John Goodman .VS. Austin Frakt

John 的招数：

Economics teaches that people reveal their preferences through their actions. If people act as though they are indifferent between being uninsured and being on Medicaid, we may infer they are equally well off in both states of the world from their own point of view. If someone drops a $20 bill on the floor in Parkland's emergency room, how long do you think it would stay there?  Probably not very long. If someone drops a Medicaid enrollment form on the floor, how long do you think it would stay there? Probably until the next janitor comes along with a broom.  Health economists tend to think Medicaid insurance is really valuable – worth a lot more, say, than $20.  Many patients, through their actions, communicate that they disagree.

there is the argument from paternalism: that people will be better off if we push them into Medicaid, whether they prefer it or not.  But even on that score, the evidence is weak. A very comprehensive  RAND study, found that the type of insurance people have — or whether they are insured at all — does not affect the quality of care they receive. With respect to cancer care, it is unclear that Medicaid matters very much. Health blogger Avik Roy summarizes other studies that find that Medicaid patients do no better and sometimes worse than the uninsured. Additional evidence is supplied byScott Gottlieb. If you're trying to get a primary care appointment, it appears your chances are better if you say you are uninsured.

 

Here's my bottom line: after we get through spending our $1 trillion under ObamaCare, there is no convincing reason to believe that the bottom half of the income distribution will have more care, better care, or better access to care than they have today.

Source: http://healthblog.ncpa.org/is-medicaid-real-insurance/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+TheJohnGoodmanHealthBlog+%28John+Goodman%27s+Health+Policy+Blog%29

weblinks 2011-4-5

引自Don Taylor的县级健康状况排名：The Robert Wood Johnson Foundation sponsors the county health rankings project that was created and maintained by the University of Wisconsin. This is a great resource, with many interactive features that allow you to display health risks, supply of health providers and outcomes for each county in the nation.  Check it out.

2010年四位长策智囊对医改进展的评论：

医护人员完全可以和服务机构分开，是独立的群体，不需要"被事业化"到医疗机构里去任职。尤其是基层社区医院这块，如果可以放开现行政策，使医护人员成为自由职业者，可以自由选择与各类医疗机构合作，则不但可以放活现有各类医疗机构中的人力资源存量，还可以吸引广大的体制外人力资源，从而节省政府对医护人员的培养投入，使提供的社区医疗卫生服务更加完善。-------余晖

接下来就是人事和编制。聘什么人、做什么，要由政府的人事编制制度来管理，公立医疗机构进一个人要打报告。有些地方这方面的改革推进得相当缓慢，地方的院长们埋怨，要进一个研究生，报告打了半年还没批下来，最后这人跑到医药企业去了。还有医院领导层的任命，卫生行政部门有一定的发言权，但各地的一把手可能也有发言权。不管怎么说，这是一种行政化的体系，医院领导在形式上还是要让卫生局任命一下。

薪酬管理也跟行政化的制度有关。政府规定了一堆条条框框，按照人事制度薪酬，每个月大家就拿那个小窄条，其实大家的收入远不止这个小窄条。

广东省高州市进行了考察，人家把这些体制都打破了，至少是突破了。实际上，当地政府以及上级政府并没有明文规定这些体制应该变成什么样，但在现实中，旧的条条框框全突破了。政府也没给钱，人家（高州市人民医院）自己弄的钱盖楼买设备。政府还规定你原来只能做这些手术，不能做那些手术，医院不管，好多手术都做了，做了也没有出事故，最后卫生行政部门还评了奖。卫生行政部门已经发了好几个文件说要在全省全国推广高州的经验，可是折腾很多年就没推广成，为什么呢？

我们仔细一看所有文件和经验总结，就是不提刚才说的去行政化，总是要求各地公立医院去学习高州市人民医院的管理。其实，学习管理哪儿不成？高州市人民医院就是去南航和白天鹅酒店学的服务管理。政府发文件要求大家去学习某一个组织的管理，这不是政府应该做的事情。政府应该做的，是想方设法改革政府与公立医院的关系。公立医院的改革，说到底是政府的改革。这句话，我记得是卫生部长陈竺所说，我不敢掠美。-------顾昕

我们最近完成的这项实证研究，是根据国务院城镇居民基本医疗保险连续3年的跟踪调查数据，以2007年为基线，2008、2009年为跟踪年份对近三万的调查人群进行了医保状态和家庭内需增长关系的分析。因为各地医保覆盖进度的差异，"产生"了在3年中保险状态改变的不同人群，为我们的比较分析提供了一个"自然实验"。结果显示：从无保险到有保险，因为降低了医疗风险的后顾之忧，家庭内需平均提高了近10%；进一步分析还发现，该影响对低收入家庭最大。

近年来，美国连续发布了若干关于用药不当导致的疾病负担和死亡的研究报告，引起了美国和国际机构对此问题的极大关注，从而推进了药品管理和合理用药相关政策制度的完善。同样的用药不当问题可能在中国更严重，但我们所知道的真实数据和实证研究非常少，更缺乏相应的科研队伍推动该领域的研究。无论如何，医疗服务质量将越来越成为我们更为重视的方面，应该纳入到医改评估的结果指标维度中。--------刘国恩

一种商品，不管它是药品还是其他商品，最终的零售价取决于市场需求和市场结构。一些商品，比如食品，是比药品还重要的生活必需品，这类商品消费者需求缺乏价格弹性，如果没有选择，高价也得购买。但是我们知道馒头的价格并不高，不是因为它不重要，而是因为满大街都是馒头铺，高度竞争性使得没人能够把馒头价格抬得"虚高"，药品道理完全相同。中央电视台报道的芦笋片的案例形象地说明了药价虚高的根源：芦笋片出厂价只有15.5元，湘雅二院却卖到了213元，患者跑遍了长沙的药店，却买不到这种药品。一个零售价达到出厂价14倍的药品，药店为何没有销售？卖给医院的同时也卖给药店，药厂何乐而不为？原因很简单，医院不同意药厂卖给药店。目前公立医院控制了药品销售80%左右的市场份额，为了保住这80%的市场份额，药厂不敢也不愿意得罪医院。一个药品若能够在药店销售，高达13倍的批零加价根本不可能维持。

因此，"药品流通中间环节过多、层层加价推高了药价"这种说法完全是颠倒了因果关系，正确的说法应该是"公立医院垄断了药品零售市场，导致了药品零售价格虚高，零售价格与出厂价之间形成了巨大的差价空间，能够允许药品流通环节多，并且层层加价。这巨大的差价给各级经销商提供了生存空间，反过来，各级经销商又和相关利益集团结成利益同盟，维护虚高的药品价格"。如果消除了公立医院的垄断地位，虚高的药品零售价格就不可能再维持，那么零售价格与出厂价之间的差价空间也就被大大压缩，"环节多、层层加价"也就无法再维持，低效率的经销商会被竞争淘汰。因此，解决药品价格虚高问题不应该从流通环节着手，而是应该从破除零售环节的垄断入手。

不管是对证券市场而言，还是对医疗服务市场或者对药品市场而言，有效监管并不需要监管者对被监管者拥有人事任免权、投资审批权等行政权力，甚至连行政处罚权都不是必需的。监管者只要拥有监察权和公开及时披露监察结果的权力，就可以对被监管者形成有效制约。---朱恒鹏

weblinks 2011-4-2

Three health ideas from Harvard. (video)

中国经济研究所和经济学家排名

OECD:  the European Union will see an increase in health expenditure of 350% by 2050. The economy is only set to expand by 180%.

Why Is There A Problem With Health Care Quality?  总之，简单的扩大医保覆盖范围和改进医疗服务的质量和数量是完全不同的。

什么是QIO质量改进组织？US在医疗照护质量上面做了大量的功夫，他们的同行评审、质量改进组织是情况呢？

According to the CMS website, Quality Improvement Organizations (QIOs) are private, mostly not-for-profit organizations, which are staffed by professionals, mostly doctors and other health care professionals, who are trained to review medical care and help beneficiaries with complaints about the quality of care and to implement improvements in the quality of care available throughout the spectrum of care.

According to Zeitler (2004), Peer Review Organizations (PROs)) were established through the Peer Review Improvement Act of 1982 (a part of the Tax Equity and Fiscal Responsibility Act of 1982), replacing Professional Standards Review Organizations (PSROs) that had been established in  1972. In FY2002, they were renamed Quality Improvement Organizations (QIOs).

宗教信仰更易肥胖？

西北大学一个四年级的医学生Feinstein在北美一个presentation上展示了一个模型，认为在控制了age, race, sex, education, income, and baseline body mass index等因素的条件下，年轻人（20-32岁）频繁（至少每周一次）参加宗教活动与50%的肥胖风险因素增加有关。这当然是一个很有意思的研究，至少在西方宗教生活是一个所有人都逃不开的话题（天朝例外）。但是这始终还只是一个会议研究，没有经过peer-review和publication。
Steve Pizer认为宗教更可能是一个肥胖模型中的一个代理变量，而不是肥胖的驱动因素(a variable that doesn't drive the result itself but stands in for something the researcher doesn't have，比如人均GDP常常用作生活水平/质量的一个代理变量)。

Source：
http://theincidentaleconomist.com/wordpress/big-hits-of-epidemiology-church-makes-you-fat/

美国医院-临床质量信息报告--州和州以上层面

全美各个州都有针对医院层面的质量报告项目，经过识别后有25个州存在这种报告，但是其信息质量在州际间、报告的健康条件、过程、健康产出测评上出入很大。各州的报告特点见这里。

而AHRQ为了协调这些口径和标准，作出了不少努力，其中MONAHRQ软件(a software product that enables organizations – such as state and local data organizations, Chartered Value Exchanges, hospital systems, and health plans – to input their own hospital administrative data and generate a data-driven Web site. )就是其中之一，这个软件可以产出交互性非常好的网站（前提是只要你输入数据就行），而软件整理出的就是关于医院和地区医护质量的报告和map。如：

• quality of care at the hospital level,
• health care utilization at the hospital level,
• preventable hospitalizations at the county level, and
• rates of conditions and procedures at the county level.

但是呢，现在还只看到三个州(Maine, Hawaii, Nevada)使用了这种软件。

Tips：
关于The Agency for Healthcare Research and Quality's (AHRQ), part of the U.S. Department of Health and Human Services, is the lead agency charged with supporting research designed to improve the quality of health care, reduce its cost, and broaden access to essential services. It's mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans.
AHRQ was established in 1989 and formerly known as the Agency for Health Care Policy and Research. Reauthorizing legislation passed in November 1999 establishes AHRQ as the lead Federal agency on quality research. The website includes clinical practice guidelines, evidence reports and technical reviews.

Source：
State-Sponsored Public Reporting Of Hospital Quality: Results Are Hard To Find And Lack Uniformity  * Joseph S. Ross,  Health Aff December 2010 29:122317-2322; doi:10.1377/hlthaff.2010.0564
A Tool For Reporting Hospital Data On Care   * Anne Elixhauser, Health Aff March 2011 30:3538; doi:10.1377/hlthaff.2011.0205