Stupid ＂medical impossible trinity＂

This article comes from WeChat WeChat official account:Gu San Gu Si (ID: GH _ A68D56C34119), Author: Gu Yuan, the first picture from: vision china.

There are not so many things in this world, but there are always some people who create various theories to create various problems. Medical impossible trinity is such a stupid theory.

There is a Mundell impossible trinity in financial theory. It is said that the financial system can only choose two of the three: free capital flow, exchange rate stability and monetary policy independence, and it is impossible to have all three, otherwise it will lead to financial collapse. In this financial theory, there is actually a premise, and that is legal tender.

Someone made up another theory with this theory, which is called impossible trinity’s theory of medical system. Cheap, efficient and good service. You can’t have both, otherwise it will lead to collapse.

At first glance, does this theory make sense? It seems to make sense.

Let me discuss the common views of this theory first. For example, the United States has chosen high efficiency and good service, which leads to extremely high medical costs. It’s so expensive that ordinary families can go bankrupt by getting a rabies vaccine and calling an ambulance. The United States is efficient and has good service, but it is expensive.

Many people praise American medical care and find it particularly humanized. Doctors and nurses are patient and smiling because they choose high efficiency and good service. Since efficiency and good service are satisfied in impossible trinity, the cost can never be cheap.

American nuclear magnetic resonance imaging costs $1,100, appendicitis surgery costs about $15,000, and hospitalization costs $5,000 a day. A federal survey in 2012 found that the average cost per ambulance ride was $224.(about 1485 yuan)To $2204(about 14610 RMB)Between

For another example, Commonwealth countries and Europe choose cheap and good service, and as a result, it is difficult to see a doctor and queue up to death. Make an appointment with a dentist for one month, an ophthalmologist for seven months, and a B-ultrasound for three months. As long as it’s not a dying disease that needs emergency treatment, you have to queue up slowly. In the case of limited medical resources, low price and good service are required, and the result is extremely low efficiency.

Similarly, the medical systems in impossible trinity, the Commonwealth and Europe chose cheap and good service. The reason is simple. Good service requires doctors to listen patiently to every patient and give them time to talk. It takes at least half an hour to see a patient like this. Every doctor can see 16 patients in an eight-hour working day.

The limited number of doctors leads to the limited number of patients you can see every day, so you need to queue up in advance to make an appointment. As long as it’s not a dying disease, it’s not unusual to wait for three to five months before it’s your turn. The Canadian documentary "You are Dead" is about the problem of long queues in the medical systems of Commonwealth countries.

Choice determines efficiency, which is the case in all Commonwealth and European countries. The inefficiency of medical system is everywhere. In order to prevent patients from waiting too long, there is even a law that 90% of patients should be treated by a specialist within 13 weeks, and the rest must be treated within 26 weeks. The waiting time for surgery should not exceed 18 months.

China, with its large population and tight per capita expenses, chose cheap and efficient.The price is high-intensity work of doctors, high turnover of beds and high turnover of outpatient clinics, so that everyone can see a doctor.

Because of the large population and limited medical resources, and I hope everyone can see a doctor, we can only choose cheap and efficient. Choosing cheap and efficient means that it is normal to see a person for three minutes and ask two sentences to diagnose the disease.

If you register in the public top three, you shouldn’t queue up. Doctors need to serve smiles and have patience to listen. Is it possible? How many patients are there in a big hospital a day? Really want to engage in patient service, every patient has to talk about his illness for half an hour, and the efficiency is simply not allowed.

It is also the best hospital in China and America. The Mayo Clinic has 15 times as many medical staff as Concord, but only half the number of patients. 15 times the number of medical staff and 1/2 of the number of patients, which means that the efficiency of Concord is 30 times that of Mayo Clinic.

The outpatient fee of Mayo Clinic started at $500, but after the outpatient fee increased in Beijing, it was 50 Qian Qi.

Do you think Concord is tired enough? In fact, compared with Beijing Children’s Hospital, Concord is already relaxed. The average daily attendance of Beijing Children’s Hospital in winter is 12,000, with a peak of 16,000. In other words, 360,000 people will be treated every month in winter.

But now the first-and second-level hospitals and community clinics can basically be on call. Except for some top hospitals, most tertiary hospitals can also go to the hospital on the same day, see a doctor on the same day, and get the results within the same day or a few days. If this is all difficult to see a doctor, it is hard to imagine that Canada, where the average waiting time for emergency treatment is six to eight hours, and Britain and the United States, where appointments are made for several months.

It is difficult to see a doctor in people’s mouth now. In fact, it is difficult to find the top three famous experts in the region.It is actually not difficult to find the top three directors in the region to see a doctor, because many hospitals are not limited to the number, and they will finish reading it on the same day. Patients are crowded into the top three, which also causes a structural shortage of hospital bed resources. Judging from the number of inpatients undertaken by hospitals at all levels, the trend is very obvious. Low-level hospitals are getting empty, but high-level hospitals are getting crowded.

The beds in the top three are overcrowded. Let’s take a look at the first-and second-level hospitals and community hospitals below. Except for the old people who prescribe drugs for chronic hypertension for a long time, they are basically empty. Why? Because patients simply don’t believe that they can cure the disease.

Ok, is there a problem with the above discussion? Is it the actual situation?The reality discussed above is true, but the theory is wrong.What’s wrong with that?

The first big mistake: the definition of inefficiency, free and high quality in the Commonwealth system is wrong

If you don’t talk about other countries, say Britain. In Britain, the annual per capita absolute medical cost is 3327 pounds.($4,356). However, in recent years, the average life expectancy in Britain has remained basically unchanged, while in other countries, it has improved significantly. For example, in Singapore, the average life expectancy is 82.7 years, and medical expenditure only accounts for 4.3% of GDP.

Health care in the UK has increased from 21 in 2014.(A total of 56 countries participated in the ranking)It fell to 35 places in 2015, down 14 places, and currently lags behind Chile, Algeria and the Czech Republic. This change means that it has fallen to the bottom half of the Bloomberg list, and it is now behind Mexico, which is equivalent to Slovakia and Peru. The NHS is notorious for frequent accidents, insufficient supply and low efficiency.

It can be seen that the medical system of the Commonwealth system is expensive, poor in quality and inefficient. Medical impossible trinity theory,Mistreating welfare medical care as free medical care and giving him a cheap label is actually just medical care implemented by taxation.The cost is very high,Per capita expenditure is close to half that of the United States.

Secondly, medical impossible trinity theory.Completely ignoring people’s needs, and actually treating queuing for medical treatment as a good service.It takes months to see a doctor. Is this called service? Is there only one dimension of good attitude as the standard of medical service quality?

I won’t see a doctor. I’m not a doctor. If you are sick, you can spend 10 thousand yuan to find me. I will accompany you with a smile all day. Is it called service? Helping patients to solve their pain is the first dimension of medical service quality, and even seeing a doctor in time can’t be done. How can this be called good service?

The second big mistake: the definition of the most special American medical care in the world is wrong.

Impossible trinity Theory defines the United States as expensive, good in service and efficient.

Consumers are pursuing cost performance when they consume any commodity.

If you spend 30 yuan to press a foot in a street foot bath shop, you won’t pursue a luxurious hall and beautiful welcome. As long as you press it comfortably, you will say that the service is really good because of its high cost performance. On the contrary, you spend 500 yuan to press a foot in a high-end club. If a stingy man brings you tea and water, you will turn around and leave, because you will calculate your input-output ratio, and you spend more money in the hope of enjoying better service.

That ambulance will cost 1200 dollars for a trip. Is this called service? Just like if you order a fast food, you get 1000 yuan RMB. Who will say that this is good service? I can’t afford to get sick. You told me that this service is efficient and good? What kind of dog theory is this?

Let’s look at what is efficient.Whether efficiency only refers to speed depends on the result.Barefoot doctors in China used to see a doctor very quickly. Most patients came to prescribe some anti-inflammatory drugs and painkillers and sent them away. There was no inspection equipment, so the speed was certainly fast.

Efficiency depends on what the result is. What is an important criterion for the quality of medical services? It is the index of life expectancy and the calculation of input cost. Americans spend an average of tens of thousands of dollars a year on medical care, but the average life expectancy of Americans is the lowest in developed countries, and it often drops in some years. What kind of efficiency and good service is this?　

The third mistake: take medical service for granted as a pot of rice.

According to impossible trinity’s definition, a good doctor’s service attitude means a good service. Hurry up and see that a doctor is called efficient and a low fee means cheap. He also made a big mistake. He ignored people’s different needs.

Does the catering market exist in impossible trinity? If you have a big dining hall that everyone must go to, there will be impossible trinity:

Ma Yun came to dinner and ate the dishes of migrant workers, which is called poor service.

It is not expensive for middle-class people to eat, but they have to queue up, which is called inefficiency.

When the poor go to eat, they find that the price is more expensive than the roadside stalls. This is called the price is not cheap.

But didn’t the multi-level catering market completely solve this problem? Isn’t it cheap, efficient and good service for everyone to eat in a place that suits them?You mix all the people at all levels of consumption. Isn’t this an artificial contradiction?As a result, no one is satisfied. Is this the inevitable impossible trinity of the medical market?

More market-oriented medical care is that the needs of the poor will also be met, and it will be efficient and cheap.

India, which we despise, will show the world a model of medical marketization in 20 or 30 years. Private hospitals in India have innovated ophthalmic cataract surgery. One doctor performed cataract surgery for five or six patients at the same time. The doctor only did the key parts, while the rest were all operated by nurses. Low cost, low charge, high efficiency and good effect.

There is a private hospital in India that needs only $1,200 for heart surgery, which is a few tenths of the price of such surgery in the United States, but the level of surgery has surpassed that of ordinary hospitals in the United States. Just because other fields in India have not developed and people’s consumption power is insufficient, the results of medical marketization in India are not eye-catching.

The fourth mistake: misjudgment of China medical care.

If we just compare the United States, Commonwealth countries and China, my point is,Compared with medical care in these countries, medical care in China is efficient, good in service and cheap.

The per capita medical expenditure in China is about 10,000 yuan, but the average life expectancy in China is close to that in the United States. That is to say, it is close to that in the United States at one sixth of the medical expenses of Americans. Isn’t this efficient? When Chinese is ill, he can see a doctor at any time. Even if he goes to see an expert, he doesn’t have to wait for months. As long as you go to the queue, even if you buy a number from a scalper, you can always see him.

If you have to wait a month to meet experts in Beijing, how can 700 thousand people go to Beijing every day? In other words, you can quickly see experts who are equal to the severity of the disease, which is good service. Because the first dimension of medical service is not a good attitude, but that the other party can solve your problems.

Then it’s cheaper, the total expenditure is less, and of course it’s cheaper. The total expenditure of Chinese is lower than that of the United States or the United Kingdom. Once again, this is a comparison, and the bar is fine.

Then why? There’s actually only one reason,The degree of marketization of medical care in China is higher than that in Europe and America.

Nani, what are you talking about? It’s acceptable to say that all medical services in Britain are public, while hospitals and insurance companies in the United States are mainly private, while hospitals in China are mainly public. What makes you conclude that medical services in China are more market-oriented?

The world is often so strange, and the name is easy to deceive people. American hospitals are playing a private name, as if they were the product of marketization. Is this true? No, you have to look at the essence through the phenomenon. What is medical marketization? To put it more popularly, it isHospitals and doctors aim at making money, and the process of making money is less interfered.The less intervention, the higher the degree of marketization.

Do you think hospitals and doctors in China aim at making money? Of course it is. Because hospitals in China are not like public hospitals in Britain, which are fully funded, but hospitals in China have very little financial allocation.The main income of the hospital comes from the fees paid by patients.

Zhu Hongbiao, inspector of the Department of Physical Reform of the National Health and Wellness Commission, said that the direct subsidies from all levels of finance to public hospitals nationwide increased from 84.9 billion yuan in 2010 to 270.5 billion yuan in 2018. There are 50,000 public hospitals and health centers, with an average allocation of more than 5 million a year. Even the money for buying equipment is not enough, let alone paying salaries.

Therefore, hospitals in Britain do not aim at making money. They are the same as civil servants, and they are fully funded units. They do not need to cater to the needs of consumers, so they have a fixed source of income.

What is the difference between a fully funded hospital and a hospital that relies on patients to pay for medical treatment? The difference is,If you want to earn money, you must cater to consumers.Otherwise, consumers will not come to see you.

Although public hospitals are subject to various controls,But doctors in China have the motivation to improve their medical skills and to form a good reputation in the local society.Because skills and reputation can be exchanged for money, which can make more consumers come here.

Why can so many doctors operate for more than ten hours from day to night? What are they for? Because medical skills need practice, contact with various cases and repeated operations. Such doctors will become scarce resources, and thus get higher income.

If doctors are managed according to the civil service system, why should doctors improve their medical level? Why are you working so hard? Can’t you see fewer patients? Can’t you do a few less operations? Don’t I get the same salary? Under real public ownership, doctors have no incentive to improve efficiency.

Therefore, for a long time, doctors in public hospitals in China have been working hard, because efforts will have results, and efforts can increase income. At present, the level of treatment and operation of doctors in China is not inferior to that of developed countries, and even leads the world in many fields. The treatment level is high and the fees are not high, which is called good service.

It’s just that Dr. China’s income is limited, so he can’t raise the operation fee, so he can replace it with a red envelope, but he can’t raise the outpatient fee, so he can replace it with drug commission and inspection commission. Of course, these methods are not good, but they still constitute an incentive for doctors, and finally they have not blocked the way for doctors to make money.

Therefore, China hospitals have the motivation to continuously expand their scale, increase equipment and wards, and doctors have the motivation to continuously improve their level. Because they can make money, although they are restricted, they still have access.

At present, the scale of well-known top-three hospitals in various places is often very large, and some of them have operating income as high as several billion yuan. Is this entirely funded by the government? No. It is brought by the rush of consumers. There are always endless queues at the entrance of the top three hospitals, and the bustling crowds come to the door on their own initiative, and they vote with banknotes.

Many people say that private hospitals in China are terrible, and there is nothing wrong. Except ophthalmology and dentistry, other private medical services are really not so good, and they are full of fraud and low quality. Why is this? Because the marketization of public hospitals is not low. If it was a fully funded unit, the doctor would have finished running.

This makes it more difficult for private hospitals and public hospitals to compete. Many doctors don’t want to leave the public to go private for the simple reason.There are many public patients, and consumers have voted with their feet to prove that public hospitals in China can partially satisfy consumers.

Going back to American medical care, American medical care is completely private. Why is it so expensive? American medical care is subject to a lot of government control. Although it is nominally private, it must be handled according to various government regulations, which is called insufficient marketization. Give a few examples and you will understand.

Private hospitals in the United States need to apply to the government to increase beds. Is this called marketization?

Doctors in the United States need to apply to the government for interstate practice. Is this called marketization?

The number of doctors in the United States is controlled by doctors’ unions, and the supply quantity is artificially controlled. Is this called marketization?

The profit rate of medical insurance companies in the United States is set by the government. Is this called marketization?

How many restrictions are there like this? There are hundreds of them, and it takes tens of thousands of words to make them clear, so I won’t expand them here.

Then I’ll tell you again, even if all the medical enterprises in China are private enterprises now, it can’t be called marketization. Because in today’s China, the government-run medical insurance is dominant, and the government becomes the consumer of medical care, and he sets the rules. Even if you are a private medical service, your customers are also the government.

Under the current medical insurance control means, private medical care will also become an inefficient service organization, because it no longer serves consumers, but caters to and obeys the rules of government-run medical insurance.

It doesn’t matter whether the medical institution is public or private. What matters is whether it is market-oriented enough. As long as there are more market-oriented factors, so that consumers can choose with their feet and medical service providers can only make money by satisfying consumers, then medical care can be cheap, good and efficient.

The so-called medical impossible trinity theory is a stupid theory, and it is an argument for the specialization of medical services. In fact, medical care and eating are the same thing, both of which are service industries. How should medical care be done?Would you be satisfied with running a public canteen now?

This article comes from WeChat WeChat official account:Gu San Gu Si (ID: GH _ A68D56C34119), author: Gu Yuan