毫不意外,，醫(yī)療問題已經(jīng)成了2020年美國總統(tǒng)大選的一個核心議題,。雖然民主黨候選人已經(jīng)拋出了好幾個醫(yī)改計劃，但大家爭論的焦點最終還要歸結在一個問題上：誰來掏這筆錢,？

這是一個好問題,，但它忽略了最重要的一點。目前,，美國的醫(yī)療費用已經(jīng)高得嚇人了,。2018年,，美國的醫(yī)療支出超過了3.6萬億美元。因此,，立法者的第一個問題應該是：美國能否以更少的錢,，提供高質量的醫(yī)療服務？

答案是肯定的,，這一點從許多發(fā)展中國家在醫(yī)療領域的創(chuàng)新上就能看出來,。以印度為例，2018年,，印度有7000多萬人處于赤貧狀態(tài),，印度的國營醫(yī)療體系可以說一塌糊涂。然而有些私營醫(yī)療機構提供的服務,，卻不亞于美國最好的醫(yī)院,，而且費用只相當于后者的零頭。

印度的納拉亞納醫(yī)療公司就是這樣的一個私人的營利性醫(yī)院系統(tǒng),，它還登上了《財富》的“改變世界”排行榜（第33名）,。在美國的研究型醫(yī)院里做一個心臟手術，患者可能得花上2萬到10萬美元,。而在納拉亞納醫(yī)院,，患者做同樣的手術只需要2100美元左右，而且手術的效果即使以美國的標準看也是很出色的,。之所以費用這樣低廉,，是因為納拉亞納醫(yī)療公司注重在整個系統(tǒng)內降低成本。比如他們使用了仿制藥,，實踐了遠程醫(yī)療,，自己生產醫(yī)療耗材，并且訓練患者家屬來進行術后護理,。他們還會對術后回收的醫(yī)療器械進行消毒并重復使用（比如開胸手術中用來固定心臟的鋼鉗等）,。

納拉亞納醫(yī)療公司甚至對高達55%的病人提供了免費或補貼的醫(yī)療服務，但它仍然是盈利的,。有人可能覺得,，醫(yī)院給患者的補貼越多，醫(yī)院虧的錢就越多,。不過納拉亞納醫(yī)療公司的使命就是服務那些缺醫(yī)少藥的患者,，在這樣的使命驅使下，它的成本創(chuàng)新邁向了更高水平,，超低的醫(yī)療價格也提升了來自付費病人的利潤,。因此，盡管它的醫(yī)療服務有一些慈善性質,，但醫(yī)院的經(jīng)濟狀況仍然是具有可持續(xù)性的,。

納拉亞納醫(yī)療公司的成本節(jié)省策略對第一世界國家是否有效,？有些確實是可以的。實際上,，納拉亞納醫(yī)療公司已于2014年在大開曼島上開設了一家有105張病床的三級護理醫(yī)院，那里的多數(shù)醫(yī)療項目的費用都比美國低60%至75%,。

與此同時,，納拉亞納醫(yī)療公司的遠程醫(yī)療方法，也為密西西比州的農村居民省了不少錢,，甚至挽救了不少人的生命,。納拉亞納醫(yī)療公司的遠程醫(yī)療網(wǎng)絡，將它設在城市里的24家醫(yī)院與800多個醫(yī)療中心聯(lián)系了起來,，使廣大貧困農村地區(qū)的居民也能夠以很低的成本接受醫(yī)療服務,。遠程醫(yī)療技術使它可以有效輻射到那些尋求治療的患者，降低農村患者的醫(yī)療支出（包括因為就醫(yī)而導致的誤工成本,、出行成本,、食宿成本等）。密西西比州是美國醫(yī)患比最低的一個州,，在那里也有一個類似的網(wǎng)絡,，將17家農村醫(yī)院、200多個醫(yī)療站點與設在杰克遜市的密西西比大學醫(yī)學中心聯(lián)系了起來,，使患者可以就近獲得專家咨詢和醫(yī)療服務,，從而節(jié)省了高昂的就診成本。遠程醫(yī)療還使定期監(jiān)測糖尿病等慢性病患者變得更容易了,，從而也降低了慢性病人被送到醫(yī)院看急診的頻率,。

此外，還有很多來自發(fā)展中國家的創(chuàng)新是很值得借鑒的,。比如波士頓的Iora Health公司是一家初級醫(yī)療服務商,，它的服務模式，就是由它的創(chuàng)始人,、CEO魯西卡·費爾南多普勒從部分非洲和加勒比國家借鑒來的,。對大多數(shù)病人的觀察和護理工作，該公司會交給所謂的“健康教練”而不是醫(yī)生來負責,。這些健康教練也經(jīng)過了嚴格訓練,，但他們的成本比醫(yī)生還是要低廉得多。Iora Health公司表示,，他們這種重點關注初級護理的方法,，使病人的住院率下降了40%，急診率下降了20%,。

來自發(fā)展中國家的科技創(chuàng)新也是不容小覷的,。比如印度班加羅爾的一家醫(yī)學創(chuàng)業(yè)公司Forus Health發(fā)明了一種成本低廉且較為便攜的掃描成像設備,，它可以檢察出白內障等眼科問題。2016年,，這種設備獲得了FDA的批準,。同年，F(xiàn)orus Health還在美國加州成立了一家子公司,，專門推廣其產品,。這也是美國采用發(fā)展中國家的創(chuàng)新技術降低醫(yī)療成本的又一范例。

以上公司表明,，對于醫(yī)療機構來說,，擴大輻射范圍與節(jié)省成本、實現(xiàn)盈利之間并不沖突,。所以,，美國可以不必糾結于哪筆錢由誰來出，而是應該著手削減這3.6萬億美元的成本,。而醫(yī)療交付方面的創(chuàng)新則為此提供了一條可行的道路,。（財富中文網(wǎng)）

本文作者Vijay Govindarajan是達特茅斯大學塔克商學院教授，也是《醫(yī)療逆向創(chuàng)新:如何實現(xiàn)基于價值的醫(yī)療服務》（Reverse Innovation in Health Care: How to Make Value-Based Delivery Work）一書的作者之一,。

譯者：樸成奎

It’s hardly surprising that health care is shaping up to be a central issue of the 2020 U.S. presidential campaign. Despite several plans floated by Democratic candidates, much of the debate still comes down to one question: Who will get stuck with the bill?

That’s a good question, to be sure, but it misses the most important point. That bill is outrageously high: More than $3.6 trillion in 2018. Instead, the first question lawmakers should be asking is this: Can America provide quality health care for less money?

The answer is yes, and that’s evident by the health care delivery innovations seen in many developing countries. Take India as an example: In 2018, more than 70 million people lived in abject poverty, and much of the state-run health care system is terrible. Yet some privately-owned Indian health care systems are providing services that rivals the quality of care found at the best U.S. hospitals—and for a fraction of the cost.

One of those companies is India’s Narayana Health, a private for-profit hospital system, which also made Fortune’s Change the World list (at no. 33). While it would cost a patient anywhere from $20,000 to $100,000 in a U.S. research hospital, Narayana performs heart surgeries for around $2,100. And its outcomes are excellent, even by U.S. standards. They do it by lowering costs throughout their system. They use generic drugs. They practice telemedicine. They manufacture their own supplies. They train patients’ family members to deliver post-op care. They sterilize and reuse medical devices (like the steel clamp used to hold the heart in place during open-heart surgery).

Narayana Health even provides free or subsidized care to 55% of its patients—and still makes a profit. It might seem that the more subsidized patients the hospital treats, the more money the hospital would be expected to lose. Narayana’s mission to serve the underserved drives cost innovations to high levels, and the resulting ultra-low-cost position boosts profit margins on the paying patients. Consequently, the hospital is financially sustainable despite the charitable care.

Could Narayana’s cost-saving strategies work in the first world? Some could and some are. In fact, Narayana has its own operation in the Grand Cayman, where it built a 105-bed tertiary care hospital in 2014. There, most medical care is priced 60% to 75% below prices charged in the U.S.

Meanwhile, Narayana’s approach to telemedicine is saving money and lives in rural Mississippi. In India, Narayana’s telemedicine network connects its 24 urban-based specialty hospitals to 800 centers, extending its reach into Indian’s vast and impoverished countryside at very little cost. Telemedicine enables a hub-and-spoke system to efficiently and economically serve patients seeking care, thereby lowering the out-of-pocket expenses (lost wages during time away from work, the cost of travel, and room and board) for the patients in rural areas. In Mississippi, the state with the worst patient-to-physician ratio, a similar network connects 17 rural hospitals and more than 200 health care sites to medical specialists at the University of Mississippi Medical Center in Jackson. The network allows patients to receive expert consultation and care near where they live, saving the high costs that they would pay at specialty hospitals. It also makes it easy to regularly monitor patients with chronic conditions, like diabetes, which can decrease the frequency of emergency room visits.

There are other innovations borrowed from the developing world offered in medicalized urban centers. For instance, Boston-based Iora Health, a primary care provider, depends on a service model that co-founder and CEO Rushika Fernandopulle saw practiced in parts of Africa and the Caribbean. The company uses health coaches rather than doctors to handle the vast majority of patient observation and care, and the highly-trained coaches cost much less than doctors. Iora reports that their primary care focused model has reduced patients’ hospitalization by 40%, and emergency room visits by 20%.

And such innovations born in developing countries also include technological advances. In 2016, Forus Health, a Bengaluru medical startup, won FDA approval for its inexpensive and portable imaging device that scans for cataracts and other eye problems. And, that same year, Forus launched a California-based subsidiary to market its products—another example of health care innovation from a developing country being adopted in the U.S., and bringing down costs.

These companies are showing health care providers can make a profit while providing more access to services for a reduced cost. So it’s time to stop arguing about who pays what, and start slashing that $3.6 trillion bill. And focusing on health care delivery innovations offers a way to do just that.

Vijay Govindarajan is the Coxe Distinguished Professor at Dartmouth’s Tuck School of Business and co-author of Reverse Innovation in Health Care: How to Make Value-Based Delivery Work.