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

譯者: Lilian Chiu 審譯者: Marssi Draw

It's 4am in the morning.

時間是早上四點。

I'm waking up in a Boston hotel room

我在波士頓一間飯店的房間中醒來，

and can only think of one thing:

腦中只能想著一件事：

tooth pain.

牙痛。

One of my ceramic inlays fell off the evening before.

前晚，我的其中一個瓷鑲體脫落了。

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

五小時之後，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,

但牙醫師並沒有修復我的瓷鑲體 好讓我脫離牙痛之苦，

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

反而在跟我推銷鈦植牙手術的優點。

Ever heard of that?

有聽過嗎？

(Laughter)

（笑聲）

It essentially means to replace a damaged tooth

基本上，就是要把一顆受損的牙齒

by an artificial one,

換成一顆人工牙齒，

that is screwed into your jaw.

用螺釘固定在你的下頜上。

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

植牙手術的估計成本 可能會高達一萬美金。

Replacing the ceramic inlay I had before

把我之前的瓷鑲體換掉，

would come in at 100 US dollars.

只要大約一百美元。

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

到底是我的健康， 還是能從我身上賺到的錢，

that was the biggest concern for my dentist?

是我的牙醫最先考量的事？

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

結果發現，我的經歷並非單一個案。

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

美國一間報社的研究指出

在美國所有的手術當中 估計有三成──

up to 30 percent of all surgical procedures --

including stent and pacemaker implantations,

包括支架和心律調節器植入、

hip replacements and uterus removals --

髖關節置換，及子宮移除──

were conducted

被執行，

although other nonsurgical treatment options had not been fully exploited

儘管其他非手術的治療方式

尚未完全被其主治醫生利用過。

by the physician in charge.

Isn't that figure shocking?

那數字不是挺嚇人的嗎？

Numbers may be slightly different in other countries,

在其他國家，數字可能稍有不同，

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

但這意味著，如果你在美國看醫生，

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

你有顯著的可能性， 會在不立即需要手術的情況下

without there being an immediate need for it.

就去接受手術治療。

Why is this?

為什麼會這樣？

Why are some practitioners incentivized to run such unnecessary procedures?

為什麼有些開業醫生會被獎勵 去做這類不必要的手術？

Well, perhaps it is because health care systems themselves

也許是因為健康照護體制本身，

incentivize in a nonideal way

用一種不盡理想的方式，

towards applying or not applying certain procedures or treatments.

鼓勵採用／不採用某些手術或治療。

As most health care systems reimburse practitioners

大部分的健康照護體制 對開業醫生的補助

in a fee-for-service-based fashion

是以一次一付的醫療費為基礎的，

on the number and kind of treatments performed,

根據所進行之治療的 數量和類型來給付，

it may be this economic incentive that tempts some practitioners

可能就是這種經濟獎勵 誘使一些開業醫生

to rather perform high-profit surgical treatments

選擇採用高利潤的手術治療，

instead of exploring other treatment options.

而不去尋求其他治療選擇。

Although certain countries started to implement

雖然有些國家開始導入

performance-based reimbursement,

以績效為基礎的補助，

anchored on a quality and efficacy matrix,

根據的是品質和功效的矩陣，

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

整體來說，現今的健康照護體制 結構中，很少會有這種方式，

to incentivize practitioners broadly

廣泛鼓勵開業醫生

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

在一開始就主動去預防疾病出現，

and to limit the procedures applied to a patient

並只對病人進行

能達到最大效用的手術。

to the most effective options.

So how do we fix this?

這問題要如何解決？

What it may take is a fundamental redesign

可能會需要從根本上重新設計

of our health care system's architecture --

我們的健康照護體制結構──

a complete rethinking of the incentive structure.

完全重新思考鼓勵結構。

What we may need is a health care system

我們需要把健康照護體制的報銷條件

that reimburses practitioners for keeping their customers healthy

改成是醫生要保持其客戶的健康，

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

而不是幾乎只支付 已病之後的治療服務。

What we may need is a transformation

我們得要轉變，

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

從現今主要在照護病人的體制，

to a system that cares for the healthy.

轉變為照護健康的體制。

To change our current "sick care" approach

把我們目前的「生病照護」方法，

into a true "health care" approach.

改變為真正的「健康照護」方法。

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

這是一種典範轉移， 從在大家生病之後才進行治療，

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

變成在他們生病之前 就維持他們的健康。

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

這種轉移，可能會讓所有 相關人士的焦點改變──

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

醫生、醫院、藥廠， 及醫療器材公司──

on the product that this industry ultimately sells:

把重心改放到這個產業 最終要銷售的產品上：

health.

健康。

Imagine the following.

想像以下情況。

What if we redesign our health care system

如果我們重新設計健康照護體制，

into one that does not reimburse practitioners

這個體制不會補助開業醫生

for the actual procedures performed on a patient

對於病人實際上執行的手術，

but rather reimburses doctors, hospitals,

而是補助醫生、醫院、

pharmaceutical and medical companies

藥廠，以及醫療器材公司，

for every day a single individual is kept healthy

每天每一個病人能保持健康無疾病，

and doesn't develop a disease?

就能得到補助？

In practical terms, we could, for example,

就實際面來說，比如，我們可以

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

用公款來支付健康費給保險公司，

for every day a single individual is kept healthy

只要每天每一個人能保持健康

and doesn't develop a disease

無疾病，

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

或是不需要任何其他形式的 急性醫療干預就付款。

If the individual becomes sick,

如果一個人生了病，

the insurance company will not receive any further monetary compensation

保險公司不會從治療這個人之疾病 所需要進行的醫療干預

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

收到任何進一步的金錢補助，

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

他們反而有義務要支付 讓客戶恢復健康的治療選擇，

to return the customer back to health.

只要有證據佐證治療的必要性。

Once the customer's healthy again,

一旦客戶再次恢復健康，

the health fee for that individual will be paid again.

他們就會再次收到那個人的健康費。

In effect, all players in the system

實際上，在這個體制中的所有參與者

are now responsible for keeping their customers healthy,

現在都有責任要保持客戶健康，

and they're incentivized to avoid any unnecessary medical interventions

他們若能避免不必要的 醫療干預，就能得到獎勵，

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

只要做到減少生病的人數。

The more healthy people there are,

大家越健康，

the less the cost to treat the sick will be,

治療疾病的成本就會越低，

and the higher the economic benefit for all parties being involved

而保持每位客戶健康的相關各方，

in keeping these individuals healthy is.

也會有更高的經濟利益。

This change of the incentive structure shifts, now,

將獎勵結構做這種改變，

the attention of the complete health care system

會轉移整個健康照護體制的注意力，

away from providing isolated and singular treatment options,

從專注在提供獨立 且單一的治療選擇，

towards a holistic view of what is useful

轉變成「全人視角」， 關注的是要做什麼

for an individual to stay healthy and live long.

才能讓人保持健康和長壽。

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

大家得要願意分享他們的健康資料，

on a constant basis,

且要經常分享，

so that the health care system understands early enough

這麼一來，健康照護體制 就能在夠早的時間點

if any assistance with regard to their health is needed.

去了解大家的健康 需要什麼樣的協助。

Physical examination,

健康檢查、

monitoring of lifetime health data

監控終身健康資料，

as well as genetic sequencing, cardiometabolic profiling

還有 DNA 定序、心血管代謝側寫，

and imaging-based technologies

以及成像相關的技術，

will allow customers to make,

會讓客戶配合健康教練

together with health coaches and general practitioners,

和一般開業醫生

optimal and science-guided decisions --

做出由科學所引導的最佳決策──

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

包括飲食、用藥，以及 身體活動相關的決策──

to diminish their unique probability

以降低每個人得到

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

每種可辨視之高風險疾病的機率。

Artificial intelligence-based data analysis

以人工智慧為基礎的資料分析

and the miniaturization of sensor technologies

以及感測器技術的微型化，

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

已經開始讓監控 個人健康狀況成為可能。

Measuring cardiometabolic parameters by devices like this

用像這樣的裝置來 測量心血管代謝參數，

or the detection of circulating tumor DNA in your bloodstream

或及早在癌症襲擊之前 就先偵測你的血液中

early on after cancer disease onset

有無血液循環腫瘤 DNA，

are only two examples for such monitoring technologies.

只是這類監控技術的兩個例子而已。

Take cancer.

比如癌症。

One of the biggest problems in certain oncological diseases

某些腫瘤疾病遇到最大的問題之一，

is that a large number of patients is diagnosed too late

就是太多病人都太晚才被診斷出來，

to allow them to be cured,

已經來不及治癒，

although the drugs and treatments that could potentially have cured them

儘管現今已經有些藥品和治療

are already existing today,

有可能治癒他們，

if the disease had only been detected earlier.

只要疾病能更早被偵測出來。

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

現在的新技術已經 能根據幾毫升的血液

to detect the presence of circulating tumor DNA

偵測出是否有血液循環腫瘤 DNA，

and thus, the presence of cancer,

因此，在早期就能用

early on in a really convenient manner.

很方便的方式偵測出癌症。

The impact that this early-stage detection can have

這種早期偵測會造成的影響

may be dramatic.

是非常巨大的。

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

非小細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 就診斷出來，五年存活率是 49%。

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

如果在第四期， 也就是很晚期才診斷出來，

is below one percent.

五年存活率是就不到 1%。

Being potentially able to prevent a large number of deaths

只要用很簡單的東西，像是 血液循環腫瘤 DNA 的血液檢測，

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

就有可能預防許多人喪命，

could make certain cancer types a manageable disease,

它能讓某些類型的癌症 變成可以控管的疾病，

as disease onset can be detected earlier

疾病的攻擊能及早被偵測出來，

and positive treatment outcomes can likely be increased.

因此也更可能會有正面的治療結果。

In 2012,

2012 年，

50 percent of all Americans had a single chronic disease,

有 50% 的美國人 得了單一種慢性病，

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

導致美國的三兆美元 健康照護預算有 86%

being spent for treating such chronic diseases.

花在治療這類慢性病上。

Eighty-six percent.

86%。

If new technologies allow now to reduce this 86 percent,

如果新技術能減低這 86%，

why have health care systems not reacted and changed already?

為什麼健康照護體制 還沒有反應和改變？

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

要把現今的生病照護體制

into a true health care system that focuses on prevention

重新設計成真正的健康照護體制，

需要把焦點放在預防和行為改變上，

and behavioral changes

requires every actor in the system to change.

這需要體制中的 每個行為者都做出改變。

It requires the political willingness to shift budgets and policies

這也需要政治意願，

將預算和政策轉向預防和健康教育，

towards prevention and health education

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

來設計一組新的財務 和非財務獎勵方式。

It requires creating a regulatory framework

這就需要創造一個規範的架構，

for the gathering, using and sharing of personal health data

來收集、使用和分享個人健康資料，

that's at the same time stringent and sensible.

既嚴格且合理的規範架構。

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

這需要醫生、醫院、保險業者、 藥廠，以及醫療器材公司

to reframe their approach and, most important,

重新調整他們的方法， 然後，最重要的是，

it can't happen without the willingness and motivation

這件事若要成真，得仰賴每個人都有

of individuals to change their lifestyle in a sustained way,

意願和動機去改變他們的 生活方式，變得更永續，

to prioritize staying healthy,

把保持健康列為優先事項，

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

此外還要能開放地 經常分享健康資料。

This change may not come overnight.

這種改變不會一夕成真。

But by refocusing the incentives within the health care industry today

但現在就在健康照護產業中 將獎勵的焦點改變為

to actively keep people healthy,

主動保持民眾健康，

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

我們不只能在一開始 就先預防更多的疾病，

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

我們也能夠偵測出某些 可預防之疾病的發生，

earlier than we do today,

且比現今能做到的更早，

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

這就會讓更多人能更長壽、更健康。

Most of the technologies that we need to initiate that change

要開始這項改變，我們所需要的技術

are already existing today.

大多已經存在了。

But this is not a technology question.

這不是個技術問題。

It is primarily a question of vision

根本上，這是個遠見

and will.

以及意願的問題。

Thanks a lot.

非常謝謝。

(Applause)

（掌聲）