毫不意外，醫(yī)療問(wèn)題已經(jīng)成了2020年美國(guó)總統(tǒng)大選的一個(gè)核心議題。雖然民主黨候選人已經(jīng)拋出了好幾個(gè)醫(yī)改計(jì)劃，但大家爭(zhēng)論的焦點(diǎn)最終還要?dú)w結(jié)在一個(gè)問(wèn)題上：誰(shuí)來(lái)掏這筆錢？

這是一個(gè)好問(wèn)題，但它忽略了最重要的一點(diǎn)。目前，美國(guó)的醫(yī)療費(fèi)用已經(jīng)高得嚇人了。2018年，美國(guó)的醫(yī)療支出超過(guò)了3.6萬(wàn)億美元。因此，立法者的第一個(gè)問(wèn)題應(yīng)該是：美國(guó)能否以更少的錢，提供高質(zhì)量的醫(yī)療服務(wù)？

答案是肯定的，這一點(diǎn)從許多發(fā)展中國(guó)家在醫(yī)療領(lǐng)域的創(chuàng)新上就能看出來(lái)。以印度為例，2018年，印度有7000多萬(wàn)人處于赤貧狀態(tài)，印度的國(guó)營(yíng)醫(yī)療體系可以說(shuō)一塌糊涂。然而有些私營(yíng)醫(yī)療機(jī)構(gòu)提供的服務(wù)，卻不亞于美國(guó)最好的醫(yī)院，而且費(fèi)用只相當(dāng)于后者的零頭。

印度的納拉亞納醫(yī)療公司就是這樣的一個(gè)私人的營(yíng)利性醫(yī)院系統(tǒng)，它還登上了《財(cái)富》的“改變世界”排行榜（第33名）。在美國(guó)的研究型醫(yī)院里做一個(gè)心臟手術(shù)，患者可能得花上2萬(wàn)到10萬(wàn)美元。而在納拉亞納醫(yī)院，患者做同樣的手術(shù)只需要2100美元左右，而且手術(shù)的效果即使以美國(guó)的標(biāo)準(zhǔn)看也是很出色的。之所以費(fèi)用這樣低廉，是因?yàn)榧{拉亞納醫(yī)療公司注重在整個(gè)系統(tǒng)內(nèi)降低成本。比如他們使用了仿制藥，實(shí)踐了遠(yuǎn)程醫(yī)療，自己生產(chǎn)醫(yī)療耗材，并且訓(xùn)練患者家屬來(lái)進(jìn)行術(shù)后護(hù)理。他們還會(huì)對(duì)術(shù)后回收的醫(yī)療器械進(jìn)行消毒并重復(fù)使用（比如開(kāi)胸手術(shù)中用來(lái)固定心臟的鋼鉗等）。

納拉亞納醫(yī)療公司甚至對(duì)高達(dá)55%的病人提供了免費(fèi)或補(bǔ)貼的醫(yī)療服務(wù)，但它仍然是盈利的。有人可能覺(jué)得，醫(yī)院給患者的補(bǔ)貼越多，醫(yī)院虧的錢就越多。不過(guò)納拉亞納醫(yī)療公司的使命就是服務(wù)那些缺醫(yī)少藥的患者，在這樣的使命驅(qū)使下，它的成本創(chuàng)新邁向了更高水平，超低的醫(yī)療價(jià)格也提升了來(lái)自付費(fèi)病人的利潤(rùn)。因此，盡管它的醫(yī)療服務(wù)有一些慈善性質(zhì)，但醫(yī)院的經(jīng)濟(jì)狀況仍然是具有可持續(xù)性的。

納拉亞納醫(yī)療公司的成本節(jié)省策略對(duì)第一世界國(guó)家是否有效？有些確實(shí)是可以的。實(shí)際上，納拉亞納醫(yī)療公司已于2014年在大開(kāi)曼島上開(kāi)設(shè)了一家有105張病床的三級(jí)護(hù)理醫(yī)院，那里的多數(shù)醫(yī)療項(xiàng)目的費(fèi)用都比美國(guó)低60%至75%。

與此同時(shí)，納拉亞納醫(yī)療公司的遠(yuǎn)程醫(yī)療方法，也為密西西比州的農(nóng)村居民省了不少錢，甚至挽救了不少人的生命。納拉亞納醫(yī)療公司的遠(yuǎn)程醫(yī)療網(wǎng)絡(luò)，將它設(shè)在城市里的24家醫(yī)院與800多個(gè)醫(yī)療中心聯(lián)系了起來(lái)，使廣大貧困農(nóng)村地區(qū)的居民也能夠以很低的成本接受醫(yī)療服務(wù)。遠(yuǎn)程醫(yī)療技術(shù)使它可以有效輻射到那些尋求治療的患者，降低農(nóng)村患者的醫(yī)療支出（包括因?yàn)榫歪t(yī)而導(dǎo)致的誤工成本、出行成本、食宿成本等）。密西西比州是美國(guó)醫(yī)患比最低的一個(gè)州，在那里也有一個(gè)類似的網(wǎng)絡(luò)，將17家農(nóng)村醫(yī)院、200多個(gè)醫(yī)療站點(diǎn)與設(shè)在杰克遜市的密西西比大學(xué)醫(yī)學(xué)中心聯(lián)系了起來(lái)，使患者可以就近獲得專家咨詢和醫(yī)療服務(wù)，從而節(jié)省了高昂的就診成本。遠(yuǎn)程醫(yī)療還使定期監(jiān)測(cè)糖尿病等慢性病患者變得更容易了，從而也降低了慢性病人被送到醫(yī)院看急診的頻率。

此外，還有很多來(lái)自發(fā)展中國(guó)家的創(chuàng)新是很值得借鑒的。比如波士頓的Iora Health公司是一家初級(jí)醫(yī)療服務(wù)商，它的服務(wù)模式，就是由它的創(chuàng)始人、CEO魯西卡·費(fèi)爾南多普勒從部分非洲和加勒比國(guó)家借鑒來(lái)的。對(duì)大多數(shù)病人的觀察和護(hù)理工作，該公司會(huì)交給所謂的“健康教練”而不是醫(yī)生來(lái)負(fù)責(zé)。這些健康教練也經(jīng)過(guò)了嚴(yán)格訓(xùn)練，但他們的成本比醫(yī)生還是要低廉得多。Iora Health公司表示，他們這種重點(diǎn)關(guān)注初級(jí)護(hù)理的方法，使病人的住院率下降了40%，急診率下降了20%。

來(lái)自發(fā)展中國(guó)家的科技創(chuàng)新也是不容小覷的。比如印度班加羅爾的一家醫(yī)學(xué)創(chuàng)業(yè)公司Forus Health發(fā)明了一種成本低廉且較為便攜的掃描成像設(shè)備，它可以檢察出白內(nèi)障等眼科問(wèn)題。2016年，這種設(shè)備獲得了FDA的批準(zhǔn)。同年，F(xiàn)orus Health還在美國(guó)加州成立了一家子公司，專門推廣其產(chǎn)品。這也是美國(guó)采用發(fā)展中國(guó)家的創(chuàng)新技術(shù)降低醫(yī)療成本的又一范例。

以上公司表明，對(duì)于醫(yī)療機(jī)構(gòu)來(lái)說(shuō)，擴(kuò)大輻射范圍與節(jié)省成本、實(shí)現(xiàn)盈利之間并不沖突。所以，美國(guó)可以不必糾結(jié)于哪筆錢由誰(shuí)來(lái)出，而是應(yīng)該著手削減這3.6萬(wàn)億美元的成本。而醫(yī)療交付方面的創(chuàng)新則為此提供了一條可行的道路。（財(cái)富中文網(wǎng)）

本文作者Vijay Govindarajan是達(dá)特茅斯大學(xué)塔克商學(xué)院教授，也是《醫(yī)療逆向創(chuàng)新:如何實(shí)現(xiàn)基于價(jià)值的醫(yī)療服務(wù)》（Reverse Innovation in Health Care: How to Make Value-Based Delivery Work）一書(shū)的作者之一。

譯者：樸成奎

It’s hardly surprising that health care is shaping up to be a central issue of the 2020 U.S. presidential campaign. Despite several plans floated by Democratic candidates, much of the debate still comes down to one question: Who will get stuck with the bill?

That’s a good question, to be sure, but it misses the most important point. That bill is outrageously high: More than $3.6 trillion in 2018. Instead, the first question lawmakers should be asking is this: Can America provide quality health care for less money?

The answer is yes, and that’s evident by the health care delivery innovations seen in many developing countries. Take India as an example: In 2018, more than 70 million people lived in abject poverty, and much of the state-run health care system is terrible. Yet some privately-owned Indian health care systems are providing services that rivals the quality of care found at the best U.S. hospitals—and for a fraction of the cost.

One of those companies is India’s Narayana Health, a private for-profit hospital system, which also made Fortune’s Change the World list (at no. 33). While it would cost a patient anywhere from $20,000 to $100,000 in a U.S. research hospital, Narayana performs heart surgeries for around $2,100. And its outcomes are excellent, even by U.S. standards. They do it by lowering costs throughout their system. They use generic drugs. They practice telemedicine. They manufacture their own supplies. They train patients’ family members to deliver post-op care. They sterilize and reuse medical devices (like the steel clamp used to hold the heart in place during open-heart surgery).

Narayana Health even provides free or subsidized care to 55% of its patients—and still makes a profit. It might seem that the more subsidized patients the hospital treats, the more money the hospital would be expected to lose. Narayana’s mission to serve the underserved drives cost innovations to high levels, and the resulting ultra-low-cost position boosts profit margins on the paying patients. Consequently, the hospital is financially sustainable despite the charitable care.

Could Narayana’s cost-saving strategies work in the first world? Some could and some are. In fact, Narayana has its own operation in the Grand Cayman, where it built a 105-bed tertiary care hospital in 2014. There, most medical care is priced 60% to 75% below prices charged in the U.S.

Meanwhile, Narayana’s approach to telemedicine is saving money and lives in rural Mississippi. In India, Narayana’s telemedicine network connects its 24 urban-based specialty hospitals to 800 centers, extending its reach into Indian’s vast and impoverished countryside at very little cost. Telemedicine enables a hub-and-spoke system to efficiently and economically serve patients seeking care, thereby lowering the out-of-pocket expenses (lost wages during time away from work, the cost of travel, and room and board) for the patients in rural areas. In Mississippi, the state with the worst patient-to-physician ratio, a similar network connects 17 rural hospitals and more than 200 health care sites to medical specialists at the University of Mississippi Medical Center in Jackson. The network allows patients to receive expert consultation and care near where they live, saving the high costs that they would pay at specialty hospitals. It also makes it easy to regularly monitor patients with chronic conditions, like diabetes, which can decrease the frequency of emergency room visits.

There are other innovations borrowed from the developing world offered in medicalized urban centers. For instance, Boston-based Iora Health, a primary care provider, depends on a service model that co-founder and CEO Rushika Fernandopulle saw practiced in parts of Africa and the Caribbean. The company uses health coaches rather than doctors to handle the vast majority of patient observation and care, and the highly-trained coaches cost much less than doctors. Iora reports that their primary care focused model has reduced patients’ hospitalization by 40%, and emergency room visits by 20%.

And such innovations born in developing countries also include technological advances. In 2016, Forus Health, a Bengaluru medical startup, won FDA approval for its inexpensive and portable imaging device that scans for cataracts and other eye problems. And, that same year, Forus launched a California-based subsidiary to market its products—another example of health care innovation from a developing country being adopted in the U.S., and bringing down costs.

These companies are showing health care providers can make a profit while providing more access to services for a reduced cost. So it’s time to stop arguing about who pays what, and start slashing that $3.6 trillion bill. And focusing on health care delivery innovations offers a way to do just that.

Vijay Govindarajan is the Coxe Distinguished Professor at Dartmouth’s Tuck School of Business and co-author of Reverse Innovation in Health Care: How to Make Value-Based Delivery Work.