medical companies

farmaceutske i medicinske kompanije

for every day a single individual is kept healthy

za svaki dan u kojem je pojedinac ostao zdrav

and doesn't develop a disease?

i koji ne oboli?

In practical terms, we could, for example,

Praktično, mogli bismo, na primjer,

use public money to pay a health fee to an insurance company

koristiti javni novac kako bismo platili naknadu osiguravajućem društvu

for every day a single individual is kept healthy

za svaki dan u kojem je pojedinac ostao zdrav

and doesn't develop a disease

i nije obolio,

or doesn't require any other form of acute medical intervention.

ili mu nije potrebna nikakva hitna medicinska intervencija.

If the individual becomes sick,

Ako se pojedinac razboli

the insurance company will not receive any further monetary compensation

osiguravajuće društvo neće dobiti novčanu nadoknadu

for the medical interventions required to treat the disease of that individual,

za medicinsku intervenciju koja je potrebna za liječenje bolesti,

but they would be obliged to pay for every evidence-based treatment option

nego će morati platiti za svaki dokazano potreban tretman,

to return the customer back to health.

kako bi klijent bio ponovno zdrav.

Once the customer's healthy again,

Kada je klijent ponovno zdrav,

the health fee for that individual will be paid again.

naknada za zdravlje će se ponovno plaćati.

In effect, all players in the system

Zapravo, svi su igrači u sustavu

are now responsible for keeping their customers healthy,

odgovorni za održavanje svojih klijenata zdravima

and they're incentivized to avoid any unnecessary medical interventions

i izbjegavaju se nepotrebne medicinske intervencije,

by simply reducing the number of people that eventually become sick.

jer se jednostavno smanjuje broj ljudi koji obolijevaju.

The more healthy people there are,

Što je više zdravih ljudi,

the less the cost to treat the sick will be,

manji će biti trošak liječenja,

and the higher the economic benefit for all parties being involved

a veća ekonomska dobit svih uključenih strana

in keeping these individuals healthy is.

u očuvanju zdravlja pojedinca.

This change of the incentive structure shifts, now,

Ova promjena strukture poticaja

the attention of the complete health care system

odvlači pozornost cijelog zdravstvenog sustava

away from providing isolated and singular treatment options,

od izoliranih i pojedinačnih postupaka,

towards a holistic view of what is useful

ka holističkom pogledu što je korisno

for an individual to stay healthy and live long.

za pojedinca da bi bio zdrav i dugo živio.

Now, to effectively preserve health,

Kako bi učinkovito očuvali zdravlje,

people will need to be willing to share their health data

ljudi bi trebali biti voljni dijeliti svoje zdravstvene podatke

on a constant basis,

na svakodnevnoj bazi,

so that the health care system understands early enough

kako bi zdravstveni sustav razumio dovoljno rano

if any assistance with regard to their health is needed.

je li potrebno učiniti nešto po pitanju njihovog zdravlja.

Physical examination,

Fizički pregledi,

monitoring of lifetime health data

praćenje zdravstvenih podataka za životnog vijeka,

as well as genetic sequencing, cardiometabolic profiling

kao i genetičko sekvenciranje, kardio-metaboličko profiliranje

and imaging-based technologies

i tehnologije bazirane na skeniranju,

will allow customers to make,

omogućit će klijentima da donesu,

together with health coaches and general practitioners,

zajedno sa zdravstvenim trenerima i liječnicima opće prakse,

optimal and science-guided decisions --

optimalne i znanstveno vođene odluke

for their diet, their medication and their physical activity --

za način prehrane, lijekove i fizičku aktivnost,

to diminish their unique probability

kako bi smanjili vjerojatnost

to fall sick of an identified, individual high-risk disease.

oboljenja od bolesti za koju postoji visoki rizik.

Analiza podataka temeljena na umjetnoj inteligenciji

Artificial intelligence-based data analysis

and the miniaturization of sensor technologies

i smanjenje senzornih tehnologija

are already starting to make monitoring of the individual health status possible.

već počinju promatrati zdravstveni status pojednica.

Measuring cardiometabolic parameters by devices like this

Mjerenje kardio-metaboličkih parametara uređajima kao što je ovaj,

or the detection of circulating tumor DNA in your bloodstream

ili otkrivanje cirkulirajuće tumorske DNA u vašem krvotoku

early on after cancer disease onset

dovoljno rano u početnoj fazi raka,

are only two examples for such monitoring technologies.

samo su dva primjera takvih tehnologija.

Take cancer.

Primjerice rak.

One of the biggest problems in certain oncological diseases

Jedan od najvećih problema kod nekih onkoloških bolesti

is that a large number of patients is diagnosed too late

je velik broj pacijenata kojima su dijagnoze postavljene prekasno

to allow them to be cured,

da bi ih se izliječilo,

although the drugs and treatments that could potentially have cured them

iako danas već postoje lijekovi i tretmani

are already existing today,

kojima bi ozdravili,

if the disease had only been detected earlier.

da je bolest dijagnosticirana ranije.

New technologies allow now, based on a few milliliters of blood,

Nove tehnologije omogućuju, na temelju nekoliko mililitara krvi,

to detect the presence of circulating tumor DNA

otkrivanje prisutnosti cirkulirajuće tumorske DNA

and thus, the presence of cancer,

i time, prisutnost raka

early on in a really convenient manner.

dovoljno rano na prikladan način.

The impact that this early-stage detection can have

Utjecaj koji ovakvo rano dijagnosticiranje može imati,

may be dramatic.

može biti dramatičan.

The five-year survival rate for non-small cell lung cancer

Petogodišnja stopa preživljavanja za rak pluća ne-malih stanica,

when diagnosed at stage one, which is early, is 49 percent.

ako je dijagnosticiran u prvoj fazi, što je vrlo rano, iznosi 49 posto.

The same, when diagnosed at stage four, which is late,

Za isti tip raka, ako je dijagnosticiran u četvrtoj fazi, što je kasno,

is below one percent.

stopa je ispod jedan posto.

Being potentially able to prevent a large number of deaths

Mogućnost sprečavanja velikog broja smrti

by something as simple as a blood test for circulating tumor DNA

jednostavnom pretragom krvi na cirkulirajuću tumorsku DNA,

could make certain cancer types a manageable disease,

neke bi tipove raka pretvorilo u bolesti koje se mogu nadzirati,

as disease onset can be detected earlier

jer se početak bolesti može rano uočiti

and positive treatment outcomes can likely be increased.

i pozitivan učinak tretmana će vrlo vjerojatno biti veći.

In 2012,

2012. godine

50 percent of all Americans had a single chronic disease,

50 posto Amerikanaca je imalo neku kroničnu bolest,

resulting in 86 percent of the $3 trillion US health care budget

što znači da je 86 posto zdravstvenog budžeta od 3 trilijuna dolara

being spent for treating such chronic diseases.

potrošeno na liječenje takvih kroničnih bolesti.

Eighty-six percent.

Osamdeset i šest posto.

If new technologies allow now to reduce this 86 percent,

Ako nove tehnologije danas omogućuju da se tih 86 posto smanji,

why have health care systems not reacted and changed already?

zašto zdravstveni sustavi već nisu reagirali i promijenili se?

Well, a redesign of what today is a sick care system

Zato jer reforma današnjeg bolesnog sustava

into a true health care system that focuses on prevention

u pravi zdravstveni sustav, čiji je fokus na prevenciji

and behavioral changes

i promjenama ponašanja,

requires every actor in the system to change.

zahtjeva od svakog sudionika u sustavu da se mijenja.

It requires the political willingness to shift budgets and policies

Zahtjeva političku volju za promjenama u budžetu i pravilima,

towards prevention and health education

ka prevenciji i zdravstvenom obrazovanju,

to design a new set of financial and non-financial incentives.

kako bi se stvorili novi financijski i nefinancijski poticaji.

It requires creating a regulatory framework

Zahtijeva kreiranje okvira pravila

for the gathering, using and sharing of personal health data

za prikupljanje, korištenje i dijeljenje osobnih zdravstvenih podataka

that's at the same time stringent and sensible.

koja su istovremeno stroga i razumna.

It needs doctors, hospitals, insurers, pharmaceutical and medical companies

Od liječnika, bolnica, osiguravatelja, farmaceutskih i medicinskih kompanija

to reframe their approach and, most important,

zahtijeva promjenu u pristupu i, što je najvažnije,

it can't happen without the willingness and motivation

ne može se dogoditi bez volje i motivacije pojedinaca

of individuals to change their lifestyle in a sustained way,

da promijene svoj stil života u održiv način,

to prioritize staying healthy,

da im prioritet bude da ostanu zdravi,

in addition to opening up for sharing the health data on a constant basis.

uz to da budu otvoreni za dijeljenje zdravstvenih podataka na dnevnoj bazi.

This change may not come overnight.

Ta promjena se neće dogoditi preko noći.

But by refocusing the incentives within the health care industry today

Ali promjenom poticaja u današnjoj zdravstvenoj industriji

to actively keep people healthy,

na to da ljude održimo zdravima,

we may not only be able to prevent more diseases in the first place

nećemo samo prvenstveno spriječiti više bolesti,

but we may also be able to detect the onset of certain preventable diseases

već bismo mogli otkriti početak nekih bolesti koje se mogu izbjeći,

earlier than we do today,

ranije nego što to uspijevamo danas,

which will lead to longer and healthier lives for more people.

što će voditi dužem i zdravijem životu ljudi.

Most of the technologies that we need to initiate that change

Većina tehnologija koje su nam za tu promjenu potrebne

are already existing today.

postoje već danas.

But this is not a technology question.

Ali nije problem u tehnologiji.

It is primarily a question of vision

To je prvenstveno pitanje vizije

and will.

i volje.

Thanks a lot.

Hvala vam puno.

(Applause)

(Pljesak)