Five years ago, I was on a sabbatical, and I returned to the medical university where I studied. I saw real patients and I wore the white coat for the first time in 17 years, in fact since I became a management consultant.
五年前趁休假的时候, 我回到我曾就读的 医学院。 我穿上白大褂,见了真正的病人, 这是自我17年前 成为管理顾问以来的头一次。
There were two things that surprised me during the month I spent. The first one was that the common theme of the discussions we had were hospital budgets and cost-cutting, and the second thing, which really bothered me, actually, was that several of the colleagues I met, former friends from medical school, who I knew to be some of the smartest, most motivated, engaged and passionate people I'd ever met, many of them had turned cynical, disengaged, or had distanced themselves from hospital management. So with this focus on cost-cutting, I asked myself, are we forgetting the patient?
我在那里的一个月, 有两件事情让我吃惊。 第一,医学院里 常常讨论的话题是医院的预算 和削减开支。 第二,也是真正让我忧心的 是我遇到的几位同事。 他们是我在医学院的昔日好友, 他们是我所认识的最聪明, 最有积极性的,热衷参与 并富有激情的人。 但是,他们中的很多人,现在变得漠然且愤世嫉俗, 或与医院管理保持距离。 当我们专注于削减开支的时候, 我问我自己,我们是否忘记了病人的存在?
Many countries that you represent and where I come from struggle with the cost of healthcare. It's a big part of the national budgets. And many different reforms aim at holding back this growth. In some countries, we have long waiting times for patients for surgery. In other countries, new drugs are not being reimbursed, and therefore don't reach patients. In several countries, doctors and nurses are the targets, to some extent, for the governments. After all, the costly decisions in health care are taken by doctors and nurses. You choose an expensive lab test, you choose to operate on an old and frail patient. So, by limiting the degrees of freedom of physicians, this is a way to hold costs down. And ultimately, some physicians will say today that they don't have the full liberty to make the choices they think are right for their patients. So no wonder that some of my old colleagues are frustrated.
很多国家,包括你们的, 也包括我的, 都在为医疗保健支出而烦恼。 这项支出占据了国家预算的很大一部分。 而许多医疗体制改革的目标 就是控制这项支出的增加。 在一些国家,看病等待期很长, 特别是需要手术的病人。 还有一些国家,新药没有补助, 于是病人也不能用上新药。 在很多的国家,医生和护士 在一定程度上成为政府削减开支的针对目标。 毕竟,那些花费昂贵的医疗措施 都是由医生和护士来决定的。 是这些人在选择高成本的实验, 也是这些人在选择给孱弱的老人做手术。 所以,(政府想)通过限制医生的自由, 来达到降低开支的目的。 最后导致的结果是医生发现 他们没有充分的自由来 为他们的病人选择最适合他们的治疗方案, 怪不得我过去的同事们 那么沮丧。
At BCG, we looked at this, and we asked ourselves, this can't be the right way of managing healthcare. And so we took a step back and we said, "What is it that we are trying to achieve?" Ultimately, in the healthcare system, we're aiming at improving health for the patients, and we need to do so at a limited, or affordable, cost. We call this value-based healthcare. On the screen behind me, you see what we mean by value: outcomes that matter to patients relative to the money we spend. This was described beautifully in a book in 2006 by Michael Porter and Elizabeth Teisberg.
在BCG(波士顿咨询公司),我们分析了这个问题, 我们问自己, 这样管理医疗保健的方法肯定是不正确的。 所以我们退一步想 “我们到底想要取得什么成效?” 归根结底,在医疗保健系统里, 我们的目标是要改善病人的身体状况, 而且是要在一定限度内 或者说能负担得起的情况下。 我们称之为“以价值为基础的医疗保健”。 在我身后的屏幕上你们可以看到 我所谓“价值”就是: 对病人有用的结果 除以看病的费用。 这在一本2006年出版的由Michael Porter 和Elizabeth Teisberg合著的书里解释得非常清楚。
On this picture, you have my father-in-law surrounded by his three beautiful daughters. When we started doing our research at BCG, we decided not to look so much at the costs, but to look at the quality instead, and in the research, one of the things that fascinated us was the variation we saw. You compare hospitals in a country, you'll find some that are extremely good, but you'll find a large number that are vastly much worse. The differences were dramatic. Erik, my father-in-law, he suffers from prostate cancer, and he probably needs surgery. Now living in Europe, he can choose to go to Germany that has a well-reputed healthcare system. If he goes there and goes to the average hospital, he will have the risk of becoming incontinent by about 50 percent, so he would have to start wearing diapers again. You flip a coin. Fifty percent risk. That's quite a lot. If he instead would go to Hamburg, and to a clinic called the Martini-Klinik, the risk would be only one in 20. Either you a flip a coin, or you have a one in 20 risk. That's a huge difference, a seven-fold difference. When we look at many hospitals for many different diseases, we see these huge differences.
在这张照片里,你们可以看到我的岳父 和他的三个漂亮的女儿。 我们开始在BCG做研究的时候, 我们决定先不看费用是多少, 而是看质量。 在研究中,(医院之间) 悬殊的治疗质量相当引人注目。 比较同一个国家里的不同医院 你会找到一些做的非常好的医院, 但是也有大量医院做的极为糟糕。 这之间的差异非常显著。 我的岳父,Erik, 患有前列腺癌, 很可能需要手术。 他住在欧洲,他可以选择去德国治疗, 那里有声望不错的医疗保健系统。 如果他去了德国的一家普通医院, 他将面临大小便失禁的风险, 差不多有五十百分的几率, 那他将有可能要重新开始穿尿布。 这和掷硬币的几率一样。 50%的风险,不是一般的高。 如果他换而选择去汉堡, 去一个叫“Martini”的医院, 风险几率则减少到5%。 一边是像掷硬币一样的50%的风险, 另一边是仅有的5%。 这是个巨大的差别,有7倍之多。 我们调查过很多医院, 和很多不同的疾病, 我们都发现了这样巨大的差别。
But you and I don't know. We don't have the data. And often, the data actually doesn't exist. Nobody knows. So going the hospital is a lottery.
但是你我不一定都知道,因为我们没有数据。 而通常,这些数据根本不存在。 没人知道。 于是,去医院看病变成了买乐透。
Now, it doesn't have to be that way. There is hope. In the late '70s, there were a group of Swedish orthopedic surgeons who met at their annual meeting, and they were discussing the different procedures they used to operate hip surgery. To the left of this slide, you see a variety of metal pieces, artificial hips that you would use for somebody who needs a new hip. They all realized they had their individual way of operating. They all argued that, "My technique is the best," but none of them actually knew, and they admitted that. So they said, "We probably need to measure quality so we know and can learn from what's best." So they in fact spent two years debating, "So what is quality in hip surgery?" "Oh, we should measure this." "No, we should measure that." And they finally agreed. And once they had agreed, they started measuring, and started sharing the data. Very quickly, they found that if you put cement in the bone of the patient before you put the metal shaft in, it actually lasted a lot longer, and most patients would never have to be re-operated on in their lifetime. They published the data, and it actually transformed clinical practice in the country. Everybody saw this makes a lot of sense. Since then, they publish every year. Once a year, they publish the league table: who's best, who's at the bottom? And they visit each other to try to learn, so a continuous cycle of improvement. For many years, Swedish hip surgeons had the best results in the world, at least for those who actually were measuring, and many were not.
但是,其实不一定得这样。我们还是有希望的。 在70年代后期,有这么一群 瑞士外科整形医生, 在年会上, 他们讨论到目前众多的 用于髋关节手术的方法。 在幻灯片的左边,是各种各样的 金属配件和髋关节假体,用于治疗 需要髋关节置换手术的病人。 他们意识到他们每个人的方法都不同。 而且他们都认为“我的方法最好”。 但其实,没人知道哪个办法最好, 他们也承认这一点。 所以他们说,“我们可能需要做质量评估 来得知哪个是最好的方法,并学习它。” 事实上,他们花了两年时间来辩论 该如何评价髋关节手术的质量。 有的说应该评价这个指标,有的说那个。 最终他们达成了共识。 之后,他们便开始(给手术结果)做评估, 也开始共享数据。 很快,他们发现如果 在把金属轴插入大腿骨之前 先打入粘合剂, 这能使手术结果保持更长时间, 而且绝大多数病人 终身不用再做手术。 他们发布了这些数据, 而这一举动改变了整个国家的临床实践。 大家都发现这样做很有意义。 从此以后,他们每年都做数据发布。 每年发布一次积分榜。 谁拔头筹,谁垫底,(一目了然)。 他们还通过访问来相互学习, 进入了一个不断进步的循环。 多年来, 瑞士的髋关节置换手术的 治疗效果问鼎全球, 至少对那些有真正参与评估的医生来说, 不过也有人没有这么做。
Now I found this principle really exciting. So the physicians get together, they agree on what quality is, they start measuring, they share the data, they find who's best, and they learn from it. Continuous improvement.
我发现这一实践非常振奋人心。 即医生们聚到一起, 共同决定什么是高质量, 他们开始量收集并共享数据, 他们发现哪个方法最好,然后加以学习。 不断改进。
Now, that's not the only exciting part. That's exciting in itself. But if you bring back the cost side of the equation, and look at that, it turns out, those who have focused on quality, they actually also have the lowest costs, although that's not been the purpose in the first place. So if you look at the hip surgery story again, there was a study done a couple years ago where they compared the U.S. and Sweden. They looked at how many patients have needed to be re-operated on seven years after the first surgery. In the United States, the number was three times higher than in Sweden. So many unnecessary surgeries, and so much unnecessary suffering for all the patients who were operated on in that seven year period. Now, you can imagine how much savings there would be for society.
这还不是仅有的振奋人心的地方。 当然这本身已经令人振奋。 但是,如果把”成本“放回到我们的公式里, 然后观察它, 你会发现那些重视质量的(医院) 恰恰在花销上是最少的。 虽然这并不是当初刻意设计的。 如果回头再看髋关节手术的故事, 几年以前,他们做了一个研究 拿美国和瑞士做了比较。 他们调查了在第一次手术后 7年内需要再手术的病人的数量。 在美国,这个数字比瑞士 高出三倍。 太多不必要的手术, 给这些七年内 再次接受手术的病人 带来了太多不必要的痛苦。 现在你可以想象换种方法 能给社会节省多少开支。
We did a study where we looked at OECD data. OECD does, every so often, look at quality of care where they can find the data across the member countries. The United States has, for many diseases, actually a quality which is below the average in OECD. Now, if the American healthcare system would focus a lot more on measuring quality, and raise quality just to the level of average OECD, it would save the American people 500 billion U.S. dollars a year. That's 20 percent of the budget, of the healthcare budget of the country.
我们根据OECD数据做了一个研究。 偶尔,OECD(经济合作与发展组织)会根据 他们可以找到的会员国家 的数据来调查医疗护理的质量。 事实上,美国在很多疾病上 的保健质量是低于 OECD平均水平的。 那么,如果美国医疗系统 致力于做更多的质量评价, 并且把质量提高到OECD的平均水平, 可为美国人民缩减 每年五千亿美元的开支。 这占到了美国整个国家 医疗保健预算的20%。
Now you may say that these numbers are fantastic, and it's all logical, but is it possible? This would be a paradigm shift in healthcare, and I would argue that not only can it be done, but it has to be done. The agents of change are the doctors and nurses in the healthcare system.
你可能会说,这些数字 看上去很美,也符合逻辑, 可这现实吗? 这将是医疗保健的模式改变, 我认为,这不仅可以做到, 而且必须做到。 而医生和护士将是 医疗系统变革的主力。
In my practice as a consultant, I meet probably a hundred or more than a hundred doctors and nurses and other hospital or healthcare staff every year. The one thing they have in common is they really care about what they achieve in terms of quality for their patients. Physicians are, like most of you in the audience, very competitive. They were always best in class. We were always best in class. And if somebody can show them that the result they perform for their patients is no better than what others do, they will do whatever it takes to improve. But most of them don't know. But physicians have another characteristic. They actually thrive from peer recognition. If a cardiologist calls another cardiologist in a competing hospital and discusses why that other hospital has so much better results, they will share. They will share the information on how to improve. So it is, by measuring and creating transparency, you get a cycle of continuous improvement, which is what this slide shows.
在我做顾问期间, 我每年要接触上百名 医生,护士, 以及医院职工。 他们有着一个共同点, 就是他们真正最关心的是 如何保障病人的医疗质量。 医生和在做的各位一样, 是非常有竞争意识的。 他们一直是班上最优秀的, 我们总是班上最优秀的。 如果有人能告诉他们, 他们的医疗效果 并不比其他医生强, 他们将不惜一切来改善现状。 但是他们很多人不知道。 医生还有一个特点, 他们喜欢得到同行的褒奖。 如果一个心脏科医生向 另一家竞争医院的心脏科医生 咨询为什么他们的 治疗效果更好,他们会分享经验。 他们会交流如何改善治疗效果的经验。 正是通过医疗效果量化和透明化, 我们进入了一个不断改善的正循环, 正如这张幻灯片所示。
Now, you may say this is a nice idea, but this isn't only an idea. This is happening in reality. We're creating a global community, and a large global community, where we'll be able to measure and compare what we achieve. Together with two academic institutions, Michael Porter at Harvard Business School, and the Karolinska Institute in Sweden, BCG has formed something we call ICHOM. You may think that's a sneeze, but it's not a sneeze, it's an acronym. It stands for the International Consortium for Health Outcome Measurement. We're bringing together leading physicians and patients to discuss, disease by disease, what is really quality, what should we measure, and to make those standards global. They've worked -- four working groups have worked during the past year: cataracts, back pain, coronary artery disease, which is, for instance, heart attack, and prostate cancer. The four groups will publish their data in November of this year. That's the first time we'll be comparing apples to apples, not only within a country, but between countries. Next year, we're planning to do eight diseases, the year after, 16. In three years' time, we plan to have covered 40 percent of the disease burden. Compare apples to apples. Who's better? Why is that?
现在,你可能觉得这是个不错的主意, 不过这已经不仅仅是个“主意”了, 它正在发生。 我们正在打造一个全球共同体, 一个很大的全球共同体, 来量化和对比 我们的成效。 BCG与两个学术院校, 哈佛商学院的Michael Porter, 以及瑞典的Karolinka学院, 合作成立了ICHOM(发音“阿嚏”) 你们可能会觉得这听起来 像打喷嚏,其实这是个缩写。 它的意思是“健康结果测评 的国际联盟”。 我们把顶尖的医生和病人 集合起来,针对每一种疾病 讨论是什么决定了医疗质量, 我们应该如何衡量, 最后形成全球统一标准。 在过去一年里,我们有四个小组在工作, 他们的项目是: 白内障,背部疼痛, 冠状动脉疾病,比如心脏病, 和前列腺癌。 这四个小组会在今年十一月 发表研究数据。 这将是我们第一次 在国家之间对比(疾病医疗的效果), 而不是仅限于单一国家内。 明年我们计划研究8种疾病, 后年,增加到16种。 我们计划用三年时间 完成对40%的疾病的分析。 比较治疗方案之间哪个更好, 为什么更好?
Five months ago, I led a workshop at the largest university hospital in Northern Europe. They have a new CEO, and she has a vision: I want to manage my big institution much more on quality, outcomes that matter to patients. This particular day, we sat in a workshop together with physicians, nurses and other staff, discussing leukemia in children. The group discussed, how do we measure quality today? Can we measure it better than we do? We discussed, how do we treat these kids, what are important improvements? And we discussed what are the costs for these patients, can we do treatment more efficiently? There was an enormous energy in the room. There were so many ideas, so much enthusiasm. At the end of the meeting, the chairman of the department, he stood up. He looked over the group and he said -- first he raised his hand, I forgot that -- he raised his hand, clenched his fist, and then he said to the group, "Thank you. Thank you. Today, we're finally discussing what this hospital does the right way."
五个月前, 我在北欧最大的医学院 组织了一次专题讨论会。 他们换了新的CEO,而她的愿景是: “我希望把管理重点放在 保证病人的治疗质量和效果上。” 在这天的研讨会上,我们跟医护人员 和后勤人员一起 谈到患白血病的孩子。 我们讨论到 我们该如何评价治疗结果? 我们在评估上能如何改进? 我们还讨论到,该如治疗这些孩子? 哪些对他们来说是重要的改善? 我们还提到费用问题。 我们有更有效的治疗方案吗? 整个讨论气氛非常热烈。 每个人都热情洋溢,提出了很多想法。 会议结束的时候, 部门主席站了起来, 他注视着大家,然后说, 差点忘了,他先举手了, 他举起手来,攥成拳头, 然后,他对大家说:“谢谢。 谢谢。今天我们终于讨论到了 我们这家医院做的一件正确的事情。”
By measuring value in healthcare, that is not only costs but outcomes that matter to patients, we will make staff in hospitals and elsewhere in the healthcare system not a problem but an important part of the solution. I believe measuring value in healthcare will bring about a revolution, and I'm convinced that the founder of modern medicine, the Greek Hippocrates, who always put the patient at the center, he would smile in his grave.
(我们所说的)医疗保健的价值, 不只是要考虑费用, 还要为我们的病人带来有效的治疗。 我们要让医院和医保系统的员工 不再是(医疗成本的)负担, 而成为(化解成本的)重要组成部分。 我相信,通过衡量 医疗保健的价值会带来一次革命, 我也相信现代医学的奠基人 一位以病人至上的 古希腊的希波克拉底(希腊的名医,称医药之父) 看到这些,会含笑九泉的。
Thank you.
谢谢。
(Applause)
(掌声)