TED@Merck KGaA, Darmstadt, Germany
Matthias Müllenbeck: What if we paid doctors to keep people healthy?
馬提亞斯．穆蘭貝克: 如果我們付錢給醫生，讓他們保持人民的健康，聽起來如何？
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如果我們獎勵醫生保持我們健康，而不是只有在我們生病時才付錢給他們，這樣聽起來如何？馬提亞斯．穆蘭貝克解釋了這項從「生病照護」體制轉變為真正的「健康照護」體制的根本改變，如何能幫我們節省不必要的成本和高風險的手術，並讓我們更健康、長壽。
Matthias Müllenbeck - Business developer
As the Biopharma director for licensing and business development at Merck KGaA, Darmstadt, Germany, Matthias Müllenbeck is responsible for leading strategic partnering initiatives in the field of oncology and immuno-oncology. Full bio
As the Biopharma director for licensing and business development at Merck KGaA, Darmstadt, Germany, Matthias Müllenbeck is responsible for leading strategic partnering initiatives in the field of oncology and immuno-oncology. Full bio
Double-click the English transcript below to play the video.
00:12
It's 4am in the morning.
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時間是早上四點。
00:16
I'm waking up in a Boston hotel room
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我在波士頓一間飯店的房間中醒來，
00:18
and can only think of one thing:
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腦中只能想著一件事：
00:21
tooth pain.
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牙痛。
00:24
One of my ceramic inlays
fell off the evening before.
fell off the evening before.
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前晚，我的其中一個瓷鑲體脫落了。
00:27
Five hours later,
I'm sitting in a dentist's chair.
I'm sitting in a dentist's chair.
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五小時之後，我坐在牙科的椅子上。
00:31
But instead of having a repair of my inlay
so that I can get rid of my pain,
so that I can get rid of my pain,
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但牙醫師並沒有修復我的瓷鑲體
好讓我脫離牙痛之苦，
好讓我脫離牙痛之苦，
00:36
the dentist pitches me on the advantages
of a titanium implant surgery.
of a titanium implant surgery.
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反而在跟我推銷鈦植牙手術的優點。
00:42
Ever heard of that?
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有聽過嗎？
00:43
(Laughter)
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（笑聲）
00:45
It essentially means to replace
a damaged tooth
a damaged tooth
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基本上，就是要把一顆受損的牙齒
00:49
by an artificial one,
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換成一顆人工牙齒，
00:50
that is screwed into your jaw.
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用螺釘固定在你的下頜上。
00:53
Estimated costs for the implant surgery
may add up to 10,000 US dollars.
may add up to 10,000 US dollars.
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植牙手術的估計成本
可能會高達一萬美金。
可能會高達一萬美金。
00:59
Replacing the ceramic inlay I had before
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把我之前的瓷鑲體換掉，
01:02
would come in at 100 US dollars.
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只要大約一百美元。
01:06
Was it my health or the money
that could be earned with me
that could be earned with me
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到底是我的健康，
還是能從我身上賺到的錢，
還是能從我身上賺到的錢，
01:10
that was the biggest concern
for my dentist?
for my dentist?
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是我的牙醫最先考量的事？
01:13
As it turned out, my experience
wasn't an isolated case.
wasn't an isolated case.
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結果發現，我的經歷並非單一個案。
01:18
A study by a US national newspaper
estimated that in the United States,
estimated that in the United States,
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美國一間報社的研究指出
在美國所有的手術當中
估計有三成──
估計有三成──
01:24
up to 30 percent of all
surgical procedures --
surgical procedures --
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01:27
including stent
and pacemaker implantations,
and pacemaker implantations,
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包括支架和心律調節器植入、
01:31
hip replacements and uterus removals --
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髖關節置換，及子宮移除──
01:34
were conducted
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被執行，
01:35
although other nonsurgical treatment
options had not been fully exploited
options had not been fully exploited
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儘管其他非手術的治療方式
尚未完全被其主治醫生利用過。
01:39
by the physician in charge.
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01:43
Isn't that figure shocking?
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那數字不是挺嚇人的嗎？
01:45
Numbers may be slightly different
in other countries,
in other countries,
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在其他國家，數字可能稍有不同，
01:48
but what it means is that
if you go to a doctor in the US,
if you go to a doctor in the US,
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但這意味著，如果你在美國看醫生，
01:52
you have a not-insignificant chance
to be subjected to a surgical intervention
to be subjected to a surgical intervention
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你有顯著的可能性，
會在不立即需要手術的情況下
會在不立即需要手術的情況下
01:57
without there being
an immediate need for it.
an immediate need for it.
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就去接受手術治療。
02:00
Why is this?
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為什麼會這樣？
02:02
Why are some practitioners incentivized
to run such unnecessary procedures?
to run such unnecessary procedures?
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為什麼有些開業醫生會被獎勵
去做這類不必要的手術？
去做這類不必要的手術？
02:09
Well, perhaps it is because
health care systems themselves
health care systems themselves
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也許是因為健康照護體制本身，
02:14
incentivize in a nonideal way
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用一種不盡理想的方式，
02:17
towards applying or not applying
certain procedures or treatments.
certain procedures or treatments.
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鼓勵採用／不採用某些手術或治療。
02:21
As most health care systems
reimburse practitioners
reimburse practitioners
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大部分的健康照護體制
對開業醫生的補助
對開業醫生的補助
02:24
in a fee-for-service-based fashion
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是以一次一付的醫療費為基礎的，
02:27
on the number and kind
of treatments performed,
of treatments performed,
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根據所進行之治療的
數量和類型來給付，
數量和類型來給付，
02:30
it may be this economic incentive
that tempts some practitioners
that tempts some practitioners
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可能就是這種經濟獎勵
誘使一些開業醫生
誘使一些開業醫生
02:34
to rather perform high-profit
surgical treatments
surgical treatments
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選擇採用高利潤的手術治療，
02:37
instead of exploring
other treatment options.
other treatment options.
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而不去尋求其他治療選擇。
02:40
Although certain countries
started to implement
started to implement
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雖然有些國家開始導入
02:43
performance-based reimbursement,
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以績效為基礎的補助，
02:45
anchored on a quality and efficacy matrix,
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根據的是品質和功效的矩陣，
02:48
overall, there's very little in today's
health care systems' architecture
health care systems' architecture
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整體來說，現今的健康照護體制
結構中，很少會有這種方式，
結構中，很少會有這種方式，
02:52
to incentivize practitioners broadly
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廣泛鼓勵開業醫生
02:54
to actively prevent the appearance
of a disease in the first place
of a disease in the first place
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在一開始就主動去預防疾病出現，
02:58
and to limit the procedures
applied to a patient
applied to a patient
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並只對病人進行
能達到最大效用的手術。
03:01
to the most effective options.
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03:03
So how do we fix this?
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這問題要如何解決？
03:07
What it may take is a fundamental redesign
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可能會需要從根本上重新設計
03:10
of our health care
system's architecture --
system's architecture --
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我們的健康照護體制結構──
03:12
a complete rethinking
of the incentive structure.
of the incentive structure.
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完全重新思考鼓勵結構。
03:16
What we may need is a health care system
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我們需要把健康照護體制的報銷條件
03:18
that reimburses practitioners
for keeping their customers healthy
for keeping their customers healthy
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改成是醫生要保持其客戶的健康，
03:22
instead of almost only paying for services
once people are already sick.
once people are already sick.
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而不是幾乎只支付
已病之後的治療服務。
已病之後的治療服務。
03:28
What we may need is a transformation
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我們得要轉變，
03:31
from today's system
that largely cares for the sick,
that largely cares for the sick,
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從現今主要在照護病人的體制，
03:34
to a system that cares for the healthy.
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轉變為照護健康的體制。
03:38
To change our current "sick care" approach
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把我們目前的「生病照護」方法，
03:41
into a true "health care" approach.
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改變為真正的「健康照護」方法。
03:44
It is a paradigm shift from treating
people once they have become sick
people once they have become sick
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這是一種典範轉移，
從在大家生病之後才進行治療，
從在大家生病之後才進行治療，
03:49
to preserving the health of the healthy
before they get sick.
before they get sick.
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變成在他們生病之前
就維持他們的健康。
就維持他們的健康。
03:53
This shift may move the focus
of all those involved --
of all those involved --
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這種轉移，可能會讓所有
相關人士的焦點改變──
相關人士的焦點改變──
03:57
from doctors, to hospitals,
to pharmaceutical and medical companies --
to pharmaceutical and medical companies --
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醫生、醫院、藥廠，
及醫療器材公司──
及醫療器材公司──
04:02
on the product that this industry
ultimately sells:
ultimately sells:
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把重心改放到這個產業
最終要銷售的產品上：
最終要銷售的產品上：
04:07
health.
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健康。
04:09
Imagine the following.
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想像以下情況。
04:12
What if we redesign our health care system
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如果我們重新設計健康照護體制，
04:15
into one that does not
reimburse practitioners
reimburse practitioners
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這個體制不會補助開業醫生
04:18
for the actual procedures
performed on a patient
performed on a patient
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對於病人實際上執行的手術，
04:20
but rather reimburses doctors, hospitals,
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而是補助醫生、醫院、
04:23
pharmaceutical and medical companies
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藥廠，以及醫療器材公司，
04:26
for every day a single
individual is kept healthy
individual is kept healthy
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每天每一個病人能保持健康無疾病，
04:29
and doesn't develop a disease?
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就能得到補助？
04:31
In practical terms, we could, for example,
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就實際面來說，比如，我們可以
04:34
use public money to pay a health fee
to an insurance company
to an insurance company
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用公款來支付健康費給保險公司，
04:38
for every day a single individual
is kept healthy
is kept healthy
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只要每天每一個人能保持健康
04:41
and doesn't develop a disease
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無疾病，
04:42
or doesn't require any other form
of acute medical intervention.
of acute medical intervention.
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或是不需要任何其他形式的
急性醫療干預就付款。
急性醫療干預就付款。
04:47
If the individual becomes sick,
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如果一個人生了病，
04:49
the insurance company will not receive
any further monetary compensation
any further monetary compensation
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保險公司不會從治療這個人之疾病
所需要進行的醫療干預
所需要進行的醫療干預
04:54
for the medical interventions required
to treat the disease of that individual,
to treat the disease of that individual,
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收到任何進一步的金錢補助，
04:58
but they would be obliged to pay
for every evidence-based treatment option
for every evidence-based treatment option
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他們反而有義務要支付
讓客戶恢復健康的治療選擇，
讓客戶恢復健康的治療選擇，
05:02
to return the customer back to health.
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只要有證據佐證治療的必要性。
05:05
Once the customer's healthy again,
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一旦客戶再次恢復健康，
05:07
the health fee for that individual
will be paid again.
will be paid again.
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他們就會再次收到那個人的健康費。
05:11
In effect, all players in the system
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實際上，在這個體制中的所有參與者
05:14
are now responsible for keeping
their customers healthy,
their customers healthy,
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現在都有責任要保持客戶健康，
05:17
and they're incentivized to avoid
any unnecessary medical interventions
any unnecessary medical interventions
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他們若能避免不必要的
醫療干預，就能得到獎勵，
醫療干預，就能得到獎勵，
05:22
by simply reducing the number of people
that eventually become sick.
that eventually become sick.
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只要做到減少生病的人數。
05:28
The more healthy people there are,
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大家越健康，
05:31
the less the cost
to treat the sick will be,
to treat the sick will be,
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治療疾病的成本就會越低，
05:35
and the higher the economic benefit
for all parties being involved
for all parties being involved
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而保持每位客戶健康的相關各方，
05:39
in keeping these individuals healthy is.
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也會有更高的經濟利益。
05:43
This change of the incentive
structure shifts, now,
structure shifts, now,
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將獎勵結構做這種改變，
05:45
the attention of the complete
health care system
health care system
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會轉移整個健康照護體制的注意力，
05:48
away from providing isolated
and singular treatment options,
and singular treatment options,
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從專注在提供獨立
且單一的治療選擇，
且單一的治療選擇，
05:52
towards a holistic view of what is useful
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轉變成「全人視角」，
關注的是要做什麼
關注的是要做什麼
05:55
for an individual
to stay healthy and live long.
to stay healthy and live long.
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才能讓人保持健康和長壽。
06:00
Now, to effectively preserve health,
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若要有效地保持健康，
06:04
people will need to be willing
to share their health data
to share their health data
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大家得要願意分享他們的健康資料，
06:07
on a constant basis,
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且要經常分享，
06:09
so that the health care system
understands early enough
understands early enough
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這麼一來，健康照護體制
就能在夠早的時間點
就能在夠早的時間點
06:12
if any assistance with regard
to their health is needed.
to their health is needed.
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去了解大家的健康
需要什麼樣的協助。
需要什麼樣的協助。
06:16
Physical examination,
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健康檢查、
06:18
monitoring of lifetime health data
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監控終身健康資料，
06:20
as well as genetic sequencing,
cardiometabolic profiling
cardiometabolic profiling
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還有 DNA 定序、心血管代謝側寫，
06:25
and imaging-based technologies
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以及成像相關的技術，
06:27
will allow customers to make,
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會讓客戶配合健康教練
06:28
together with health coaches
and general practitioners,
and general practitioners,
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和一般開業醫生
06:32
optimal and science-guided decisions --
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做出由科學所引導的最佳決策──
06:34
for their diet, their medication
and their physical activity --
and their physical activity --
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包括飲食、用藥，以及
身體活動相關的決策──
身體活動相關的決策──
06:39
to diminish their unique probability
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以降低每個人得到
06:41
to fall sick of an identified,
individual high-risk disease.
individual high-risk disease.
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每種可辨視之高風險疾病的機率。
06:47
Artificial intelligence-based
data analysis
data analysis
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以人工智慧為基礎的資料分析
06:49
and the miniaturization
of sensor technologies
of sensor technologies
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以及感測器技術的微型化，
06:51
are already starting to make monitoring
of the individual health status possible.
of the individual health status possible.
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已經開始讓監控
個人健康狀況成為可能。
個人健康狀況成為可能。
06:57
Measuring cardiometabolic parameters
by devices like this
by devices like this
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用像這樣的裝置來
測量心血管代謝參數，
測量心血管代謝參數，
07:01
or the detection of circulating
tumor DNA in your bloodstream
tumor DNA in your bloodstream
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或及早在癌症襲擊之前
就先偵測你的血液中
就先偵測你的血液中
07:04
early on after cancer disease onset
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有無血液循環腫瘤 DNA，
07:07
are only two examples
for such monitoring technologies.
for such monitoring technologies.
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只是這類監控技術的兩個例子而已。
07:11
Take cancer.
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比如癌症。
07:13
One of the biggest problems
in certain oncological diseases
in certain oncological diseases
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某些腫瘤疾病遇到最大的問題之一，
07:16
is that a large number of patients
is diagnosed too late
is diagnosed too late
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就是太多病人都太晚才被診斷出來，
07:20
to allow them to be cured,
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已經來不及治癒，
07:22
although the drugs and treatments
that could potentially have cured them
that could potentially have cured them
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儘管現今已經有些藥品和治療
有可能治癒他們，
07:25
are already existing today,
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07:27
if the disease had only
been detected earlier.
been detected earlier.
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只要疾病能更早被偵測出來。
07:31
New technologies allow now,
based on a few milliliters of blood,
based on a few milliliters of blood,
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現在的新技術已經
能根據幾毫升的血液
能根據幾毫升的血液
07:35
to detect the presence
of circulating tumor DNA
of circulating tumor DNA
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偵測出是否有血液循環腫瘤 DNA，
07:37
and thus, the presence of cancer,
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因此，在早期就能用
07:39
early on in a really convenient manner.
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很方便的方式偵測出癌症。
07:42
The impact that this early-stage
detection can have
detection can have
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這種早期偵測會造成的影響
07:46
may be dramatic.
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是非常巨大的。
07:48
The five-year survival rate
for non-small cell lung cancer
for non-small cell lung cancer
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非小細胞肺癌的五年存活率，
07:52
when diagnosed at stage one,
which is early, is 49 percent.
which is early, is 49 percent.
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如果在第一期，也就是很早期
就診斷出來，五年存活率是 49%。
就診斷出來，五年存活率是 49%。
07:58
The same, when diagnosed
at stage four, which is late,
at stage four, which is late,
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如果在第四期，
也就是很晚期才診斷出來，
也就是很晚期才診斷出來，
08:03
is below one percent.
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五年存活率是就不到 1%。
08:06
Being potentially able
to prevent a large number of deaths
to prevent a large number of deaths
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只要用很簡單的東西，像是
血液循環腫瘤 DNA 的血液檢測，
血液循環腫瘤 DNA 的血液檢測，
08:10
by something as simple as a blood test
for circulating tumor DNA
for circulating tumor DNA
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就有可能預防許多人喪命，
08:15
could make certain cancer types
a manageable disease,
a manageable disease,
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它能讓某些類型的癌症
變成可以控管的疾病，
變成可以控管的疾病，
08:18
as disease onset can be detected earlier
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疾病的攻擊能及早被偵測出來，
08:21
and positive treatment outcomes
can likely be increased.
can likely be increased.
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因此也更可能會有正面的治療結果。
08:27
In 2012,
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2012 年，
08:30
50 percent of all Americans
had a single chronic disease,
had a single chronic disease,
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有 50% 的美國人
得了單一種慢性病，
得了單一種慢性病，
08:34
resulting in 86 percent
of the $3 trillion US health care budget
of the $3 trillion US health care budget
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導致美國的三兆美元
健康照護預算有 86%
健康照護預算有 86%
08:40
being spent for treating
such chronic diseases.
such chronic diseases.
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花在治療這類慢性病上。
08:44
Eighty-six percent.
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86%。
08:48
If new technologies allow now
to reduce this 86 percent,
to reduce this 86 percent,
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如果新技術能減低這 86%，
08:53
why have health care systems
not reacted and changed already?
not reacted and changed already?
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為什麼健康照護體制
還沒有反應和改變？
還沒有反應和改變？
08:58
Well, a redesign of what today
is a sick care system
is a sick care system
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要把現今的生病照護體制
09:03
into a true health care system
that focuses on prevention
that focuses on prevention
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重新設計成真正的健康照護體制，
需要把焦點放在預防和行為改變上，
09:07
and behavioral changes
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09:08
requires every actor
in the system to change.
in the system to change.
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這需要體制中的
每個行為者都做出改變。
每個行為者都做出改變。
09:12
It requires the political willingness
to shift budgets and policies
to shift budgets and policies
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這也需要政治意願，
將預算和政策轉向預防和健康教育，
09:16
towards prevention and health education
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09:18
to design a new set of financial
and non-financial incentives.
and non-financial incentives.
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來設計一組新的財務
和非財務獎勵方式。
和非財務獎勵方式。
09:22
It requires creating
a regulatory framework
a regulatory framework
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這就需要創造一個規範的架構，
09:25
for the gathering, using and sharing
of personal health data
of personal health data
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來收集、使用和分享個人健康資料，
09:30
that's at the same time
stringent and sensible.
stringent and sensible.
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既嚴格且合理的規範架構。
09:33
It needs doctors, hospitals, insurers,
pharmaceutical and medical companies
pharmaceutical and medical companies
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這需要醫生、醫院、保險業者、
藥廠，以及醫療器材公司
藥廠，以及醫療器材公司
09:37
to reframe their approach
and, most important,
and, most important,
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重新調整他們的方法，
然後，最重要的是，
然後，最重要的是，
09:41
it can't happen without
the willingness and motivation
the willingness and motivation
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這件事若要成真，得仰賴每個人都有
09:45
of individuals to change their lifestyle
in a sustained way,
in a sustained way,
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意願和動機去改變他們的
生活方式，變得更永續，
生活方式，變得更永續，
09:49
to prioritize staying healthy,
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把保持健康列為優先事項，
09:51
in addition to opening up for sharing
the health data on a constant basis.
the health data on a constant basis.
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此外還要能開放地
經常分享健康資料。
經常分享健康資料。
09:56
This change may not come overnight.
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這種改變不會一夕成真。
09:58
But by refocusing the incentives
within the health care industry today
within the health care industry today
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但現在就在健康照護產業中
將獎勵的焦點改變為
將獎勵的焦點改變為
10:03
to actively keep people healthy,
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主動保持民眾健康，
10:05
we may not only be able to prevent
more diseases in the first place
more diseases in the first place
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我們不只能在一開始
就先預防更多的疾病，
就先預防更多的疾病，
10:09
but we may also be able to detect
the onset of certain preventable diseases
the onset of certain preventable diseases
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我們也能夠偵測出某些
可預防之疾病的發生，
可預防之疾病的發生，
10:13
earlier than we do today,
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且比現今能做到的更早，
10:15
which will lead to longer
and healthier lives for more people.
and healthier lives for more people.
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這就會讓更多人能更長壽、更健康。
10:20
Most of the technologies
that we need to initiate that change
that we need to initiate that change
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要開始這項改變，我們所需要的技術
10:23
are already existing today.
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大多已經存在了。
10:25
But this is not a technology question.
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這不是個技術問題。
10:27
It is primarily a question of vision
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根本上，這是個遠見
10:31
and will.
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以及意願的問題。
10:33
Thanks a lot.
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非常謝謝。
10:34
(Applause)
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（掌聲）
ABOUT THE SPEAKER
Matthias Müllenbeck - Business developerAs the Biopharma director for licensing and business development at Merck KGaA, Darmstadt, Germany, Matthias Müllenbeck is responsible for leading strategic partnering initiatives in the field of oncology and immuno-oncology.
Why you should listen
Throughout his career in various roles at Merck KGaA, Darmstadt, Germany, Matthias Müllenbeck worked on strategic asset, technology and diagnostic-licensing deals and on bringing to market innovative chemical products. He holds a PhD in immunology from the Humboldt University in Berlin and has worked at the Max-Planck Institute for infection biology in Berlin, at Bayer, and at the Albert-Schweizer Hospital in Lambarané, Gabon.
Matthias Müllenbeck | Speaker | TED.com