The Anatomy of Health Care in the United States
The Anatomy of Health Care in the United States
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DOI：
10.1001/jama.2013.281425
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发表时间：
2013-11-13
影响因子：
120.7
通讯作者：
Yoshimura, Satoshi
中科院分区：
文献类型：
--
作者：
Moses, Hamilton, III;Matheson, David H. M.;Yoshimura, Satoshi
美国的医疗保健包括接受、提供和资助医疗保健的人之间的各种复杂的相互关系。在本文中，公开可用的数据被用来确定医疗保健的趋势，主要是从1980年到2011年，在资金的来源和使用（“经济解剖”），接受和提供护理的人和组织，以及由此产生的价值创造和健康成果。2011年，美国医疗保健雇用了15.7%的劳动力，支出为2.7万亿美元，自1980年以来翻了一番，占美国国内生产总值（GDP）的17.9%。自1970年以来，特别是自2002年以来，年增长率有所下降，但每年3%的增长率超过了任何其他行业和GDP。政府资助从1980年的31.1%增加到2011年的42.3%。尽管用于医疗保健的资源有所增加，但多项健康指标，包括出生时的预期寿命和许多疾病的存活率，显示美国落后于其他国家。这项分析的结果与几个常见的假设相矛盾。自2000年以来，（1）价格（特别是医院费用[+4.2%/年]、专业服务[3.6%/年]、药物和器械[+4.0%/年]以及行政费用[+5.6%/年]），而不是服务需求或人口老龄化，导致了91%的成本增长;（2）个人自付保费及自付部分的开支，由23%下降至11%;及（3）慢性病占整体人口开支的84%，而不单止是老年人。三个因素产生了最大的变化：（1）合并，减少了综合医院，增加了单一专科医院和医生团体，使医疗系统、保险公司、药房和福利管理者成为金融集中地;（2）信息技术，投资已经发生，但价值难以捉摸;以及（3）患者作为消费者，利用社交媒体、非正式网络、新的公共信息来源和自我管理软件，在传统渠道之外寻求影响力。这些力量在患者的选择、个人护理和注意力目标之间产生了紧张;医生的专业精神和自主性目标;公共和私人支付者的目标是在大量人群中实现总经济价值。对成本和结果的衡量（适用于群体）正在取代个人的偏好。越来越多的临床医生被期望用社会和经济目标来代替单个病人的需求。这些相互矛盾的力量很难调和，造成日益不稳定和政治紧张的风险。需要进行一次全国性的对话，以最佳数据和信息为指导，旨在明确理解选择、权衡和期望，使用更广泛的健康和价值定义。
Health care in the United States includes a vast array of complex interrelationships among those who receive, provide, and finance care. In this article, publicly available data were used to identify trends in health care, principally from 1980 to 2011, in the source and use of funds ("economic anatomy"), the people receiving and organizations providing care, and the resulting value created and health outcomes. In 2011, US health care employed 15.7% of the workforce, with expenditures of $2.7 trillion, doubling since 1980 as a percentage of US gross domestic product (GDP) to 17.9%. Yearly growth has decreased since 1970, especially since 2002, but, at 3% per year, exceeds any other industry and GDP overall. Government funding increased from 31.1% in 1980 to 42.3% in 2011. Despite the increases in resources devoted to health care, multiple health metrics, including life expectancy at birth and survival with many diseases, shows the United States trailing peer nations. The findings from this analysis contradict several common assumptions. Since 2000, (1) price (especially of hospital charges [+4.2%/y], professional services [3.6%/y], drugs and devices [+4.0%/y], and administrative costs [+5.6%/y]), not demand for services or aging of the population, produced 91% of cost increases; (2) personal out-of-pocket spending on insurance premiums and co-payments have declined from 23% to 11%; and (3) chronic illnesses account for 84% of costs overall among the entire population, not only of the elderly. Three factors have produced the most change: (1) consolidation, with fewer general hospitals and more single-specialty hospitals and physician groups, producing financial concentration in health systems, insurers, pharmacies, and benefit managers; (2) information technology, in which investment has occurred but value is elusive; and (3) the patient as consumer, whereby influence is sought outside traditional channels, using social media, informal networks, new public sources of information, and self-management software. These forces create tension among patient aims for choice, personal care, and attention; physician aims for professionalism and autonomy; and public and private payer aims for aggregate economic value across large populations. Measurements of cost and outcome (applied to groups) are supplanting individuals' preferences. Clinicians increasingly are expected to substitute social and economic goals for the needs of a single patient. These contradictory forces are difficult to reconcile, creating risk of growing instability and political tensions. A national conversation, guided by the best data and information, aimed at explicit understanding of choices, tradeoffs, and expectations, using broader definitions of health and value, is needed.