如何解決健康照護的成本危機?

Solving the Health Care Cost Crisis
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哈佛商學院教授暨《哈佛商業評論》文章〈為醫界把脈〉(How to Solve the Cost Crisis in Health Care)的作者麥可.波特(Michael Porter)和羅伯.柯普朗(Robert S. Kaplan)說明,為什麼醫療機構必須從正確的衡量方法開始著手。

亞迪.伊格納西斯:歡迎來到《哈佛商業評論》的The Idea。我是總編輯亞迪.伊格納西斯,今天受訪的是哈佛商學院教授羅伯.柯普朗和麥可.波特,我們要討論如何解決健康照護的成本危機。麥可,我想從你開始。你要解決的問題是什麼?

麥可.波特:好的,亞迪,你知道,健康照護的成本已經失控,全世界都如此,不只美國而已。我們的國內生產毛額,有很大一部分與健康照護密切相關。每年都有成長。許多這類問題,其中有些問題與人口老化和醫療科技有關,但我們發現,這個問題的主要部分非常令人驚訝。那就是健康照護組織不知道如何正確衡量本身的成本。

他們把成本,與自己獲得收入的方式混淆在一起。他們根據各部門來加總成本,而不是根據病人和病人的需求、滿足病人的需求來計算。他們不正確地分攤成本,產生各種偏差,完全混淆了真正的成本。因此,過去降低健康照護成本的努力,一直都沒有成效,而是全面降低價格,在不合理之處降低,並在不合理的情況下任意減少服務。

他們無法清楚了解,哪些事情真正能讓系統更有生產力。

羅伯.柯普朗:讓我針對麥可的回答補充一個面向,那就是人們甚至無法對成本的定義達成共識。政府談到成本時,指的是他們的成本,他們必須支付供醫療機構的給付費用。因此他們談論降低成本時,是指我們該如何減稅以降低政府收入,促使政付減少支付給醫療系統的費用。

消費者考慮到他們的成本時,想的是要花多少錢才能獲得醫療,或支付保險。但成本的正確定義是,醫療組織本身在系統內要付出的成本。進行根本改革的唯一方法,是處理那個系統中的成本,解決麥可描述的問題。

亞迪.伊格納西斯:好,那麼我們該如何解決這個問題?

羅伯.柯普朗:其實解決方案並不很複雜。架構相當簡單,雖然我的確花了二十年才讓它變得這麼簡單。

這套架構以病人為分析單位。正是病人引發了對所有這些醫療資源的需求。因此,這必須是你的基本成本計算單位。我們以兩個階段的程序來討論。一個是只檢視病人在整個照護週期中,所經歷的行政和臨床流程,從他們最初出現症狀,一直到照護結束為止,只要描繪出其中涉及的所有流程,並確認投入的資源,包括醫師、護理師、行政人員,但也包括設備和設施,這些是在每個流程中用來治療病人的。

第二部分就是衡量每一種資源的成本。要支付多少成本,才能提供醫師、護理師、行政人員和設備?然後,你衡量病人花在每種資源上的時間,乘以成本,就能得到整個照護週期的成本。

麥可.波特:我們學到的一些有用的心得是,你必須衡量一組患有某一種疾病的病人。你應了解治療乳癌或糖尿病的成本,而不是加總計算提供門診或影像等特定服務的成本。當你針對病人的醫療情況來衡量時,就能將成本與結果進行比較,開始提出有關價值的問題。

我們有創造價值嗎?我們必須進行這個流程以改善結果嗎?令人訝異的是,這類討論從未在健康照護領域裡進行。從未有資訊可以進行這種討論,真正地比較成本和結果。

亞迪.伊格納西斯:這聽起來是很棒的計畫,如果你是要從頭打造一套健康照護系統的話。讓我們來討論實際面。你會如何改革像美國這樣的系統,也就是混亂、利益已根深柢固?你會如何改變舊系統,讓它更像你描述的這種系統?

羅伯.柯普朗:我們發現,這個過程若只是走過整個流程、繪製流程圖、同意哪個流程會使用哪些資源,以及提供這些資源要花多少成本,那麼不會有爭議。你可以回去檢視數據。這確實提供一個很棒的論壇,讓彼此相爭的單位,也就是行政人員說要削減成本,而臨床醫師說,嘿,我們治療病人救了他們的 命,讓他們透過這個論壇開始真正對話。所以,轉型會來自內部。

它會來自於這些不同的醫療組織內部,因為這是他們應該做、而且早就應該做的事情。這很明顯。我們發現臨床醫師能認同這一點,因為這符合他們的工作。當然,外部會有壓力,壓力來自不同的保險公司,來自政府,要求減少付款。若要讓這些力量凝聚在一起,唯一的方法就是,醫療組織要變得更有效率,更加聚焦,並以更低的成本提供相同或更好的照護,因為他們的保險給付,不會像過去幾十年那樣持續增加。

麥可.波特:亞迪,我已經在健康照護領域工作了大約十年。這篇文章絕對是我寫過有關健康照護最樂觀的一篇。因為這明確顯示,我們可以大幅改善病人的照護,用更少的資源做到,而且基本上沒有人需要減薪。許多人認為健康照護的問題很棘手。成本問題難以解決。以為問題背後的驅動力量是我們無法掌控的,但其實並非如此。我們真的可以解決這個問題。

亞迪.伊格納西斯:這會有什麼成效?你是否有估算,如果像這樣的系統推展到全美國各地,在健康照護和總體成本方面會有哪些成效?

羅伯.柯普朗:由於這個產業的現況,以及對營運成本的理解不足,因此若是採取這種清楚、透明、可據以採取行動的觀點,來看待提供服務的成本、未使用的醫療容量在哪裡、我們在哪裡使用錯誤的醫療資源來治療特定情況,以及在昂貴的設施裡運作,而不是在花費較低的郊區診所,那麼我們應該很容易可以看到系統降低至少10%或20%的成本,而且不會犧牲醫療結果。就像麥可針對週期時間所說的,這實際上可以同時改善結果。

亞迪.伊格納西斯:我知道你參與過幾項試行計畫。我想大致了解,你從中發現了什麼。

羅伯.柯普朗:我們目前正在與七、八個試行計畫地點合作,其中約半數聚焦在相同的手術,就是人工膝關節置換手術。因此,我們有機會檢視他們使用的不同流程,和在每個流程中使用的不同資源,然後比較它們的結果和成本。

我們在德國合作的診所提供和美國相似的結果,而只使用25%的資源。其中有個原因其實是價格,他們為護理師和醫師支付的費用,比美國少一些,但也有生產力的差異,大約介於兩倍到四倍的差異,就只是在他們安排醫療照護的方式方面的差別。

麥可.波特:我們目前面對愈來愈多需求,要進行愈來愈多試行計畫。因此我認為,健康照護領域已經準備好採取新做法。現在正是時候,情況也合適,當前的挑戰是協助讓計畫可行,讓計畫盡可能容易實施,協助提供工具和支持,讓組織能夠真正推動這項計畫。但十年後,每家主要的醫療服務機構都會這麼做。他們必須這麼做。

亞迪.伊格納西斯:我覺得很有趣的是,你們兩位會在這個主題上合作。你們能告訴我一些有關這段合作的故事嗎?

麥可.波特:大約十年前,我偶然踏入這個領域,其實是因為我有位同事的孩子病得很重。我一再跟她談論她的孩子,談他在健康照護系統經歷的一切。我們開始對這件事感興趣,一起討論,然後就做了一些研究。

我研究這個領域已經好一段時間,一直沒有真正了解這個成本議題,直到兩年前才改觀,當時我開始提出一些問題,我覺得那些問題很明顯,但沒人能回答。就像,如果提供這項服務,這家機構與那家機構相比的成本是多少?每個人都會清清喉嚨,然後搖搖手,可是他們真的不知道答案。所以,我直覺想到去問羅伯,他是否研究過健康照護的成本議題。

他說,他曾經很接近要做研究了,但沒什麼機會真正從內部了解大型組織。我跟幾家領導業界的醫療中心關係很好。所以我們就同意要試試看。和羅伯合作非常愉快,我們進展的速度也非常驚人。

亞迪.伊格納西斯:訪談非常有趣。我想要感謝兩位今天受訪。這是《哈佛商業評論》的The Idea。更多資訊,請上hbr.org。


Michael Porter and Robert S. Kaplan, Harvard Business School professors and authors of the HBR article "How to Solve the Cost Crisis in Health Care," explain why providers must start with proper measurement.

Adi Ignatius: Welcome to The Idea from Harvard Business Review. I’m Adi Ignatius, editor in chief, and joining me toady are Harvard Business School professors Robert Kaplan and Michael Porter to talk about how to solve the cost crisis in health care. Mike, let me start with you. What is the problem you’re trying to solve?

Michael Porter: Well Adi, as you know, cost in health care are out of control—all over the world, not just in the United States. An enormous share of our GDP is tied up in health care. It’s growing every year. A lot of these problems, some of the problem has to do with aging populations and medical technology, but what we’ve discovered is actually a major part of the problem is incredible surprising. And that is that organizations in health care don’t know how to measure their cost properly.

They confuse cost with how much they get paid. They add up cost around departments, not around the patient, and the patient’s need, and meeting the patient’s need. They allocate cost improperly, with all kinds of biases that really confuse what the actual cost are. And because of this, efforts in the past at cost reduction in health care have been completely ineffective—across the board price cuts when that makes no sense, arbitrary reductions in services where that makes no sense.

And really, the inability to get visibility on the things that could really make the system more productive.

Robert Kaplan: Let me just add one more dimension to what Mike said to the problem is that people don’t even agree on what they mean by costs. When the government talks about cost, they mean their costs, what they have to spend to reimburse providers. And so when they talk about reducing costs, they mean how can we starve the beast and reduce the payments into the system.

Consumers think about their costs, what it costs them to get medical care or to pay for their insurance. But the correct definition of cost is the cost incurred within the system by the provider organizations themselves. And the only way to get fundamental reform is to work on the cost within that system and solving the problems that Mike described.

Adi Ignatius: OK, so how do we fix it?

Robert Kaplan: Well, the solution, actually, is not that complex. The framework is simple, though it did take me 20 years to get this simple.

And it focuses on the patient as the unit of analysis. It’s the patient that’s triggering the demand for all these medical resources. And so that has to be your fundamental costing unit. And we get at it in a two-stage procedure. One is to just look at the administrative and clinical processes that a patient goes through over a complete cycle of care, when they first presented with symptoms until the conclusion of their care, and just map all the processes that are involved in that and identify the resources, which are the physicians, and the nurses, and the administrators, but also the equipment and the facilities that are used at treating the patient at each of these processes.

Then the second part is just to measure the cost of each of these resources. What does it cost to supply a physician, a nurse, a clerk, a piece of equipment? And then you measure how much time that the patient spends with each of these resources, multiplies that by the cost, and that gives you the cost over a complete cycle of care.

Michael Porter: And some of the powerful things we’ve learned is you have to do that measurement around a set of patients with a given medical condition. So you want to understand the cost of treating breast cancer or diabetes, rather than accumulate the cost of providing a particular service, like an outpatient visit or an image. And when you do it around the patient’s medical condition, then you can compare the cost to the outcomes and start asking value questions.

Are we creating value? Do we need to do this process in order to improve the outcome? And that discussion, as astonishing as you would believe, has never happened in health care. There’s never been the information to have that discussion that really compares costs and outcomes.

Adi Ignatius: So this sounds like a great plan if you’re building a health care system from the ground up. Let’s talk practical. I mean, how would you reform a system like the one in the US, with its messy, that has entrenched interest? How would you change it to be more like this?

Robert Kaplan: What we have found is that the process of just going through, doing the process maps, and agreeing which resources are done at which process, and what does it cost to supply the resource, this is not controversial. I mean, you can get back to the data. And it actually has provided a great forum by which these warring factions, you know, administrators saying cut costs, and clinicians saying, hey, we cure and save patients, start to speak the same language. And so the transformation will come from within.

It’s going to come from within these various provider organizations because this is what they should be doing and should have been doing. And it’s kind of obvious. I mean, we’ve found that the clinicians buy into this because it corresponds to what they’re doing. There’s also pressure, of course, on the outside, from various insurance companies and from the government, to cut the payments. And the only way these forces are going to come together is if the provider organizations get more efficient, get more focused, and deliver the same or better care at lower cost because their reimbursements are not going to continue to escalate the way they have over the past several decades.

Michael Porter: Adi, you know, I’ve been working now for about a decade in health care. And this article is the most optimistic single thing about health care that, certainly, I’ve ever done. Because it really shows that we can make tremendous improvements in caring for patients and do it with a lot less resources, and nobody, intrinsically, has to take a pay cut. And so many people feel that the health care problem is intractable. The cost problem is intractable. It’s driven by forces beyond our control—it’s actually isn’t. We can actually solve this problem.

Adi Ignatius: And what would this do? Do you have any estimate, if a system like this rolled out across the US, what would that do in terms of health care and in terms of overall costs?

Robert Kaplan: Given the state of the industry today, and its lack of understanding of the cost of doing business, having this clear, transparent, an actionable view on what it’s costing them to deliver care, where the unused capacity is, where we’re using the wrong medical resources to treat a given condition, doing things in expensive facilities rather than much less expensive at suburban clinics, I’d be surprised if we couldn’t get at least 10% or 20% of the cost out of the system without sacrificing outcomes and, as Mike was saying on the cycle times, actually improving outcomes at the same time.

Adi Ignatius: I know that you’ve been involved in some pilot projects. And I’d love to know briefly what you’re finding from that.

Robert Kaplan: We’re currently working with seven or eight pilot sites, about half of which are focused on the same procedure, which is a total knee replacement. And so we have the opportunity of seeing the different processes they’re using, the different resources they’re using at each of these processes, and compare their outcomes and costs.

The clinic that we’re working with in Germany was able to deliver comparable outcomes to the US using the 25% of the resources. Now some of that is actually prices, they’re paying a little bit less for their nurses and physicians than we do in the US, but there are productivity differences of somewhere between two, to four, to one, just in the way they’re organizing the delivery of medical care.

Michael Porter: And we are facing now a very growing demand for more and more pilots. So I think the health care field is ready for this. This is the moment, the circumstances are right, and the challenge now is to help make this actionable, help make it as easy as possible to implement, help provide the tools and the support to allow organizations to actually implement this. But 10 years from now, every major health care delivery organization is going to do this. They have to.

Adi Ignatius: So it’s very intriguing to me that the two of you have come together on this topic. Can you tell me a little bit about this collaboration came about?

Michael Porter: Well, I stumbled into this field perhaps a decade ago, really because a colleague of mine had a child that was extremely sick. And I spent day, after day, after day talking with her about her child and what was going onto him as he was migrating his way through the health care system. And we started getting interested in it, and talking about it, and that led to some work.

So I’ve been at this for a while but I had never gotten close enough to really understand this cost issue until perhaps two years ago, when I started asking questions, that seemed obvious to me, that nobody could ever answer. Like, oh, what’s the cost of doing this service in this facility versus that facility? And everybody would clear their throats and wave their hands, but they really didn’t know. And so I get this hunch and asked Bob if he had ever done any work on costing in health care.

And he said, well, he’d been close to doing work, but had never quite had a chance to really get under the tent in a real important organization. I had some great relationships with some leading medical centers. And so we just agreed that we would give this a shot. And it’s just been enormously gratifying to work with Bob and the rate of progress here has been really breathtaking.

Adi Ignatius: That was fascinating. I want to thank both of you for being with us today. That was The Idea from Harvard Business Review. For more, go to hbr.org.



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