<p><img src="https://imageproxy.pbkrs.com/https://cdn.pixabay.com/photo/2015/07/10/20/54/stethoscope-840125_960_720.jpg?x-oss-process=image/auto-orient,1/interlace,1/resize,w_1440,h_1440/quality,q_95/format,jpg" alt="" original-src="https://imageproxy.pbkrs.com/https://cdn.pixabay.com/photo/2015/07/10/20/54/stethoscope-840125_960_720.jpg"/></p>
<p><em>图片来源：Pixabay</em></p>
<p><strong>对于我们这些对美国医疗系统复杂金融结构了解不多的人来说，医疗行业正处于一种死亡螺旋中</strong>，这将让所有人感到惊讶，除了那些理解系统不可持续性的内部人士。</p>
<p>为了帮助我们这些外部人士理解死亡螺旋，<strong>我请了一位高级医生来引导我们&#34;追踪资金流向&#34;。</strong></p>
<p>特朗普抨击&#34;肥胖、富有的保险公司&#34;，因为立法者提出了&#34;修复&#34;平价医疗法案的方案。</p>
<p><em>由于这是当今的热点问题，并且在我的专业领域内，这里有一些想法。</em></p>
<h3><strong>执行摘要</strong></h3>
<p>多种条件正在促成美国医疗服务交付的广泛重组，导致形成一种双层交付模式：对于能够支付的人，提供高质量、高效、创新的现金支付服务；而对于无法支付的人，则提供低质量、等待分配的医疗服务。</p>
<p>如果你负担不起，就不要生病。</p>
<p>医疗系统通过虚高的商业房地产（CRE）、患者健康信息（PHI）的销售、供应链的整合以及为了重新分配联邦资金而获得的回扣来赚钱。除了少量程序外，医疗服务本身是亏损的。它是进入的必要条件，而不是价值的来源。因此，医疗服务的交付旨在防止亏损，而不是促进创新。</p>
<p>大多数医疗系统的首席执行官是金融工程师，而不是医疗服务交付专家，他们将自己的房地产管理基础设施的规模与医疗服务管理基础设施进行比较；前者总是比后者强大得多。</p>
<p>保险公司已成为公用事业，管理政府支付项目。随着《平价医疗法案》的实施，它们作为商业模式承受风险的能力被抛弃；它们不再具备这样做的基础设施或人才。你不如让他们去做鞋子。</p>
<p>这种单一文化、垄断的腐败，以及对疫情的反应都使两者都受到了重创。</p>
<p>医疗系统面临着吞吐量的深刻中断，它们通过动用储备、进一步抬高 CRE、推高 PHI 销售的界限、增加回扣计划，以及最重要的是，完全依赖于即将结束的政府救助来应对。</p>
<p>进一步的整合和与私人资金的合作是它们唯一的出路。最近的经验教训是，私人资金将把医疗服务的交付削减到最大限度，以便最大化其他价值来源。大量的管理人员和高管也将失去他们的工作。</p>
<p>在《平价医疗法案》实施后，保险公司的唯一现金奶牛是资金过剩且充满欺诈的基于价值的医疗（VBC）医疗保险和医疗补助项目，例如医疗保险优势。欺诈行为现在正在被刑事起诉，过度支付已不复存在，而在疫情期间延迟的医疗费用，现在由保险公司承担，正在以多倍的形式显现。</p>
<p>保险公司除了作为支付管理者外，根本没有前进的道路。预计将出现大规模整合，从个别蓝十字公司开始。政府一直抵制，但现在面临合并或破产的选择。到 2028 年，可能只剩下 Coventry、United 和 Centene，不再有蓝十字。</p>
<p>《平价医疗法案》本身正处于死亡螺旋中。它被设想为一个普遍的强制风险池，但由于做出了太多例外，只有最病重的人和没有选择的人才能在这里获得医疗服务，前者由后者、政府和日益减少的覆盖范围进行补贴。疫情期间的补贴掩盖了这一点，失去补贴后，覆盖范围变得毫无意义。不参与将是它的终结。</p>
<p>此外，政府医疗项目长期以来通过压低获取医疗服务所需资源的支付来获得补贴；临床医生、劳动力、管理，甚至是便盆。即使是系统内薪酬最高的医生，自 2010 年以来也没有增加实际工资；护理人员的工资之所以上涨，仅仅是因为许多人已成为自由职业的代理工人。我曾被提供一个临时职位，时薪 145 美元，和 8 年前的报价相同。</p>
<p>所有这些资源现在在系统外的价值高于在系统内。因此，这些资源正在向现金支付市场迁移。曾经庞大的政府市场和可靠的支付足以弥补两个市场之间的价值差异，即现金与第三方支付。现在不再如此。</p>
<p>当前的按服务收费（FFS）医疗系统的遗留成本、管理/领导专业知识和商业模式使得除了最具品牌的医疗系统外，几乎没有系统能够在现金支付模式中竞争。</p>
<p>进入现金支付市场的机会将根据管辖区的不同而有所不同：在某些州是非法的，在其他州受到限制，还有一些州则是免费的。</p>
<p>预计政策将演变为一种高额、自付、可滚存的健康储蓄账户（HSA），与基于收入的补贴配对，并配有政府补贴的灾难性护理项目。至少在年轻人和不满者选择社会主义之前。</p>
<p>对受益者的 2000 美元直接支付，如今正在考虑的，完全无效，尤其是因为这笔钱必须借贷，并将进一步加剧通货膨胀。</p>
<p><strong>真正的改革必须包括：</strong></p>
<p>1. 使限制现金支付的州和联邦法律无效。</p>
<p>2. 禁止非营利（NFP）/宗教组织参与第三方支付项目。税收免除商业模式的竞争优势及其所导致的固有腐败使得它们的参与不符合公众利益。</p>
<p>3. 取消对临床医生在医疗服务交付中拥有权的限制。</p>
<p>4. 在医疗服务交付中重新加强反垄断执法。</p>
<p><strong>可以添加其他内容，但如果这些内容没有成为任何&#34;改革&#34;的一部分，那么所做的一切只是以稍微不同的方式向垄断卡特尔倾斜资金。</strong></p>
<p>不会有任何改善。</p>
<p>需要改革的不是支付，而是交付。</p>
<p>很多人的薪水依赖于掩盖这一事实。</p>
<p><strong>感谢高级董事总经理带我参观医疗保健的财务死亡螺旋。</strong> 我早就说过，当前这种掠夺性卡特尔形式的医疗保健将会使国家破产：</p>
<p>为什么美国的医疗保健（病痛护理）系统是破碎且无法修复的（2014 年 7 月 16 日）</p>
<p>病痛护理将使国家破产（2011 年 3 月 21 日）</p>
<p><strong>我的问题：</strong></p>
<p>1. 这些金融管道中有任何是私人保险吗，还是所有的只是通过盈利的抽水操作在转移政府资金？</p>
<p>2. 一个拒绝将数字失调、超加工饮食和差劲的健身与 “健康” 联系起来的 “医疗保健” 系统，怎么可能产生 “健康” 作为输出？</p>
<p><strong>这些问题是禁忌，因为答案会使整个系统崩溃。</strong></p>
<p><strong>医疗保险成本：</strong> 抛物线：</p>
<p><img src="https://imageproxy.pbkrs.com/https://www.oftwominds.com/photos2025/medicare7-25.png?x-oss-process=image/auto-orient,1/interlace,1/resize,w_1440,h_1440/quality,q_95/format,jpg" alt="" original-src="https://imageproxy.pbkrs.com/https://www.oftwominds.com/photos2025/medicare7-25.png"/></p>
<p><strong>医疗补助成本：</strong> 抛物线：</p>
<p><img src="https://imageproxy.pbkrs.com/https://www.oftwominds.com/photos2025/medicaid7-25.png?x-oss-process=image/auto-orient,1/interlace,1/resize,w_1440,h_1440/quality,q_95/format,jpg" alt="" original-src="https://imageproxy.pbkrs.com/https://www.oftwominds.com/photos2025/medicaid7-25.png"/></p>
<hr/>
<p><em>更多来自此作者：</em></p>
<p>中产阶级正在崩溃</p>
<p>人工智能是增长的催化剂，还是崩溃的催化剂？</p>
<p>人工智能的风险不是天网</p>

梦百合

<p>美国医疗保健系统正处于财务死亡螺旋中，原因包括商业房地产的膨胀、患者健康信息的出售以及对政府救助的依赖。保险公司沦为支付管理者，面临整合或破产的局面。《平价医疗法案》（ACA）正在失败，补贴掩盖了其低效。资源正在转向现金支付市场，真正的改革需要废除当前系统。建议将高额健康储蓄账户与政府补贴的灾难性护理相结合，作为解决方案</p>

<p><img src="https://imageproxy.pbkrs.com/https://cdn.pixabay.com/photo/2015/07/10/20/54/stethoscope-840125_960_720.jpg" alt="" original-src="https://cdn.pixabay.com/photo/2015/07/10/20/54/stethoscope-840125_960_720.jpg"/></p>
<p><em>Image Source: Pixabay</em></p>
<div class="lb-trans"><p><em>图片来源：Pixabay</em></p>
</div><p><strong>Unbeknownst to those of us with little inside knowledge of the complex financial plumbing of the US healthcare system, healthcare is in a death spiral</strong> that will surprise everyone but insiders who grasp the system's unsustainability.</p>
<div class="lb-trans"><p><strong>对于我们这些对美国医疗系统复杂金融结构了解不多的人来说，医疗行业正处于一种死亡螺旋中</strong>，这将让所有人感到惊讶，除了那些理解系统不可持续性的内部人士。</p>
</div><p>To help us outsiders understand the death spiral, <strong>I asked a senior MD to guide us through &#34;follow the money.&#34;</strong></p>
<div class="lb-trans"><p>为了帮助我们这些外部人士理解死亡螺旋，<strong>我请了一位高级医生来引导我们&#34;追踪资金流向&#34;。</strong></p>
</div><p>Trump Blasts &#34;Big, Fat, Rich Insurance Companies&#34; As Lawmakers Propose Ways To 'Fix' Obamacare.</p>
<div class="lb-trans"><p>特朗普抨击&#34;肥胖、富有的保险公司&#34;，因为立法者提出了&#34;修复&#34;平价医疗法案的方案。</p>
</div><p><em>Since this is the issue of the day and it falls within my expertise, here are some thoughts.</em></p>
<div class="lb-trans"><p><em>由于这是当今的热点问题，并且在我的专业领域内，这里有一些想法。</em></p>
</div><h3><strong>Executive Summary</strong></h3>
<div class="lb-trans"><h3><strong>执行摘要</strong></h3>
</div><p>Multiple conditions are aligning for a broad realignment of medical care delivery in the US, resulting in the development of a two-tiered delivery model: high-quality, efficient, innovative cash-pay for those who can pay and low-quality, wait-rationed care delivery for those who can't.</p>
<div class="lb-trans"><p>多种条件正在促成美国医疗服务交付的广泛重组，导致形成一种双层交付模式：对于能够支付的人，提供高质量、高效、创新的现金支付服务；而对于无法支付的人，则提供低质量、等待分配的医疗服务。</p>
</div><p>If you can't afford it, don't get sick.</p>
<div class="lb-trans"><p>如果你负担不起，就不要生病。</p>
</div><p>Health systems make their money through inflated commercial real estate (CRE), the sale of patient health information (PHI), the consolidation of supply chains, and kickbacks in exchange for redirecting federal dollars. Absent a tiny sliver of procedures, the delivery of healthcare itself is a loss leader. It is a requirement for entry, not a source of value. As such, care delivery managed to prevent loss, not promote innovation.</p>
<div class="lb-trans"><p>医疗系统通过虚高的商业房地产（CRE）、患者健康信息（PHI）的销售、供应链的整合以及为了重新分配联邦资金而获得的回扣来赚钱。除了少量程序外，医疗服务本身是亏损的。它是进入的必要条件，而不是价值的来源。因此，医疗服务的交付旨在防止亏损，而不是促进创新。</p>
</div><p>Most health system CEOs are financial engineers, not care delivery specialists, and compare the size of their real estate management infrastructure with their care delivery management infrastructure; the former is always much more robust than the latter.</p>
<div class="lb-trans"><p>大多数医疗系统的首席执行官是金融工程师，而不是医疗服务交付专家，他们将自己的房地产管理基础设施的规模与医疗服务管理基础设施进行比较；前者总是比后者强大得多。</p>
</div><p>Insurers have become utilities, administering government payment programs. Their ability to bear risk as a business model was discarded with the ACA; they no longer have the infrastructure or talent to do so. You might as well ask them to make shoes.</p>
<div class="lb-trans"><p>保险公司已成为公用事业，管理政府支付项目。随着《平价医疗法案》的实施，它们作为商业模式承受风险的能力被抛弃；它们不再具备这样做的基础设施或人才。你不如让他们去做鞋子。</p>
</div><p>This monoculture, the corruption of monopoly, and finally the response to the pandemic have crippled both.</p>
<div class="lb-trans"><p>这种单一文化、垄断的腐败，以及对疫情的反应都使两者都受到了重创。</p>
</div><p>Health systems faced a profound interruption in throughput, which they dealt with by tapping reserves, inflating CRE further, pushing the boundaries of PHI sales, increasing their kickback programs, and, most importantly, becoming fully dependent on the now ending government bailouts.</p>
<div class="lb-trans"><p>医疗系统面临着吞吐量的深刻中断，它们通过动用储备、进一步抬高 CRE、推高 PHI 销售的界限、增加回扣计划，以及最重要的是，完全依赖于即将结束的政府救助来应对。</p>
</div><p>Further consolidation and partnering with private money is their only path forward. Recent experience teaches that private money will cut the delivery of healthcare to the bare minimum needed to maximize the other sources of value. A whole lot of administrators and C-suiters are also going to lose their jobs.</p>
<div class="lb-trans"><p>进一步的整合和与私人资金的合作是它们唯一的出路。最近的经验教训是，私人资金将把医疗服务的交付削减到最大限度，以便最大化其他价值来源。大量的管理人员和高管也将失去他们的工作。</p>
</div><p>After the ACA, the Insurer's only cash cow was the immensely overfunded and fraud-filled Value-Based Care (VBC) Medicare and Medicaid programs, such as Medicare Advantage. The fraud is now being criminally prosecuted, the overpayments are gone, and the cost of care delayed during the pandemic, which the insurers now bear, are being realized manifold.</p>
<div class="lb-trans"><p>在《平价医疗法案》实施后，保险公司的唯一现金奶牛是资金过剩且充满欺诈的基于价值的医疗（VBC）医疗保险和医疗补助项目，例如医疗保险优势。欺诈行为现在正在被刑事起诉，过度支付已不复存在，而在疫情期间延迟的医疗费用，现在由保险公司承担，正在以多倍的形式显现。</p>
</div><p>Insurers simply have no path forward other than as payment administrators. Look for massive consolidation, starting with the individual Blues. The government has been resistant, but now it's a choice of merger or bankruptcy. In 2028, probably only Coventry, United, and Centene will be left standing, no more blues.</p>
<div class="lb-trans"><p>保险公司除了作为支付管理者外，根本没有前进的道路。预计将出现大规模整合，从个别蓝十字公司开始。政府一直抵制，但现在面临合并或破产的选择。到 2028 年，可能只剩下 Coventry、United 和 Centene，不再有蓝十字。</p>
</div><p>The ACA itself is in a death spiral. Envisioned as a universal mandatory risk pool, so many exceptions have been made that only the sickest and those who have no choice get their care there, the former being subsidized by the latter, the government, and ever-dwindling coverage. The pandemic subsidies masked it, and without them, the coverage is nonsensical. Non-participation will be its end.</p>
<div class="lb-trans"><p>《平价医疗法案》本身正处于死亡螺旋中。它被设想为一个普遍的强制风险池，但由于做出了太多例外，只有最病重的人和没有选择的人才能在这里获得医疗服务，前者由后者、政府和日益减少的覆盖范围进行补贴。疫情期间的补贴掩盖了这一点，失去补贴后，覆盖范围变得毫无意义。不参与将是它的终结。</p>
</div><p>In addition, government medical care programs have long been subsidized by suppressing payment for the resources used to obtain care delivery; clinicians, labor, administration, and even bedpans. Real wages for even the highest-paying doctors working within the system haven't increased since 2010; nursing wages have gone up only because so many have become free-lancing agency workers. I got offered a locums position for $145/hour, the same as I was offered 8 years ago.</p>
<div class="lb-trans"><p>此外，政府医疗项目长期以来通过压低获取医疗服务所需资源的支付来获得补贴；临床医生、劳动力、管理，甚至是便盆。即使是系统内薪酬最高的医生，自 2010 年以来也没有增加实际工资；护理人员的工资之所以上涨，仅仅是因为许多人已成为自由职业的代理工人。我曾被提供一个临时职位，时薪 145 美元，和 8 年前的报价相同。</p>
</div><p>All those resources are now worth more outside the system than inside. Thus, those resources are migrating to the cash-pay market. Used to be the huge government market, and dependable payments were enough to overcome the difference in value between the two markets, cash vs third party. No longer.</p>
<div class="lb-trans"><p>所有这些资源现在在系统外的价值高于在系统内。因此，这些资源正在向现金支付市场迁移。曾经庞大的政府市场和可靠的支付足以弥补两个市场之间的价值差异，即现金与第三方支付。现在不再如此。</p>
</div><p>The legacy costs, management/leadership expertise, and business models of current Fee For Service (FFS) health systems preclude all but the most highly branded health systems from competing in the cash-pay model.</p>
<div class="lb-trans"><p>当前的按服务收费（FFS）医疗系统的遗留成本、管理/领导专业知识和商业模式使得除了最具品牌的医疗系统外，几乎没有系统能够在现金支付模式中竞争。</p>
</div><p>Access to the cash-pay market will vary based on jurisdiction: it's illegal in some states, hamstrung by others, free in still more.</p>
<div class="lb-trans"><p>进入现金支付市场的机会将根据管辖区的不同而有所不同：在某些州是非法的，在其他州受到限制，还有一些州则是免费的。</p>
</div><p>Look for policy to evolve into a high-dollar, deductible, roll-over Health Savings Account (HSA) with income-based subsidies paired with a government-subsidized catastrophic care program. At least until the young and disaffected elect a socialist.</p>
<div class="lb-trans"><p>预计政策将演变为一种高额、自付、可滚存的健康储蓄账户（HSA），与基于收入的补贴配对，并配有政府补贴的灾难性护理项目。至少在年轻人和不满者选择社会主义之前。</p>
</div><p>A $2,000 direct payment to beneficiaries, such as is currently contemplated, is completely ineffectual, especially since it has to be borrowed and will just increase inflation that much further.</p>
<div class="lb-trans"><p>对受益者的 2000 美元直接支付，如今正在考虑的，完全无效，尤其是因为这笔钱必须借贷，并将进一步加剧通货膨胀。</p>
</div><p><strong>True reform must include:</strong></p>
<div class="lb-trans"><p><strong>真正的改革必须包括：</strong></p>
</div><p>1. Invalidation of state and federal laws that restrict cash pay.</p>
<div class="lb-trans"><p>1. 使限制现金支付的州和联邦法律无效。</p>
</div><p>2. Prohibition of not-for-profit (NFP) / Religious organizations from third-party payment programs. The competitive advantage of the tax-free business model and the inherent corruption it has engendered render their participation not in the public interest.</p>
<div class="lb-trans"><p>2. 禁止非营利（NFP）/宗教组织参与第三方支付项目。税收免除商业模式的竞争优势及其所导致的固有腐败使得它们的参与不符合公众利益。</p>
</div><p>3. Removal of restrictions on clinician ownership in healthcare delivery.</p>
<div class="lb-trans"><p>3. 取消对临床医生在医疗服务交付中拥有权的限制。</p>
</div><p>4. Renewed criminal anti-trust enforcement in medical care delivery.</p>
<div class="lb-trans"><p>4. 在医疗服务交付中重新加强反垄断执法。</p>
</div><p><strong>Others can be added, but if each of these is not a part of any 'reform,' than all that is being done is pouring money into a monopolizing cartel, just in a slightly different way.</strong></p>
<div class="lb-trans"><p><strong>可以添加其他内容，但如果这些内容没有成为任何&#34;改革&#34;的一部分，那么所做的一切只是以稍微不同的方式向垄断卡特尔倾斜资金。</strong></p>
</div><p>No improvement will occur.</p>
<div class="lb-trans"><p>不会有任何改善。</p>
</div><p>It's not payments that need reform, it's delivery.</p>
<div class="lb-trans"><p>需要改革的不是支付，而是交付。</p>
</div><p>And a lot of folks' paychecks depend on obfuscating that fact.</p>
<div class="lb-trans"><p>很多人的薪水依赖于掩盖这一事实。</p>
</div><p><strong>Thank you, senior MD ,for the guided tour of healthcare's financial death spiral.</strong> I have long stated that healthcare in its current extractive-cartel form will bankrupt the nation all by itself:</p>
<div class="lb-trans"><p><strong>感谢高级董事总经理带我参观医疗保健的财务死亡螺旋。</strong> 我早就说过，当前这种掠夺性卡特尔形式的医疗保健将会使国家破产：</p>
</div><p>Why America's Healthcare (Sickcare) System Is Broken and Unfixable (July 16, 2014)</p>
<div class="lb-trans"><p>为什么美国的医疗保健（病痛护理）系统是破碎且无法修复的（2014 年 7 月 16 日）</p>
</div><p>Sickcare Will Bankrupt the Nation (March 21, 2011)</p>
<div class="lb-trans"><p>病痛护理将使国家破产（2011 年 3 月 21 日）</p>
</div><p><strong>My questions:</strong></p>
<div class="lb-trans"><p><strong>我的问题：</strong></p>
</div><p>1. Is any of this financial plumbing actually private insurance, or is it all just sluicing government funding through a profitable skimming operation?</p>
<div class="lb-trans"><p>1. 这些金融管道中有任何是私人保险吗，还是所有的只是通过盈利的抽水操作在转移政府资金？</p>
</div><p>2. How can a 'healthcare' system that refuses to connect digital derangement, ultra-processed diet, and poor fitness to 'health' possibly generate 'health' as an output?</p>
<div class="lb-trans"><p>2. 一个拒绝将数字失调、超加工饮食和差劲的健身与 “健康” 联系起来的 “医疗保健” 系统，怎么可能产生 “健康” 作为输出？</p>
</div><p><strong>These questions are taboo because the answers would implode the entire system.</strong></p>
<div class="lb-trans"><p><strong>这些问题是禁忌，因为答案会使整个系统崩溃。</strong></p>
</div><p><strong>Medicare costs:</strong> parabolic:</p>
<div class="lb-trans"><p><strong>医疗保险成本：</strong> 抛物线：</p>
</div><p><img src="https://imageproxy.pbkrs.com/https://www.oftwominds.com/photos2025/medicare7-25.png" alt="" original-src="https://www.oftwominds.com/photos2025/medicare7-25.png"/></p>
<p><strong>Medicaid costs:</strong> parabolic:</p>
<div class="lb-trans"><p><strong>医疗补助成本：</strong> 抛物线：</p>
</div><p><img src="https://imageproxy.pbkrs.com/https://www.oftwominds.com/photos2025/medicaid7-25.png" alt="" original-src="https://www.oftwominds.com/photos2025/medicaid7-25.png"/></p>
<hr/>
<div class="lb-trans"><hr/>
</div><p><em>More By This Author:</em></p>
<div class="lb-trans"><p><em>更多来自此作者：</em></p>
</div><p>The Middle Class Is Cracking</p>
<div class="lb-trans"><p>中产阶级正在崩溃</p>
</div><p>Is AI A Catalyst For Growth - Or For Collapse?</p>
<div class="lb-trans"><p>人工智能是增长的催化剂，还是崩溃的催化剂？</p>
</div><p>The Risk Of AI Isn't Skynet</p>
<div class="lb-trans"><p>人工智能的风险不是天网</p>
</div>

为什么医疗保健行业陷入死亡螺旋：追踪资金流向