经济学人下载:美国医疗行业 对医疗费用动动刀

America's hospital industry
美国医疗行业

Taking a scalpel to costs
对医疗费用动动刀

Hospital operators brace themselves for health-care reform
医院负责人正为医保制度改革做准备

EARLIER this month America's hospital bosses gathered in Washington, DC, with vice-president Joseph Biden.
本月早些时候，美国医院的领导者们和副总统Joseph Biden齐聚华盛顿。

To the amazement of many, they vowed to accept a cut of $155 billion in their expected revenues over the next decade as part of a grand bargain on health-care reform.
令人感到惊奇的是，他们郑重同意在接下来的十年将预期收益削减1550亿美元，作为医疗保健改革已取得的巨大成效中的一部分。

How can they justify giving away such a vast sum?
他们为什么会同意放弃这么大一笔收益？

There are several explanations, not all of them altruistic.
对此有很多种解释，他们的动机也不全出于利他。

Taken together, they show that the industry's leaders are bracing themselves for a period of upheaval.
总之，他们已经显示出整个行业的领导人正积极应对未来行业的大变动。

For hospitals, the positive thing about health-care reform is that it is going to be good for business.
对医院来说，医保改革带来的好处是它对商业有利。

It will be welcome news to an industry that is hardly in rude health.
改革对于一个不太健康的行业来说总是好事。

Despite two decades of consolidation, hospitals' finances remain anaemic; over a quarter of them regularly post negative operating margins.
诚然，医保行业走过了二十年的稳固期，但是医院的财经状况仍旧不景气，超过四分之一的医院存在周期性亏损。

The recession is making things worse.
而且现在的经济危机更是加剧了形势恶化。

Moody's, a credit-rating agency, notes that many patients are putting off non-essential treatments.
信贷评级机构Moody's注意到很多患者正在推迟一些非必须的治疗。

So any reforms that promise a flood of new demand for health services should be welcome.
因此任何可以使得医疗服务的需求大幅增长的改革承诺都应该是大受欢迎的。

Rich Umbdenstock, the head of the American Hospital Association and one of the bosses who shared the stage with Mr Biden,
作为美国医院协会会长的Rich Umbdenstock和与副总统Biden先生见面会谈的领导人之一，

acknowledges that extending health insurance to most of America's nearly 50m uninsured will benefit his industry in the long term.
承认从长远看来，为没有享受医保的五千万美国人提供保险将会使整个行业受益。

Those unfortunates still turn up at emergency rooms and often do not pay their bills.
这些没有医保的人们经常出现在急诊室里而且无力支付医药单。

The government gives hospitals some money to compensate them for this, but the AHA says it does not cover the full cost,
对此，政府会给医院发放一定数额的资金以作弥补，但是美国医院协会表示，这些金额不足以支付资金缺口。

which it put at $34 billion in 2007, up from $3.9 billion in 1980.
这些缺口已经从1980年的39亿上升到2007年的340亿，

Paul Mango of McKinsey, a consultancy, estimates that the hospitals recover only 10-12% of this cost.
大约占医院每年财政收入的5%。来自咨询公司麦肯锡公司的Paul Mango估计，医院大概只能收回这些资金的10-12%，

But he says the problem would be greatly reduced under a system of universal health-insurance which included subsidies for the indigent, as the proposed health reforms envisage.
但他也说，如果可以建立一个大部分人都享受医保并且贫困人口得到补助的体制，这些资金缺口就可以被大大减少，而这种体制正是当前的医疗改革尝试建立的。

Herbert Pardes, chief executive of New York-Presbyterian, a research hospital, says the large numbers of underinsured patients, who frequently fail to pay their bills in full, cost hospitals still more.
Herbert Parades是纽约一家研究型医院Presbyterian的总裁，他说，很多保额不足的病人不能全额支付他们的医疗花费，这仍旧给医院带来越来越大的负担。

The huge sums the hospitals stand to gain from reducing such losses make even $155 billion over ten years look like a reasonable amount of money to sacrifice to secure such a bonanza.
如果医院在未来十年可以通过削减这种损失而获得1550亿的利润，那么这样的暂时性损失也是合理的。

But there are less virtuous reasons why the hospitals offered such a generous-sounding deal.
但是人们不知道医院愿意放弃这样一笔利润的背后仍有很多不太高尚的原因。

As Mr Umbdenstock notes, it was less painful than the $225 billion or more in cuts that Barack Obama had been pressing for earlier in the year.
正如Umbdenstock先生所说，相比奥巴马总统今年早些时候敦促的2250亿甚至更多的财政削减计划，现行的削支方案就没有那么痛苦了。

This is a tacit acknowledgment that hospital chiefs were seeking to avert the one thing that strikes fear into their hearts: the spread of price controls.
医院负责人们早已心照不宣地承认，他们通过这样的变通，正在努力避免物价被控制，这正是会令他们惊恐不安的事情。

Because of the creeping expansion of Medicare and Medicaid, the publicly funded health-care schemes for the elderly and the poor,
在美国，为老年病人和残疾病人的国家医疗照顾体制正在慢慢向更多的公民扩展，

the government already pays over half the bills at the average American hospital.
正因为如此，平均下来政府已经为每家医院支付了超过半数的医疗费。

But the political left is clamouring for a government-run insurance plan, to compete with private ones, as part of any reform effort.
但是政治左派却在改革之中叫嚣一个政府操作的保险计划，以此来和私人运营计划相抗衡。

The problem, argues Toby Cosgrove, chief executive of the Cleveland Clinic, a hospital group, is that the existing public schemes routinely underpay hospitals for care.
Toby Gosgrove是，一个名为Cleveland Clinic的理疗团体总裁，他说，这样做的问题在于，现行的医保体制总是使得医院获得不足额的补助。

Some economists question that claim.
一些经济学家对此持怀疑态度。

Even so, it is probably right to suggest,
尽管如此，正如Cosgrove医生所建议的，

as Dr Cosgrove does, that any public insurance plan based on Medicare's pricing would squeeze hospitals hard and, as a result, require private insurers to cross-subsidise the bill.
依照目前国家医疗照顾体制的集款方式所运营的任何公共保险计划都会使医院出现资金困难，结果仍旧需要投保个人来买单。

In addition to a determination to head off any moves towards greater government control over prices,
采取此项改革的一个重要原因是医院领导人们下定决心阻止政府对医药价格的进一步控制，

another even less noble reason for offering the price cut was a desire to thwart a proposed change to the tax status of non-profit hospitals, which make up most of the national total of 5,700 or so.
相比而言另一个不怎么高尚的原因则是领导者们试图通过减少削减开支来抵制改变非营利性医院税收政策的提案，非营利性医院在全美有5700家之多。

On the ground that they provide charitable care, many religious and community hospitals have been granted an exemption allowing them to issue tax-free bonds,
由于很多宗教和社区医院提供慈善性的救助，他们都享有税收优惠的政策，可以发放免税证券，免收财产和收入税收等等。

avoid taxes on property and income, and so on. But investigations by the Internal Revenue Service and others have revealed that many in fact provide very little charitable care, while paying enormous salaries or going on acquisition sprees.
但是美国国内收入署和其他一些机关的调查表明，有些医院提供很少的慈善性救助，他们所做的无非是领取高额工资，无节制地享受收益。

On this proposal, the industry may carry the day.
在这样的提案下，整个行业的反对可能会占上风。

Although the tax break is hard to defend, closing the loophole would lead to many small, weak hospitals shutting down—something voters would be unlikely to tolerate.
尽管人们很难为税务减免而辩护，结束这样的漏洞可能会导致很多小型医院的倒闭，这正是选民们不能容忍的事情。

Even those hospitals that survived might spark a backlash.
甚至那些得以幸存的医院也会引发人们强烈的反对。

Dr Pardes argues that abolishing the tax advantages would mean higher running costs that would inevitably be passed through to those patients who have private insurance.
Parades医生说废除税收优惠政策即意味着更高的运作成本，这无疑将给那些拥有个人医疗保险的病人施加经济负担。

The other great fear of hospital bosses is being forced to accept greater competition.
医院负责人们的另一个隐忧是被迫进入激烈的行业竞争。

Although the industry is fragmented, Jon Scholl of the Boston Consulting Group points out that because pricing is done at city or regional level, there are local pockets of power.
波士顿咨询集团的Jon Scholl指出，现在的医疗行业处于支离破碎的状态，由于定价的过程是在某一城市或地区范围之内完成的，本地权利口袋影响定价的行为是存在的。

Alain Enthoven, an economist at Stanford University's business school who helped inspire the managed health care movement of the 1990s, promoted an approach that succeeded in squeezing costs at the time,
Alain Enthoven是来自斯坦福大学商学院的经济学家，他曾经在二十世纪90年代推动管理医保运动的开展。

but ultimately failed as patients rebelled against the restrictions it placed on their choice of doctors and treatments.
当时他推行的改革方案在削减成本方面颇有成效，但因为病患不满他们失去了选择医生和疗法的自由而抗议，这项改革以失败告终。

Mr Enthoven argues that the consolidation that followed managed care has resulted in too little competition.
Enthoven先生认为，改革失败后的相对稳固导致了今日几无竞争存在的行业格局。

Antitrust action in the hospital field has been woefully weak, he says.
他说：反垄断在医疗行业只是一句可悲的空话。

There are some innovative competitors emerging to challenge hospitals.
当然还是有一些富有创新精神愿意挑战垄断的竞争者出现。

Paul Keckley of Deloitte, a consultancy, estimates that there are over 1,000 retail health clinics operating today at Wal-Mart stores,
Deloitte咨询公司的Paul Keckley估计，在沃尔玛店铺，Walgreen药店还有其他的一些便利商店，总共有超过1000家药品零售诊所存在。

Walgreens pharmacies and other convenient locations, and their numbers are expected to multiply in the next few years.
在今后几年，这些零售诊所的数量有可能翻倍。

Some of these cheap and cheerful outfits are staffed by nurse practitioners, which incenses doctors and hospital bosses.
一些有医师资格的护士在这里工作，他们的工资水平比医师低很多，这让医生和医院负责人们很是恼怒。

The nascent boom in medical tourism could also disrupt the hospital business,
但医疗旅游近期的初步兴起还是困扰医疗行业的一个原因。

even if every hip-replacement patient does not actually go to India to get it done.
尽管不是每一个需要做髋关节置换手术的病人都选择去印度治疗，

Mr Keckley points out that in several parts of the country the mere introduction of insurance plans offering cheap surgery abroad has forced local hospitals to respond by slashing their prices—something unheard of in this industry.
Keckley先生指出，在美国的一些地方，出现了一些提供便宜海外手术的医疗保险计划，这就使得当地医院不得不采取减价策略，但事实上，减价在医疗行业是前所未闻的事情。

Mr Enthoven argues that if reforms are done properly, they would force hospitals to get organised to compete and get more efficient.
Enthoven先生说，如果改革可以成功实施，那么这将促使医院组织性更强的去参与行业竞争，而且将使整个行业提高效率。

Alas, the omens are not good.
但是，目前的预兆不太好。

One of the explicit concessions wrung by the hospital bosses from the White House was a promise to crack down on clinics owned by doctors.
医院负责人们与政府方面协商出的一个明确让步就是打击私人医生开设的诊所。

These outfits are guilty of anti-competitive self-dealing, since the doctor has a financial motive to refer cases to his own firm,
因为医生们出于经济动机可能会向自己的私人诊所推荐病例，这些小诊所违反了反竞争的自利交易原则，

but what hospital bosses were really concerned about was that such clinics are competing hard with them, and siphoning off the most profitable patients.
但事实上医院负责人们真正担心的问题是这些小诊所正与大医院激烈的竞争，大医院可能因此失掉那些可以让他们赚大钱的病例。

As this back-room deal illustrates, the strongest motives behind the hospitals' ostensibly generous price cut were self-serving ones: to reduce competition, not boost it,
正如这个密室协议所证明的，在医院表面慷慨削减开支的背后，最真实的动机却是自我获利：

and to head off any increase in government influence over their prices.
非但不促进，反而减少竞争，并竭力避免任何可能出现的政府对价格的管制。

As health-care reform forges ahead, reformers are desperate to find cost savings and the hospital industry is a juicy target.
医保改革就在眼前，改革者们将会失望的发现医疗行业减少开支的目标很难实现。

So its bosses felt they had to cut a deal.
所以行业负责人们觉得他们必须做笔交易。

As Julius Hobson of Bryan Cave, a veteran health lobbyist, puts it: If you're not at the table, then you're on the menu.
Julius Hobson，是Bryan Cave公司的一个老兵健康游说者，现在的情形正如他所说：如果你不愿意主动出击，那你就等着被人利用吧。