动物的生命也有价值

"Economic Value, the Value of Economists, and the Meaning of Life "
Don Coursey，芝大Harris学院教授

[Excerpt]:

In the study, I looked at every land animal on the official list of
endangered species. Then I took the total amount of spending by the
government on each species and divided it by the population of that
species. The result was a measure of value, not value defined by its
biological importance, but a measure of how much we as a nation are
willing to spend on each member of each endangered species.

My measure of value was based on analyzing a set of political and
bureaucratic outcomes.... had no morality attached to them.

To many, my conclusions about species value seem at odds with the
basic instinct that all life is worth saving. This is what makes
public policy involving economic valuation of life so difficult. It
also makes economists unpopular at cocktail parties. The fundamental
notions of budgets, opportunity costs, and trade-offs become
complicated when they are publicly applied to the value of life. The
challenge facing the economist in these settings is to find a way of
advancing economic reality through the cloud of emotional attachment
people hold toward life.

hat is a child worth? The question itself may be repugnant. Some may
say that the value of a child's life is infinite, that it is
hierarchically more important than other values, or that it is only
appropriate to use philosophical or ethical tools to describe a
child's value. But while we may all feel that the value of a child's
life is infinite, in most cases we do not act as if that is the case.

source：http://www.econlib.org/library/Columns/Courseyvalue.html#

Argu From HA -- 城乡卫生服务差距

北大公卫简伟研2010年12月在HA的"China's Rural-Urban Care Gap Shrank For Chronic Disease Patients, But Inequities Persist"引来一轮争议。
首先原文使用2003-08年的国家调查数据，分析城乡慢性病患者的卫生服务和保险。农村居民相比03年更易于开展住院治疗了，但是因为高copayment rate，他们放弃治疗的几率是城市居民的两倍。作者还提到服务差距缩小的最强证据是中部，西部和东部的证据比较mixed（有意思~~）

Wang Xin去信"Narrowing The Rural-Urban Care Gap In China"，认为2010年制定的新一轮五年计划中的要推广的社保卡将有效缩小城乡服务差距，作者认为这是发展中国家解决类似问题的好榜样，因为
People who are insured can use the social security card at any time and any place for services such as checking their personal social security record and being reimbursed for medical expenses. With this card, rural residents can go to any covered hospital in China for medical treatment and enjoy the same reimbursement as urban residents.

简回信"Chinese Rural-Urban Care Gap: The Authors Respond"，认为社保卡新系统主要是用来simplify medical services transactions and does not directly address the rural-urban care gap，因为
It is important to consider the role of socioeconomic development as well as the integration of the rural and urban health insurance systems. Unbalanced socioeconomic development has led to dramatic differences in local governments' financing capabilities. The funding pool for health insurance in rural China is at the county level, which makes service rebates outside residents' home counties administratively complicated.
而且
The approach to closing the rural-urban gap is likely to be multifaceted, requiring new financing and service-provision mechanisms and greater availability of services. No single policy is likely to constitute a magic bullet. Monitoring and evaluation will be key.

source：10.1377/hlthaff.2011.0203 Health Aff March 2011 vol. 30 no. 3 537
10.1377/hlthaff.2011.0208 Health Aff March 2011 vol. 30 no. 3 537
10.1377/hlthaff.2009.0989 Health Aff December 2010 vol. 29 no. 12 2189-2196

谁是US最快乐的人？

Gallup-Healthways Well-Being Index，他们的网站是www.well-beingindex.com

他们干的活是专门收集美国人（个体或群体）每天对幸福和快乐的心态意向，结果发现这些特征是最快乐的标志：male, Asian-American, a religious Jew, self-employed, living in Hawaii, married, has children, receiving a household income of at least $120,000。然后顺着这个profile去寻找这个理论上最快乐的人，结果居然被他们找到了，哈哈，你说奇迹不。就是下面的这位（羡慕啊~~）：

Courtesy of Alvin Wong The (theoretically) happiest person in America, Alvin Wong, with his wife, Trudy Schandler-Wong.

value-based purchasing (VBP) programs & ACA

The quality of healthcare services is so complicated, then how to incorporated the true "quality and value" into the payment system? below is from Jason's <Health Reform's Value-Based Purchasing Provisions>:

The Affordable Care Act of 2010 includes a number of provisions to study and/or implement value-based purchasing (VBP) programs in the United States' health care system.  These provisions target Medicare payment policies in particular.  Today I review a Robert Wood Johnson (RWJ) article which provides an overview of the ACA provisions related to VBP.

There are four Sections of the ACA which I will focus on: Section 3022, 3007, 3013, and 3021.  Let's get to it.

• Section 3022 calls for a Medicare Shared Savings Program, which would provide payments specifically for new accountable care organizations. The legislation specifically requires measurement and assessment of quality as reflected in clinical processes and outcomes, patient and caregiver experience with care, and utilization reflecting efficiency and effectiveness of care, such as hospital admissions for ambulatory care sensitive conditions.

• Section 3007 creates a new "value-based payment modifier," which, starting in 2015, will be used to provide differential payments based on quality and cost of care. Since the payment adjustments are to be budget neutral, some physicians would receive bonuses and others penalties under this provision. Presumably, the IOM's study will be influential in determining how CMS might apply a value-based payment modifier.

Further, the Act continues to advance the notion of bringing value into payments made to physicians, hospitals, and other providers through established payment mechanisms:

• Section 3013 provides for the identification of gaps in quality measures and authorizes (but does not appropriate) funding intended to fill those gaps, relying on collaboration between CMS, the Agency for Healthcare Research and Quality (AHRQ) and the National Quality Forum, which will be primarily responsible for identifying the measure gaps. Priorities are to be given to the following areas: i)  health outcomes; ii)  functional status; iii) coordination of care; iv) meaningful use of health IT; v) safety; vi) patient experience; vii) efficiency; and viii) disparities.

• Section 3021 creates a Center for Medicare and Medicaid Innovation within the Centers for Medicare and Medicaid Services to test payment and service delivery models that reduce costs while preserving or enhancing the quality of care provided under Medicare, Medicaid, and CHIP, and funds it at $10 billion every 10 years. The legislation specifically suggests pursuing models that transition providers away from fee-for-service and toward comprehensive pay

Source:

• Berenson RA "Moving Payment from Volume to Value: What Role for Performance Measurement?", Quick Strike Series, Urban Institute, Robert Wood Johnson Foundation, Dec 14, 2010.

什么是ACO？

ACOs are sometimes said to be the brain child of Elliott Fisher, who heads the Dartmouth Atlas Project. But as Uwe Reinhardt pointed out the other day, the idea is actually an old idea. It's called Kaiser Permanente.

ACOs have been called "HMOs on steroids." They will have capitated payments and, like the traditional HMO, the ACO will get to keep any money it doesn't spend. But the organization will also incorporate all the latest fads in health policy: electronic medical records (EMRs), pay-for-performance (P4P) incentives, quality report cards, etc.

The results from the few demonstration projects with ACOs are lackluster and mixed. But that doesn't seem to matter to the Obama administration. Medicare will start contracting with ACOs beginning next year.

If that doesn't strike you as strange, you need to know that "evidence-based medicine" is one of the buzz words among policy wonks these days and is supposed to be the foundation for ACO management. But if that's a good idea for doctors, isn't it equally good for policymakers? If we abided by evidence-based policy, would we put all of our marbles in the ACO basket? Basically no.

The latest comprehensive review of all the studies of report cards and other quality-measuring-and-reporting techniques finds they don't work and may do more harm than good. Just as teachers will "teach to the test" if test results are how they are graded and rewarded, doctors will tend to "practice medicine to the test" if that is how they are paid. If you're the patient, that may not be good for you. The latest comprehensive review of all the studies of electronic medical records finds they do not live up to their promises. And the most recent study of pay-for-performance from Britain finds that it doesn't work either.

What about Kaiser? Its integrated medical records system is impressive and Kaiser is also promoting e-mail and telephone consultations. On the other hand, Harvard Business School professor Regina Herzlinger has taken the organization to task for letting people die.

But let's give Kaiser the benefit of the doubt for the moment. The real question is not: how well does Kaiser perform? There are lots of centers of excellence around the country: Cleveland Clinic, Mayo Clinic, Intermountain Healthcare. The real question is: can the performance be replicated?

There is no law against ACOs (other than Stark restrictions that limit flexibility). So if ACOs can reduce costs and raise quality, why don't we see them everywhere?

As it turns out, when Kaiser tried to replicate in Dallas what it does in Palo Alto, it failed. This isn't surprising. If high-quality, low-cost medicine were easy to replicate we wouldn't be having all the problems we are having.

When health policy experts associated with the Brookings Institution studied the "best" hospital regions around the country, they found few objective (replicable) characteristics. Some had doctors on staff. Some paid fee-for-service. Some had electronic medical records. Some did not. A separate study of high-performing doctor groups found much the same thing.

Evidence-based policy would admit ignorance about what works and why, and would let a thousand flowers bloom. It would pay more for low-cost, high-quality care, regardless of how it is achieved. We have previously suggested ways of doing that.

By contrast, the non-evidence based approach of the Obama administration will force everybody into the same model. As Scott Gottlieb has pointed out, this approach not only will stifle innovation and entrepreneurship, it is already causing venture capital to leave the health care market completely.

So how do we explain the administration's commitment to ACOs? Whether they raise or lower costs, whether they raise or lower quality, there is one thing that ACOs will indisputably accomplish. They will drive doctors into organizations where their behavior can be controlled. For the first time in our history, both the practice of medicine and the way money is spent on medical care will fall under federal control.

ACOs are the portal through which we will all march toward a truly nationalized health care system.

source：http://healthblog.ncpa.org/the-hmo-in-your-future/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+TheJohnGoodmanHealthBlog+%28John+Goodman%27s+Health+Policy+Blog%29