美国的医疗体系趣闻

Andrew M. Baer
What's wrong with the US healthcare system?
I am hungry. Let’s go shopping. Let’s buy chicken. (I am sort of vegetarian, but let’s keep it simple.) At local store X, chicken is $1.50 per lb. Next door, at local store Y, it is 1.58 per lb. About a mile away, local store Z is selling it for $1.48 per lb. All things being equal, that is to say, chicken is chicken, I suspect most of us would go to store Z.
Why don’t we try something different. Not everyone eats chicken…at least not daily or even once a week. I have a lot of money and I am going to do something interesting. Why not sell food insurance. Tell you what, for a family of 4, I will charge $1,500 per month. (For arguments sake, let’s say a family of 4 spends $1,000 per month on food.) Additionally, you will use your insurance at the store, unless you buy particular items or more of a particular item than your insurance plan allows, then you have to pay a deductible.
As my insurance business grows along with the monopoly on food it has created, the price of chicken is now $24.00 per lb.

美国的医疗体系出了什么问题？
我饿了，我们去购物吧，我们买鸡肉哈。（我是素食主义者，不过还是简单点吧。）在当地的X商店，鸡肉每磅1.5美元。隔壁的Y商店，每磅1.58美元。大约一英里外，当地的Z商店以每磅1.48美元的价格出售。在所有条件相同的情况下，也就是说，鸡肉就是鸡肉，我怀疑我们大多数人都会去Z商店的。
我们为什么不尝试一些不同的东西呢。不是每个人都吃鸡肉……至少不是每天或每周吃一次。我有很多钱，我要做一些有趣的事情。为什么不出售食品保险呢。告诉你吧，对于一个四口之家，我将收取每月1500美元的费用。（为了论证起见，假设一个四口之家每月在食物上花费1000美元。）此外，你将在商店使用你的保险，除非你购买了特定的物品或超过你的保险计划允许的特定物品，那么你就必须支付免赔额。
随着我的保险业务的发展以及它对食品的垄断，现在鸡肉的价格是每磅24美元。

As you enter the store to buy less food than you could prior to my food insurance industry, you can see me in front of the store making extra money at a three card Monte table…or maybe a shell game…kind of a metaphor for what this is all about.
Are you beginning to get the idea? Yes, the analogy is off the wall, but so is the medical insurance business.
I am not going to go into the entire history of health insurance but I will touch on some points along the time line. At the beginning of the 20th century, with the industrial revolution in full swing, what we now know as workman’s compensation insurance began in 1910 when states began enacting laws to protect workers. Initially, an injured worker would see his own physician and the bill would be covered by the workers compensation fund. Subsequently, some companies hired their own physicians to provide care. Both of these models would evolve over time into models that we see today.
Interestingly, even prior to this, since around the time of the civil war, some employers took a portion of their employees pay to put into a sickness fund that would be used to pay employees something during times they did not work due to illness. However, for the most part, absent workman’s compensation paid visits, the majority of physician and hospital visits were paid out of pocket by the patient.

随着你在商店买的食物比推行食品保险行业之前买的要少，你可以看到我在店门口的三张赌桌上赚外快，也许是个骗局……这是对这一切的隐喻。
你开始有这个认知了吗？是的，这种类比很离谱，但医疗保险业务就是如此。
我不打算详细介绍医疗保险的整个历史，但我将沿着时间线谈谈一些要点。20世纪初，随着工业革命的全面展开，我们现在所说的工伤保险始于1910年，当时各州开始颁布法律保护工人。最初，受伤的工人会自己去看医生，费用将由工人赔偿基金支付。随后，一些公司聘请了自己的医生来提供护理。随着时间的推移，这两种模型都会演变成我们今天看到的模型。
有趣的是，甚至在这之前，因为大约在内战期间，一些雇主从员工工资中拿出一部分投入疾病基金，用于支付员工因病不工作时的工资。然而，在大多数情况下，在没有工伤保险的情况下，找医生和医院就诊都是由患者自掏腰包支付的。

One must also take into consideration the fact that medicine as we know it today had quite a revolution since the first colonists came to America. At that time, all American physicians were trained in Europe. There were no CT scans, MRIs, blood work, or antibiotics. Jenner’s work on smallpox would not come until the end of the 19th century.
Blood letting was a popular treatment of the time. The “physician” doing the procedure might likely be your barber. The medicines of the day were predominantly botanical. Surgery as we no it today was non-existent.

我们还必须考虑到这样一个事实，即自第一批殖民者来到美国以来，我们今天所知的医学已经发生了相当大的革命。当时，所有的美国医生都在欧洲接受培训。没有CT扫描、核磁共振成像、血液检查或抗生素。詹纳（Jenner）关于天花的研究直到19世纪末才问世。
放血是当时流行的治疗方法。做手术的“医生”可能是你的理发师。当时的药物主要是植物药，我们今天所说的手术是不存在的。

Interestingly, while the age of enlightenment would bring science or what we today call evidence based medicine into being. American physicians kept many of the traditional non-evidence based procedures in their armamentarium. Today, a patient going into cardiac arrest brings to mind the image of a crash cart, defibrillator, and CPR. Back in the 1700s a shortage of such equipment necessitated the use of other means. So, what did they do. The answer lies in a common expression uttered by an individual who believes he is being duped or lied to. “blowing smoke.” For those that do not know the full expression, it is, “he is blowing smoke up my ass, or more properly put in doctor speak, rectum. Ever wonder where the expression came from? You guessed it. A method of revival was to give a rectal smoke enema. It started in 1774 in London by two doctors, William Hawes and Thom-as Cogan who administered the procedure at a cost of 4 guineas, about $756 in today’s dollars. (To be sure, the unconscious patient’s wallet would be examined to see if it contained a Blue Cross/Blue Shield card, or American Express.)

有趣的是，启蒙时代带来了科学，也就是我们今天所说的循证医学。美国医生在他们的医疗设备中保留了许多传统的非循证程序。今天，一个心脏骤停的病人会让人想起急救车、除颤器和心肺复苏术。早在18世纪，这种设备是短缺的，于是就需要使用其他手段。那么，他们做了什么呢？答案在于一个认为自己被欺骗或被欺骗的人说出的一个常见表达方式——“吹烟”。对于那些不知道如何完整表达的人来说，是“他把烟插到屁股上，或者更确切地说，插进直肠。有没有想过这个表达是怎么来的？你猜对了。”：一种恢复的方法是从直肠处烟雾灌肠。1774年，两位医生（William Hawes和Thom as Cogan）在伦敦执行这项业务流程，他们的手术费用为4几尼，换算成今天的美元约为756美元。（可以肯定的是，昏迷患者的钱包会被检查，看看里面是否有蓝十字/蓝盾卡或美国运通卡）

In America both before and after the revolution, doctors could be paid in cash and if they could not afford the bill, they would likely pay in goods. At this juncture, an important point needs to be made. In the 1700s and 1800s, most notably in Europe, physicians in particular, and surgeons were highly respected members of society despite the fact that in reality, there was very little they could do for many of the common afflictions of mankind. While they may have been highly respected, what they were not was what we would call wealthy by today’s standards. One did not enter into medicine to become wealthy

在美国，无论是革命前还是革命后，看医生都可以用现金支付，如果他们付不起医药费，他们可能会用商品支付。在这个节骨眼上，有一点很重要。在18世纪和19世纪，尤其是在欧洲，医生和外科医生是社会中备受尊敬的成员——尽管事实上，他们对人类的许多常见疾病无能为力。虽然他们可能受到了高度尊重，但以今天的标准来看，他们并不是我们所说的富人，毕竟行医不是为了致富。

We should look at this further by noting changes in language. The traditional definition of a profession is that it is a “calling.” It is something one does not for monetary gain or social status, but rather for the benefit of mankind. Historically, there were only three professions, the clergy, law, and medicine…nothing else. Physicians in the 1700s and 1800s were financially in what today we would call the middle class. One did not undertake medical training in the hope of attaining great wealth.
Unfortunately, the concept of medicine as a calling has been lost. Approaching medicine as a personal calling is not a requirement for entrance into medical school although, perhaps it should be because in my opinion the practice of medicine requires a certain selflessness that I think is necessary to be a good physician. Of importance with respect to healthcare finance this plays an important role in understanding the economics of physician salaries today and differences in how the different specialties are compensated. If all physicians have answered a calling, then they would be paid equally. however, they are not as will be discussed subsequently.

我们应该通过注意语言的变化来进一步了解这一点。职业（ profession）的传统定义是“使命感（calling）”。它不是为了获得金钱利益或社会地位，而是为了人类的利益。历史上，只有三种职业，神职人员、法律和医学，没有其他职业。18世纪和19世纪的医生在经济上属于今天我们所说的中产阶级。人们接受医学训练不是为了获得巨大的财富。
不幸的是，医学作为一种“使命感（calling）”的概念已经消失了。将医学视为一种个人使命并不是进入医学院的必要条件，尽管也许应该这样做，因为在我看来，医学实践需要一定的无私精神，我认为这是成为一名好医生所必需的。重要的是尊重，对于医疗保健金融来说，这在理解当今医生工资的经济学和不同专业如何补偿的差异方面发挥着重要作用如果所有的医生都响应了“使命感（calling）”那么他们就会得到同样的报酬。然而，它们不像后面将要讨论的那样。

Getting back to the history of insurance, the depression hit hospitals very hard. Justin Kimble, an administrator at Baylor Hospital devised a plan that would pay hospitals and can be considered a forerunner of Blue Cross. He enrolled 1250 Dallas, TX teachers in to the plan. For 50 cents a month they would be provided 21 days of hospital care. The AMA was opposed to this so only the hospital and not the physicians were covered. In 1932 in Sacramento a plan was created not for one hospital but for all of those in a particular community. These plans were all non-profit. It should be noted, especially because it is the crux of my position, the states did not view these plans as insurance. The looked at them as pre-paid plans. However, in 1933, the NY state insurance commissioner deemed these plans as insurance. His reasoning was that these plans were collecting money for services to be rendered in the future. In a sense, he likened them to life or casualty insurance both of which are paid out at a future time. As will be subsequently discussed I beleive this was a mistake that has had serious consequences in terms of its impact causing the healthcare problems we have tody.

回到保险业的历史，大萧条对医院的打击非常严重。贝勒医院（Baylor Hospital）的行政人员贾斯汀·金布尔（Justin Kimble）设计了一项向医院支付费用的计划，可以被视为蓝十字的先驱。他招募了德克萨斯州达拉斯市的1250名教师加入该计划。每月支付50美分，他们将获得21天的医院护理。美国医学协会反对这样做，所以只有医院而不是医生被覆盖。1932年，萨克拉门托制定了一项计划，不是针对一家医院，而是针对某一特定社区的所有人，这些计划都是非营利性的。应该注意的是，特别是因为这是我立场的关键，各州并没将这些计划视为保险。他们将其视为预付费计划。然而，1933年，纽约州保险专员将这些计划视为保险。他的理由是，这些计划是在为未来提供的服务筹集资金。从某种意义上说，他把它们比作人寿保险或意外伤害保险，两者都是在未来的某个时候支付的。正如随后将要讨论的那样，我认为这是一个错误，造成了严重的后果，导致了我们今天的医疗问题。

In 1939, the California Physicians Service developed what would become Blue Shield. It was an indemnity plan which paid the patient for each event. The patient would be responsible for paying the physician bill. Commercial insurance was another matter. The companies that provided Life, Casualty, and other insurance could not see how health could be insured. Once a patient obtained the insurance, there was no disincentive to be sick. This was resolved by only offering hospital coverage. An admission to a hospital could only be done after a physician determined the patient was ill. However, they did offer coverage for the surgeon because surgery was considered a discrete event. As will be discussed, I think this reasoning was also unsound.
Around this time, prepaid plans for physician services would also develop. Physicians were against this because at the time they used a sliding scale with wealthy patients paying more. It was thought that the plans by ending the sliding scale would reduce physician profits because the wealthy were defraying the cost of the poor. However, the plans continued.

1939年，加州医生服务开发了后来的蓝盾计划。这是一项赔偿计划，每次发生医疗事故都向病人支付费用。病人将负责支付医药费。商业保险则是另一回事。提供人寿、伤亡和其他保险的公司不知道如何为健康投保。一旦病人获得了保险，就没有什么阻碍他们生病的抑制因素了。这个问题的解决办法是只提供医院保险。只有在医生确定病人生病后，才能允许病人入院。然而，他们确实为外科医生提供了保险，因为手术被认为是一个独立事件。正如下面将要讨论的，我认为这个推理也是不合理的。
大约在这个时候，医生服务的预付费计划也得到发展。医生们对此表示反对，因为当时他们使用的是浮动比例，富裕的病人支付的费用更高。人们认为，该计划通过结束浮动比例将减少医生的利润，因为富人在支付穷人的费用。然而，这些计划仍在继续。

We must keep in mind that up until the 60s , the majority of people had no insurance coverage for visits to their primacy care doctor. With the sliding scale, people were able to pay for a simple visit. You paid for your laundry, your food, a hair cut, a manicure. A doctor’s visit was just another expense. Let’s look at this more closely. In 1954 how much do you think a physician office visit cost. As for the office visit, around $3.50. A house call, many of you won’t remember them but yes, the doctor used to come to your home. How much….a dollar more…about $4.50. The point being this was an expense that could easily be paid out of pocket for most people. The fact that this was possible has an impact upon a potential remedy to one facet of healthcare costs, primary care and some other specialist office visits.

我们必须记住，直到60年代，大多数人都没有去看初级保健医生的保险。随着规模的不断扩大，人们可以支付得起看医生的费用了，你付了洗衣费、食物费、理发费和美甲费，看医生只是另一笔费用而已。让我们更仔细地看一下这个问题。1954年，你认为看一次医生要花多少钱。就诊，大约3.5美元，医生出诊，你们中的许多人都不记得了，但是医生过去常来你家，多少钱，比去医院就诊多一美元…大约4.50美元。重点是，对于大多数人来说，要付这笔费用都很容易的。这一事实对医疗保健费用、初级保健和其他专家问诊方面的潜在法定补偿措施产生了影响。

Private Health Insurance grew rapidly in the 40s and 5os. for a number of reasons. World War II brought with it wage and price controls decreasing discretionary spending. The second reason was expansion of organized labor. The Taft Hartley Act of 1947 made health insurance a condition of employment.Taft Hartley then was an important milestone in the creation of the healthcare mess. The third reason is that the US tax code did not specify whether employee sponsored health insurance was taxable. In 1943 the IRS issued a ruling stating that employee sponsored health care was not taxable.
There were also not as many insurance companies to drive a wedge between the provider of a service and the customer that interferes with supply and demand which drives prices in a free market.
Physicians, (read surgeons) created one for themselves that eventually became what we know as Blue Shield.
Ever look at a physician bill? Your primary care physician might bill $100 for what amounts to a 30 minute visit. However, any medical specialty or surgical bill for a procedure will be much more. The reason is that since surgeons created insurance for themselves they were smart. Since people were not going to pay out of pocket, why not jack up the fees. The rest is history. This is why physicians, the ones who are supposed to help you stay well get paid less for their time than those who do procedures.

私人健康保险在40年代和50年代迅速发展。原因有很多，第二次世界大战带来了工资和价格管制，减少了可自由支配的开支。第二个原因是有组织的劳工的扩张。1947年的《劳资关系法》将医疗保险作为就业条件。《劳资关系法》当时是造成医疗混乱的一个重要里程碑。第三个原因是，美国税法没有明确规定雇员发起的健康保险是否应纳税。1943年，美国国税局发布了一项裁决，声明员工发起的医疗保健不征税。
也没有那么多的保险公司在服务提供者和客户之间制造隔阂，干扰自由市场中驱动价格的供求关系。
医生（外科医生）为自己创建了一个，最终成为我们所知的蓝盾保险。
看过医生账单吗?你的初级保健医生可能会为30分钟的就诊收费100美元。然而，医疗专业或手术费用将要更多。原因是，既然外科医生为自己创造了保险，他们就很聪明。既然人们不会自掏腰包，为什么不提高费用呢，剩下的就是历史了。这就是为什么医生，那些应该帮助你保持健康的人，他们的时间报酬比那些做手术的人要少的原因。

One time I sustained a laceration to my finger. It was not a big deal. However, when I went to the ED, they wanted me to see a plastic surgeon. I thought it was a bit of over kill. Though trained in Internal Medicine, I had done enough Family Medicine and was very comfortable sewing up lacerations. However, I could not sew up my own finger. (I could teach you to do it.. it really is not hard!)
I go to the plastic surgeon and he injects me with lidocaine and sews it up in a couple of minutes. Sometime later when I saw the explanation of benefits I hit the roof. The physician used a couple of different computerized procedural codes (CPT codes) to bill for the injection of lidocaine as well for sewing up the laceration. I used to charge $50 to $75 for doing the same procedure. He charge over $2,000. That is right…over $2,000.
I called him up. At first I was polite. He became very defensive. His justification was simply that insurance was paying for it anyway.

有一次我的手指被划破了,这没什么大不了的。然而，当我去急诊室时，他们想让我去看整形外科医生。我觉得这有点过分了。尽管我学的是内科，但我学过足够多的家庭医学，对缝合伤口非常熟练。然而，我不会缝自己的手指；我可以教你怎么做，这真的不难!
我去找整形外科医生，他给我注射利多卡因，几分钟后缝合好了。过了一段时间，当我看到福利政策的解释时，我大吃一惊。医生使用了几个不同的计算机程序代码（CPT代码）来支付利多卡因注射和缝合划伤处的费用。我以前做同样的手术收费50到75美元。他这要价两千多美元。没错，超过2000美元。
我给他打了电话。起初我很有礼貌。他变得很有戒心。他的理由很简单，保险公司无论如何都会支付这笔费用的。