America s hospital industry

　　美國醫療行業

　　Taking a scalpel to costs

　　對醫療費用動動刀

　　Hospital operators brace themselves forhealth-care reform

　　醫院負責人正為醫保制度改革做準備

　　EARLIER this month America s hospital bossesgathered in Washington, DC, with vice-president Joseph Biden.

　　本月早些時候，美國醫院的領導者們和副總統Joseph Biden齊聚華盛頓。

　　To the amazement of many, they vowed to accept a cut of $155 billion in their expectedrevenues over the next decade as part of a grand bargain on health-care reform.

　　令人感到驚奇的是，他們鄭重同意在接下來的十年將預期收益削減1550億美元，作為醫療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?

　　他們為什么會同意放棄這么大一筆收益?

　　There are several explanations, not all of them altruistic.

　　對此有很多種解釋，他們的動機也不全出于利他。

　　Taken together, they show that the industry s leaders are bracing themselves for a period ofupheaval.

　　總之，他們已經顯示出整個行業的領導人正積極應對未來行業的大變動。

　　For hospitals, the positive thing about health-care reform is that it is going to be good forbusiness.

　　對醫院來說，醫保改革帶來的好處是它對商業有利。

　　It will be welcome news to an industry that is hardly in rude health.

　　改革對于一個不太健康的行業來說總是好事。

　　Despite two decades of consolidation, hospitals finances remain anaemic; over a quarterof them regularly post negative operating margins.

　　誠然，醫保行業走過了二十年的穩固期，但是醫院的財經狀況仍舊不景氣，超過四分之一的醫院存在周期性虧損。

　　The recession is making things worse.

　　而且現在的經濟危機更是加劇了形勢惡化。

　　Moody s, a credit-rating agency,notes that many patients are putting off non-essential treatments.

　　信貸評級機構Moody s注意到很多患者正在推遲一些非必須的治療。

　　So any reforms that promise a flood of new demand for health services should be welcome.

　　因此任何可以使得醫療服務的需求大幅增長的改革承諾都應該是大受歡迎的。

　　Rich Umbdenstock, the head of the American Hospital Association and one of the bosses whoshared the stage with Mr Biden,

　　作為美國醫院協會會長的Rich Umbdenstock和與副總統Biden先生見面會談的領導人之一，

　　acknowledges that extending health insurance to most of America s nearly 50m uninsuredwill benefit his industry in the long term.

　　承認從長遠看來，為沒有享受醫保的五千萬美國人提供保險將會使整個行業受益。

　　Those unfortunates still turn up at emergency rooms and often do not pay their bills.

　　這些沒有醫保的人們經常出現在急診室里而且無力支付醫藥單。

　　The government gives hospitals some money to compensate them for this, but the AHAsays it does not cover the full cost,

　　對此，政府會給醫院發放一定數額的資金以作彌補，但是美國醫院協會表示，這些金額不足以支付資金缺口。

　　which it put at $34 billion in 2007, up from $3.9 billion in 1980.

　　這些缺口已經從1980年的39億上升到2007年的340億，

　　Paul Mango of McKinsey, a consultancy, estimates that the hospitals recover only 10-12% ofthis cost.

　　大約占醫院每年財政收入的5%。來自咨詢公司麥肯錫公司的Paul Mango估計，醫院大概只能收回這些資金的10-12%，

　　But he says the problem would be greatly reduced under a system of universalhealth-insurance which included subsidies for the indigent, as the proposed health reformsenvisage.

　　但他也說，如果可以建立一個大部分人都享受醫保并且貧困人口得到補助的體制，這些資金缺口就可以被大大減少，而這種體制正是當前的醫療改革嘗試建立的。

　　Herbert Pardes, chief executive of New York-Presbyterian, a research hospital, says thelarge numbers of underinsured patients, who frequently fail to pay their bills in full, costhospitals still more.

　　Herbert Parades是紐約一家研究型醫院Presbyterian的總裁，他說，很多保額不足的病人不能全額支付他們的醫療花費，這仍舊給醫院帶來越來越大的負擔。

　　The huge sums the hospitals stand to gain from reducing such losses make even $155 billionover ten years look like a reasonable amount of money to sacrifice to secure such abonanza.

　　如果醫院在未來十年可以通過削減這種損失而獲得1550億的利潤，那么這樣的暫時性損失也是合理的。

　　But there are less virtuous reasons why the hospitals offered such a generous-soundingdeal.

　　但是人們不知道醫院愿意放棄這樣一筆利潤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 BarackObama had been pressing for earlier in the year.

　　正如Umbdenstock先生所說，相比奧巴馬總統今年早些時候敦促的2250億甚至更多的財政削減計劃，現行的削支方案就沒有那么痛苦了。

　　This is a tacit acknowledgment that hospital chiefs were seeking to avert the one thingthat strikes fear into their hearts: the spread of price controls.

　　醫院負責人們早已心照不宣地承認，他們通過這樣的變通，正在努力避免物價被控制，這正是會令他們驚恐不安的事情。

　　Because of the creeping expansion of Medicare and Medicaid, the publicly funded health-careschemes for the elderly and the poor,

　　在美國，為老年病人和殘疾病人的國家醫療照顧體制正在慢慢向更多的公民擴展，

　　the government already pays over half the bills at the average American hospital.

　　正因為如此，平均下來政府已經為每家醫院支付了超過半數的醫療費。

　　But the political left is clamouring for a government-run insurance plan, to compete withprivate ones, as part of any reform effort.

　　但是政治左派卻在改革之中叫囂一個政府操作的保險計劃，以此來和私人運營計劃相抗衡。

　　The problem, argues Toby Cosgrove, chief executive of the Cleveland Clinic, a hospitalgroup, is that the existing public schemes routinely underpay hospitals for care.

　　Toby Gosgrove是，一個名為Cleveland Clinic的理療團體總裁，他說，這樣做的問題在于，現行的醫保體制總是使得醫院獲得不足額的補助。

　　Some economists question that claim.

　　一些經濟學家對此持懷疑態度。

　　Even so, it is probably right to suggest,

　　盡管如此，正如Cosgrove醫生所建議的，

　　as Dr Cosgrove does, that any public insurance plan based on Medicare s pricing wouldsqueeze hospitals hard and, as a result, require private insurers to cross-subsidise the bill.

　　依照目前國家醫療照顧體制的集款方式所運營的任何公共保險計劃都會使醫院出現資金困難，結果仍舊需要投保個人來買單。

　　In addition to a determination to head off any moves towards greater government controlover prices,

　　采取此項改革的一個重要原因是醫院領導人們下定決心阻止政府對醫藥價格的進一步控制，

　　another even less noble reason for offering the price cut was a desire to thwart a proposedchange to the tax status of non-profit hospitals, which make up most of the national total of5,700 or so.

　　相比而言另一個不怎么高尚的原因則是領導者們試圖通過減少削減開支來抵制改變非營利性醫院稅收政策的提案，非營利性醫院在全美有5700家之多。

　　On the ground that they provide charitable care, many religious and community hospitalshave been granted an exemption allowing them to issue tax-free bonds,

　　由于很多宗教和社區醫院提供慈善性的救助，他們都享有稅收優惠的政策，可以發放免稅證券，免收財產和收入稅收等等。

　　avoid taxes on property and income, and so on. But investigations by the Internal RevenueService and others have revealed that many in fact provide very little charitable care, whilepaying enormous salaries or going on acquisition sprees.

　　但是美國國內收入署和其他一些機關的調查表明，有些醫院提供很少的慈善性救助，他們所做的無非是領取高額工資，無節制地享受收益。

　　On this proposal, the industry may carry the day.

　　在這樣的提案下，整個行業的反對可能會占上風。

　　Although the tax break is hard to defend, closing the loophole would lead to many small,weak hospitals shutting downsomething voters would be unlikely to tolerate.

　　盡管人們很難為稅務減免而辯護，結束這樣的漏洞可能會導致很多小型醫院的倒閉，這正是選民們不能容忍的事情。

　　Even those hospitals that survived might spark a backlash.

　　甚至那些得以幸存的醫院也會引發人們強烈的反對。

　　Dr Pardes argues that abolishing the tax advantages would mean higher running costs thatwould inevitably be passed through to those patients who have private insurance.

　　Parades醫生說廢除稅收優惠政策即意味著更高的運作成本，這無疑將給那些擁有個人醫療保險的病人施加經濟負擔。

　　The other great fear of hospital bosses is being forced to accept greater competition.

　　醫院負責人們的另一個隱憂是被迫進入激烈的行業競爭。

　　Although the industry is fragmented, Jon Scholl of the Boston Consulting Group points out thatbecause pricing is done at city or regional level, there are local pockets of power.

　　波士頓咨詢集團的Jon Scholl指出，現在的醫療行業處于支離破碎的狀態，由于定價的過程是在某一城市或地區范圍之內完成的，本地權利口袋影響定價的行為是存在的。

　　Alain Enthoven, an economist at Stanford University s business school who helped inspire themanaged health care movement of the 1990s, promoted an approach that succeeded insqueezing costs at the time,

　　Alain Enthoven是來自斯坦福大學商學院的經濟學家，他曾經在二十世紀90年代推動管理醫保運動的開展。

　　but ultimately failed as patients rebelled against the restrictions it placed on their choice ofdoctors and treatments.

　　當時他推行的改革方案在削減成本方面頗有成效，但因為病患不滿他們失去了選擇醫生和療法的自由而抗議，這項改革以失敗告終。

　　Mr Enthoven argues that the consolidation that followed managed care has resulted in toolittle competition.

　　Enthoven先生認為，改革失敗后的相對穩固導致了今日幾無競爭存在的行業格局。

　　Antitrust action in the hospital field has been woefully weak, he says.

　　他說：反壟斷在醫療行業只是一句可悲的空話。

　　There are some innovative competitors emerging to challenge hospitals.

　　當然還是有一些富有創新精神愿意挑戰壟斷的競爭者出現。

　　Paul Keckley of Deloitte, a consultancy, estimates that there are over 1,000 retail healthclinics operating today at Wal-Mart stores,

　　Deloitte咨詢公司的Paul Keckley估計，在沃爾瑪店鋪，Walgreen藥店還有其他的一些便利商店，總共有超過1000家藥品零售診所存在。

　　Walgreens pharmacies and other convenient locations, and their numbers are expected tomultiply in the next few years.

　　在今后幾年，這些零售診所的數量有可能翻倍。

　　Some of these cheap and cheerful outfits are staffed by nurse practitioners, which incensesdoctors and hospital bosses.

　　一些有醫師資格的護士在這里工作，他們的工資水平比醫師低很多，這讓醫生和醫院負責人們很是惱怒。

　　The nascent boom in medical tourism could also disrupt the hospital business,

　　但醫療旅游近期的初步興起還是困擾醫療行業的一個原因。

　　even if every hip-replacement patient does not actually go to India to get it done.

　　盡管不是每一個需要做髖關節置換手術的病人都選擇去印度治療，

　　Mr Keckley points out that in several parts of the country the mere introduction of insuranceplans offering cheap surgery abroad has forced local hospitals to respond by slashing theirpricessomething unheard of in this industry.

　　Keckley先生指出，在美國的一些地方，出現了一些提供便宜海外手術的醫療保險計劃，這就使得當地醫院不得不采取減價策略，但事實上，減價在醫療行業是前所未聞的事情。

　　Mr Enthoven argues that if reforms are done properly, they would force hospitals to getorganised to compete and get more efficient.

　　Enthoven先生說，如果改革可以成功實施，那么這將促使醫院組織性更強的去參與行業競爭，而且將使整個行業提高效率。

　　Alas, the omens are not good.

　　但是，目前的預兆不太好。

　　One of the explicit concessions wrung by the hospital bosses from the White House was apromise to crack down on clinics owned by doctors.

　　醫院負責人們與政府方面協商出的一個明確讓步就是打擊私人醫生開設的診所。

　　These outfits are guilty of anti-competitive self-dealing, since the doctor has a financialmotive to refer cases to his own firm,

　　因為醫生們出于經濟動機可能會向自己的私人診所推薦病例，這些小診所違反了反競爭的自利交易原則，

　　but what hospital bosses were really concerned about was that such clinics are competinghard with them, and siphoning off the most profitable patients.

　　但事實上醫院負責人們真正擔心的問題是這些小診所正與大醫院激烈的競爭，大醫院可能因此失掉那些可以讓他們賺大錢的病例。

　　As this back-room deal illustrates, the strongest motives behind the hospitals ostensiblygenerous price cut were self-serving ones: to reduce competition, not boost it,

　　正如這個密室協議所證明的，在醫院表面慷慨削減開支的背后，最真實的動機卻是自我獲利：

　　and to head off any increase in government influence over their prices.

　　非但不促進，反而減少競爭，并竭力避免任何可能出現的政府對價格的管制。

　　As health-care reform forges ahead, reformers are desperate to find cost savings and thehospital industry is a juicy target.