要想解决“看病贵”的问题，这些国际创新经验值得学习

毫不意外，医疗问题已经成了2020年美国总统大选的一个核心议题。虽然民主党候选人已经抛出了好几个医改计划，但大家争论的焦点最终还要归结在一个问题上：谁来掏这笔钱？

这是一个好问题，但它忽略了最重要的一点。目前，美国的医疗费用已经高得吓人了。2018年，美国的医疗支出超过了3.6万亿美元。因此，立法者的第一个问题应该是：美国能否以更少的钱，提供高质量的医疗服务？

答案是肯定的，这一点从许多发展中国家在医疗领域的创新上就能看出来。以印度为例，2018年，印度有7000多万人处于赤贫状态，印度的国营医疗体系可以说一塌糊涂。然而有些私营医疗机构提供的服务，却不亚于美国最好的医院，而且费用只相当于后者的零头。

印度的纳拉亚纳医疗公司就是这样的一个私人的营利性医院系统，它还登上了《财富》的“改变世界”排行榜（第33名）。在美国的研究型医院里做一个心脏手术，患者可能得花上2万到10万美元。而在纳拉亚纳医院，患者做同样的手术只需要2100美元左右，而且手术的效果即使以美国的标准看也是很出色的。之所以费用这样低廉，是因为纳拉亚纳医疗公司注重在整个系统内降低成本。比如他们使用了仿制药，实践了远程医疗，自己生产医疗耗材，并且训练患者家属来进行术后护理。他们还会对术后回收的医疗器械进行消毒并重复使用（比如开胸手术中用来固定心脏的钢钳等）。

纳拉亚纳医疗公司甚至对高达55%的病人提供了免费或补贴的医疗服务，但它仍然是盈利的。有人可能觉得，医院给患者的补贴越多，医院亏的钱就越多。不过纳拉亚纳医疗公司的使命就是服务那些缺医少药的患者，在这样的使命驱使下，它的成本创新迈向了更高水平，超低的医疗价格也提升了来自付费病人的利润。因此，尽管它的医疗服务有一些慈善性质，但医院的经济状况仍然是具有可持续性的。

纳拉亚纳医疗公司的成本节省策略对第一世界国家是否有效？有些确实是可以的。实际上，纳拉亚纳医疗公司已于2014年在大开曼岛上开设了一家有105张病床的三级护理医院，那里的多数医疗项目的费用都比美国低60%至75%。

与此同时，纳拉亚纳医疗公司的远程医疗方法，也为密西西比州的农村居民省了不少钱，甚至挽救了不少人的生命。纳拉亚纳医疗公司的远程医疗网络，将它设在城市里的24家医院与800多个医疗中心联系了起来，使广大贫困农村地区的居民也能够以很低的成本接受医疗服务。远程医疗技术使它可以有效辐射到那些寻求治疗的患者，降低农村患者的医疗支出（包括因为就医而导致的误工成本、出行成本、食宿成本等）。密西西比州是美国医患比最低的一个州，在那里也有一个类似的网络，将17家农村医院、200多个医疗站点与设在杰克逊市的密西西比大学医学中心联系了起来，使患者可以就近获得专家咨询和医疗服务，从而节省了高昂的就诊成本。远程医疗还使定期监测糖尿病等慢性病患者变得更容易了，从而也降低了慢性病人被送到医院看急诊的频率。

此外，还有很多来自发展中国家的创新是很值得借鉴的。比如波士顿的Iora Health公司是一家初级医疗服务商，它的服务模式，就是由它的创始人、CEO鲁西卡·费尔南多普勒从部分非洲和加勒比国家借鉴来的。对大多数病人的观察和护理工作，该公司会交给所谓的“健康教练”而不是医生来负责。这些健康教练也经过了严格训练，但他们的成本比医生还是要低廉得多。Iora Health公司表示，他们这种重点关注初级护理的方法，使病人的住院率下降了40%，急诊率下降了20%。

来自发展中国家的科技创新也是不容小觑的。比如印度班加罗尔的一家医学创业公司Forus Health发明了一种成本低廉且较为便携的扫描成像设备，它可以检察出白内障等眼科问题。2016年，这种设备获得了FDA的批准。同年，Forus Health还在美国加州成立了一家子公司，专门推广其产品。这也是美国采用发展中国家的创新技术降低医疗成本的又一范例。

以上公司表明，对于医疗机构来说，扩大辐射范围与节省成本、实现盈利之间并不冲突。所以，美国可以不必纠结于哪笔钱由谁来出，而是应该着手削减这3.6万亿美元的成本。而医疗交付方面的创新则为此提供了一条可行的道路。（财富中文网）

本文作者Vijay Govindarajan是达特茅斯大学塔克商学院教授，也是《医疗逆向创新:如何实现基于价值的医疗服务》（Reverse Innovation in Health Care: How to Make Value-Based Delivery Work）一书的作者之一。

译者：朴成奎

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.