391: More Is Less - This American Life

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00:00 00:00 Transcript Share This American Life Life Partners How to Listen Episodes Recommended About Overview Staff Announcements Fellowships Jobs Music Make Radio On The Road FAQ Submissions Merch Contact Us Our Other Shows Merch Follow Us Life Partners Subscribe to our newsletter Full episode Toggle Audio and Transcript Sync Transcript | Episode #391 | October 9, 2009 391: More Is Less Note: This American Life is produced for the ear and designed to be heard.

00:00 00:00 文字记录 分享此 美国生活 生活伙伴 如何收听 剧集 推荐 关于 概述 员工公告 奖学金 工作 音乐 在路上制作电台 常见问题解答 提交 商品 联系我们 我们的其他节目 商品 关注我们 生活伙伴 订阅我们的时事通讯 整集 切换音频和文字记录同步 文字记录 | 内容第 391 集 | 2009 年 10 月 9 日 391：多即少 注意：《This American Life》是为耳朵而制作的，旨在让人们听到。

If you are able, we strongly encourage you to listen to the audio, which includes emotion and emphasis that's not on the page.

如果可以的话，我们强烈建议您收听音频，其中包括页面上没有的情感和重点。

Transcripts are generated using a combination of speech recognition software and human transcribers, and may contain errors.

文字记录是使用语音识别软件和人工转录员结合生成的，可能包含错误。

Please check the corresponding audio before quoting in print.

请在印刷版引用前检查相应的音频。

Prologue Ira Glass I was in the kitchen cooking some food for my dog, which I don't say with pride.

序言 Ira Glass 我当时在厨房里为我的狗做饭，我并不自豪地说出这一点。

I don't even approve of people cooking for their dogs, but he's got health problems and without boring you with a lot of details, there's no getting around it.

我什至不赞成人们为他们的狗做饭，但他有健康问题，如果没有很多细节让你感到无聊，那就无法回避。

And I was listening to Marketplace, which is actually the point of this story I'm telling you.

我正在听 Marketplace，这实际上就是我告诉你的这个故事的重点。

I was listening to the radio on Marketplace and I heard this commentary by one of the regular commentators, this conservative commentator, David Frum, who said that new numbers had just been released by the government.

我正在听 Marketplace 上的广播，听到一位常规评论员、保守派评论员 David Frum 的评论，他说政府刚刚发布了新数据。

Showing that when you look at family incomes-- and what happened to family incomes during the Bush presidency.

当你观察家庭收入时就会发现这一点，以及布什总统任期内家庭收入的变化。

George W.

乔治·W.

Bush has the worst economic performance of any two-term president since the numbers were collected.

自统计数据以来，布什的经济表现是所有两届总统中最差的。

Jimmy Carter did worse, but he only had one term.

吉米·卡特的表现更差，但他只任职一届。

I asked Frum to come onto our show to talk about this finding.

我邀请弗鲁姆参加我们的节目来谈论这一发现。

This is a little painful.

这有点痛苦。

I was part of the Bush administration.

我曾是布什政府的一员。

In fact, I was part of the Bush administration's economic team.

事实上，我是布什政府经济团队的一员。

So I take this a little personally.

所以我个人认为这有点。

But Frum says, and this was his point on Marketplace , that it's important to understand why Bush's performance was so bad.

但弗鲁姆表示，理解布什的表现为何如此糟糕很重要，这就是他在 Marketplace 上的观点。

Frum says that over those eight years what employers actually paid for each worker rose.

弗鲁姆说，在这八年里，雇主为每个工人支付的实际工资有所增加。

And it rose a lot: 25%.

而且涨幅很大：25%。

But--

但是——

Employees received none of that money.

员工们一分钱都没有收到。

The median American worker was earning less in the year 2007 than that worker was earning adjusting for inflation in the 2000.

2007 年美国工人的收入中位数低于 2000 年通货膨胀调整后的收入。

And yet, his employer was paying 25% more.

然而，他的雇主却多付了 25% 的工资。

So where did that money go?

那么这些钱去了哪里呢？

And the answer is, it all went to pay the rising cost of health care.

答案是，这一切都用来支付不断上涨的医疗费用。

The average cost of a health insurance policy for a family of four between 2000 and 2007 more than doubled, from $6,000 to $13,000.

2000 年至 2007 年间，一个四口之家的健康保险平均费用增加了一倍多，从 6,000 美元增加到 13,000 美元。

A $7,000 climb.

攀登 7,000 美元。

Coincidentally, during the boom years of President Clinton, when Americans did so well, family incomes rose about that same amount, $6,500.

巧合的是，在克林顿总统执政的繁荣时期，当美国人经济状况良好时，家庭收入也增加了大约同样的数额，即 6,500 美元。

This is just how quickly health care costs are rising in this country.

这就是这个国家医疗保健费用上涨的速度。

If you take into account health care, George W.

如果考虑到医疗保健，乔治·W·布什 (George W.

Bush stops being the worst two-term president in the modern America era for family incomes.

布什不再是现代美国家庭收入最差的两任总统。

If you were to compare, say, President Bush's performance to Harry Truman's or the Ford-Carter years, it looks good.

比如说，如果你将布什总统的表现与哈里·杜鲁门或福特·卡特时代进行比较，你会发现它看起来不错。

If you compare it to the Clinton years, the Reagan years, or the Johnson years, it doesn't look so good.

如果你把它与克林顿时代、里根时代或约翰逊时代相比，它看起来就不太好了。

So basically he's somewhere in the middle?

所以基本上他处于中间位置？

He's kind of like--

他有点像——

No, I would say the lower part of the middle.

不，我想说的是中间的下部。

I don't want to oversell the record.

我不想过度推销这张唱片。

Rising health care costs are affecting everything in the economy.

不断上涨的医疗保健费用正在影响经济的方方面面。

Rising health care costs are the thing that's driving our health care system off the rails.

不断上涨的医疗保健费用是导致我们的医疗保健系统脱轨的原因。

It's what's led so many people to being uninsured.

这就是导致这么多人没有保险的原因。

It's making it hard for US businesses to compete.

这使得美国企业难以竞争。

It's gobbling up more and more of all spending in the United States.

它吞噬了美国越来越多的支出。

I saw this number recently that said that at the current rate of growth, in just 9 years, the amount that the average American family is going to spend on health care each year is going to be $38,000.

我最近看到一个数字，说按照目前的增长速度，仅仅9年之后，美国家庭平均每年在医疗保健上的花费将达到38,000美元。

$38,000.

38,000 美元。

That's more than half of what family income will be that year.

这是当年家庭收入的一半以上。

What was striking about that was that this isn't one of those projections that the government does looking at health care costs 75 years from now, showing how grim it's going to be far in the future.

令人震惊的是，这并不是政府对 75 年后医疗保健成本所做的预测之一，显示了遥远的未来将是多么严峻。

This is nine years from now at the current rate of growth.

按照目前的增长率计算，距离现在已经是九年了。

Basically, this is going to happen.

基本上，这将会发生。

Half of our incomes are going to be going to health care very, very soon, unless somebody does something.

除非有人采取行动，否则我们一半的收入很快就会用于医疗保健。

At this point, we, Americans, spend 50% more on health care than any country in the world, and the money isn't buying us better health.

目前，我们美国人在医疗保健上的支出比世界上任何国家都多 50%，而这些钱并没有给我们带来更好的健康。

If you look at the numbers, when it comes to infant mortality compared to other countries, we are 45th.

如果你看一下数字，就婴儿死亡率而言，与其他国家相比，我们排在第 45 位。

Worse than Cuba.

比古巴还差。

When it comes to life expectancy, we're 50th.

就预期寿命而言，我们排在第 50 位。

Behind, by the way, Bosnia and South Korea.

顺便说一句，后面是波斯尼亚和韩国。

And so today we ask the question, why is this happening?

所以今天我们要问一个问题，为什么会发生这种情况？

What's going on in health care that makes it so impossible to hold costs down?

医疗保健领域到底发生了什么，使得控制成本变得如此不可能？

We're tackling these questions now, this week, as health care is being debated in Washington.

本周，我们正在解决这些问题，因为华盛顿正在讨论医疗保健问题。

Because fixing our health care system means fixing two different things: getting more people covered by insurance and slowing the increases in health care costs.

因为修复我们的医疗保健系统意味着修复两件不同的事情：让更多的人获得保险和减缓医疗保健成本的增长。

And the bills on Capitol Hill right now seem much more about solving the insurance problem than about controlling costs.

目前国会山的法案似乎更多的是为了解决保险问题，而不是控制成本。

So we're going to do something we've never done.

所以我们要做一些我们从未做过的事情。

We're going to two shows about this, this week and next week.

我们将在本周和下周观看两场有关此的演出。

This is a co-production we're doing with NPR News .

这是我们与 NPR 新闻频道联合制作的节目。

Next week, the most entertaining hour, I guarantee, that you're ever going to hear on the insurance industry.

下周，我保证，您将听到关于保险业的最有趣的时刻。

This week, we ask why costs keep rising.

本周，我们要问为什么成本不断上涨。

From WBEZ Chicago it's This American Life distributed by Public Radio International, I'm Ira Glass.

来自芝加哥 WBEZ 的《This American Life》由国际公共广播电台发行，我是 Ira Glass。

Our show today in four acts.

我们今天的演出分四幕。

Act one, Dartmouth Atlas Shrugged, in which we examine whether doctors are the ones to blame for rising costs.

第一幕“达特茅斯阿特拉斯耸耸肩”，我们检查医生是否应该为费用上涨负责。

Act two, Every Cat Scan has Nine Lives, in which we wonder if patients are the problem.

第二幕，每只猫扫描都有九条命，我们想知道患者是否是问题所在。

Act three, Who Would Win in a Fight Between a Polar Bear and an Insurance Company?

第三幕，北极熊和保险公司的战斗谁会获胜？

Is the problem the insurance companies?

是保险公司的问题吗？

And act four, Now What?

第四幕，现在怎么办？

In which we learn what the new health care bills do to fix all this, if they do anything.

在其中我们了解到新的医疗保健法案对解决所有这些问题有何作用（如果有的话）。

Stay with us.

留在我们身边。

There are all kinds of reasons that health care costs have risen so quickly over the last few decades.

过去几十年来医疗保健费用增长如此之快的原因有很多。

We have higher administrative costs than other countries because our health care system with its insurers and providers is so complicated.

我们的行政成本比其他国家更高，因为我们的医疗保健系统及其保险公司和提供者非常复杂。

We use more expensive high tech gear, our drugs cost more.

我们使用更昂贵的高科技装备，我们的药品更贵。

But there's a whole school of thought that blames a lot of the rising costs on doctors.

但有一个完整的思想流派将成本上涨的大部分归咎于医生。

Prescribing drugs that people don't really need, doing too many procedures.

开出人们并不真正需要的药物，进行太多的手术。

And the reason people think this all goes back to the work of one person, a health researcher named Jack Wennberg.

人们认为这一切的原因都可以追溯到一个人的工作，他是一位名叫杰克·温伯格的健康研究员。

NPR science correspondent, Alix Spiegel, explains what that's all about.

NPR 科学记者阿利克斯·斯皮格尔 (Alix Spiegel) 解释了这一切。

To understand the work of Jack Wennberg, let's start with one patient and one medical problem, a young woman with a sharp pain in her lower uterus.

为了了解杰克·温伯格的工作，让我们从一名患者和一个医疗问题开始，她是一名子宫下部剧烈疼痛的年轻女性。

I was having a lot of problem, just a constant ache right here that never went away.

我遇到了很多问题，只是这里持续疼痛，从未消失。

And my boss kept saying, you should go get that checked.

我的老板一直说，你应该去检查一下。

You should go get that checked.

你应该去检查一下。

Because I was like doubling right over.

因为我就像是翻倍了。

It was like a really, really deep ache all the time.

一直以来，这就像一种非常非常深的疼痛。

In 1974, Roxanne Tremblay was 29 years old.

1974 年，罗克珊·特伦布莱 (Roxanne Tremblay) 29 岁。

A single mom living in a small apartment in Lewiston, Maine.

一位单亲妈妈住在缅因州刘易斯顿的一间小公寓里。

Because Roxanne was the only one supporting her young daughter, she had to be able to work, and the pain was getting in the way.

因为罗克珊是唯一支持她年幼女儿的人，所以她必须能够工作，而疼痛却阻碍了她。

The pain was a problem.

疼痛是一个问题。

So Roxanne went to see her gynecologist, a nice man who did a short exam, and then kindly explained that Roxanne would need an operation.

于是罗克珊去看了她的妇科医生，一位好心的人做了一次简短的检查，然后善意地解释说罗克珊需要接受手术。

Three weeks later, Tremblay had her uterus and ovaries removed, a total hysterectomy.

三周后，特伦布莱切除了她的子宫和卵巢，即全子宫切除术。

It was what he called the seed of cancer.

这就是他所说的癌症种子。

It wasn't cancer, but it had the potential of developing into it.

它不是癌症，但有发展成癌症的潜力。

Now Roxanne didn't mind losing her uterus.

现在罗克珊并不介意失去子宫。

She never planned to get married or have kids again.

她从未打算再结婚或生孩子。

But she was slightly surprised that her doctor had been so quick, and before surgery hadn't taken any x-rays or anything.

但让她有些惊讶的是，她的医生动作这么快，手术前也没有拍任何X光片什么的。

No pictures.

没有图片。

No. Alix Spiegel He just felt you were--

不，阿利克斯·斯皮格尔（Alix Spiegel）他只是觉得你——

And based on what I told him that it should come out.

根据我告诉他的，它应该出来。

29 years old is pretty young for a hysterectomy.

29岁做子宫切除术还算年轻。

But in the mid '70s in Lewiston, Maine, lots of women were getting them.

但在 70 年代中期，在缅因州刘易斯顿，很多女性都开始佩戴它们。

Roxanne, herself, knew a bunch.

罗克珊本人就知道很多。

My boss that I had when I worked at Kmart, she had one shortly after I did.

我在凯马特工作时的老板，在我工作后不久她也有了一个。

One of my friends that I've had since I was six years old, she lives right five minutes from here, she had one.

我从六岁起就有的一位朋友，她就住在离这里五分钟路程的地方，她有一个。

Just about anybody you talked to would say, oh, I had a hysterectomy.

几乎所有与你交谈过的人都会说，哦，我做了子宫切除术。

Oh, yeah.

哦，是的。

So I did.

所以我做到了。

So and so did mine.

我的也是如此。

Our I just remember there was a lot of them.

我只记得有很多。

I do remember that.

我确实记得这一点。

Now most Lewiston women, including Roxanne, weren't suspicious about the hysterectomies.

现在，包括罗克珊在内的大多数刘易斯顿妇女对子宫切除术并不怀疑。

And this is where Jack Wennberg's research comes in.

这就是杰克·温伯格的研究发挥作用的地方。

Until Jack Wennberg made Lewiston and its hysterectomies famous, no one had even noticed.

在杰克·温伯格让刘易斯顿及其子宫切除术闻名之前，没有人注意到这一点。

But in the late '70s, Wennberg published a paper, "A Study of Health Care in Maine." And in it he showed that an unusually large number of women in Lewiston were having their uterus removed.

但在 70 年代末，温伯格发表了一篇论文“缅因州医疗保健研究”。在其中，他表明刘易斯顿有异常多的女性接受了子宫切除术。

He projected that 70% would have a hysterectomy by age 70.

他预计 70% 的人会在 70 岁时接受子宫切除术。

While a couple towns over, the number was much smaller-- 25%.

虽然距离几个城镇较远，但这个数字要小得多——25%。

That paper was one of a series of studies of Maine and Vermont published by Wennberg in the '70s and '80s.

这篇论文是温伯格在 70 年代和 80 年代发表的关于缅因州和佛蒙特州的一系列研究之一。

Studies which ultimately, completely transformed our understanding of what's going on in health care in this country.

这些研究最终彻底改变了我们对这个国家医疗保健现状的理解。

Which is how come I ended up in Wennberg's dining room.

这就是为什么我最终会来到温伯格的餐厅。

Hello.

你好。

Hello.

你好。

This is me trying to set the levels on my recording equipment.

这是我试图在我的录音设备上设置电平。

To do this I asked Wennberg what I ask most people, "could you say a little something?" This is what I got.

为此，我问温伯格，就像我问大多数人的那样：“你能说点什么吗？”这就是我得到的。

[SPEAKING GERMAN] Alix Spiegel 19th century German poetry.

[说德语] 阿利克斯·斯皮格尔 19 世纪德国诗歌。

Apparently, for fun in college, Wennberg committed foreign verse to memory.

显然，为了在大学里找乐子，温伯格把外国诗句牢记在心。

Wennberg's that kind of guy.

温伯格就是这样的人。

The kind of guy whose side projects tend to be unusually rigorous.

这种人的副业往往异常严格。

This was certainly the case in health care.

医疗保健领域当然就是这种情况。

You see, when Wennberg started out in the late '60s, what he was trying to do was improve medicine in the state of Vermont, get better medical services to rural communities.

你看，当温伯格在 60 年代末开始创业时，他想做的是改善佛蒙特州的医疗水平，为农村社区提供更好的医疗服务。

He'd gotten a grant to overhaul Vermont's health care system.

他获得了一笔拨款来彻底改革佛蒙特州的医疗保健系统。

But because Wennberg is such a thorough type of fellow, he made a pretty extreme decision.

但由于温伯格是一个非常彻底的人，他做出了一个相当极端的决定。

He decided he'd try to collect information about every medical transaction of every person in every town in the whole state.

他决定尝试收集全州每个城镇每个人的每笔医疗交易信息。

That way he'd know what was going on.

这样他就知道发生了什么事。

What was going on in home health agencies, what was going on in nursing homes, hospitals, doctors' offices.

家庭健康机构、疗养院、医院、医生办公室正在发生什么。

And we need to know for each patient what their diagnosis is, what their treatment was, how much money was spent, and what the outcomes were insofar as we could actually measure them.

我们需要知道每个患者的诊断是什么，他们的治疗是什么，花了多少钱，以及我们可以实际测量的结果是什么。

Now to collect these records, Wennberg hired a bunch of researchers, people dubbed the Pit Crew, who year after year were sent out to medical records rooms to collect records.

为了收集这些记录，温伯格聘请了一群研究人员，他们被称为“维修人员”，他们年复一年地被派往病历室收集记录。

It was a massive undertaking.

这是一项艰巨的任务。

Every medical transaction in the state of Vermont.

佛蒙特州的每笔医疗交易。

It took two years of road trips just to collect the records for 1969.

为了收集 1969 年的记录，我们花了两年的时间进行公路旅行。

But once he had all the information, Wennberg began to slice it and dice it in all kinds of ways.

但一旦掌握了所有信息，温伯格就开始以各种方式对其进行切割和切割。

And what immediately jumped out was that medicine from town to town in Vermont was practiced in entirely different ways.

立即跳出来的是，佛蒙特州各个城镇的行医方式完全不同。

As soon as we set out to do the analyses, we began to see these extraordinary differences.

一旦我们开始进行分析，我们就开始看到这些非凡的差异。

In one town, say 50% of the men would have a prostate procedure.

假设在一个城镇，50% 的男性会接受前列腺手术。

But in another town only 30 miles away, only 15% would.

但在 30 英里外的另一个城镇，只有 15% 的人愿意。

Ditto with mastectomies, hemorrhoid removal, back surgery.

乳房切除术、痔疮切除术、背部手术也是如此。

Basically, town after town was a version of Lewiston, Maine, in the sense that some procedures might be incredibly numerous, or conversely, incredibly rare.

基本上，一个又一个城镇都是缅因州刘易斯顿的一个版本，从某种意义上说，某些程序可能非常多，或者相反，非常罕见。

It just didn't make sense.

这根本没有道理。

We lived right on the boundary between Stowe and Waterbury Center, Vermont.

我们住在佛蒙特州斯托和沃特伯里中心之间的边界处。

And if my kids had been going to the school system in Stowe, they would have had a 75% chance of getting their tonsils out.

如果我的孩子们去斯托的学校系统，他们就有 75% 的机会摘除扁桃体。

If they'd gone to the Waterbury School-- where they actually did-- it was about 20%.

如果他们去了沃特伯里学校（他们确实就读过），那么这个比例大约是 20%。

So what was going on?

那么到底发生了什么事呢？

Why the differences?

为什么会有这些差异？

Well, there are two possible explanations.

嗯，有两种可能的解释。

The first explanation is that it was the doctors.

第一个解释是，是医生干的。

Doctor behavior was somehow to blame.

医生的行为在某种程度上是罪魁祸首。

The second was that it was the patients.

第二个是患者。

That people in some areas were just much sicker than people in other areas.

某些地区的人们比其他地区的人们病情严重得多。

Or maybe they just wanted more services for some reason.

或者也许他们只是出于某种原因想要更多的服务。

Which brings us back to the city of Lewiston, Maine, and yet another woman who had a hysterectomy.

这让我们回到了缅因州刘易斯顿市，还有另一位接受了子宫切除术的妇女。

Oh, hi there, little dogs.

哦，嗨，小狗们。

Carol Bradford Come in.

卡罗尔·布拉德福德 进来。

You found me.

你找到了我。

A couple miles down the way from Roxanne Tremblay, on a quiet Lewiston street, is the home of Carol Bradford.

距离罗克珊·特伦布莱 (Roxanne Tremblay) 几英里远，在一条安静的刘易斯顿街上，是卡罗尔·布拉德福德 (Carol Bradford) 的家。

Carol is another Lewiston woman who had her uterus removed in the 1970s.

卡罗尔是另一位刘易斯顿妇女，她在 20 世纪 70 年代接受了子宫切除术。

She had fibroids.

她患有肌瘤。

And like Roxanne, she's happy with the result.

和罗克珊一样，她对结果感到满意。

But when I asked, Bradford had a theory about the high hysterectomy rate in Lewiston back then.

但当我问起时，布拉德福德对当时刘易斯顿的高子宫切除率有一个理论。

Lewiston, she explained, is mostly Catholic.

她解释说，刘易斯顿大部分是天主教徒。

Some women were having too many children.

有些妇女生了太多孩子。

There are families here with 10, 12 children.

这里有10、12个孩子的家庭。

It's a possibility that women came to the point where they just really couldn't deal with any more children, and were begging the doctors to do something about it.

有可能女性已经到了实在无法再照顾更多孩子的地步，并恳求医生对此采取一些措施。

That's my personal opinion.

这是我个人的看法。

Not just her opinion.

不只是她的意见。

Most people assume that when you go into a doctor's office, the doctor is simply responding.

大多数人认为，当您走进医生的办公室时，医生只是简单地做出回应。

Responding to sickness in your body, responding to the needs and concerns you have.

应对您身体的疾病，应对您的需求和担忧。

But in the studies he did in Vermont and Maine, Wennberg demonstrated that it's a lot more complicated than this.

但温伯格在佛蒙特州和缅因州进行的研究表明，情况比这复杂得多。

The women of Lewiston weren't having more hysterectomies because more of them were Catholic or because more of them were sick.

刘易斯顿的女性接受子宫切除术的比例并不是因为她们中有更多人是天主教徒，也不是因为她们中有更多人生病。

Wennberg showed that in terms of sickness and demographics, the populations of the communities in states like Maine and Vermont were actually incredibly homogeneous.

温伯格表明，就疾病和人口统计而言，缅因州和佛蒙特州等州的社区人口实际上非常相似。

Which according to Jack Wennberg could mean just one thing: it wasn't the patients.

根据杰克·温伯格的说法，这可能只意味着一件事：不是病人。

It wasn't true.

这不是真的。

It wasn't correct.

这是不正确的。

Because we could easily see that it wasn't that patients were different between regions.

因为我们很容易看出，不同地区的患者并不存在差异。

So it wasn't illness that was driving this.

所以这并不是疾病造成的。

This must be coming from the provider side.

这必须来自提供商方。

The provider side, the doctors.

提供方，即医生。

That was the first insight.

这是第一个洞察。

That it was doctors not patients that drove medical consumption.

推动医疗消费的是医生而不是患者。

And that there are all kinds of things that influenced the decisions a doctor makes when you go into his office.

当你走进医生的办公室时，各种各样的因素都会影响医生做出的决定。

Sickness plays a role, but a much smaller role than we originally thought.

疾病确实起到了一定作用，但其作用比我们最初想象的要小得多。

So, what are the things that influence doctor decisions?

那么，影响医生决策的因素有哪些呢？

To answer this question, I went back to Maine to talk to doctors themselves.

为了回答这个问题，我回到缅因州与医生本人交谈。

Doctors who explained that the work of Jack Wennberg inspired a small revolution in the state.

医生们解释说，杰克·温伯格的工作激发了该州的一场小革命。

You see, after Wennberg published a paper on his early discoveries, a small group of Maine doctors gathered to take action.

你看，在温伯格发表了一篇关于他的早期发现的论文后，一小群缅因州的医生聚集在一起采取行动。

They decided that physicians in Maine should, and could, themselves figure out why these strange geographical variations in care were taking place.

他们认为缅因州的医生应该而且能够自己弄清楚为什么护理方面会出现这些奇怪的地理差异。

And the best way to do that this group figured, was to get all the doctors in Maine to sit down together on a regular basis, look at Maine city by city, and then hash out together why the care they were giving was so different.

该小组认为，实现这一目标的最佳方法是让缅因州的所有医生定期坐在一起，逐个城市地查看缅因州，然后一起讨论为什么他们提供的护理如此不同。

Bob Keller is a back doctor who worked on this project.

鲍勃·凯勒（Bob Keller）是一名背部医生，参与了这个项目。

And he told me that in the beginning there was only one small problem with the plan: many of the doctors in Maine hated it.

他告诉我，一开始这个计划只有一个小问题：缅因州的许多医生都讨厌它。

Number one, they were insulted.

第一，他们受到侮辱。

They were angry.

他们很生气。

Their judgment was being challenged.

他们的判断受到了挑战。

That was not allowed.

那是不允许的。

There were variable responses.

反应各异。

In some cases they just didn't believe it, and they would try to find holes in the data.

在某些情况下，他们就是不相信，他们会试图找出数据中的漏洞。

One of the classics.

经典之一。

Oh, we have more workers' compensation here.

哦，我们这里的工伤赔偿多一些。

We have more heavy industry here.

我们这里有更多的重工业。

And we were able to work through most of those things and demonstrate that wasn't the case.

我们能够解决大部分问题并证明事实并非如此。

But they would-- our population's older.

但他们会——我们的人口年纪更大了。

More of them need prostatectomies.

其中更多的人需要前列腺切除术。

Well, we adjust for age, so that's not an argument anymore.

好吧，我们会根据年龄进行调整，所以这不再是一个争论。

And some doctors never could deal with that.

有些医生永远无法解决这个问题。

And they would leave the study groups.

他们将离开学习小组。

They just said, this is baloney; we're not going along with this.

他们只是说，这是胡说八道；我们不会同意这一点。

But in time, says Keller, many doctors did warm to these ideas.

但凯勒说，随着时间的推移，许多医生确实对这些想法产生了兴趣。

They began to accept the data and they began to accept that indeed, different physicians were using different thought processes or decision-making processes in dealing with patients.

他们开始接受这些数据，并开始接受这样一个事实：不同的医生在与患者打交道时使用不同的思维过程或决策过程。

And so in the state of Maine, for years there was this incredible experiment.

因此，在缅因州，多年来一直进行着这项令人难以置信的实验。

Four or five times a year each medical specialty got together for a kind of Talmudic dissection of doctor choice conducted by the doctors themselves.

每年，每个医学专业都会聚集四到五次，由医生自己进行一种塔木德式的医生选择剖析。

They wanted to look at all of the geographical differences, figure out why they existed, and then try to bring their medical decisions in line with one another.

他们想要研究所有的地理差异，找出它们存在的原因，然后尝试使他们的医疗决策相互一致。

They figured that by doing this they could eliminate unnecessary care.

他们认为通过这样做可以消除不必要的护理。

Now, when talking in these groups, the Maine doctors usually seemed to agree on what criteria they would use for making treatment decisions.

现在，当在这些小组中交谈时，缅因州的医生似乎通常就他们将使用什么标准来做出治疗决定达成一致。

So for instance, everyone agreed that you only operate on a back after there'd been three months of pain.

例如，每个人都同意只有在疼痛三个月后才对背部进行手术。

But when they went back to the data, it showed that in the privacy of their own offices, many doctors were doing something completely different.

但当他们回顾数据时，发现许多医生在自己办公室的私密空间里做着完全不同的事情。

Why?

为什么？

One possible reason was fear of lawsuits.

可能的原因之一是担心诉讼。

Some doctors felt that, criteria be damned, if they didn't do every possible thing they might get sued.

一些医生认为，标准是该死的，如果他们不采取一切可能的措施，他们可能会被起诉。

Another was temperament.

另一个是气质。

Some doctors were just much more eager to take action.

一些医生只是更渴望采取行动。

Then there was the role of medical culture.

然后是医学文化的作用。

In some communities it had evolved over time that, let's say, when a kid got a temperature of 102, he was sent to the hospital.

在一些社区，随着时间的推移，情况逐渐演变，比如，当一个孩子发烧到 102 度时，他就会被送往医院。

Well, in the next town over, kids with that temperature were advised to just stay home.

嗯，在下一个城镇，建议发烧的孩子呆在家里。

And then there was the number of doctors in a community.

然后是社区中医生的数量。

One of the many doctors I talked to while I was in Maine was this eye specialist named Frank Read.

我在缅因州期间采访过的众多医生之一是眼科专家弗兰克·里德（Frank Read）。

He's another doc who participated in these groups.

他是参加这些小组的另一位医生。

And he told me this story.

他告诉我这个故事。

My old partner that I joined here in 1971 was asked by a friend of his, you know, at what level of vision do you do a cataract operation?

我1971年加入这里的老伙伴，他的一个朋友问，你知道，你在什么水平的视力下做白内障手术？

And he said, well, if there's one ophthalmologist in town, it's 2200.

他说，好吧，如果镇上有一位眼科医生，那就是 2200。

2200 is pretty bad vision.

2200 视力很差。

Frank Read If there are two ophthalmologists in town, it's 2080.

Frank Read 如果镇上有两位眼科医生，那是 2080 年。

Not so bad vision.

视力还不错。

Frank Read If there are three ophthalmologists in town, it's 2040.

Frank Read 如果镇上有三位眼科医生，那是 2040 年。

Pretty good vision.

视力相当好。

In other words, the criteria easily shifts.

换句话说，标准很容易改变。

According to later work done by Jack Wennberg, the number of doctors in an area can influence the amount of medical services consumed.

根据杰克·温伯格后来所做的研究，一个地区的医生数量可以影响医疗服务的消费量。

The more doctors, the more appointments, the more procedures, the more money spent.

医生越多，预约越多，程序越多，花的钱就越多。

You could actually see this dynamic especially clearly during the '70s.

事实上，在 70 年代，你可以特别清楚地看到这种动态。

Because to drive down costs in medicine, the federal government created a program to send more people to medical school.

因为为了降低医疗成本，联邦政府制定了一项计划，将更多的人送入医学院。

The theory was that when there were more doctors, doctors would be forced to drop their prices to compete for patients.

该理论认为，当医生数量增加时，医生将被迫降低价格以争夺患者。

Basic economics.

基础经济学。

But that's not what happened.

但事实并非如此。

The doctors just adjusted their criteria for doing stuff and had the patients they had come in more often.

医生们只是调整了他们的工作标准，并更频繁地接诊病人。

Because in health care, supply drives demand.

因为在医疗保健领域，供应驱动需求。

So when the supply of doctors and clinics increases, the demand for medical services goes up.

因此，当医生和诊所的供应增加时，对医疗服务的需求就会增加。

Often, Frank Read says, for a completely innocent reason.

弗兰克·里德说，通常是出于完全无辜的原因。

I don't want to be sitting on my thumbs all the time.

我不想一直坐在我的拇指上。

I want to be busy.

我想变得忙碌。

And that may unconsciously loosen my criteria for doing a particular procedure.

这可能会在不知不觉中放松我执行特定程序的标准。

Which brings us, finally, to the subject, which incredibly, was never ever discussed during the nearly 20 years the doctors met: money.

最后，我们谈到了这个话题，令人难以置信的是，在医生们见面的近 20 年里，这个话题从未被讨论过：金钱。

Specifically, the idea that doctors might be prescribing more visits and more procedures so that they could make more money.

具体来说，医生可能会开更多的就诊和更多的手术，这样他们就可以赚更多的钱。

Frank Read and Bob Keller told me that this subject was completely verboten.

弗兰克·里德和鲍勃·凯勒告诉我，这个话题是完全禁止的。

We didn't want to talk about money.

我们不想谈论钱。

That's something that we wouldn't want to acknowledge because it would have been a show stopper.

这是我们不想承认的事情，因为这会成为一个阻碍。

I mean it would have then gone right to the question of greed.

我的意思是，接下来就直接讨论贪婪的问题了。

And you're not going to keep a doc at the table if you say you're greedy.

如果你说你很贪婪，你就不会把医生留在餐桌上。

Doctors are uncomfortable acknowledging the role of money, but every doctor I talked to admitted, it affects medical decision-making.

医生们不愿意承认金钱的作用，但我采访过的每位医生都承认，金钱会影响医疗决策。

Including Gordon Smith, head of the Maine Medical Association.

其中包括缅因州医学协会会长戈登史密斯。

Of course it does.

当然可以。

That's just common sense.

这只是常识。

That's human nature.

这就是人性。

The payment system is an important influence.

支付系统是一个重要的影响因素。

You see, the majority of doctors in this country are not on salary, but are paid for each thing they do: a la carte.

你看，这个国家的大多数医生都没有工资，而是按他们所做的每件事获得报酬：点菜。

That's what they mean when they say, fee for service.

这就是他们所说的服务费的意思。

A phrase you've probably heard a lot.

这句话你可能听过很多次了。

And the way fee for service affects doctor behavior is clear.

服务费对医生行为的影响是显而易见的。

Gordon Smith.

戈登·史密斯。

If you pay people more the more things they do, they're going to do more things.

如果你付给人们的钱越多，他们做的事情越多，他们就会做更多的事情。

Bob Keller points to his own specialty-- he's a back doctor-- and says one of the most popular operations among back doctors these days is this complicated procedure called an instrumented fusion.

鲍勃·凯勒指出了他自己的专业——他是一名背部医生——并表示，如今背部医生中最受欢迎的手术之一就是这种称为器械融合的复杂手术。

When a patient has a back problem, the doctor can go in and insert metal rods.

当病人有背部问题时，医生可以进去插入金属棒。

Keller says in the old days the doctor used a much simpler and safer operation, but the new, more complicated one costs more.

凯勒说，过去医生使用一种更简单、更安全的手术，但新的、更复杂的手术成本更高。

Surgeons could charge more because they were doing these complicated procedures, and so they were putting the screws in.

外科医生可以收取更多费用，因为他们正在做这些复杂的手术，所以他们要放入螺钉。

They billed for putting the screws.

他们为安装螺丝付费。

They were putting the plates in, they billed for putting the plates in.

他们把盘子放进去，他们为放入盘子付费。

Doing all these things.

做所有这些事情。

In the old days a fusion was very much a simpler operation with no external devices.

在过去，融合是一种非常简单的操作，不需要外部设备。

It was all done with the patient's own tissues and bone.

这一切都是用病人自己的组织和骨头完成的。

So you had a whole new high-tech procedure that was enormously attractive to spine surgeons.

所以你有一个全新的高科技手术，对脊柱外科医生来说非常有吸引力。

And it literally took off in this country.

它确实在这个国家起飞了。

At the same time, as most good spine surgeons will admit, they had no research to support what they were doing.

与此同时，正如大多数优秀的脊柱外科医生承认的那样，他们没有研究来支持他们所做的事情。

In fact, says Keller, the one high quality study that did exist wasn't so positive.

事实上，凯勒说，一项确实存在的高质量研究并不那么积极。

It showed that it isn't so great actually, as people thought it was.

这表明它实际上并不像人们想象的那么好。

And they also showed that interestingly enough, that the old fashioned non-instrumented fusion was as successful as the instrumented fusion.

有趣的是，他们还表明，老式的非仪器融合与仪器融合一样成功。

Which was a real blow.

这是一个真正的打击。

And here in miniature is one of the big problems with the way our current system is set up.

这就是我们当前系统设置方式的大问题之一。

It's a problem some call, more is not better.

这是一个问题，并不是越多越好。

Doctors exist in a system that encourages-- and really because of their fear of malpractice suits-- actually forces them to do more.

医生所处的系统鼓励——实际上是因为他们担心医疗事故诉讼——实际上迫使他们做更多的事情。

More surgery, more tests, more stuff of every kind.

更多的手术，更多的测试，更多的各种东西。

And while most Americans just assume that more care is good, it turns out that more isn't always better for patients.

虽然大多数美国人只是认为更多的护理是好的，但事实证明，更多的护理并不总是对患者更好。

Because every time you get a medical procedure, you risk the possibility of complications and doctor error.

因为每次您接受医疗手术时，您都面临着出现并发症和医生失误的风险。

In 2003, there was this enormous landmark study published by a Jack Wennberg protege named Elliott Fisher.

2003 年，杰克·温伯格 (Jack Wennberg) 的弟子埃利奥特·费舍尔 (Elliott Fisher) 发表了一项具有里程碑意义的巨大研究。

He compared areas throughout the United States.

他比较了美国各地的情况。

Areas where elderly people got relatively small amounts of health care services to areas where elderly people got a lot of health care services.

老年人获得相对较少医疗保健服务的地区与老年人获得较多医疗保健服务的地区。

A lot.

很多。

Here's Fisher.

这是费舍尔。

The patients in the high spending regions were getting about 60% more care.

高支出地区的患者获得的护理量增加了约 60%。

So 60% more days in the hospital, twice as many specialist visits.

因此住院天数增加了 60%，专科医生就诊次数增加了一倍。

And yet, when we followed patients for up to five years, the mortality rate whether you were poor or rich, urban or rural, if you lived in one of these higher intensity communities, your survival was certainly no better.

然而，当我们对患者进行长达五年的跟踪调查时，无论你是穷人还是富人、城市还是农村，如果你生活在这些强度较高的社区之一，你的生存率肯定不会更好。

And in many cases, worse.

在许多情况下，情况更糟。

After Wennberg's original work in Vermont and Maine, a group of health care researchers set up a shop at Dartmouth College and created something called the Dartmouth Atlas of Health Care.

温伯格在佛蒙特州和缅因州完成最初的工作后，一群医疗保健研究人员在达特茅斯学院开设了一家商店，并创建了名为“达特茅斯医疗保健地图集”的东西。

Basically, a countrywide version of what Wennberg did in New England.

基本上，这是温伯格在新英格兰所做的全国性版本。

The huge warehouse of data compiled by these researchers has led to a lot of insights about our system.

这些研究人员编制的庞大数据仓库让我们对我们的系统有了很多见解。

Including this very disturbing statistic that you sometimes hear in the health care debate.

包括您有时在医疗保健辩论中听到的这个非常令人不安的统计数据。

They've estimated that about one-third of the medical care delivered in this country is unnecessary.

他们估计，这个国家大约有三分之一的医疗服务是不必要的。

One-third.

三分之一。

Doctors and hospitals doing things to you and me that we don't need.

医生和医院对你我做我们不需要的事情。

Stuff that doesn't make us any more healthy.

那些不会让我们变得更健康的东西。

Care delivered by a system that pushes doctors to do more when less is probably better.

一个系统提供的护理会促使医生做更多的事情，而实际上越少越好。

Alix Spiegel.

阿利克斯·斯皮格尔。

Coming Up, patients are told that they should do with less.

接下来，患者被告知他们应该少做点什么。

That the test or procedure that they want for themselves is unnecessary.

他们自己想要的测试或程序是不必要的。

And surprise, they are not too happy about it.

令人惊讶的是，他们对此并不太高兴。

That's in a minute from Chicago Public Radio and Public Radio International when our program continues.

一分钟后，芝加哥公共广播电台和国际公共广播电台将继续我们的节目。

It's This American Life , I'm Ira Glass.

这就是美国生活，我是艾拉·格拉斯。

Each week on our show of course, we choose a theme, bring you different kinds of stories on that theme.

当然，我们的节目每周都会选择一个主题，为您带来有关该主题的不同类型的故事。

Today's show, "More is Less." This is the first of two shows that we're going to be doing, this week and next, explaining the health care system, or parts of it anyway.

今天的节目《多即是少》。这是我们本周和下周要做的两场节目中的第一场，解释医疗保健系统或其中的一部分。

Today we're asking the question, why are health care costs rising so much that they threaten our entire economy?

今天我们要问的问题是，为什么医疗保健费用上涨如此之多，以至于威胁到我们的整个经济？

We've arrived at act two of our show.

我们已经到了演出的第二幕了。

Act Two: Every Cat Scan Has Nine Lives.

第二幕：每只猫扫描都有九条命。

This summer at a press conference, President Obama described how he wants to slow the increase in health care costs.

今年夏天的一次新闻发布会上，奥巴马总统描述了他希望如何减缓医疗保健费用的增长。

He's going to do it by having patients everywhere adjust a bit.

他将通过让各地的患者进行一些调整来做到这一点。

They're going to have to give up paying for things that don't make them healthier.

他们将不得不放弃为那些不会让他们更健康的东西付费。

Why would we want to pay for things that don't work?

为什么我们要为不起作用的东西付费？

Of course when he says it that way it sounds like it could not be easier.

当然，当他这样说时，听起来就再简单不过了。

According to the Dartmouth Atlas of Health, as you've just heard before the break, one-third of medical spending is on treatments and tests that are not actually necessary.

根据达特茅斯健康地图集，正如您在休息前听到的那样，三分之一的医疗支出用于实际上不必要的治疗和检查。

And in some cases, may actually harm us.

在某些情况下，实际上可能会伤害我们。

And President Obama's stimulus package devotes a billion dollars to studying and determining which procedures those are.

奥巴马总统的经济刺激计划投入了 10 亿美元来研究和确定这些程序。

So, let's just eliminate the stuff that doesn't work, right?

那么，让我们消除那些不起作用的东西吧？

Well, one of our producers, Lisa Pollak, explains why, in practice, that is not so easy to do.

我们的制作人之一 Lisa Pollak 解释了为什么在实践中这并不容易做到。

In the spirit of the president's advice, here's a story about what happened at one hospital when one doctor tried to resist ordering a test for a patient.

本着总统建议的精神，这里有一个关于一家医院发生的故事，当时一名医生试图拒绝为病人进行检查。

The patient was a teenage girl who'd been in a minor car wreck.

病人是一名遭遇过小型车祸的十几岁女孩。

As a precaution she was brought into the ER on a backboard with one of those collars around her neck.

作为预防措施，她被放在一块背板上带进急诊室，脖子上戴着一个项圈。

The doctor was Jerome Hoffman.

医生是杰罗姆·霍夫曼。

He's a professor of emergency medicine at UCLA.

他是加州大学洛杉矶分校的急诊医学教授。

And the first thing he needed to do was rule out the risk of an injury to the girl's cervical spine.

而他要做的第一件事，就是排除女孩颈椎受伤的风险。

He was able to do this without taking an x-ray.

他无需进行 X 光检查就能做到这一点。

Because when he examined the girl, her condition matched this list of five criteria.

因为当他检查这个女孩时，她的状况符合这五个标准。

For instance, she had no tenderness in the middle of the back of her neck that indicate to doctors when a fracture is extremely unlikely.

例如，她的颈后中部没有压痛，这向医生表明骨折的可能性极小。

Hoffman told the girl's mother that her daughter was fine, no need for an x-ray, and the mother seemed OK with this.

霍夫曼告诉女孩的母亲，她的女儿很好，不需要做X光检查，而母亲似乎对此表示同意。

But a couple minutes later, the dad showed up.

但几分钟后，爸爸出现了。

Dr. Hoffman.

霍夫曼博士。

Jerome Hoffman And the dad was a very tall, very powerful figure, who was very upset and spoke very loudly.

杰罗姆·霍夫曼（Jerome Hoffman）爸爸是一个非常高大、非常有权势的人物，他非常沮丧，说话声音很大。

And he also happened to mention that he was a lawyer and that there would be consequences for any error that we made.

他还碰巧提到他是一名律师，我们犯的任何错误都会产生后果。

And he said that he wanted to get not just an x-ray, but a CAT scan of her neck.

他说他不仅想对她的脖子进行 X 光检查，还想进行 CAT 扫描。

A CAT scan.

CAT 扫描。

Which is not only more expensive than an x-ray, but uses much more radiation.

这不仅比 X 射线更昂贵，而且使用更多的辐射。

So I tried to explain to him that a, she didn't really need the x-ray, or the cat scan.

所以我试图向他解释，她其实并不需要 X 光检查或猫扫描。

And b, that there was some harm with it.

b，它有一些危害。

In fact, if you do a thousand CAT scans to a young woman like this, there's a pretty good chance that some small number-- one, two, something like that-- may have harm from it.

事实上，如果你对像这样的年轻女性进行一千次 CAT 扫描，很有可能少数人（一个、两个或类似的人）可能会受到伤害。

And the harm is not trivial harm, it's important harm.

而且这种伤害不是微不足道的伤害，而是重要的伤害。

She could get a cancer of her thyroid that in 15, 20 years might actually be fatal.

她可能会患上甲状腺癌，在 15、20 年内实际上可能会致命。

So while I can't say with 100% certainty that her neck was fine, I was pretty sure-- 99.9% at least, in my judgment, it would be more harmful than beneficial to her to do the test for her.

因此，虽然我不能 100% 肯定地说她的脖子没问题，但我相当确定——至少 99.9%，根据我的判断，为她做检查对她来说弊大于利。

So I tried to explain this to the dad and I tried to be really nice and patient, but he was having none of it.

所以我试图向父亲解释这一点，我试着表现得非常友善和耐心，但他不同意。

He said things like, you will do a CAT scan.

他说，你会做 CAT 扫描。

And then I said to him something that, actually I had long known, but it never crystallized for me exactly in this way until that moment.

然后我对他说了一些话，实际上我早就知道了，但直到那一刻，它才以这种方式具体化。

I said to him, you know, for me it really is the right thing to do the CAT scan.

我对他说，你知道，对我来说，做 CAT 扫描确实是正确的事情。

I said, you know, if I don't do the CAT scan, you're probably going to lodge a complaint about me.

我说，你知道，如果我不做CAT扫描，你可能会投诉我。

If I do the CAT scan, you're going to be really happy with me.

如果我进行 CAT 扫描，您会对我感到非常满意。

I said, in addition, I'm almost certain that your daughter is fine.

我说，另外，我几乎可以肯定，你女儿没事。

But there's maybe a one in a million chance that she isn't.

但她不是的可能性可能是百万分之一。

That there really is a hidden fracture and I'm missing it.

确实存在隐藏的裂缝，而我却忽略了它。

And if that's the case, the CAT scan will save my butt.

如果是这样的话，CAT 扫描将拯救我的屁股。

And on the other hand, if I do the CAT scan and your daughter gets a cancer 20 years from now, no one will blame me.

另一方面，如果我做了 CAT 扫描，而您的女儿 20 年后患上了癌症，没有人会责怪我。

I said, in addition, I'm spending a lot of time talking to you here that I need to be going doing other things.

我说，另外，我花了很多时间在这里和你说话，我需要去做其他事情。

If I get the CAT scan, I could do it in a second.

如果我能进行 CAT 扫描，我可以在一秒钟内完成。

It would be done with.

就这样完成了。

It would be easy.

这很容易。

And I said, finally, the really strange thing is that I'll get paid more if I do the CAT scan.

最后我说，真正奇怪的是，如果我做 CAT 扫描，我会得到更多的报酬。

Because the way that bills are made, you get paid more for more complex patients.

由于账单的制作方式，对于病情复杂的患者，您可以获得更高的报酬。

And the insurance companies of the world think that it proves that the patient was more complex and more difficult if you had to do a CAT scan.

世界各地的保险公司都认为，如果必须进行 CAT 扫描，就证明病人的情况更加复杂、更加困难。

So everything about this was pushing me to do the CAT scan.

所以这一切都促使我去做 CAT 扫描。

I said that to him.

我对他这么说。

And I said, there's only one problem, which is that when I decided to become a doctor, I made a pledge.

我说，只有一个问题，就是当我决定成为一名医生时，我做出了承诺。

And the pledge was that I would put my patient's interest in front of my own interest.

我的承诺是我会把病人的利益置于我自己的利益之上。

And in this case, my judgment was that it was not in my patient's interest to do the CAT scan.

在这种情况下，我的判断是进行 CAT 扫描不符合我的患者的利益。

And therefore, I can't do it.

因此，我做不到。

And it was really strange.

这真的很奇怪。

It was interesting because this big guy, very powerful guy who had been really yelling and angry and screaming, his jaw dropped and he was silent.

这很有趣，因为这个大个子，非常强大的家伙，一直在大喊大叫，生气，尖叫，他的下巴掉了下来，他保持沉默。

He didn't know what to say.

他不知道该说什么。

Oh no. That was the end of the story.

哦不。故事就这样结束了。

I hope it's the end of the story.

我希望这是故事的结局。

It's been over a year now and I haven't gotten that famous embossed letter with the lawsuit, so I'm assuming that everything turned out fine.

现在已经一年多了，我还没有收到诉讼中那封著名的浮雕信，所以我假设一切都很顺利。

Hoffman told me this story is not an isolated example.

霍夫曼告诉我，这个故事并不是一个孤立的例子。

Things like this happen all the time in his department.

这样的事情在他的部门里时常发生。

Whether it's people wanting antibiotics for illnesses that antibiotics have been proven not to help, or tests such as x-rays and CAT scans.

无论是人们需要使用抗生素来治疗已被证明抗生素无济于事的疾病，还是 X 射线和 CAT 扫描等检查。

Where a patient thinks, well, don't I need to be sure that I don't have appendicitis?

病人会想，我不需要确定自己没有阑尾炎吗？

Or this, that, or the other thing.

或者这个，那个，或者其他的东西。

And really, the right thing for the doctor to do is to think.

事实上，医生正确的做法就是思考。

And in many cases, not to do any tests.

而且在很多情况下，不做任何测试。

At least not right now.

至少现在不是。

There's a place for tests and there's a place for interventions.

有测试的地方，也有干预的地方。

But not in every case.

但并非在所有情况下都是如此。

And yet, the incentive to the doctor is often, just do everything.

然而，对医生的激励往往是尽一切努力。

And the truth is, a lot of us like it that way.

事实上，我们很多人都喜欢这样。

It's hard to understand how doing everything could be bad for us.

很难理解为什么做任何事情都会对我们不利。

We think, better safe than sorry.

我们认为，安全总比后悔好。

Do everything possible.

尽一切可能。

In a study published earlier this year, half the public believes someone's getting unnecessary health care.

在今年早些时候发表的一项研究中，一半公众认为有人正在接受不必要的医疗保健。

But only 16% thought it was them.

但只有 16% 的人认为是他们。

We're so wired to think that more health care is better that when someone suggests we might be better off with less, it's upsetting.

我们本能地认为医疗保健越多越好，因此当有人建议我们少一点医疗保健可能会更好时，我们会感到不安。

Even daring to raise the question, is this device or test or pill really making us healthier, can send people into a panic.

即使敢于提出这样的问题：这种设备、测试或药丸真的能让我们更健康吗？也会让人们陷入恐慌。

Consider the PSA test, the blood test used to screen men for prostate cancer.

考虑一下 PSA 测试，这是一种用于筛查男性前列腺癌的血液测试。

The question of whether the benefits of this test outweigh the risks is one of the most controversial issues in medicine.

这项测试的好处是否大于风险是医学界最具争议的问题之一。

Some doctors worry that the test is leading to unnecessary treatment.

一些医生担心该测试会导致不必要的治疗。

Because it catches many prostate cancers that are so slow growing they would never be harmful if left alone.

因为它可以捕获许多生长缓慢的前列腺癌，如果置之不理，它们永远不会有害。

In 2002, two medical journal editors, both doctors, made this point in an op-ed for the San Francisco Chronicle .

2002 年，两位医学期刊编辑（均为医生）在《旧金山纪事报》的一篇专栏文章中提出了这一点。

Gavin Yamey and Michael Wilkes wrote that since early detection hadn't been proven through randomized control trials to reduce a man's risk of dying from prostate cancer, getting the test might not be right for every man.

加文·亚米（Gavin Yamey）和迈克尔·威尔克斯（Michael Wilkes）写道，由于随机对照试验尚未证明早期检测可以降低​​男性死于前列腺癌的风险，因此进行这项测试可能并不适合每个男性。

Their op-ed, published under the headline, "Prostate Cancer Screening: Is It Worth the Pain," did not go over so well.

他们发表的题为“前列腺癌筛查：值得这样做吗”的专栏文章反响不佳。

Lots of people wished that we would die.

很多人希望我们死掉。

That's Gavin Yamey.

那是加文·亚米。

Since many of the readers believed the PSA test had saved their lives, they didn't appreciate being told that the test wasn't effective.

由于许多读者相信 PSA 测试挽救了他们的生命，因此他们不喜欢被告知该测试无效。

Lots of people wished we would have a very slow death from a nasty cancer.

很多人希望我们能够因可怕的癌症而缓慢死亡。

People accused us of having the deaths of thousands of men on our hands for writing this piece.

人们指责我们因为写这篇文章而导致了数千人的死亡。

Of geriatricide.

杀戮老人。

People wrote both to us and to our bosses accusing us of being sort of like the Nazis.

人们写信给我们和我们的老板，指责我们有点像纳粹。

And specifically, accusing us of being like Mengele.

具体来说，指责我们像门格勒一样。

Others accusing us of truly being men-haters and wanting to wipe out the male population.

其他人则指责我们确实是仇视男性的人，想要消灭男性人口。

When the president says we can cut health care costs by eliminating things that don't work, things for which there's no evidence, it sidesteps the fact that in medicine the evidence isn't always so clear cut.

当总统说我们可以通过消除那些不起作用、没有证据的事情来削减医疗保健成本时，他回避了这样一个事实：在医学上，证据并不总是那么明确。

And that's true with the PSA test.

PSA 测试也是如此。

There's a lot more evidence about PSA now than there was when Yamey and Wilkes wrote their op-ed.

现在关于 PSA 的证据比 Yamey 和 Wilkes 撰写专栏文章时多得多。

In fact, two long-awaited studies came out this Spring.

事实上，两项期待已久的研究在今年春天发布了。

One showed that the PSA test did not reduce a man's risk of dying from prostate cancer.

其中一项研究表明，PSA 测试并不能降低男性死于前列腺癌的风险。

The other showed it reduced prostate cancer deaths by 20%.

另一项研究表明，它可以将前列腺癌死亡率降低 20%。

But it also showed that for every life saved because of PSA screening, 48 other men were diagnosed and treated.

但它也表明，每因 PSA 筛查而挽救一条生命，就有 48 名其他男性得到诊断和治疗。

In other words, for each prostate cancer death prevented, dozens of men endured surgery or radiation, risking serious side effects, like impotence and incontinence.

换句话说，每预防一次前列腺癌死亡，就有数十名男性接受手术或放射治疗，冒着阳痿和失禁等严重副作用的风险。

Doctors interpret this evidence differently.

医生对这一证据的解释不同。

Some I talked to said it's proof that the test saves lives.

我采访过的一些人说，这证明该测试可以拯救生命。

Others said it shows we might be hurting more men than we're helping.

其他人则表示，这表明我们伤害的人可能多于帮助的人。

Because the evidence is ambiguous and the balance of risks and benefits is really a judgment call, most national guidelines say that doctors should let men know the pros and cons of PSA testing, and let them decide whether to have it.

由于证据不明确，而且风险和收益的平衡实际上需要判断，因此大多数国家指南都表示，医生应该让男性了解 PSA 检测的利弊，并让他们决定是否进行该检测。

But most of the time this is not what happens.

但大多数时候情况并非如此。

Studies show that the majority of men get the test without any discussion at all.

研究表明，大多数男性在没有任何讨论的情况下就接受了测试。

It's automatic, a no-brainer.

这是自动的，无需动脑子。

And honestly, it's not hard to see why.

老实说，不难看出原因。

To question whether the test is necessary, a doctor is flying in the face of all sorts of cultural forces.

为了质疑这项测试是否有必要，医生正在面对各种文化力量。

Like the idea that if you can find cancer early, you always should.

就像这样的想法：如果你能及早发现癌症，你就永远应该这样做。

Not to mention all the billboards and free PSA screening events and celebrities in TV ads telling men to get tested.

更不用说所有的广告牌和免费的公益广告放映活动以及电视广告中的名人告诉男性要接受检测。

Want to do something really special for your man this Christmas?

今年圣诞节想为你的男人做一些特别的事情吗？

Call his doctor and schedule his prostate exam.

打电话给他的医生并安排他的前列腺检查。

Prostate exams save lives and prostates.

前列腺检查可以挽救生命和前列腺。

Here's another from the NFL.

这是 NFL 的另一则报道。

Man So get screened and don't let prostate cancer take you out of the game.

Man So 接受筛查，不要让前列腺癌让您退出游戏。

And of course, Larry King.

当然还有拉里·金。

Larry King Men over 40, take your PSA test.

Larry King 40 岁以上的男士，请参加 PSA 测试。

It's a simple, little blood test.

这是一个简单的小血液测试。

You get the result in a couple days.

几天后你就会得到结果。

A few doctors I talked to mentioned another reason that physicians might be wary of bucking the PSA trend.

我采访过的几位医生提到了医生可能对逆 PSA 趋势持谨慎态度的另一个原因。

They told me what happened to a doctor named Dan Merenstein.

他们告诉我一位名叫丹·梅伦斯坦的医生发生了什么事。

Merenstein was trained in evidence-based medicine, and about 10 years ago, when he was a family practice resident, a 53-year-old man came to him for a routine physical.

梅伦斯坦接受过循证医学培训，大约 10 年前，当他还是一名家庭医生时，一名 53 岁的男子来找他做常规体检。

Merenstein says he followed the guidelines.

梅伦斯坦说他遵循了这些指导方针。

Talked to the patient about the benefits and risks of getting the PSA test.

与患者讨论进行 PSA 检测的好处和风险。

And the man chose not to have it.

而这个男人选择不拥有它。

Then, a year and a half later, the man went to another doctor.

一年半后，该男子去看了另一位医生。

That doctor tested the man's blood without discussing it with him.

那位医生没有与他讨论就测试了他的血液。

His PSA level was extremely high and a biopsy found an aggressive, incurable cancer.

他的 PSA 水平极高，活检发现患有侵袭性、无法治愈的癌症。

Now there is was proof that having an earlier PSA test would have changed the man's fate.

现在有证据表明，尽早进行 PSA 测试可能会改变该男子的命运。

But Merenstein and his residency program were sued for malpractice.

但梅伦斯坦和他的住院医师项目因渎职而被起诉。

At the trial, the patient's attorney argued that Merenstein shouldn't have given the man a choice to have the PSA test, no matter what the national guideline said.

在审判中，该患者的律师辩称，无论国家指南如何规定，梅伦斯坦都不应该让该男子选择进行 PSA 检测。

The attorney put other family doctors on the stand.

律师让其他家庭医生出庭作证。

And they said, you know, we don't talk to patients.

他们说，你知道，我们不与病人交谈。

This is Dr. Merenstein.

这是梅伦斯坦博士。

Dr. Dan Merenstein That's what they do in ivory towers.

Dan Merenstein 博士 这就是他们在象牙塔里所做的事情。

You know, I order tests.

你知道，我安排了测试。

Patients come to me for me to order the test.

患者来找我要求进行检查。

I'm the one that went to medical school.

我是那个上医学院的人。

And these are the tests we order.

这些是我们订购的测试。

And if Dr. Merenstein had ordered this-- they said this straight under oath.

如果梅伦斯坦博士下令这样做——他们是在宣誓后直接说的。

And if Dr. Merenstein had ordered a PSA, this patient would live a long, productive life.

如果 Merenstein 医生要求进行 PSA，这位患者将会过上长寿而富有成效的生活。

But because Dr. Merenstein failed to, this patient is going to die surely.

但由于梅伦斯坦医生未能做到这一点，这名患者必死无疑。

Merenstein was exonerated, but his residency program was found liable for a million dollars.

梅伦斯坦被证明无罪，但他的住院医师计划被认定需承担 100 万美元的责任。

The jury, just like the doctors on the stand, rejected the idea of following the guidelines based on evidence.

陪审团和证人席上的医生一样，拒绝遵循基于证据的指导方针的想法。

To them, the best care meant doing everything you can.

对他们来说，最好的护理意味着尽你所能。

I should have just ordered it.

我应该刚刚订购的。

There should have been no discussion.

本来就不应该有讨论。

It shouldn't have been up to the patient.

这不应该由病人决定。

So that was the approach they took.

这就是他们采取的方法。

And they took this approach that this thing called evidence-based medicine is just a way to save money, just a way to ration care.

他们采取的方法是，这种称为循证医学的东西只是一种省钱的方法，只是一种配给护理的方法。

After the trial, like a lot of doctors who had been sued, Merenstein found it hard not to see patients as potential plaintiffs.

审判结束后，像许多被起诉的医生一样，梅伦斯坦发现很难不将患者视为潜在的原告。

I think you view people differently after that and you look at patients and you say, this mole, which a thousand times before I would say I'm pretty confident on how to evaluate moles and which ones I need to take off myself, and which ones I think are fine to stay, and which ones need to go.

我认为在那之后你对人的看法有所不同，你看着病人，你说，这颗痣，我之前一千次说过，我对如何评估痣非常有信心，哪些痣我需要自己摘掉，哪些我认为可以留下来，哪些需要去除。

You know, I think I started sending more moles to dermatologists to remove and sending more people with what I was pretty confident was irritable bowel or something like that to GI doctors to get scoped and things like that more than I should have.

你知道，我想我开始将更多的痣送到皮肤科医生那里去除，并将更多我非常有信心患有肠易激或类似疾病的人送到胃肠道医生那里进行内窥镜检查和类似的事情，这超出了我应该做的范围。

It sort of just didn't feel right.

感觉有点不对劲。

It didn't feel right, he said, because it didn't feel like he was doing what was best for the patients.

他说，这感觉不对，因为感觉他没有在做对病人最好的事情。

These days, when it comes to the PSA test, Merenstein starts by following the evidence.

如今，当谈到 PSA 测试时，梅伦斯坦首先遵循证据。

He still tells his patients the pros and cons, but then he gives them a little nudge and adds something he never used to.

他仍然告诉他的病人优点和缺点，但随后他给了他们一点推动，并添加了一些他从未习惯过的东西。

"Most people," he tells his patients, "get the test."

“大多数人，”他告诉他的病人，“都会接受测试。”

Lisa Pollak.

丽莎·波拉克。

If you're a man and you heard this story and you want to know more about the pros and cons of getting the PSA test, there's a good summary at the Mayo Clinic web site.

如果您是一名男性，并且您听过这个故事，并且想了解更多有关 PSA 测试的利弊，梅奥诊所网站上有一个很好的总结。

Those people really know what they're doing.

这些人真的知道他们在做什么。

Act 3, Who Would Win in a Fight Between a Polar Bear and an Insurance Company?

第三幕，北极熊和保险公司的战斗谁会获胜？

So if doctors aren't going to keep costs down and patients aren't going to keep costs down, how about insurance companies?

因此，如果医生不打算降低成本，患者也不打算降低成本，那么保险公司呢？

Out of everybody in the health care system, you would think that this would be the one group most interested in keeping costs down because they are the ones who actually make the payments to doctors and hospitals, and every dollar they save is basically a dollar they get to keep.

在医疗保健系统中的每个人中，您可能会认为这是对降低成本最感兴趣的群体，因为他们是实际向医生和医院付款的人，他们节省的每一美元基本上都是他们可以保留的美元。

A dollar that goes into their profits.

一美元就变成了他们的利润。

Or, if you want to get very technical about this, it's a dollar less that they could charge you and me in premiums.

或者，如果您想了解更多技术信息，他们可以向您和我收取一美元的保费。

Well, we looked into this and it turns out that there are a lot of reasons that insurance companies have a hard time holding down health care costs.

好吧，我们对此进行了调查，结果发现保险公司难以控制医疗费用的原因有很多。

But they all boil down to one thing.

但它们都归结为一件事。

Insurance companies are not always as powerful as you would think.

保险公司并不总是像你想象的那么强大。

The way that insurance works is that each insurance company makes its own contract, its own deal, with each local hospital group or health provider system.

保险的运作方式是，每个保险公司与每个当地医院集团或医疗服务提供者系统签订自己的合同、自己的交易。

And that deal spells out how much the insurance company is going to reimburse for every different kind of procedure and test.

该协议规定了保险公司将为每种不同类型的手术和测试报销多少费用。

And even in cities where a company is the biggest insurer in the market, even then, it does not necessarily have the power to boss hospitals around and push down costs and bargain down prices.

即使在一家公司是市场上最大的保险公司的城市，它也不一定有能力左右医院、压低成本和讨价还价。

Take, as an example, the pricing showdown between Blue Cross of California-- huge insurance company-- and this big network of hospitals and clinics called Sutter Health.

以加州蓝十字保险公司（大型保险公司）与名为萨特健康公司（Sutter Health）的大型医院和诊所网络之间的定价摊牌为例。

Sarah Koenig, another one of our producers, tells what happened.

我们的另一位制片人莎拉·科尼格 (Sarah Koenig) 讲述了发生的事情。

Back in 2000, Sutter was demanding huge rate increases from Blue Cross, averaging something like 30% or 35%.

早在 2000 年，萨特就要求 Blue Cross 大幅提高费率，平均提高 30% 或 35%。

That was a shocker.

那真是令人震惊。

Blue Cross was the biggest insurer in the state, which meant it was used to getting cheaper rates from hospitals than the smaller guys.

Blue Cross 是该州最大的保险公司，这意味着它习惯于从医院获得比小保险公司更便宜的保险费。

But Sutter was enormous too.

但萨特也很伟大。

It had more than a hundred health care facilities all over Northern California, including more than two dozen hospitals.

它在北加州各地拥有一百多个医疗机构，其中包括两打多家医院。

Sutter had what's called a geographic lock on the Bay Area.

萨特对湾区有所谓的地理锁定。

So of the several hundred thousand Blue Cross customers there--

因此，在数十万 Blue Cross 客户中——

Almost everybody received, or knew, or went to Sutter for their medical care.

几乎每个人都接受过、知道或前往萨特寻求医疗护理。

That's Michael Chee.

那是迈克尔·奇。

At the time, he was spokesman for Blue Cross of California.

当时，他是加州蓝十字会的发言人。

And Blue Cross's position was that Sutter's demands were out of line.

蓝十字的立场是萨特的要求不合常理。

They weren't justified by the medical costs and inflation data Blue Cross had researched.

蓝十字研究的医疗费用和通胀数据并不能证明他们的观点是合理的。

So Blue Cross offered a lower figure.

因此 Blue Cross 给出了较低的数字。

Sutter rejected it, saying Blue Cross had been underpaying them for years.

萨特拒绝了这一提议，称蓝十字多年来一直克扣他们的工资。

It got contentious.

这引起了争议。

Blue Cross still refused to pay.

蓝十字仍然拒绝付款。

So Sutter said, if you don't, you can tell your members to go elsewhere, find other doctors, go to other hospitals.

所以萨特说，如果你不这样做，你可以告诉你的会员去其他地方，找其他医生，去其他医院。

The brinksmanship that kind of occurred was, well, if we close our doors, all these people-- hundreds of thousands of them-- are going to be forced to travel an extra 30 minutes, an extra 10 miles, and that was not acceptable to the membership.

所发生的边缘政策是，如果我们关门，所有这些人——数十万人——将被迫多走 30 分钟，多走 10 英里，这是会员无法接受的。

So the membership began to express its opinion in the negotiations.

于是成员国开始在谈判中表达自己的意见。

Blue Cross got dozens, sometimes hundreds of phone calls a day, all thanks to a new pressure tactic used by Sutter.

蓝十字每天接到几十个、有时数百个电话，这一切都归功于萨特使用的新压力策略。

Sutter urged its patients to call Blue Cross's customer service line and complain.

萨特敦促患者拨打 Blue Cross 的客户服务热线进行投诉。

Michael Chee and his bosses started seeing news stories about the dispute, stories that favored Sutter.

迈克尔·奇和他的老板开始看到有关这场纠纷的新闻报道，这些报道对萨特有利。

In response, Blue Cross launched a major marketing push of its own to try to convince customers everything would be OK if they would just find different doctors.

作为回应，Blue Cross 发起了自己的重大营销活动，试图说服顾客，只要找到不同的医生，一切都会好起来的。

Michael Chee did interviews with reporters.

迈克尔·奇接受了记者采访。

He sent tens of thousands of letters to Blue Cross members saying things like, "We are saddened and disappointed that Sutter has put its energy into instigating members like you to contact us."

他向蓝十字会员发送了数万封信，信中写道：“我们对萨特投入大量精力煽动像您这样的会员与我们联系感到悲伤和失望。”

Blue Cross bought ads in local newspapers, publishing lists of non-Sutter care centers, explaining who all the doctors were and what they specialized in.

蓝十字在当地报纸上购买广告，公布非萨特护理中心的名单，解释所有医生是谁以及他们的专长。

And pointing out that those facilities weren't much farther than Sutter's.

并指出这些设施并不比萨特的远。

So you guys sort of mounted this campaign to try to convince your membership, we can do this, we can live without Sutter?

所以你们发起这个活动是为了说服你们的会员，我们可以做到这一点，我们可以在没有萨特的情况下生活？

They came back to you and said--

他们回到你身边并说——

And said, I can't live without Sutter.

并说，没有萨特我就活不下去。

You know, we want what we want.

你知道，我们想要我们想要的。

I've been with my doctor here at this location for many years, and I don't want to have to look for somebody new.

我在这个地方和我的医生在一起已经很多年了，我不想再去找新的人了。

I don't want to have to make any extra effort.

我不想做任何额外的努力。

I mean did you explain, as a company also, like this is potentially going to cost you guys more because your premiums are going to go up?

我的意思是，你是否解释过，作为一家公司，这可能会让你们付出更多的代价，因为你们的保费会上涨？

Absolutely.

绝对地。

Absolutely.

绝对地。

One of the things we tried to tell members and employers was, this is our job.

我们试图告诉会员和雇主的一件事是，这是我们的工作。

Our job is to control health care costs, so that your premiums don't constantly go up.

我们的工作是控制医疗保健成本，以便您的保费不会不断上涨。

So that you're not constantly paying more.

这样您就不会经常支付更多费用。

And one of the ways we do that is by these negotiations.

我们做到这一点的方法之一就是通过这些谈判。

None of this worked.

这些都不起作用。

Customers didn't budge.

顾客没有让步。

Neither did anybody else.

其他人也没有。

State lawmakers got dragged into the fight to mediate.

州立法者被卷入调解斗争中。

Finally, because they couldn't live without each other, Sutter and Blue Cross worked out a compromise.

最后，由于他们离不开彼此，萨特和蓝十字达成了妥协。

Sutter didn't get all the money it asked for.

萨特没有得到所要求的全部资金。

It wasn't a 30% increase.

这不是30%的增长。

The actual number wasn't made public.

实际数字并未公开。

But they got enough that it resulted in hiked up premiums.

但他们得到的足够多，导致保费上涨。

That's one reason medical costs in San Francisco, where Sutter is totally dominant, are still more expensive than cities nearby, like Oakland and San Jose, where Sutter isn't quite as strong.

这就是萨特完全占据主导地位的旧金山的医疗费用仍然比萨特不那么强大的奥克兰和圣何塞等附近城市昂贵的原因之一。

So that now a family of four in San Francisco pays $45 more per month to Blue Cross than it would pay in San Jose for exactly the same coverage.

因此，现在旧金山的一个四口之家每月向 Blue Cross 支付的费用比在圣何塞支付的完全相同的保险费用多 45 美元。

Michael Chee is still sort of baffled that it worked out this way.

迈克尔·奇（Michael Chee）仍然对事情发展成这样感到困惑。

That people don't respond to bottom line reasoning when it comes to where and how they get care.

当谈到在哪里以及如何获得护理时，人们不会对底线推理做出反应。

He says costs will keep rising until we consumers start sacrificing a little, making different health care choices.

他说，成本将继续上升，直到我们消费者开始做出一些牺牲，做出不同的医疗保健选择。

Based on knowledge, based on facts, not based on our feelings, not based on what we want.

基于知识，基于事实，不基于我们的感受，不基于我们想要的。

Without those kinds of sacrifices, we're always going to be stuck in this argument of, I want what I want, and what I want can be very expensive and not the most cost effective thing.

如果没有这些牺牲，我们总是会陷入这样的争论：我想要我想要的东西，而我想要的东西可能非常昂贵，而且不是最具成本效益的东西。

As it happened, I interviewed Michael Chee from the hospital.

碰巧，我采访了医院的迈克尔·奇。

He'd had an accident involving one of those jet ski things and suffered a head trauma.

他在一次涉及摩托艇的事故中发生了事故，头部受到了创伤。

Natasha Richardson had a very similar injury to mine.

娜塔莎·理查森的伤势与我的非常相似。

Mine was probably actually more severe.

我的情况可能实际上更严重。

Quite honestly, I shouldn't be talking to you right now.

老实说，我现在不应该和你说话。

I should be dead.

我应该死了。

Michael Chee lives in Burbank, California, near Los Angeles.

迈克尔·奇 (Michael Chee) 住在加利福尼亚州伯班克，靠近洛杉矶。

But he had the accident on the Colorado River in Nevada and was airlifted to Las Vegas for treatment.

但他在内华达州的科罗拉多河上发生事故，被空运到拉斯维加斯接受治疗。

For his two week rehab, he wanted to go home to LA, and had been arguing about that with his insurance company.

在为期两周的康复治疗中，他想回到洛杉矶的家中，并一直在与保险公司争论这个问题。

Which happens to be Blue Cross.

这恰好是蓝十字。

There are providers that I have a preference for closer to home, closer to where I live, that I wanted to go to for my care because I know them, I trust them.

我更喜欢那些离家更近、离我住的地方更近的医疗服务提供者，我想去他们那里接受护理，因为我认识他们，我信任他们。

But my insurance would not accommodate my medical transport from here to there because those rehab services were available right here without having to move me.

但我的保险不支持我从这里到那里的医疗运输，因为这些康复服务就在这里，无需转移我。

But Wait, weren't you just making the exact opposite argument before, that patients should be willing to sacrifice for lower costs and quality care?

但是等等，您之前不是提出了完全相反的论点，即患者应该愿意为降低成本和高质量的护理而做出牺牲吗？

So here I am, away from home for two weeks getting my rehabilitation done.

所以我在这里，离开家两周，完成我的康复工作。

Yes.

是的。

I mean when you're injured and you have the kind of injury that I have, you want to be close friends and family because it's just more comforting.

我的意思是，当你受伤并且受到像我一样的伤害时，你想成为亲密的朋友和家人，因为这更令人安慰。

That doesn't mean that's a smart medical decision.

这并不意味着这是一个明智的医疗决定。

That just means that's what I want emotionally.

这只是意味着这就是我在情感上想要的。

I know, I know.

我知道，我知道。

But hearing this, you completely-- your sympathies are completely with the patient.

但听到这个，你完全——你完全同情病人。

You just think, of course you want to go home and be around your friends and family.

你只是想，你当然想回家和你的朋友和家人在一起。

And you've had this traumatic thing happen and it's totally upsetting, and probably very frightening.

你已经经历了这种创伤性的事情，它非常令人沮丧，而且可能非常可怕。

And of course, you want to go home.

当然，你想回家。

You know what I mean?

你知道我的意思？

I think it's a real dilemma.

我认为这是一个真正的困境。

It is a dilemma.

这是一个两难的境地。

And I felt that.

我也感觉到了。

And I went through that entire emotional process.

我经历了整个情感过程。

Do you think Blue Cross has made the right decision in your case?

您认为 Blue Cross 在您的案件中做出了正确的决定吗？

I think so.

我想是的。

From a cost standpoint, yes.

从成本角度来看，是的。

We probably can all agree that Blue Cross made the right choice in trying to save money on Michael Chee.

我们可能都同意蓝十字在迈克尔·奇身上省钱的做法是正确的。

But we agree only in the cold light of day.

但我们只是在寒冷的日子里才达成一致。

And that's what I mean by the dilemma.

这就是我所说的困境的意思。

As patients, we don't usually consider things in the cold light of day.

作为患者，我们通常不会以冷酷的眼光来考虑事情。

It's no wonder we don't respond to pocketbook arguments about how to save money on our own care.

难怪我们不会回应关于如何在自己的护理上省钱的争论。

And that's partly what makes us, the patients, a secret weapon in these negotiations.

这也是我们患者成为这些谈判中的秘密武器的部分原因。

At least for the doctors and hospitals.

至少对于医生和医院来说是这样。

Because we side with them every time.

因为我们每次都站在他们一边。

Because we like our doctors.

因为我们喜欢我们的医生。

We trust them.

我们信任他们。

We basically hate our insurers, even though the insurers are paid to represent us in negotiating the price of our own care.

我们基本上讨厌我们的保险公司，尽管保险公司是受雇代表我们谈判我们自己的护理价格。

And we unwittingly side with the doctors in another battle we don't even know is going on between doctors and insurers.

在另一场我们甚至不知道医生和保险公司之间正在发生的战斗中，我们不知不觉地站在了医生一边。

The one about eliminating unnecessary medical services and procedures.

关于消除不必要的医疗服务和程序的问题。

As you heard earlier in the show, the Dartmouth Health Atlas estimates about a third of every health care dollar we spend is wasted on tests and treatment we don't need.

正如您在节目前面听到的那样，达特茅斯健康地图集估计，我们花费的每一笔医疗保健费用中约有三分之一被浪费在我们不需要的测试和治疗上。

So if health insurance companies know they're shelling out all that money on stuff that isn't necessary, why can't they do something about it?

因此，如果健康保险公司知道他们把所有的钱都花在了不必要的东西上，为什么他们不能采取一些措施呢？

I put this to Jack Rowe, the former CEO of Aetna, one of the biggest health insurers in the country.

我把这个问题交给了美国最大的健康保险公司之一安泰保险 (Aetna) 的前首席执行官杰克·罗 (Jack Rowe)。

When he was in charge, he watched Aetna's expenses and its profits very, very carefully.

当他负责时，他非常非常仔细地观察安泰的开支和利润。

Why doesn't an insurance company go, I want that 30% to 40%?

为什么保险公司不去，我要30%到40%？

You know what I mean?

你知道我的意思？

It seems like this is a lot of money sitting there that you guys could profit from.

看来你们可以从中获利很多钱。

Is there any way to get at that percentage?

有什么办法可以达到这个百分比吗？

Insurance companies are trying very hard to develop approaches, which will not only improve quality but reduce overuse.

保险公司正在努力开发方法，不仅可以提高质量，还可以减少过度使用。

So they're trying, and it's true, Aetna has all kinds of programs.

所以他们正在尝试，确实，安泰保险有各种各样的计划。

Good, money-saving programs to promote cheaper drugs, to make sure diabetics and cardiac patients do all the preventative things to keep them out of the emergency room.

良好的省钱计划可以推广更便宜的药物，确保糖尿病患者和心脏病患者采取所有预防措施，让他们远离急诊室。

Plus Aetna, like all insurance companies, has guidelines for new technologies they will and won't cover.

此外，与所有保险公司一样，Aetna 对于承保和不承保的新技术制定了指导方针。

And all the scientific studies that back up that policy.

以及支持该政策的所有科学研究。

But the fact is, if companies like Aetna say no too often, they risk losing customers.

但事实是，如果像 Aetna 这样的公司经常说“不”，他们就有失去客户的风险。

So there's great sensitivity over that because physicians say that the insurance companies are practicing medicine.

因此，对此非常敏感，因为医生说保险公司正在行医。

And who are they to tell me whether or not this patient needs this operation?

他们又是谁来告诉我这个病人是否需要做这个手术呢？

As you recall, that's one of the things that led to the great pushback.

正如您所记得的，这是导致巨大阻力的原因之一。

The great pushback, also known in the insurance industry as the backlash.

巨大的阻力，在保险行业也称为反弹。

He's talking about HMOs.

他正在谈论 HMO。

Back in the 1980s, employers went to insurance companies and pleaded with them to keep down costs.

早在 20 世纪 80 年代，雇主就向保险公司请求降低成本。

And that's when the HMO came into vogue.

就在那时，HMO 开始流行。

By the mid '90s, most employers used HMOs to cover their employees.

到了 90 年代中期，大多数雇主都使用 HMO 来为员工提供保险。

And it pretty much worked.

这非常有效。

Health care costs stopped rising for the first time in a long time.

医疗保健费用长期以来首次停止上涨。

One year they even fell.

有一年他们甚至跌倒了。

But a big part of keeping costs down was tightly controlling which doctors patients could see, and denying coverage for procedures that doctors argued were necessary.

但降低成本的一个重要部分是严格控制患者可以看哪些医生，并拒绝承保医生认为必要的手术。

Insurance companies were inundated with complaints.

保险公司收到大量投诉。

From physicians, and hospitals, also from patients who were getting complaints from physicians about their insurers.

来自医生和医院，也来自收到医生对其保险公司投诉的患者。

Politicians.

政治家。

Also we're getting complaints from doctors, and hospitals, and patients.

我们还收到来自医生、医院和患者的投诉。

There were dramatic stories in the press about people who'd been denied lifesaving operations.

媒体上有关于那些被拒绝接受救生手术的人的戏剧性故事。

There were class action lawsuits, legislation to limit their powers.

有集体诉讼、限制他们权力的立法。

Then there was that Helen Hunt movie.

然后是海伦亨特的电影。

Remember, As Good As It Gets , where she plays the mother of this poor asthmatic boy who needed some tests he didn't get.

请记住，在《尽善尽美》中，她扮演了一个患有哮喘的可怜男孩的母亲，他需要一些检查，但他没有得到。

They said my plan didn't cover it and that it wasn't necessary anyways.

他们说我的计划没有涵盖它，而且无论如何也没有必要。

Why, should they have?

为什么，他们应该有？

Well.

出色地。

Woman [BLEEP] HMO, bastard pieces of [BLEEP] OK, I'm sorry.

女人 [BLEEP] HMO，混蛋的 [BLEEP] 好吧，对不起。

It's OK.

没关系。

Actually, I think that's their technical name.

事实上，我认为这是他们的技术名称。

Jack Rowe was one of two insurance executives I talked to who mentioned that movie.

杰克·罗是我采访过的两位提到这部电影的保险公司高管之一。

It left a big impression on the insurance industry.

这给保险业留下了深刻的印象。

Because when people saw it in the theaters, they reportedly broke into applause.

因为据报道，当人们在电影院看到这部电影时，他们爆发出热烈的掌声。

As a result of those years of opposition, insurance companies will only fight doctors and patients to a point.

由于这些年的反对，保险公司只会在一定程度上与医生和患者对抗。

They don't want to go back to the days of the HMOs, of being the hard-asses telling everyone no. Even though they did successfully hold down costs back then.

他们不想回到 HMO 的时代，不想成为对所有人说“不”的顽固分子。尽管他们当时确实成功地控制了成本。

And they did it without making people sicker.

他们做到了这一点并没有让人们病情加重。

There were anecdotal horror stories for sure.

肯定有轶事恐怖故事。

But overall, as a country, our medical care didn't suffer.

但总体而言，作为一个国家，我们的医疗保健并没有受到影响。

We were just as healthy.

我们同样健康。

But that's not how we remember it.

但我们记忆中的情况并非如此。

And now you always hear, no one should stand between you and your doctor.

现在你总是听到，没有人应该挡在你和你的医生之间。

This is Uwe Reinhardt, a health care economist at Princeton university.

我是乌韦·莱因哈特 (Uwe Reinhardt)，普林斯顿大学的医疗保健经济学家。

You know what that means?

你知道这意味着什么吗？

That means no one should ever control utilization, even if it's unnecessary.

这意味着任何人都不应该控制利用率，即使这是不必要的。

If your doctor thinks it's necessary, no one should ever say no. And almost anyone who's looked at the data says, oh yes, somebody should.

如果您的医生认为有必要，任何人都不应拒绝。几乎所有看过这些数据的人都会说，哦，是的，有人应该这样做。

According to Reinhardt, the fact that insurers can't completely crack down on unnecessary procedures is just one of a whole host of reasons why the insurance industry really can't control costs in the American health care system right now.

莱因哈特认为，保险公司无法完全打击不必要的程序这一事实只是保险业目前无法控制美国医疗保健系统成本的众多原因之一。

Do insurance companies actually have an incentive to keep costs down?

保险公司真的有动力降低成本吗？

I've often asked myself that question.

我经常问自己这个问题。

Obviously, when you compete against another insurers, it's good to have lower premiums.

显然，当您与其他保险公司竞争时，保费较低是件好事。

But the insurance industry as a whole, basically, their profits tend to be 3% to 5% of whatever money flows through their books.

但保险业作为一个整体，基本上，他们的利润往往是账面上资金流动的 3% 到 5%。

So the more money flows through the books, the more profit they make.

因此，流经账簿的资金越多，他们赚取的利润就越多。

Suppose a guard waved a magic wand and said, OK, now health care costs in America are half of what they are now.

假设一名警卫挥舞着魔杖说，好吧，现在美国的医疗费用是现在的一半。

Then the insurance industry's book of business would be half of what it is now, and therefore, their profits would be half of what it is now.

那么保险业的营业额将是现在的一半，因此，他们的利润将是现在的一半。

It's not totally clear to me the insurance industry would love that.

我并不完全清楚保险业会喜欢这样。

As it stands, insurance companies are doing pretty well.

就目前而言，保险公司的表现相当不错。

They don't make anything close to the 30% profits of, say, Microsoft, or Merck Pharmaceuticals.

他们的利润远不及微软或默克制药公司 30% 的利润。

Or even the 10% profits of Exxon Mobil, but Fortune magazine lists the health insurance industry as the 35th most profitable industry in the country based on 2008 revenue.

甚至是埃克森美孚10%的利润，但《财富》杂志根据2008年的收入将健康保险行业列为美国第35个最赚钱的行业。

What's the 34th most profitable industry you ask, just above the insurers?

您问第 34 位最赚钱的行业是什么，仅次于保险公司？

That would be medical facilities.

那将是医疗设施。

Sarah Koenig.

莎拉·科尼格.

Act Four: Now What?

第四幕：现在怎么办？

Ira Glass Act Now What?

Ira Glass 现在行动什么？

OK, so far this hour we've illustrated just some of the main things that are driving up health care costs.

好的，到目前为止，我们已经说明了一些推高医疗保健成本的主要因素。

And truthfully, putting this show together over the last few months, it's been hard not to get sort of depressed.

说实话，在过去的几个月里把这个节目放在一起，很难不感到有点沮丧。

Not only do the problems seem like they're built into the very foundation of our health care system, but the health reform debate that's going on right now in Washington doesn't seem to be about cutting costs at all.

这些问题不仅看起来像是我们医疗保健系统的根基，而且华盛顿目前正在进行的医疗改革辩论似乎根本不是为了削减成本。

Democrats and republicans are arguing over who's going to get insurance, and public option, and how it's paid for.

民主党人和共和党人正在争论谁将获得保险、公共选择权以及如何支付费用。

Not to mention death panels and abortion.

更不用说死亡小组和堕胎了。

There's really not much discussion about how to fix the health care system as a whole to slow the runaway costs that threaten our entire economy.

关于如何从整体上修复医疗保健系统以减缓威胁我们整个经济的失控成本，确实没有太多讨论。

The stuff we've been talking about all this hour.

我们这一个小时一直在谈论的事情。

And so to end our hour, we invited somebody who's been following this very closely in Washington, DC, Susan Dentzer.

为了结束这一小时，我们邀请了一位在华盛顿特区密切关注此事的人苏珊·丹泽 (Susan Dentzer)。

She's been reporting on the politics and economics of health care since the 1980s for Newsweek , and then later for US News & World Report.

自 20 世纪 80 年代以来，她一直为《新闻周刊》和《美国新闻与世界报道》报道医疗保健的政治和经济问题。

She's seen HMOs come and go, she's seen Hillary Clinton's health care plan come and go, and now she's monitoring the latest attempt to remake the health care system as the editor of a policy journal called Health Affairs .

她见证了 HMO 的来来去去，见证了希拉里·克林顿 (Hillary Clinton) 医疗保健计划的来来往往，而现在，她作为一份名为《健康事务》的政策杂志的编辑，正在关注重塑医疗保健系统的最新尝试。

And I'll be frank, when I sat down with her to talk about what is actually in the bills, she totally blew my mind.

坦白说，当我和她坐下来谈论账单中的实际内容时，她完全让我大吃一惊。

We'll get that part in a minute, but first, the actual detail of the bills when it comes to cutting costs.

我们很快就会看到这一部分，但首先是削减成本方面的账单的实际细节。

There is some stuff in these bills that addresses rising costs.

这些法案中有一些内容可以解决成本上升的问题。

If you are a glass half full kind of person, you look at it this way.

如果你是一个半满杯子的人，你就会这样看。

There are some measures in the bills that would give the secretary of health and human services, among others, enormous authority to experiment with new ways to deliver health care.

法案中的一些措施将赋予卫生与公众服务部部长等人巨大的权力来试验提供医疗保健的新方法。

This doesn't mean that little, experimental projects Dentzer says.

丹泽说，这并不意味着实验性项目很小。

The head of HHS will have czar like powers to change very basic things in how the system works by changing how Medicare pays doctors and hospitals.

卫生与公众服务部负责人将拥有沙皇般的权力，可以通过改变医疗保险向医生和医院支付费用的方式来改变系统运作方式中非常基本的事情。

And so for example, Medicare could stop paying fee for service.

例如，医疗保险可以停止支付服务费。

That system where doctors get money for every procedure that they do.

在这个系统中，医生为他们所做的每一个手术都获得报酬。

They could bundle doctors and patients into groups to cut inefficiency and waste.

他们可以将医生和患者分组，以减少效率低下和浪费。

The bills also set up a Medicare commission, which could do the kind of restructuring and cutting that would be too hot politically for Congress to do itself.

这些法案还设立了一个医疗保险委员会，该委员会可以进行重组和削减，这对于国会来说在政治上太热门而无法自行完成。

Now the weaknesses of these bills, Dentzer says, is that they don't force the head of HHS or anybody in the government to make any changes at all.

丹泽说，这些法案的弱点在于，它们根本没有迫使卫生与公众服务部负责人或政府中的任何人做出任何改变。

There are no deadlines.

没有最后期限。

And the amount that's going to get saved if everything goes perfectly, according to the Congressional Budget Office, is much smaller than health care costs are going to rise.

根据国会预算办公室的数据，如果一切顺利，节省的金额将远小于医疗保健费用的上涨。

But the idea is that Medicare is such a huge part of the health care system, it pays for a fourth of all the health care in the country.

但我们的想法是，医疗保险是医疗保健系统的重要组成部分，它支付了该国四分之一的医疗保健费用。

It's the biggest insurer in America.

它是美国最大的保险公司。

Changes made in Medicare would be adopted by others.

医疗保险中所做的改变将被其他人采纳。

So the notion is to really create a platform for gradual change.

所以我们的想法是真正创建一个逐步变革的平台。

And is part of the impulse behind this basically to say, we are not going to agree in the Senate and the House on the exact ways to cut costs and exactly which things to do?

这背后的部分冲动是否基本上是说，我们不会在参议院和众议院就削减成本的确切方法以及具体要做哪些事情达成一致？

And so let's just agree, somebody's going to do that.

所以让我们同意，有人会这么做。

It's going to be the head of the Department of Health and Human Services and some of these other things that you're saying.

它将是卫生与公众服务部的负责人以及你所说的其他一些事情。

But let's not discuss that here.

但我们不在这里讨论这个。

Yes, that's part of it.

是的，这是其中的一部分。

And the other realistic piece of this is if you tried to build all of this into the bill right now.

另一个现实的部分是，如果您现在尝试将所有这些内容纳入法案中。

If you said, we're going to make sweeping changes in the system.

如果你说，我们将对系统进行彻底的改变。

We're going to completely pay you in a totally different way.

我们将以完全不同的方式向您付款。

We're going to take you doctors who've been out in the hinterlands collecting your fee for service monies and basically restructure the system in such a way that you might have to live your life really differently.

我们将带你们去内陆地区收取服务费用的医生，并基本上以这样一种方式重组系统，使你们可能不得不过上完全不同的生活。

Just try putting that into a bill that gets everybody to accept it.

尝试将其写入一项让每个人都接受的法案中。

You can't.

你不能。

Susan Dentzer told me that there are people in the administration who are deeply involved in the details of how to cut health care costs, and she talks to them.

苏珊·丹泽告诉我，政府中有些人深入参与了如何削减医疗保健费用的细节，她与他们进行了交谈。

But she says they don't talk about this stuff much publicly for similar reasons.

但她说，出于类似的原因，他们很少公开谈论这些事情。

It's a political loser.

这是一个政治失败者。

It's a tough sell to say to people, not only will you get less health care, you'll be better off.

这很难向人们推销，因为你不仅会得到更少的医疗保健，而且会过得更好。

OK, now I'm going to tell you the thing that Susan Dentzer says that totally shocked me.

好吧，现在我要告诉你苏珊·丹泽所说的让我完全震惊的事情。

She told me that for the first time since she's been covering health care decades ago, all the major players in health care-- the hospitals, the insurance companies, the doctors-- she says they are all for the first time agreeing that something has to change.

她告诉我，自从她几十年前报道医疗保健以来，这是第一次，医疗保健领域的所有主要参与者——医院、保险公司、医生——她说他们第一次同意必须做出一些改变。

And she says this is the biggest political achievement made in health reform so far.

她说，这是迄今为止医疗改革取得的最大政治成就。

Almost all the stakeholders in health care have been at the table and are talking about all of this.

几乎所有医疗保健领域的利益相关者都出席了会议并讨论了所有这些问题。

They know that the system cannot persist the way it is.

他们知道系统无法维持现状。

That we've got to do things differently.

我们必须以不同的方式做事。

We have got to get more value out of the dollars spent on health care.

我们必须从医疗保健支出中获得更多价值。

How recent is that agreement?

该协议是多久之前达成的？

Is that because of Obama and his people like saying, OK, here's what we're going to do?

这是因为奥巴马和他的人民喜欢说，好吧，这就是我们要做的事情？

Not really.

并不真地。

We would probably be at this juncture no matter who had been elected president.

无论谁当选总统，我们都可能处于这个时刻。

Because of what was happening to the cost over the course of this decade.

因为这十年来成本发生了变化。

Right, there's this growing consensus, like it's going up so fast.

是的，这种共识正在不断增长，就像它增长得如此之快一样。

Well, health insurance premiums went up 130% from the year 2000 to now.

嗯，从 2000 年到现在，健康保险费上涨了 130%。

Two years ago I was talking to an insurance executive from one of the leading insurance companies and I said, OK, so what's the situation like, and draw me the analogy with the threat alert system.

两年前，我与一家领先保险公司的一位保险高管交谈，我说，好吧，那么情况是什么样的，并用威胁警报系统来类比。

You know, red alert, orange, green, whatever.

你知道，红色警报、橙色警报、绿色警报等等。

He said, we're on red alert.

他说，我们处于红色警戒状态。

We're on red alert.

我们处于红色警戒状态。

The system is falling apart.

系统正在崩溃。

The insurance companies?

保险公司？

Susan Dentzer Yes.

苏珊·丹泽 是的。

I'm just surprised to hear the insurance companies are on red alert because they are still making nice profits.

我只是惊讶地听到保险公司处于红色警戒状态，因为他们仍然赚取可观的利润。

But they can see the handwriting on the wall.

但他们可以看到墙上的字迹。

They see the system crumbling.

他们看到这个系统正在崩溃。

They understand the pressures that will ensue if things get really out of hand.

他们了解如果事情真的失控将会随之而来的压力。

Just imagine if we had had 100 million people uninsured, what kind of pressures there would have been for, say, a single payer system.

试想一下，如果有 1 亿人没有保险，单一支付系统会面临什么样的压力。

They know that.

他们知道这一点。

They think the only solution now for preserving any part of the system as a private system is to stop the bleeding now.

他们认为，现在将系统的任何部分保留为私有系统的唯一解决方案就是立即止血。

And so in addition to the health care reform happening in Washington, Susan Dentzer says there's a second reform that's happening right now all over the country.

因此，苏珊·丹泽表示，除了华盛顿正在进行的医疗改革之外，全国各地目前正在进行第二项改革。

Hospitals and health care providers and state legislatures coming up with their own ways to restructure and contain costs.

医院和医疗保健提供者以及州立法机构提出了自己的重组和控制成本的方法。

That's what gives her hope.

这就是给她希望的原因。

That things are so hopeless for every player across the board that a consensus is actually taking hold that things can't continue as they have.

对于所有玩家来说，事情都是如此无望，以至于事实上已经形成了共识，事情不能再像现在这样继续下去。

And she sees people and organizations taking action.

她看到人们和组织正在采取行动。

Alix Spiegel is going to be doing more stories on this subject on NPR News .

阿利克斯·斯皮格尔 (Alix Spiegel) 将在 NPR 新闻中就此主题发表更多报道。

You can find those in the coming days at npr.org/health.

您可以在未来几天内访问 npr.org/health 找到这些内容。

This American Life is distributed by Public Radio International.

《美国生活》由国际公共广播电台发行。

WBEZ management oversight for our program by our boss, Mr. Torey Malatia, who says, you know, you think people get upset when you mess with their health care.

我们的老板托里·马拉蒂亚 (Torey Malatia) 先生对我们的项目进行 WBEZ 管理监督，他说，你知道，当你扰乱他们的医疗保健时，你认为人们会感到不安。

Try changing the broadcast time of Car Talk.

尝试更改 Car Talk 的广播时间。

Lots of people wish that we would die.

很多人希望我们死掉。

And lots of people wished that we would have a very slow death from a nasty cancer.

许多人希望我们能够慢慢地死于可怕的癌症。

I'm Ira Glass, back next week with the second hour we're doing on health care.

我是艾拉·格拉斯（Ira Glass），下周回来参加我们讨论医疗保健的第二个小时。

The Planet Money team takes on the insurance business right here on This American Life.

Planet Money 团队在 This American Life 上承接保险业务。

This American Life is produced in collaboration with WBEZ Chicago and delivered to stations by PRX The Public Radio Exchange.

《This American Life》与 WBEZ Chicago 合作制作，并由 PRX 公共广播电台传送到各电台。