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

翻译人员: Echo Sun 校对人员: Yolanda Zhang

It's 4am in the morning.

时间是凌晨四点。

I'm waking up in a Boston hotel room

我在波士顿一间 酒店的客房中醒来，

and can only think of one thing:

脑中只能想着一件事：

tooth pain.

牙痛。

One of my ceramic inlays fell off the evening before.

前一晚，我的一个瓷镶体脱落了。

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

五小时之后，我坐在牙科的椅子上。

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

但牙医并没有修复我的瓷镶体， 好让我脱离牙痛之苦，

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

反而在跟我推销 钛植牙手术的优点。

Ever heard of that?

有听过吗？

(Laughter)

（笑声）

It essentially means to replace a damaged tooth

基本上，就是要把一颗受损的牙齿

by an artificial one,

换成一颗人工牙齿，

that is screwed into your jaw.

用螺钉固定在你的下颌上。

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

植牙手术的估计花费 可能会高达一万美金。

Replacing the ceramic inlay I had before

但把我之前的瓷镶体换掉，

would come in at 100 US dollars.

只要大约一百美元。

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

到底是我的健康， 还是能从我身上赚到的钱，

that was the biggest concern for my dentist?

是我的牙医最先考虑的事？

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

结果发现，我的经历并非个案。

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

美国一家全国性报纸的研究指出， 在美国所有的手术当中，

up to 30 percent of all surgical procedures --

大约有三成——

including stent and pacemaker implantations,

包括支架和心律调节器植入、

hip replacements and uterus removals --

髋关节置换，及子宫移除——

were conducted

被实施，

although other nonsurgical treatment options had not been fully exploited

尽管其他非手术的 治疗方式尚未完全

by the physician in charge.

被其主治医生采用过。

Isn't that figure shocking?

那数字不是挺吓人的吗？

Numbers may be slightly different in other countries,

在其他国家，数字可能稍有不同，

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

但这意味着，如果你在美国看医生，

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

你有极大的可能性， 会在不立即需要手术的情况下

without there being an immediate need for it.

被要求进行手术治疗。

Why is this?

为什么会这样？

Why are some practitioners incentivized to run such unnecessary procedures?

为什么有些从业医生 会被鼓励去做这类不必要的手术？

Well, perhaps it is because health care systems themselves

也许是因为医疗体制本身，

incentivize in a nonideal way

用一种不尽理想的方式，

towards applying or not applying certain procedures or treatments.

鼓励采用，或不采用 某些手术或治疗。

As most health care systems reimburse practitioners

大部分的医疗系统 对从业医生的补助

in a fee-for-service-based fashion

是以按次付费的医疗费为基础的，

on the number and kind of treatments performed,

根据治疗的数量和类型来付款，

it may be this economic incentive that tempts some practitioners

可能就是这种经济上的奖励 诱使一些从业医生

to rather perform high-profit surgical treatments

选择采用高利润的手术治疗，

而不去寻求其他治疗方案。

instead of exploring other treatment options.

Although certain countries started to implement

虽然有些国家开始导入

performance-based reimbursement,

以绩效为基础的补助，

anchored on a quality and efficacy matrix,

综合考虑治疗的质量和效率，

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

整体来说，现今的医疗 系统结构中，很少会有某种方式，

to incentivize practitioners broadly

广泛鼓励开业医生

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

在一开始就主动预防疾病出现，

and to limit the procedures applied to a patient

并只对病人进行

to the most effective options.

效果最佳的手术。

So how do we fix this?

这问题要如何解决呢？

What it may take is a fundamental redesign

可能会需要从根本上重新设计

of our health care system's architecture --

我们的医疗系统结构——

a complete rethinking of the incentive structure.

完全重新思考激励性的结构。

What we may need is a health care system

我们需要把医疗系统的补助条件

that reimburses practitioners for keeping their customers healthy

改成是医生要保持其客户的健康，

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

而不是几乎只支付 已患病之后的治疗服务。

What we may need is a transformation

我们需要转变，

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

从现今主要的治疗疾病的体制，

to a system that cares for the healthy.

转变为预防疾病的体制。

To change our current "sick care" approach

把我们目前的“疾病诊治”方法，

into a true "health care" approach.

改变为真正“健康维护”方法。

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

这是一种示范性的转移， 从在大家生病之后才进行治疗，

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

变成在他们生病之前 努力维持他们的健康。

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

这种转移，可能会让 所有相关群体的焦点发生改变——

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

医生、医院、药厂， 及医疗器材公司——

on the product that this industry ultimately sells:

把重心转移到这个产业 最终要销售的产品上：

health.

健康。

Imagine the following.

想像以下情况。

What if we redesign our health care system

如果我们重新设计医疗系统，

into one that does not reimburse practitioners

这个系统不会对于病人

实际上执行的手术而补助从医者，

for the actual procedures performed on a patient

but rather reimburses doctors, hospitals,

而是让医生、医院、

pharmaceutical and medical companies

药厂，以及医疗器材公司，

for every day a single individual is kept healthy

确保每天每一个病人能健康无疾病，

and doesn't develop a disease?

就能得到补助？

In practical terms, we could, for example,

从实践的角度来说，比如，我们可以

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

用公款来支付健康费给保险公司，

for every day a single individual is kept healthy

只要每天每一个人能保持健康

and doesn't develop a disease

无疾病，

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

或是不需要任何 其他形式的急性医疗干预就付款。

If the individual becomes sick,

如果一个人生了病，

the insurance company will not receive any further monetary compensation

保险公司不会从治疗 所需要进行的医疗干预中

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

收到任何进一步的金钱补助，

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

他们反而有义务要支付 让客户恢复健康的治疗选择，

to return the customer back to health.

只要能够证明治疗的必要性。

Once the customer's healthy again,

一旦客户再次恢复健康，

the health fee for that individual will be paid again.

他们就会再次收到那个人的健康费。

In effect, all players in the system

实际上，在这个体制中的所有参与者

are now responsible for keeping their customers healthy,

现在都有责任要保持客户健康，

and they're incentivized to avoid any unnecessary medical interventions

他们若能避免不必要的 医疗干预，就能得到奖励，

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

只要做到减少生病的人数。

The more healthy people there are,

大家越健康，

the less the cost to treat the sick will be,

治疗疾病的成本就会越低，

and the higher the economic benefit for all parties being involved

而保持每位客户健康的相关各方，

in keeping these individuals healthy is.

也会有更高的经济利益。

This change of the incentive structure shifts, now,

将奖励结构做这种改变

the attention of the complete health care system

会转移整个医疗体制的注意力，

away from providing isolated and singular treatment options,

从专注在提供独立 且单一的治疗选择，

towards a holistic view of what is useful

转变成从整体的角度关注要做什么，

for an individual to stay healthy and live long.

才能让人保持健康和长寿。

Now, to effectively preserve health,

若要有效地保持健康，

people will need to be willing to share their health data

大家需要愿意，并且经常分享

on a constant basis,

他们的健康数据，

so that the health care system understands early enough

这么一来，医疗系统就能及时

if any assistance with regard to their health is needed.

了解大家保持健康 需要什么样的协助。

Physical examination,

体检、

monitoring of lifetime health data

监控终身健康数据，

as well as genetic sequencing, cardiometabolic profiling

还有DNA测序、心血管代谢分析，

以及成像相关的技术，

and imaging-based technologies

will allow customers to make,

会让客户配合健康教练

together with health coaches and general practitioners,

和广大从业医生，

optimal and science-guided decisions --

做出由科学引导的最佳决策——

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

包括饮食、用药， 以及身体活动相关的决策——

to diminish their unique probability

以降低每个人得到

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

每种可认定的高风险疾病的机率。

Artificial intelligence-based data analysis

以人工智能为基础的数据分析

and the miniaturization of sensor technologies

以及传感器技术的微型化，

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

已经开始让监控 个人健康状况成为可能。

Measuring cardiometabolic parameters by devices like this

用像这样的装置来 测量心血管代谢参数，

or the detection of circulating tumor DNA in your bloodstream

或赶在癌症袭击之前 就先检测你的血液中

early on after cancer disease onset

有无血液循环肿瘤DNA，

只是这类监控技术的 两个例子而已。

are only two examples for such monitoring technologies.

Take cancer.

比如癌症。

One of the biggest problems in certain oncological diseases

（治疗）某些肿瘤疾病遇到 最大的问题之一，

is that a large number of patients is diagnosed too late

就是太多病人都太晚才确诊，

to allow them to be cured,

已经来不及治愈，

although the drugs and treatments that could potentially have cured them

尽管现今已经有些 药品和治疗手段

are already existing today,

有可能治愈他们，

if the disease had only been detected earlier.

只要疾病能更早被筛查出来。

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

最新的技术已经能 根据几毫升的血液

to detect the presence of circulating tumor DNA

检测出是否有 血液循环肿瘤DNA，

and thus, the presence of cancer,

因此，在早期就能用

early on in a really convenient manner.

很方便的方式检测出癌症。

The impact that this early-stage detection can have

这种早期检测会造成的影响

may be dramatic.

是非常巨大的。

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

非小细胞肺癌的五年存活率，

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

如果在第一期，也就是很早期 就诊断出来，五年存活率是49%。

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

如果在第四期， 也就是晚期才诊断出来，

is below one percent.

五年存活率就不到1%。

Being potentially able to prevent a large number of deaths

只要用很简单的东西， 比如血液循环肿瘤DNA的血液检测，

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

就有可能防止许多人因此丧命，

could make certain cancer types a manageable disease,

它能让某些类型的 癌症变成可以控制的疾病，

as disease onset can be detected earlier

疾病的发生能及早被检测出来，

and positive treatment outcomes can likely be increased.

因此也更可能会有正面的治疗结果。

In 2012,

2012年，

50 percent of all Americans had a single chronic disease,

有50%的美国人得了单一种慢性病，

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

导致美国三万亿美元的 医疗预算中有86%

being spent for treating such chronic diseases.

花在治疗这类慢性病上。

Eighty-six percent.

86%。

If new technologies allow now to reduce this 86 percent,

如果新技术能减低这86%，

why have health care systems not reacted and changed already?

为什么医疗体系 还没有做出应对和改变？

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

要把现今的疾病治疗体系

into a true health care system that focuses on prevention

重新设计成真正的 聚焦在预防和行为改变上的

and behavioral changes

预防性医疗体系，

requires every actor in the system to change.

这需要体制中的 每个行为者都做出改变。

It requires the political willingness to shift budgets and policies

这也需要政治意愿将预算和政策

towards prevention and health education

转向预防和健康教育，

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

来设计一组新的经济 和非经济上的奖励方式。

It requires creating a regulatory framework

这就需要创造一个规范的构架，

for the gathering, using and sharing of personal health data

来收集、使用和分享个人健康数据，

严格且合理的规范构架。

that's at the same time stringent and sensible.

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

这需要医生、医院、保险从业者、 药厂，以及医疗器材公司

to reframe their approach and, most important,

重新调整他们的方法， 而且，最重要的是，

it can't happen without the willingness and motivation

这件事若要成真， 需要依靠每个人都有

of individuals to change their lifestyle in a sustained way,

意愿和动机去改变他们的 生活方式，变得更可持续，

to prioritize staying healthy,

把保持健康列为优先事项，

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

此外还要能开放地 经常分享健康数据。

This change may not come overnight.

这种改变不会一夕成真。

But by refocusing the incentives within the health care industry today

但现在就行动，在医疗产业中 将奖励的焦点转变为

to actively keep people healthy,

主动保持民众健康，

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

我们不但能在一开始 就先预防更多的疾病，

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

也能够检测出 某些可预防之疾病的发生，

earlier than we do today,

且比现今能做到的更早，

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

这就会让更多人 能更长寿、更健康。

Most of the technologies that we need to initiate that change

要开始这项改变， 我们所需要的技术

大多已经存在了。

are already existing today.

But this is not a technology question.

但这不是个技术问题。

It is primarily a question of vision

根本上讲，这是个远见，

and will.

以及意愿的问题。

Thanks a lot.

非常感谢。

(Applause)

（掌声）