It's 4am in the morning. I'm waking up in a Boston hotel room and can only think of one thing: tooth pain. One of my ceramic inlays fell off the evening before. Five hours later, I'm sitting in a dentist's chair. But instead of having a repair of my inlay so that I can get rid of my pain, the dentist pitches me on the advantages of a titanium implant surgery. Ever heard of that?
時間是早上四點。 我在波士頓一間飯店的房間中醒來, 腦中只能想著一件事: 牙痛。 前晚,我的其中一個瓷鑲體脫落了。 五小時之後,我坐在牙科的椅子上。 但牙醫師並沒有修復我的瓷鑲體 好讓我脫離牙痛之苦, 反而在跟我推銷鈦植牙手術的優點。 有聽過嗎?
(Laughter)
(笑聲)
It essentially means to replace a damaged tooth by an artificial one, that is screwed into your jaw. Estimated costs for the implant surgery may add up to 10,000 US dollars. Replacing the ceramic inlay I had before would come in at 100 US dollars. Was it my health or the money that could be earned with me that was the biggest concern for my dentist?
基本上,就是要把一顆受損的牙齒 換成一顆人工牙齒, 用螺釘固定在你的下頜上。 植牙手術的估計成本 可能會高達一萬美金。 把我之前的瓷鑲體換掉, 只要大約一百美元。 到底是我的健康, 還是能從我身上賺到的錢, 是我的牙醫最先考量的事?
As it turned out, my experience wasn't an isolated case. A study by a US national newspaper estimated that in the United States, up to 30 percent of all surgical procedures -- including stent and pacemaker implantations, hip replacements and uterus removals -- were conducted although other nonsurgical treatment options had not been fully exploited by the physician in charge. Isn't that figure shocking? Numbers may be slightly different in other countries, but what it means is that if you go to a doctor in the US, you have a not-insignificant chance to be subjected to a surgical intervention without there being an immediate need for it. Why is this? Why are some practitioners incentivized to run such unnecessary procedures?
結果發現,我的經歷並非單一個案。 美國一間報社的研究指出 在美國所有的手術當中 估計有三成── 包括支架和心律調節器植入、 髖關節置換,及子宮移除── 被執行, 儘管其他非手術的治療方式 尚未完全被其主治醫生利用過。 那數字不是挺嚇人的嗎? 在其他國家,數字可能稍有不同, 但這意味著,如果你在美國看醫生, 你有顯著的可能性, 會在不立即需要手術的情況下 就去接受手術治療。 為什麼會這樣? 為什麼有些開業醫生會被獎勵 去做這類不必要的手術?
Well, perhaps it is because health care systems themselves incentivize in a nonideal way towards applying or not applying certain procedures or treatments. As most health care systems reimburse practitioners in a fee-for-service-based fashion on the number and kind of treatments performed, it may be this economic incentive that tempts some practitioners to rather perform high-profit surgical treatments instead of exploring other treatment options. Although certain countries started to implement performance-based reimbursement, anchored on a quality and efficacy matrix, overall, there's very little in today's health care systems' architecture to incentivize practitioners broadly to actively prevent the appearance of a disease in the first place and to limit the procedures applied to a patient to the most effective options.
也許是因為健康照護體制本身, 用一種不盡理想的方式, 鼓勵採用/不採用某些手術或治療。 大部分的健康照護體制 對開業醫生的補助 是以一次一付的醫療費為基礎的, 根據所進行之治療的 數量和類型來給付, 可能就是這種經濟獎勵 誘使一些開業醫生 選擇採用高利潤的手術治療, 而不去尋求其他治療選擇。 雖然有些國家開始導入 以績效為基礎的補助, 根據的是品質和功效的矩陣, 整體來說,現今的健康照護體制 結構中,很少會有這種方式, 廣泛鼓勵開業醫生 在一開始就主動去預防疾病出現, 並只對病人進行 能達到最大效用的手術。
So how do we fix this? What it may take is a fundamental redesign of our health care system's architecture -- a complete rethinking of the incentive structure. What we may need is a health care system that reimburses practitioners for keeping their customers healthy instead of almost only paying for services once people are already sick. What we may need is a transformation from today's system that largely cares for the sick, to a system that cares for the healthy. To change our current "sick care" approach into a true "health care" approach. It is a paradigm shift from treating people once they have become sick to preserving the health of the healthy before they get sick. This shift may move the focus of all those involved -- from doctors, to hospitals, to pharmaceutical and medical companies -- on the product that this industry ultimately sells: health.
這問題要如何解決? 可能會需要從根本上重新設計 我們的健康照護體制結構── 完全重新思考鼓勵結構。 我們需要把健康照護體制的報銷條件 改成是醫生要保持其客戶的健康, 而不是幾乎只支付 已病之後的治療服務。 我們得要轉變, 從現今主要在照護病人的體制, 轉變為照護健康的體制。 把我們目前的「生病照護」方法, 改變為真正的「健康照護」方法。 這是一種典範轉移, 從在大家生病之後才進行治療, 變成在他們生病之前 就維持他們的健康。 這種轉移,可能會讓所有 相關人士的焦點改變── 醫生、醫院、藥廠, 及醫療器材公司── 把重心改放到這個產業 最終要銷售的產品上: 健康。
Imagine the following. What if we redesign our health care system into one that does not reimburse practitioners for the actual procedures performed on a patient but rather reimburses doctors, hospitals, pharmaceutical and medical companies for every day a single individual is kept healthy and doesn't develop a disease? In practical terms, we could, for example, use public money to pay a health fee to an insurance company for every day a single individual is kept healthy and doesn't develop a disease or doesn't require any other form of acute medical intervention. If the individual becomes sick, the insurance company will not receive any further monetary compensation for the medical interventions required to treat the disease of that individual, but they would be obliged to pay for every evidence-based treatment option to return the customer back to health. Once the customer's healthy again, the health fee for that individual will be paid again.
想像以下情況。 如果我們重新設計健康照護體制, 這個體制不會補助開業醫生 對於病人實際上執行的手術, 而是補助醫生、醫院、 藥廠,以及醫療器材公司, 每天每一個病人能保持健康無疾病, 就能得到補助? 就實際面來說,比如,我們可以 用公款來支付健康費給保險公司, 只要每天每一個人能保持健康 無疾病, 或是不需要任何其他形式的 急性醫療干預就付款。 如果一個人生了病, 保險公司不會從治療這個人之疾病 所需要進行的醫療干預 收到任何進一步的金錢補助, 他們反而有義務要支付 讓客戶恢復健康的治療選擇, 只要有證據佐證治療的必要性。 一旦客戶再次恢復健康, 他們就會再次收到那個人的健康費。
In effect, all players in the system are now responsible for keeping their customers healthy, and they're incentivized to avoid any unnecessary medical interventions by simply reducing the number of people that eventually become sick. The more healthy people there are, the less the cost to treat the sick will be, and the higher the economic benefit for all parties being involved in keeping these individuals healthy is.
實際上,在這個體制中的所有參與者 現在都有責任要保持客戶健康, 他們若能避免不必要的 醫療干預,就能得到獎勵, 只要做到減少生病的人數。 大家越健康, 治療疾病的成本就會越低, 而保持每位客戶健康的相關各方, 也會有更高的經濟利益。
This change of the incentive structure shifts, now, the attention of the complete health care system away from providing isolated and singular treatment options, towards a holistic view of what is useful for an individual to stay healthy and live long.
將獎勵結構做這種改變, 會轉移整個健康照護體制的注意力, 從專注在提供獨立 且單一的治療選擇, 轉變成「全人視角」, 關注的是要做什麼 才能讓人保持健康和長壽。
Now, to effectively preserve health, people will need to be willing to share their health data on a constant basis, so that the health care system understands early enough if any assistance with regard to their health is needed. Physical examination, monitoring of lifetime health data as well as genetic sequencing, cardiometabolic profiling and imaging-based technologies will allow customers to make, together with health coaches and general practitioners, optimal and science-guided decisions -- for their diet, their medication and their physical activity -- to diminish their unique probability to fall sick of an identified, individual high-risk disease.
若要有效地保持健康, 大家得要願意分享他們的健康資料, 且要經常分享, 這麼一來,健康照護體制 就能在夠早的時間點 去了解大家的健康 需要什麼樣的協助。 健康檢查、 監控終身健康資料, 還有 DNA 定序、心血管代謝側寫, 以及成像相關的技術, 會讓客戶配合健康教練 和一般開業醫生 做出由科學所引導的最佳決策── 包括飲食、用藥,以及 身體活動相關的決策── 以降低每個人得到 每種可辨視之高風險疾病的機率。
Artificial intelligence-based data analysis and the miniaturization of sensor technologies are already starting to make monitoring of the individual health status possible. Measuring cardiometabolic parameters by devices like this or the detection of circulating tumor DNA in your bloodstream early on after cancer disease onset are only two examples for such monitoring technologies.
以人工智慧為基礎的資料分析 以及感測器技術的微型化, 已經開始讓監控 個人健康狀況成為可能。 用像這樣的裝置來 測量心血管代謝參數, 或及早在癌症襲擊之前 就先偵測你的血液中 有無血液循環腫瘤 DNA, 只是這類監控技術的兩個例子而已。
Take cancer. One of the biggest problems in certain oncological diseases is that a large number of patients is diagnosed too late to allow them to be cured, although the drugs and treatments that could potentially have cured them are already existing today, if the disease had only been detected earlier. New technologies allow now, based on a few milliliters of blood, to detect the presence of circulating tumor DNA and thus, the presence of cancer, early on in a really convenient manner. The impact that this early-stage detection can have may be dramatic. The five-year survival rate for non-small cell lung cancer when diagnosed at stage one, which is early, is 49 percent. The same, when diagnosed at stage four, which is late, is below one percent. Being potentially able to prevent a large number of deaths by something as simple as a blood test for circulating tumor DNA could make certain cancer types a manageable disease, as disease onset can be detected earlier and positive treatment outcomes can likely be increased.
比如癌症。 某些腫瘤疾病遇到最大的問題之一, 就是太多病人都太晚才被診斷出來, 已經來不及治癒, 儘管現今已經有些藥品和治療 有可能治癒他們, 只要疾病能更早被偵測出來。 現在的新技術已經 能根據幾毫升的血液 偵測出是否有血液循環腫瘤 DNA, 因此,在早期就能用 很方便的方式偵測出癌症。 這種早期偵測會造成的影響 是非常巨大的。 非小細胞肺癌的五年存活率, 如果在第一期,也就是很早期 就診斷出來,五年存活率是 49%。 如果在第四期, 也就是很晚期才診斷出來, 五年存活率是就不到 1%。 只要用很簡單的東西,像是 血液循環腫瘤 DNA 的血液檢測, 就有可能預防許多人喪命, 它能讓某些類型的癌症 變成可以控管的疾病, 疾病的攻擊能及早被偵測出來, 因此也更可能會有正面的治療結果。
In 2012, 50 percent of all Americans had a single chronic disease, resulting in 86 percent of the $3 trillion US health care budget being spent for treating such chronic diseases. Eighty-six percent. If new technologies allow now to reduce this 86 percent, why have health care systems not reacted and changed already?
2012 年, 有 50% 的美國人 得了單一種慢性病, 導致美國的三兆美元 健康照護預算有 86% 花在治療這類慢性病上。 86%。 如果新技術能減低這 86%, 為什麼健康照護體制 還沒有反應和改變?
Well, a redesign of what today is a sick care system into a true health care system that focuses on prevention and behavioral changes requires every actor in the system to change. It requires the political willingness to shift budgets and policies towards prevention and health education to design a new set of financial and non-financial incentives. It requires creating a regulatory framework for the gathering, using and sharing of personal health data that's at the same time stringent and sensible. It needs doctors, hospitals, insurers, pharmaceutical and medical companies to reframe their approach and, most important, it can't happen without the willingness and motivation of individuals to change their lifestyle in a sustained way, to prioritize staying healthy, in addition to opening up for sharing the health data on a constant basis.
要把現今的生病照護體制 重新設計成真正的健康照護體制, 需要把焦點放在預防和行為改變上, 這需要體制中的 每個行為者都做出改變。 這也需要政治意願, 將預算和政策轉向預防和健康教育, 來設計一組新的財務 和非財務獎勵方式。 這就需要創造一個規範的架構, 來收集、使用和分享個人健康資料, 既嚴格且合理的規範架構。 這需要醫生、醫院、保險業者、 藥廠,以及醫療器材公司 重新調整他們的方法, 然後,最重要的是, 這件事若要成真,得仰賴每個人都有 意願和動機去改變他們的 生活方式,變得更永續, 把保持健康列為優先事項, 此外還要能開放地 經常分享健康資料。
This change may not come overnight. But by refocusing the incentives within the health care industry today to actively keep people healthy, we may not only be able to prevent more diseases in the first place but we may also be able to detect the onset of certain preventable diseases earlier than we do today, which will lead to longer and healthier lives for more people.
這種改變不會一夕成真。 但現在就在健康照護產業中 將獎勵的焦點改變為 主動保持民眾健康, 我們不只能在一開始 就先預防更多的疾病, 我們也能夠偵測出某些 可預防之疾病的發生, 且比現今能做到的更早, 這就會讓更多人能更長壽、更健康。
Most of the technologies that we need to initiate that change are already existing today. But this is not a technology question. It is primarily a question of vision and will.
要開始這項改變,我們所需要的技術 大多已經存在了。 這不是個技術問題。 根本上,這是個遠見 以及意願的問題。
Thanks a lot.
非常謝謝。
(Applause)
(掌聲)