美国医改相关论文中英文.docx

Clinical Therapeutics/Volume 35, Number 4, 2013Editor-in-Chiefs NoteHealth Care ReformHealth care and health policy continue to be controversial domestic issues in the United States. Despite a slowing in the rate of growth of annual costs, most Americans feel that their budgets are strained by what they have to pay for health care, and most employers feel that their share of these costs for their employees is excessive. Currently, many Americans still do not have health care coverage. In an effort to remedy such concerns, a series of laws were enacted in recent years. The first of these, the American Recovery and Reinvestment Act, was signed into law by President Obama in 2009. In 2010, after considerable conflict and disagreement, the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act became law. Also in 2010, the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act were signed into law. Although these new laws (taken together, they are often called Obamacare) should have a positive and beneficial impact on the health care of most Americans, there will be many challenges to these efforts as their provisions are phased in over the next several years.Before we can have meaningful reforms, we must make improvements in our study designs and assessment instruments. Comparative effectiveness research (CER) is considered by many to be a key component of reform. However, there are limitations to analyses that use secondary databases and nonrandomized, controlled studies. Furthermore, how variables such as adherence, duration of exposure, and definitions, as well as types of outcomes, are handled can substantially affect the validity of CER. The articles by Campbell et al and Cohen in this issue are thoughtful commentaries on CER. These are among a collection of very scholarly reports in this issue assembled by our Topic Editor for Pharmacoeconomics and Health Policy, Denys T. Lau, PhD.We are pleased to be one of a select group of journals who are publishing the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement by Don Husereau, BScPharm, MSc, and colleagues. This valuable document is intended as a guide for future researchers.Finally, we must consider all of the areas not addressed by health care reform. Here are just a few topics that have concerned me.1,2 When, if ever, will we have tort reform? Why cant we have stricter bicycle helmet laws? Will we ever have realistic shelf-life regulations for medicines? How can we reduce the number of accidental gun-related injuries? Will we ever have electronic medical record systems that can bridge across institutions and practices? I invite any of our readers who have solutions to these and other unaccounted for costs to the health care system to submit letters to the editor.Richard I. Shader,MDEditor-in-ChiefREFERENCES1. Shader RI. Good news and disappointing news: a new era in health care delivery. J Clin Psychopharmacol. 2010;30:223224.2. Shader RI. The cart before the horse? Health insurance reform before health care reform. J Clin Psychopharmacol. 2009;29:413414翻译：临床治疗/35卷，第4期，2013首席编辑的注解医疗改革医疗保健和卫生政策在美国国内仍然是争议的问题。尽管每年的成本增长速度放缓，大多数美国人认为，他们通过预算支付医疗保健很勉强，而且大多数雇主觉得自己分享承担他们员工的这些成本中所占的份额过大。目前，许多美国人仍然没有医疗保险。为了努力弥补这种担忧，近年来颁布一系列的法律。其中第一，美国复苏与再投资法案，是由奥巴马总统于2009年签署而成为法律，在2010年，经过大量的矛盾和分歧后，访问保护照顾医疗保险受益人与养老救济法成为法律。此外，在2010年，患者保护与平价医疗法案和医疗卫生和教育协调法被签署成为法律。虽然这些新的法律（合在一起，他们通常被称为奥巴马医改）应该对保健大多数美国人的积极和有益的影响，他们这些努力会面临许多挑战使他们的措施在未来几年中分阶段进行。在之前，我们已经有了意义深长的改革，现在我们必须要改进我们的研究设计和评估工具。比较效益研究（CER）被许多人认为是改革的一个重要组成部分。但是，在应用辅助数据库和非随机，对照研究分析时也会存在局限性。此外,如何坚持变量,曝光时间,定义,以及结果的类型和处理都可以显著影响CER的有效性。坎贝尔和科恩在这个文章中,对CER这个问题给出了一些深思熟虑的评论。这是由我们的首席编辑药物经济学和卫生政策Denys T. Lau,博士收集的一组关于这个问题的非常学术报告。我们很高兴成为医药学士、硕士Don Husereau, ,和他的同事们陈述的综合卫生经济评价报告标准(CHEERS)期刊中的一员。这篇有价值的文档将为未来的研究者提供指导。最后，我们必须考虑所有没有被医疗改革涉及的领域。下面是我已经关注的几点，如果有的话，什么时候，我们将有民事侵权改革么？为什么我们不能有更严格的自行车头盔的法律吗?我们会有了现实的规定保质期的药品吗?我们如何能减少与枪支相关的意外伤害的数量?我们会有能够桥跨机构并且能够实践的电子病历系统么?我邀请任何有能够解决卫生保健系统中这些问题和其他下落不明的花费的办法的读者向编者发函。理查德.萨德尔 医学博士首席编辑参考文献：1. Shader RI. Good news and disappointing news: a new era in health care delivery. J Clin Psychopharmacol. 2010;30:223224.2. Shader RI. The cart before the horse? Health insurance reform before health care reform. J Clin Psychopharmacol. 2009;29:413414The NHSHealth reform in a cold climateThe governments reforms to the NHS are viewed asits biggest failure. They are better than that“WITH the Conservatives there will be no more of the tiresome, meddlesome, top-down restructures that have dominated the last decade of the NHS.” So said David Cameron in 2009,and many were convinced. Voters made Mr Cameron prime minister in2010 inpart because the Conservative Party cut into Labours lead on health care, which it had enjoyed almost since it founded the NHS in 1948. The Tories quickly squandered their advantage. But their legacy will be better than they seem to believe.In spite of his promise, Mr Camerons Conservative-Liberal Democrat coalition government embarked on reforms that would reshape the NHS from the top down. The immense Health and Social Care Act of 2012 increased competition, gave the service greater autonomy and put more decisions about the purchase of care in the hands of local doctors, known in Britain as general practitioners, or GPs. The changes were so big that they could be seen from space ,quipped Sir David Nicholson, the departing head of the NHS.The government soon came to wish they would disappear. The reforms were never popular with a bemused public. Doctors groups argued they would lead to a more fragmented and privatised system. Others worried that GPs would be incapable of commissioning care. EdMiliband, Labours leader, dubbed the reforms Mr Camerons “poll tax”, a reference to the policy that helped fell Margaret Thatcher. In this case it was Andrew Lansley, the health secretary, who fell. Less than six months after his reforms were passed, Mr Lansley was replaced by Jeremy Hunt, who talks about them as little as possible.The health reforms were supposed to make the NHS more independent. Yet Mr Hunt now styles himself a patients championhe is known to ring hospitals to ask about waiting times. This is a concession to reality: politicians will always be held accountable for the performance of the NHS. Still, the frantic smothering of the reforms conceals something useful. A policy that has caused the government so much embarrassment is quietly bearing fruit.Let 211 flowers bloomThe biggest change was the creation of 211 Clinical Commissioning Groups (CCGs), which placed about 60% of the NHS budget in the hands of local doctors and health workers. They became responsible for procuring hospital care, mental-health services and the like. Navigating a muddled system, the cannier ones have figured out ways to realign the incentives of hospitals, which are often paid per procedure, with those of GPs, who aim to keep people healthy and at home.The commissioning group in Bedfordshire, for example, has bundled some 20 contracts for musculoskeletal care (treatment for things like weak knees and cracked hips) into one five-year contract that was won by Circle, a commercial health group. Far from fragmenting the system, as critics had feared, this has made Circle responsible for integrating the services of local providers. Patients will be told which are doing best. Circle and its partners must achieve an agreed set of outcomes to receive some of their pay. Paolo Pieri, Circles chief financial officer expects the deal will not only improve care but save Bedfordshire some 30m($50m).Not all commissioning groups are as bold. But perhaps a quarter are considering contracts like the one in Bedfordshire, reckons Mr Pieri. Diane Bell, a doctor there, says more than 40 CCG shave contacted her group. “Every CCG I look at is doing brave and innovative work,” says Shane Gordon, who heads one in Essex.The Labour Partywhich launched a series of NHS reforms during its 13 years in powersays this sort of innovation was on the way anyway, and may have been delayed. Thanks to the giant restructuring of the NHS “we lost two or three years”, says Andy Burnham, the shadow health secretary. He also criticises a regulatory regime that leaves many providers confused. Fair enough. But the reforms replaced bureaucrats with clinicians, which seems to have encouraged creative thinking. Dr Bell was warned by an old hand that outcomes-based contracting would stir up a fight in her group. When she suggested it, though, the other GPs quickly bought in.If Labour wins the next election, Mr Miliband might ground CCGs just as they are taking flight. Although he has no plans to restructure the NHS yet again, his laudable aim of integrating health and social care, which currently falls outside the NHSs remit, would probably shift responsibility to a different local body. Mr Burnham would also clip the wings of reformers by giving NHS providers a built-in advantage in the competition for contracts.But the biggest threat to CCGs and what some of them are doing to improve services is not politics but whether they can move fast enough to keep in front of a funding squeeze, says Thomas Cawston of Reform, a think-tank. Though the NHS has been protected from the worst of austerity, it could fall short by 30 billion by 2020the result of rising demand from a growing elderly population. Sir David warns that without more cash, the service could tip into the red next year.As money runs short, the real test will arrive. It could be an opportunity for health reformers. Or bureaucrats could panic and revert to old ways. Whatever happens, the next government will not be able to duck the issue.国民健康保险制度遇冷的医改政府医改被指其最大败笔。“盛名”之下其实难副“有了保守党，NHS(National Health Service 英国国民健康保险制度)近十年主要的恼人、好事、专制的医疗结构会一扫而光”，这是英国首相卡梅伦在2009年说过的话，且广受信服。2010年，选民把戴维卡梅伦选为首相，有部分原因是因为保守党插手了工党主导的医疗保健项目，这个项目几乎自从1948年设立了NHS就赞誉颇多。然而保守党很快就把优势糟蹋一空。但“遗产”比他们大部分人认为的要丰厚。即便是承诺在前，卡梅伦领导的保守党和自由民主党联合政府着意的改革仍将自上而下的改造NHS。2012年，声势浩大的医疗社会保障法案使竞争更加激烈，给医疗服务业更大的自主权，以及把决定医疗开销的权利交由本地医生掌握，这类医生在英国被称为全科医生，简称全医。NHS前主管戴维尼克尔森爵士曾调侃，这么大的变革，在太空都能看到。很快，政府就希望这些变革能尽快消失。迷惑的民众并不欢迎这些改革。医生群体称，这个权利会让他们最终导致一个更加零碎化、私有化的医疗系统。还有人担心，全科医生并没有能力被委任护理。工党领袖埃德米利班德把这些改革戏称为卡梅伦的“人头税”，一个曾经让撒切尔夫人下台的参考政策。而现在，下台的是卫生部长安德鲁兰斯。兰斯的改革通过不到六个月内，他就被杰里米亨特代替了，而后者几乎对改革只字不谈。医疗改革旨在让NHS更加独立。然而杰里米亨特现在自比为病人的胜利，因为大家都知道他常常打电话给医院询问等待时间。这是承认现实：政客永远要为NHS的表现负责。但是，改革密不透风的大动干戈掩盖了一些有用的东西。一个让政府非常窘迫的政