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好了，各位。
Alright, everybody.
欢迎回来。
Welcome back.
这是达沃斯的全情投入。
It's All In at Davos.
我的好友大卫·萨克斯在这里。
My bestie David Sacks is here.
玩得很开心。
Having a great time.
我们到了。
We're here.
你们能在背景里听到这个吗？
Can you guys catch this in the background?
天哪。
Oh my god.
太棒了。
It's amazing.
太惊人了。
It's stunning.
这就是达沃斯的体验。
This is the Davos experience.
看起来很真实。
It looks real.
我知道。
I know.
嗯，从这里看，它有点像绿幕，因为景色实在太如画了。
Well, it kinda looks like a green screen from here because it's just so picturesque.
这简直就像，这并不是
It's literally like a It's not
绿幕。
green screen.
确实是。
It is.
这真的是一个真正的而且
It's a real real And
我们一会儿会走到悬崖边，你会看到所有的道德表演、ESG、DEI高管，整个区域都弥漫着这种气息。
we'll we'll look over the ledge here, what you'll see is all of the virtue signaling, ESG, DEI executives, you'll you'll just it's emanating from this entire area.
他们在这里每栋建筑上都安装了太阳能板。
And they put solar over every single building here.
但没有一块是接通电源的。
None of it's plugged in.
这只是为了美观，但大卫和我都非常兴奋，要在这里做一系列采访。
It's just for aesthetics, but we're really excited, David and I, to do a bunch of interviews here.
哇。
Wow.
今天，我们为你准备了一个很棒的访谈，我们将与梅赫梅达兹医生讨论健康和医疗体系。
Today, we've got a great one for you, and we're gonna talk about health, and we're gonna talk about the health care system with none other than doctor Mehmedaz.
你现在是CMS的负责人。
You're the administrator now for CMS.
你从被称为美国的医生，变成了像我的朋友大卫·萨克斯那样的公务员。
You've gone from being America's doctor, dare I say, to being a civil servant like my friend, David Sachs.
你为什么选择在事业巅峰时期投身这样的公共服务？
Why did you choose, really, height of your powers career to to go into public service like this?
所以我从事的是变革行业。
So I'm in the change business.
你们也是。
You guys are as well.
如果你从事的是变革行业，而你所追求的项目并没有带来显著的改变，那你就会想转去做其他能实现你所期望影响的事情。
And if you're in the change business and the project you're pursuing is not making a significant change, then you wanna move on to something else that could make the impact you desire.
尤其是在医疗领域，我们没有奢侈去浪费几年人生去追求那些无法真正改善人民生活质量与机会的事务。
And especially in health care, we don't have the luxury of fooling around for years of our lives pursuing interests that don't result in meaningfully changing the the quality of life, but also the opportunity that the American people have.
所以我喜欢当电视主持人，我做了十三年。
And so I love being a TV host, did it for thirteen years.
我热爱做外科手术，这几乎是我整个职业生涯直到最近都在做的事。
I love practicing surgery, which I've done my whole life till recently.
这是我做过的最好的工作。
This is the best job I've ever had.
这是我做过最好的工作，不仅因为我能和这些优秀的人共事，更因为你能真正实现你渴望的改变。
And it's the best job I've had because of the people that I get to work with, but also because you truly do get to make the change that I desire.
我认为，很多观看《Olin播客》的人也想改变一些东西，我鼓励每个人都大胆尝试，偶尔碰壁也没关系。
And I think a lot of folks the vision they watch the Olin podcast is they they wanna change stuff too, and I encourage everybody to, you know, take some big swings, and you'll break things once in a while.
但如果你想真正改变让你困扰的基础设施，就必须全速前进，而本届政府为我们提供了实现这一目标的独特机会。
But if you wanna be able to change meaningfully the the infrastructure of whatever's bothering you, you gotta go out at full speed, and this administration offers us a unique opportunity to do that.
这很有趣，大卫。
It is interesting, David.
你也一直习惯于快速推进。
You were used to going at a pretty fast pace as well.
我想我们的预期是，嘿。
And then I think our expectation was, hey.
你进入了公共服务领域。
You get into public service.
这需要建立共识，而且会花很多时间。
It's gonna be about consensus building, and it's gonna take a lot of time.
不管你对特朗普怎么说。
Say what you will about Trump.
有些人可能不认同他的每一项政策，但他确实能推动落实。
Some people might not agree with every policy, but he ships.
他就像一位不断快速推出产品的创始人。
He's like a founder who ships and ships product fast.
这同样也是你的特点，他做事很果断
That's also been your He's hard
让人难以跟上他的节奏。
to keep up with.
我的意思是，他行动极其迅速，和他共事非常有趣，因为他一心只想把事情做成。
I mean, he moves incredibly fast, and it makes him really fun to work for because he wants to get things done.
是的
Yeah.
他每天都要把事情做完。
Every day he wants to get things done.
有一种紧迫感。
There's a sense of urgency.
是的
Yeah.
你知道，当你在椭圆形办公室和总统开会时，向他汇报一个问题。
And you know, you'll be in a meeting with the president in the Oval Office and you'll tell him about a problem.
他的第一反应就是拿起电话，立刻打电话去解决。
His first instinct is to pick up the phone and call and fix it right then and there.
是的
Yeah.
他一次又一次开会，一小时接一小时，一天接一天，一周接一周地这么做。
And he does that meeting after meeting, hour after hour, day after day, week after week.
当你将这种想要把事情办成的渴望与他立即付诸行动的风格结合起来时，会产生巨大的影响。
And when you compound that desire to get things done and he acts on it right there, it has a huge impact.
而且他似乎非常享受这种凝聚人心的过程，尤其是在这个政府中，我认为这与第一个任期明显不同。
And he seems to get great pleasure in bringing together, especially in this administration, which I think is distinctly different than the first.
第一个任期时，他对政治还不熟悉，他引进了许多职业政客，我想可能是别人告诉他这些是合适的人选。
First administration, he was new to politics, and he brought in a lot of career politicians that I think maybe people told him were the right people.
这一次，他明确地去寻找那些在各自领域中被证明是赢家的专家，当然也包括你。
This time, he has explicitly gone and looked for people with expertise who are proven winners in the field, yourself included.
他希望我们主动承担责任。
He wants us to carry the water.
这种做法贯穿于政府的各个部门。
And this is, think, across the different parts of the administration.
他希望找到那些不必总依赖总统来讲述故事的人，因为媒体所反映的叙事往往完全偏离了事实。
He wants individuals that don't have to rely on the president to tell the story all the time because so much of the narrative that is reflected in the media is just completely off.
我甚至不是说他们是有意为之。
I'm not even saying that they're doing it on purpose.
他们根本无法理解你所做决策的次要和三级影响，因此我们的职责就是不仅要向媒体，还要向美国民众说明我们正在努力做什么。
They literally don't understand some of the secondary and tertiary impacts of the decisions you're making and it's our job to therefore tell, not just the media, but the American people what we're trying to do.
如果你的治理方式非传统，这一点就尤其重要。
And that's especially important if you're unorthodox in how you govern.
这在CMS至少是一个根本性的现实。
And this is a fundamentally important reality, at least at CMS.
大卫，我不清楚在开发人工智能时是什么情况，那里可能本来就没有一套规则手册，但医疗保健领域不同，自从人类离开非洲五万年以来，营地里就有医生了。
David, I don't know how it is in developing AI where there probably wasn't a rule book before anyway, but healthcare, there have been doctors since the dawn of Well, since humans left Africa fifty thousand years ago, there were doctors in the encampment.
因此，政府中也存在一套做事的方式，但这些方式并不总是正确的。
And so there is a way of doing things and in government that exists as well, but it's not always the right way to do things.
例如，我们有能力制定法律。
So for example, we have the ability to make laws.
政府的几乎每一个部门都可以做到这一点。
Every part of the administration pretty much can.
我们让国会去做事。
We get Congress to do stuff.
事情并不总是如你所愿，而且需要花费大量时间，最终达成的协商结果有时并不理想。
It doesn't always turn out the way you want it to turn out and it takes a lot of time and the negotiated final result sometimes falls short.
第二个重要领域是规则制定，像我们这样的行政机构可以制定所有人都必须遵守的规则。
You have rule making, second big area, is administrative entities like ours can write the rules that everyone has to follow.
我们会支付你这么多钱。
We're going pay you this much.
我们不会再允许这些人这么做。
We're not going let these people do that anymore.
这确实需要一些时间，而且容易陷入法律纠纷。
It does take some time and it's prone to lawfare.
我的意思是，你所监管的对象如果不喜欢你的做法，他们可以起诉你，从而阻止你。
By that I mean the people you're regulating, if they don't like what you're saying, they can sue you and they can stop you.
在这个政府中，如果反对党不喜欢你的做法，即使这是最好的举措，比如我们曾有一项减少欺诈的规则，但那些蓝州城市并不喜欢，因为这是他们不喜欢的总统提出的，于是他们申请了禁令，现在这件事正陷入法庭诉讼。
And in this administration, if the other party doesn't like what you're doing, even if it's the best thing, we had a rule that would reduce fraud but the blue cities didn't like it because it was coming from someone they didn't like, the president, so they enjoined it and that's now caught up in court.
我们现在会赢，但这可能需要好几年。
Now we'll win but it could take years.
所以这是第二种主要方式。
So that's the second big way.
对吧？
Right?
所以你要制定法律，颁布规则。
So you make laws, you pass rules.
第三种方式是历史上政府未曾充分运用的，我认为以前没有发挥出最大潜力；而这位总统因为是出色的谈判者，能够推动我们采用历史上从未有过的方式——即运用召集权力。
The third way, which historically government has not used, I don't think as effectively as possible, and this president, because he's a great negotiator, is able to to push us in ways that historically not been done is to just use the power to convene.
美国政府可以将平时不会交谈的人聚集在一起。
The US government can bring people together who would not normally talk.
它可以为行业提供安全港，让各方齐聚一堂，讨论以往他们试图回避的问题。
They can give safe harbor to industry to come together and discuss problems that historically they would try away
这方面的绝佳例子是什么？
What's the great example of that?
我在想，是不是制药公司？他们有东西要失去，因为特朗普当总统时就一直很明确地说过：嘿。
I'm I'm wondering if it's the drug companies who they have something to lose because Trump's been president Trump has been very clear, hey.
我希望这些价格能降下来。
I want these prices lowered.
为什么我们总是扑克桌上的冤大头？
Why are we the sucker at the poker table?
我们支付的价格是加拿大的十倍。
We're paying 10 times what Canada's paying.
在你的经验中，这是最好的例子吗？
Is that the best example in in your experience so
对。
far?
这是个很好的例子。
It's a great example.
最惠国药品定价机制专门针对你所指出的问题，即我们为完全相同的产品支付了远高于欧洲同行的价格，而这些产品往往产自同一工厂。
Most favored nation drug pricing specifically addresses the problem you outlined, which is we just pay a bunch more for the exact same product made the same factory often in America than our counterparts do here in Europe.
因此，总统说，我们必须改变这种情况。
So the president says, you we need to change that.
所以他让去跟制药公司谈谈。
So he says, go talk to the drug companies.
给他们制造一些风险机会。
Create some opportunities for risk for them.
你知道的。
You know?
制定一些规则。
Make some rules.
开展一些项目，如果我们付诸实施，会严重打击他们。
Create some project projects that if we were to act on them would really hurt them.
施加一点压力。
A little pressure.
施加一点压力。
A little pressure.
你知道的，把撬棍准备好。
You know, build the crowbars Yeah.
还有棒球棒。
And the baseball bats.
好的。
Okay.
砍一些树，打磨木料，但不要使用它们。
Cut some trees down, hone the wood, but don't use them.
对。
Right.
他明确表示，不要伤害制药业的创新本质。
And he's very specifically said, do not hurt the innovative nature of pharmaceuticals.
它们对我们的国家很重要。
They are important to our nation.
它们挽救生命。
They save lives.
我们希望拥有世界上最具创新力的产业，因为那是我们实现差异化的机会所在。
We want to have the most innovative industries in the world because that's where the opportunities are to differentiate ourselves.
这也是我们国家命运的一部分——要做最好的。
It's also part of our national destiny, be the best.
所以不要伤害这个行业，但要削减它的冗余部分。
So don't hurt the industry, but take some of the fat out of it.
缩减开支，把钱还给美国人民，而且这也是一种公平的做法。
Pull it back and give it to the American people, Plus, it's a fair way of doing things.
从隐喻的角度来看，当你想到北约以及总统对北约国家说的话——我们共同应对外部威胁，保护彼此。
And metaphorically, when you think about NATO and the president saying to NATO countries, we're all in it together to protect ourselves against external threats.
你们得增加更多资金。
You guys gotta put up more money.
我们会增加投入，但你们要按比例增加得更多。
We'll put up more, but proportionally more.
这必须是公平的。
It's got to be fair.
他们基本上都做到了，只有一两个例外。
And they all did that pretty much with one or two exceptions.
他对制药行业也采取了同样的做法。
He did the same thing with pharmaceuticals.
他说存在外部威胁，比如俄罗斯或外国政府。
He said there's an external threat which is Russia or, you know, foreign governments.
还有像癌症这样的内部威胁。
There's internal threats like cancer.
是的。
Yeah.
所以我们希望每个人都出一份力。
So we want everyone to chip in.
在美国，我们用于制药产品的支出占GDP的0.8%。
We pay in The United States point 8% of our GDP towards pharmaceutical products.
0.8%。
Point 8%.
0.8%的
Point 8% of
我们GDP的1%用于药品。
our 1% of our GDP goes to drugs.
那不是医疗体系，我认为医疗体系占17%。
That's not the health care system, which I think is 17%.
对。
Right.
其中的1%，占我们医疗支出的整整6%，直接流向了制药公司。
1% of it, a full 6% of our health care, goes just directly to the drug companies.
所以我们希望
So we want
你的数学是怎么回事？
What's with your math?
这相当惊人。
It's quite quite impressive.
是的。
Yeah.
谢谢。
Thank you.
所以，我提出这一点是因为这些百分比在这里很重要。
So Point well, point I only bring this up because the percentages make a difference here.
第八点。
Point 8%.
这就像我们在玩二十一点。
It's like Comes from us playing blackjack.
计算器到这个。
Calculator to this.
我知道。
I know.
我知道你
I know you
不知道。
don't know.
是的
Yeah.
这源于我们一起玩二十一点和扑克。
Comes from us playing blackjack and poker together.
我在这儿输了很多钱给那些外行。
You I've lost a lot of paying two outers over here.
我确实输了很多钱给这个人，所以我再也不和他下棋了。
I well, I've been I've lost a lot of money to this guy, and I don't play him in chess anymore.
弯曲，但不要折断。
Bend, but don't break.
你希望他们稍微弯曲一点，保持合理，但你不希望破坏整个行业。
You want them to bend a little bit, be reasonable, but you don't wanna break the industry.
作为一名医生
As a what's doctor
这件事的关键是，你经常听到‘可负担性’这个术语
the upshot of this, because you So hear this term affordability a
普通美国人支付的药价会更低吗？
the average American's gonna pay less for their drug prices?
我们会支付得更少。
We're gonna pay less.
我们正在告诉所有欧洲国家。
The Europeans, we are telling the all the countries.
我们正处于这些讨论之中。
We're in the middle of these discussions.
我们刚刚让英国同意了，其他国家也在和我们讨论，他们只支付0.3%。
We've just gotten the British to say yes, and other countries are talking to us about the fact that they pay point 3%.
他们花的钱不到我们的半成，却能占便宜，因为他们的民众并不知道，如果在欧洲患上癌症，尤其是晚期癌症，你的存活率远低于美国；而且由于平均要延迟好几年才能获得这些药物，而美国能很快获得，是的，你可能花得更少，但你的民众正在付出代价。
So less than half of what we pay percent wise is being spent by them and they get away with it because their people don't realize that if you get cancer, more advanced cancers in Europe, your survival rate's way below The US and if you don't get access to the drugs, which they don't for several years on average, that we get in The US, yes, you can get it for cheaper but your people are paying a price.
这正是我今天要传达的重要信息。
And this is kind of the important message that I'm going deliver today.
最重要的信息是：不要把医疗保健看作一种支出。
The most important message is don't think about healthcare like an expense.
把它看作一种投资，因为如果我能帮助普通美国人多工作一年，是因为他们以更合理的价格获得了药物，没有在药房却步，或者因为我们能够正确处理其他健康问题。
Think of it as an investment because if I can get the average American to work one year longer because I got the medication at a better price, they didn't turn away at the drugstore, or because we're able to do something else correct Morbilities.
随便吧。
Whatever.
错过了这个趋势。
Missing The the movement.
我们会讨论所有这些。
We'll talk about all this.
但如果你能让普通美国人多工作一年，这对美国经济的价值就是3万亿美元。
But if you can get the average American to work one year longer, that is worth $3,000,000,000,000 to The US economy.
这是巨大的。
It's massive.
我们需要让人们感觉良好，感受到自己对未来的掌控力，并确信自己能对世界产生影响，这样他们才愿意在工作中继续努力；而这一年的额外工作时间，顺便说一下，也能帮助我们应对国家面临的其他财务危机。
We need to get people feeling their best, feeling that they have agency over their future with confidence that they're gonna make a difference in the world so they want to keep trying to do it at the workplace and that extra one year, which gets them closer to Medicare, by the way, also helps deal with other financial crises that we're facing as a nation.
所以，这才是正确看待这个问题的方式。
So this is the way to think about it the right way.
降低实际医疗成本。
Get the actual cost of care down.
不要只是往系统里投入更多钱。
Don't just pay more money into the system.
降低实际医疗成本，让我们花的钱获得更大的价值。
Get the actual cost of care down so the money we're spending gets us more value.
我们花在医疗上的钱是那些拥有全民医疗保健国家的两倍。
We're spending twice as much as these other countries who have universal health care.
你确实提到，他们获得治疗的时间会晚一些。
Now you did point out that they get things later.
所以我们的系统更好，
So we have a better system,
但我们为此付出了高昂的代价。
but we pay through the nose for it.
这确实是对当前状况的准确描述
That that would be an accurate way of describing the current state
状况吗？
of affairs?
表述得非常准确。
Precisely stated.
是的。
Yes.
好的。
Okay.
那我们如何让每个美国人都获得医疗保障？
So how do we get every American health care?
因为我相信，我们面临的很多紧张情绪源于一些人可能没有现在在座的这些人那么富裕，他们每天都活在这种恐惧中。
Because I believe a lot of the tension we have comes from a fear from people maybe who are not as well off as as the people on the pod right now, and they live with that fear.
我们不会活在这种恐惧中。
We don't live with that fear.
我们知道，如果我们需要医疗，我们一定能解决。
We know if we need to get health care, we're gonna figure it out.
我们可以自费支付，或者由保险支付，但有些人会因为这个而破产。
We'll be able to pay for it out of pocket or insurance will pay for it, but there are people who go bankrupt because of this.
作为医生，我猜你支持全民医疗保障？
You believe in universal hair health care, I would assume, as a doctor?
我希望每个人都能获得医疗保障。
I want everyone to have access to health care.
但如何为它筹资才是这里的关键问题。
But how we pay for it is the defining issue here.
你如何让这个体系保持动力去照顾你？
How do you keep the system incentivized to take care of you?
如果我告诉全美国的人，你们都有医疗保障，然后又告诉医生：给他们提供医疗，但你们不用处理财务成本，那么你们就会突然开始限制医疗服务的获取。
If I tell everybody in America that you have healthcare, and then I tell the doctors, Give them healthcare, but they don't deal with the financial costs, then you all of a sudden start to restrict the access to care.
所以你们可以在像社会化医疗国家那样获得医疗保障。
So you can get the health care like you do in socialised medicine countries.
但你得等上六个月、一年甚至更久，或者根本得不到治疗。
You just have to wait six months or a year or longer or you don't get the care at all.
当你跟美国人讨论这个问题时，他们会说：等等，等等，稍等一下。
And when you start having that discussion with Americans, they say, Wait, wait, hold on second.
是的，我当然希望以合理的价格获得医疗服务。
Yes, of course I want to get the health care for an affordable price.
但核心问题是，我到底要等多久才能得到治疗？
But the question the fundamental question is, how long till I actually get the care?
有
There are
有些人被拒之门外，他们早已习以为常。
some Being denied is something they live with.
所以他们抱怨自己的全民医疗。
So they complain about their universal health care.
我们则抱怨没有全民医疗。
We complain about not having universal health care.
这两者有什么
What are the two
或者，我会关注那些寻求国际治疗的患者流动情况。
or Well, the thing I would look at is the flow of patients who seek treatment internationally.
我听过很多关于加拿大人来美国接受治疗的故事。
I hear lots of stories about Canadians coming to The U.
美。
S.
为了接受治疗，因为他们不想
To get treatment because they don't want
等两年才得到最新的治疗方案
to wait two years To get the latest for
有些人不仅是为了最新的治疗，而是因为如果等两年，他们可能就死了。
some proceed not just the latest, to get some procedure because they could be dead in two years.
所以他们来到这里。
So they come here.
我没听说过任何美国人
I don't hear any Americans
嗯
Well
谈论去加拿大接受治疗。
talking about going to Canada to get treated.
实际上，我们有不少例子，涉及一些需要自费的手术和治疗。
Actually do have a number of examples of that in surgeries and treatments that you have to pay for out of pocket.
整形、牙科，人们都在前往，这已经变成了一种旅游现象，有些人甚至会搬迁地点。
Cosmetic, dental, people are going, and this has become tourism, and there are people who do change locations.
是的。
Yes.
这些是手术程序。
This is procedures.
你提到了整形手术。
You mentioned cosmetic surgery.
对。
Yeah.
这确实是一个趋势。
That's definitely a trend.
而且，还有一些手术我们在美国并不做。
And also, there's some procedures that we don't do in America.
干细胞。
Stem cells.
干细胞。
Stem cells.
它们仍在接受监管审批。
They're still going through the regulatory process.
但更大的问题其实是戴维提出的：大多数美国人抱怨医疗体系已经崩溃。
But the bigger issue really is one David's raising, which is most Americans complain that the health care system is broken.
几乎没有人会为了获得顶级的救命医疗而离开本国。
Almost none would leave the country to get top tier health care for a life threatening problem.
因此，我们面临着这种奇特的机遇。
And so we have this sort of bizarre opportunity.
我认为这确实是一个机会。
I do think it's an opportunity.
我们如何让顶级医疗服务惠及真正需要的人，同时保持价格的可持续性？
How do we make the top tier health care available to to folks who need it but do it at a price that is sustainable?
我认为这就是你的专业领域发挥作用的地方。
And that's where I think your specialty area comes into play.
在本届政府之前，由于我们缺乏能够令人信服地承诺实现这一目标的技术，人们对于做出重大变革持犹豫态度。
Before this administration, I think because we didn't have the right technologies to promise convincingly that we could do this, there was a hesitancy to make big shifts.
我们现在大胆推进，因为我们认为人工智能已经成熟。
We're taking big swings because we think AI is ready.
我们认为医疗领域可能发生的科技变革值得补贴。
We think the tech transformation that's could happen in health care is worth subsidizing.
我的意思是，让那些开发应用程序、帮助你应对自身医疗危机（比如糖尿病）的顶尖创业者成为可能。
And by that, I mean making it possible for top tier entrepreneurs who are building apps that can help you deal with the medical crisis that you're dealing with, their diabetes.
我们可以通过向系统注入资金，使这些努力变得值得，从而吸引投资者支持你，获得合理的估值。
We can put money into the system to make that worth you doing so you can get investors to support you, you can get a fair valuation.
所以，用技术降低成本，这显然是巨大的胜利。
So technology to lower the price, obviously, that's a huge win.
让我问你一个棘手的问题。
Let me ask you the the difficult question.
作为医生，最近有一些研究指出，目前大型语言模型提供的建议不仅优于普通医生，而且更有亲和力，患者也更喜欢使用大型语言模型而非普通医生。
As a doctor, there have been studies that came out recently that not only do LLMs currently give better advice than the average general practitioner, they have better bedside manner, and the customers or the patients enjoy the LLM more than they enjoyed a GP.
你看到这个研究了吗？
Did you see that?
我还没看过这个。
I haven't seen that.
这项研究出自哈佛或麻省理工学院。
This is a study that came out of either Harvard or MIT.
我会把链接放在节目笔记里，但这是一项相当突破性的研究。
I'll put it in the show notes, but this is a pretty groundbreaking.
你有什么看法？
What are your thoughts?
如果你要进入一个新社会，你必须去看全科医生，他们问你一堆问题，然后查阅医学资料，得出他们的建议，这个想法好吗？
If you were going to a new society, is this idea that you have to go to the GP, they ask you a bunch of questions, then they go on their medical texts, figure out what their advice is.
对于普通感冒或脚踝扭伤，与其这样，不如像大多数没有保险的美国人或自我导向的人那样做，是不是更好？
Is that the best modality, or would it be better for the common cold, for an ankle sprain, to do what most Americans without insurance are doing or people who are self directed?
他们去使用一个大型语言模型。
They go on a large language model.
模型会告诉他们如何处理这些问题，然后他们自己动手解决，可以处理一些小问题。
It says, here's how you deal with these issues, and they do it themselves, and they can take care of a couple things.
难道不是直接让他们先自己处理这些事，再决定是否该去看全科医生更好吗？
Wouldn't it be better to just have them do this stuff and then decide if they should go see their GP?
我认为可以采取一种混合方式，稍微降低一些风险。
I think there's a hybrid of that that derisks it a little bit.
早期确实存在幻觉等问题，而美国人对这些错误非常不能容忍。
Early on, there are definitely problems with hallucination and the like that that Americans we're very intolerant to.
但我们其实能理解，一个拥有医学博士头衔的人犯错是难免的。
We actually understand if a human being who has an MD degree makes a mistake.
我们认为人工智能是完美的，因此完全无法容忍任何错误。
We think AI is perfect and are completely intolerant.
他们甚至犯了轻微的过失。
They've even been a minor transgression.
是的。
Yeah.
你之前说的没错，这类研究现在已经做了好几次了。
What you said earlier is true, and these studies have been done several times now.
大型语言模型在执照考试中的表现更好，因为它们掌握的是通用知识。
The The large language models do better on board exams, so they take general knowledge.
它们比医生更优秀。
They're better than a doctor.
它们比医生更有耐心。
They're more patient than a doctor.
如果你和一个由AI驱动的虚拟形象交谈，它会一整天不厌其烦地回答关于糖尿病的同样十个问题。
If you talk to an AI informed avatar, they'll answer the same 10 questions on diabetes all day long and not get bored.
你去问问全科医生，他们在接待了十位患有糖尿病、问了同样十个问题的病人之后，回答就会变得有点生硬，这完全是人之常情——我不想一遍遍回答同样的问题，但病人却需要你这么做。
Talk to a general practitioner after they've talked to 10 patients with diabetes who've asked the same 10 questions, you get a little terse in your responses, that's just human nature, I don't want to answer the same question every time, but that's what patients need you to do.
所以我认为我们有机会，我们也研究了一些这样的模型。
So I think we have the opportunity and we looked at some of these models.
事实上，约翰·杜尔带了一群非常有洞察力的创业者来到公司，讨论如何将普通全科医生的效率提升五倍，甚至十倍的可能性。
In fact, John Doerr brought a bunch of very thoughtful entrepreneurs into the building to talk about the possibility of us taking the average general practitioner and making them five times, maybe even 10 times more efficient.
现在，重点来了。
Now here's the big deal.
美国的全科医生数量不足。
There are not enough GPs in America.
我们可能需要两到三倍的数量，才能跟上欧洲的水平。
We probably need two to three times more just to keep up with Europe.
这只是按人均计算。
It's just per capita.
我们的比例远低于他们，因为我的儿子刚完成医学院学业。
We're way below because like, because my son just finished medical school.
他在哥伦比亚大学就读时，那里医学院里很少有学生打算成为全科医生。
There aren't many kids in medical school at Columbia where he went who are going to become GPs.
他们都想成为眼科医生，或者骨科医生，因为这些职业收入高得多。
They all want to be ophthalmologists and, you know, orthopedic surgeons because they pay a lot more.
而且他们为了学业背负了巨额贷款。
And they got big loans for their Yeah.
而且他们
And they're
负债累累。
in debt.
他们负债累累。
They're in debt.
而这正是
And this is
就连哥伦比亚大学的学费都是免费的。
even Columbia's free.
如果你没钱，在哥伦比亚大学就不需要支付学费。
If don't have money, you don't have to pay tuition at Columbia.
他们这么做是为了让孩子们去从事全科医疗，但至今尚未产生预期的效果。
They did that so that kids would go into general practice and it hasn't had the desired impact yet.
但更广泛的问题是，在这一过渡时期，我们如何让人工智能发挥作用，让人们感到安心？
But the broader question is, how do we allow AI to play a role as this transition period happens so people feel confident?
其中一种方式是让AI承担大部分工作，尤其是借助基因AI，消除文书工作和琐碎事务，只向医生提供关键信息。
And one way of doing it is to allow it to do most of the work and then, especially with the Genetic AI, take the paperwork out of it, the busy work out of it, and feed the doctor the key information.
作为一名医生，我最重要的工作是什么？
What's the most important thing I do as a doctor?
我看着你的眼睛，观察你，努力与你建立联系。
I look at you in the eyes and I read you and I try to connect with you.
我们大脑皮层的50%，也就是我们高级认知功能的50%，都用于解读你的表情。
50% of our cortex, of our high high cognitive function, 50% of it is to read your face.
我们天生就是社会性动物，懂得理解那些细微的差别，比如大卫感到无聊了。
We're hardwired to be social animals, to understand the subtle little David's bored.
你没有。
You're not.
我得调整一下节奏。
I gotta change the pacing.
我得把他拉回来。
I gotta get back him.
他正在用右脑做卡片计算。
He's doing card calculations in his Right.
公平地说，大卫直到凌晨一点才休息。
In fairness to David, he was out till 1AM.
他们带他参加了四场会议。
They dragged him to four meetings.
我九点就上床了。
I was in bed at nine.
我的睡眠质量很好。
I have good sleep health.
我戴上了我的WHOOP。
I got my WHOOP.
我拿到了我的睡眠评分。
I got my sleep score.
我和你一样，是个枕头公主，奥兹医生。
I am a pillow princess like you, doctor Oz.
我听说你对睡眠特别讲究。
I hear that you're extreme about your sleep.
嗯，我是个称职的守护者。
Well, I'm a good steward.
我妻子是个世界级的睡眠高手。
My wife is a world class sleeper.
她会自带枕头。
She brings her own pillows.
顺便说一句，你妻子真可爱。
Your wife is delightful, by the way.
谢谢。
Thank you.
在我们上台之前，我先对丽莎进行了一个小时的采访。
I did an hour interview with Lisa before we even got on stage here.
我当时就想，哇。
I was like, wow.
她真令人印象深刻。
She's impressive.
为了进一步说明这一点，我觉得这很有趣。
To build on this point, I mean, think it's interesting.
我认为未来的医生和患者都会变得更聪明，他们各自都会使用自己的工具，比如患者会使用像ChatGPT、Grok这样的消费级产品等等。
I think we're gonna get smarter doctors and smarter patients and they're each gonna use their own version of So, you know, what patients are gonna use is consumer product, ChatGPT, Grok, you know, and so forth.
我觉得有趣的是，当他们能把自己的血液检测报告输入进去的时候。
What's interesting I think is when they can dump in their blood panels.
是的。
Yes.
因为人工智能在阅读PDF和非结构化数据方面非常出色。
Because AI is so good at reading PDFs, just unstructured data.
所以你可以把所有资料都输入进去，询问诊断结果，从而获得更深入的理解，自己研究病情。
So you dump all your stuff in it, you ask for a diagnosis, you get smarter, you can research your own condition.
你不会浪费医生的时间去问一些基础问题了。
You're not wasting frankly the doctor's time by asking basic
你成了一个更明智的消费者。
You're a better consumer.
你成了一个更明智的客户。
You're a better customer.
没错。
Right.
你成长为一位更懂行的患者。
You grow up doctor.
然后医生们可以使用ChatGPT或其他工具，但他们实际使用的是更专业、更专门的工具，我见过的那些就是如此。
Then the doctors, they can use ChatGPT or what have you but actually they're using specialized, much more specialized tools that the ones I've seen.
它们会直接给你引用医学期刊的来源。
They will give you a citation directly to a medical journal.
你可以把这一点带给医生，因为这很重要，这样你就知道它不是虚构的。
You can bring Because that's to your important to doctors so you know it's not hallucinating.
只是从你所知道的那里获得答案，是的。
Just getting the answer from you know, Yeah.
这就像，那是杰里米的你
And it's like, that was on Jeremy's You
你需要知道这个
need to know what the
来源是什么。
source is.
这没问题。
Which is fine.
对。
Right.
展开剩余字幕（还有 480 条）
如果你从乔那里获取信息，就反过来推导到顿悟。
If you if you get information from Joe, then work backwards to enlightenation.
完美。
Perfect.
让我问问你关于这个趋势的事。
Let me ask you about this trend.
这是自我主导的医疗保健。
This is self directed health care.
Function Health 在做血液检测，Superpower 也是。
There's Function Health doing blood labs, Superpower.
Whoop 刚刚开始提供这些服务。
Whoop just started offering them.
Aura、Apple Watch、Eight Sleep。
Aura, Apple Watch, Eight Sleep.
我是这家公司的投资人。
I'm an investor in that one.
坦白说。
Full disclosure.
它表现得非常好。
It's doing great.
这些设备现在正在把所有这些数据整合起来，开始告诉你你的生命跨度、你的实际年龄与健康年龄之间的差异。
These things are now putting all that data together and starting to tell you your life's your health span, your, you know, your actual age versus your health age.
我不确定这个指标具体是什么。
I don't know sure what that metric is.
但人们现在正在测量各种数据，获得一些相关信息，然后去见全科医生。
But people are now measuring things and getting some knowledge of this and then going to a GP.
我遇到的问题是，我不在意价格，我可以找任何一位私人医生，但目前愿意这样工作的医生非常少。
The problem I'm having is, and I'm not price sensitive, I could get any concierge doctor I want, there's very few doctors who wanna work like this at the moment.
这必须改变。
That's something's gotta change.
但你对这群从事自我主导医疗的人怎么看？他们每年做两次血液检测，把数据输入数据库，Pronovo使用三维扫描，Nico、Daniel的新公司提供300美元的全身扫描。
But what do you think of this new group of people who are doing self directed health care, doing two blood labs a year, putting it into a database, Pronovo with the three d scans, Nico, Daniel x new company, doing a $300 full body scan.
所有这些，会成为范式转变吗？
All of this, is this gonna be the paradigm shift?
二八法则。
Eighty twenty rule.
如果百分之二十的美国人按照你说的去做，他们会的，是的。
If twenty percent of Americans do what you're saying and they will Yeah.
这会让整个医学体系运作得更好。
It'll make all of medicine function better.
我实际上更担心另一端的人群。
I'm actually concerned about the other end of the spectrum.
说说看。
Tell me.
那些不去看医生的人。
The people who don't go to their doctors.
医疗补助对象，医疗补助对象更有可能是那些弱势群体，收入较低，接受政府医疗保险的人。
Medicaid patients Medicaid patients are twice as likely Medicaid is the folks who are vulnerable, are have made less money, they're getting government health insurance.
对。
Right.
医疗保险是给
Medicare is for
那就是我们的全民医疗保健。
the That is our universal health care.
对。
Right.
我们需要在这里提供帮助。
That's that's where we need help.
是的。
Yeah.
那些无力支付医疗费用的医疗补助患者，取消医生预约的可能性是医疗保险患者的两倍。
The chance of a Medicaid patient who doesn't pay for their health care because they don't have the means to do it, the chance of them cancelling their doctor's appointment is twice that of a Medicare patient.
因此，很难为他们提供照顾。
And so it's hard to take care of them.
现在，他们有两份工作，如果提前离职就会被解雇，他们没有灵活调整日程的自由，也没有交通工具。
Now, they have two jobs, they'll get fired if they leave the job early, they don't have the flexibility of moving their calendar around, they don't have transportation.
他们不来的原因有很多，但如果我无法把医疗服务送到他们身边，对我们来说就是一场重大危机。
There's lots of reasons they don't show, but if I can't get health care to them, that's a major crisis for us.
因此，人工智能真正的机遇在于让医疗服务更加普及。
And so the real opportunity for AI is democratizing health care.
是的。
Yes.
看，你们已经很聪明了。
See, you guys are already smart.
你们刚才脱口而出就列出了十几家在做出色工作的公司。
You just listed off top of your head a dozen companies all doing great work.
大多数人根本不知道这些公司存在，也不了解它们在做什么。
Most people have no idea these companies exist or what they do exist.
对。
Right.
所以，如果我能把我的实验室数据输入AI，而我对医疗健康了解不多，我也可以在准备好接收信息时，以我能理解的方式获得相关信息。
And so if I can put into AI my labs and I don't know much about healthcare, I can get information sent to me in a way that I can process it at the time I'm ready to hear it.
现在我再给你一个可能有用的数据点。
Now I'll give you one more data point that might be useful.
所有医疗保险参保人，所有65岁及以上的老年人，每年都可以免费接受一次健康检查。
All Medicare patients, all seniors 65, all of them are given a free wellness exam every year.
有多少人会去接受这项免费体检？低于百分之五。
What percentage of people take their free medical exam without Less than five percent.
不，没那么糟糕。
No, it's not that bad.
哦。
Oh.
低于百分之五十。
It's less than fifty percent.
低于百分之五。
Less than five percent.
好的。
Okay.
但大多数人并不去做。
But most people don't do it.
它就在那里。
It's there.
我们认为发生这种情况的部分原因是你们没有将其视为优先事项。
Part of the reason we think this happening is you don't prioritize it.
这里有一个更重要的数据点。
And here's the more important data point.
真正去看医生的人认为自己更不健康，但实际上他们比不去看医生的人健康得多，因为无知是幸福的。
People who actually see their doctor think they're sicker, but they're actually much healthier than people who don't see their doctor because ignorance is bliss.
那些不去看医生或不寻求任何健康建议的人认为自己状态很好，但客观来说，他们的状况要差得多。
People don't go to their doc or seek any kind of health advice think that they're doing great, and actually objectively, they're doing much worse.
因此，我们有机会通过说‘好吧，我会在你所在的地方与你相遇’来普及这一点。
So we have an opportunity to democratize this by saying, okay, I'm gonna meet you where you are.
你根本不关心去看医生，即使它是免费的。
You don't care about going to see a doctor even though it's free.
这是属于你的。
It's yours.
在这个我们正在构建的新医疗科技生态系统中，我和艾米·格利森在一起，她也来自Randoz，帮助推动这一切的落地。
In this new health tech ecosystem we're building out, I'm with Amy Gleason, who also Randoz, you know, helping to to to roll this all out.
我们正在让每一家科技公司都能更轻松地参与进来。
We're making it easier for every tech company to participate.
已有600家公司签署承诺，同意实现互操作性、数据透明，并为美国民众开发这些工具。
600 companies have signed a pledge agreeing to interoperability, data transparency, and to build these tools for the American people to be able to use them.
一旦我赋予你更充分的能力来照顾自己，你就能改变整个体系。
Now once I deputize you to be better equipped to take care of yourself, you change the system.
因为当你第一次问医生问题时，作为唯一的患者，他们根本不会在意。
Because when you ask a doctor a question, the first time you're the only patient, they don't pay attention.
当第二个患者问同样的问题时，我们就改变了。
The second patient who asks the same question, we change.
作为一名医生，我告诉你，当患者推动我们关注医生办公室中的环境信息采集时，这对我们很有帮助，这样我就能获得一份关于你向我陈述内容的医疗报告。
As a physician, I'm telling you, it helps us to have patients pushing us to pay attention to, for example, ambient collection of information in the doctor's office, so I get a medical report on what you told me.
为什么？
Why?
因为医生告诉患者的信息，有50%在患者离开诊室前就被遗忘了。
Because 50% of what a doctor tells a patient is forgotten before the patient leaves the office.
所以当你的孩子问你：‘嘿，医生怎么说的？’
So when your kid asks you, Hey, what happened with the doctor?
你却想不起来了。
You don't remember.
你紧张、焦虑，医生说话又快，还用了很多专业术语。
You're nervous, you're anxious, the doctor spoke quickly, used big words.
把这些都拆解清楚。
Break all that down.
突然间，信息就能顺畅地流动了。
All of a sudden, information gets flowing easily.
现在你有了更多的利益相关者。
Now you've got a lot more stakeholders.
那么最终的利益相关者是谁？
And who's the ultimate stakeholder?
患者。
The patient.
因此，历史上一直被医疗记录公司掌控的医疗记录
So the medical records who historically have been hijacked by medical record companies
而且被隐藏了。
And hidden.
而且被隐藏了。
And hidden.
那你该怎么获取它们呢？
Like how do you ever get them?
是的。
Yeah.
现在所有这些公司都说：好吧。
And all those companies now are saying, alright.
我们明白这个笑话了。
We get the joke.
这又回到了总统身上。
And this is again, back to the president.
他对这件事可不是在开玩笑。
He's not fooling around in this stuff.
当他告诉你他希望你共享数据时，你知道如果你不解决这个问题，他一定会找你算账。
When he tells you he wants you to share data, you know he's gonna come after your ass if you don't deal with this problem.
所以他们都来了，说：好吧。
And so they've all come and said, alright.
你知道，我们现在也明白这个笑话了。
You know, we're in on the joke now.
制药公司，当我们谈判最惠国待遇时，当我们质疑他们并说你们对同样的产品收费高出好几倍时，他们是怎么说的？
The pharma companies, when we're negotiating most favored nation, you know what they said when we challenged them and said, you're you're charging several times more for the same products?
他们说，好吧。
They said, alright.
嗯，我们知道总有一天你会找上门来。
Well, we knew one day you'd come knocking.
我们知道他会这么做。
We knew he'd do it.
所以我们真的觉得总统会对我们采取行动，因此我们愿意谈判。
So and we actually think the president would do something to us, so we're gonna negotiate.
你不想浪费这份权力。
And you don't wanna throw away that power.
你知道，别求原谅。
You know, don't beg for forgiveness.
要推动行动。
Push for action.
是的。
Yeah.
你知道的，去把事情办成。
You know, go make things happen.
如果没成功也没关系，你还有更多机会。
And if they don't work out fine, you you you get more more bites at the apple.
就关于那个承诺这一点，因为我收到了
Just on that point about the pledge, because I got
去白宫参加那个活动。
to attend that event at the White House.
是你组织的。
You organized it.
别太谦虚了。
Well Don't be modest.
我的意思是，这功劳太大了，但说实话，主要是你和艾米·格里森还有肯尼迪秘书，你们只是不知为啥邀请了我。
Mean, it's gonna be a little bit too much credit, but it was honestly, it was you and Amy Gleason and Secretary Kennedy, and you guys just happened to invite me for some reason.
但这真的很有趣，因为以我这个外行的理解，法律赋予了我们获取自己医疗记录的权利。
But it was it was really interesting because this is my kind of layman's understanding of it which is the law gives us the right to our own medical records.
但在实际操作中，我们得不到这些记录。
But in practice, we don't get them.
HIPAA法规？
HIPAA regulations?
这是因为存储健康记录的公司使用的是专有格式，我们并不知道如何获取这些数据，即使获取了也不知道该如何使用。
Well, it's because companies that store the health records do it in proprietary formats and we don't really know how to get that data and what would we do with it even if we did.
因此，关键在于让这些健康记录与我们可能使用的其他医疗公司共享。
So the key is to get those health records shared to all the other medical companies in the space that we might want to use.
这就是承诺的力量——让这600家公司参与进来。但我认为人工智能才是这里的神奇粘合剂，因为人工智能非常擅长读取不同格式的数据并进行转换。
Hence the power of the pledge, get these 600 companies But I think that AI is kind of the magic glue here because AI is so good at reading data from different formats and translating it.
完美。
Perfect.
所以你并不需要一个完美的API，不需要。
So you don't need like a perfect API Nope.
再也不需要了。
Anymore.
你只需要获取非结构化数据，丢进去，它就能正常工作了。
You just get the unstructured data, dump it in, and now it just works.
这正是我们开始看到的情况。
Which is what we're starting to see.
我把我的Eight Sleep数据、WHOOP数据、血液检测结果都输入到四大平台中的每一个，然后向它们提问。
I'm taking my Eight Sleep data, my WHOOP data, my blood panels, and I'm putting it into all four of the major ones, asking it.
我会拍下我每一种补充剂或饮品的照片。
I take pictures of every one of my supplements or drinks.
这会产生什么影响？
What impact will this have?
这会对睡眠产生什么影响？
Which impact will this have on sleeping?
是的。
Yep.
我觉得这简直是一个巨大的胜利。
I think that's, like, this gigantic win.
是的
Yeah.
你能实现法律赋予你的权利，真正拥有自己的医疗数据，并将其转化为可用的格式，再通过聊天界面来理解它。
You being able to realize the promise that the law gives you to actually own your own medical data, but to get it in a usable format that now you can use again a chat interface to understand it.
这是技术上的模糊化。
It's technological obscurification.
让我们直呼其名吧
Let's call it what
就是这样。
it is.
他们总是试图使用专有格式来获得技术优势，并为自己的业务筑起护城河。
They're trying to use this proprietary formats always to get a technological advantage and to have a moat around their business.
人工智能能解码这些数据，使其变得可用，现在你可以与之互动了。
AI just decodes that and makes it usable, and now you can you can interact with it.
我能提一下其中一个原因吗？
Can can I bring up one the reasons?
所以，医生。
So, Doctor.
奥兹，你提到了民主化。
Oz, you mentioned democratization.
你和我曾经讨论过，有些州实际上正试图禁止在心理治疗中使用人工智能。
You and I have had a conversation about certain states are actually trying to ban the use of AI to be used in therapy.
我想你当时对我说的是：你知道吗？
And I think the point you made to me is, you know what?
在全国各地，比如农村地区，有很多地方根本没有精神科医生或精神健康服务。
There's a lot of places all over the country, like rural areas, where there aren't psychiatrists or there isn't psychiatric care.
因此，至少人工智能提供了一个基础水平的服务。
So at least AI provides a baseline level of service.
第一版可能并不完美。
Version one may not have been perfect.
可能曾出现一些幻觉，但每年都在变得越来越好。
There may have been some hallucinations, but it is getting better and better every year.
如果你禁止它，那么很多人就什么都没有了，对吧？
If you ban it, then a lot of people are just gonna have nothing, right?
说得真好。
Beautifully stated.
让我们稍微展开说一下，但总体来说，AI即将来到你附近的社区，你是阻止不了的。
Let's just go over let's unwrap that a little bit but I'd just at a high level say, AI is coming to a neighborhood near you, you're not stopping it.
是的。
Yeah.
所以它一定会存在，患者也会使用它，因此你必须积极参与，而不是逃避。
So it's gonna be there and patients are gonna use it and so you have to engage it, running from it.
我们不能对这个问题视而不见。
We cannot stick our head in the sand on this one.
有些事情你还可以拖延，我已鼓励每一位州长全力推进，但要以正确的方式进行。
There's other things you can sort of delay, I've encouraged every governor, go full bore at this, but do it in the right way.
让专业人士能够充分发挥其执照所赋予的能力。
Allow professionals to function at the height of their licensure.
我们为什么不能更好地利用药剂师呢？
Why don't we use pharmacists better?
大概有七万名药剂师，对吧？
There's probably 70,000 pharmacists, right?
换个角度想，几乎所有的美国人，95%的人，都住在五英里范围内的药店附近。
Think about it this way, almost all Americans, 95%, live within five miles of a pharmacy.
他们通常并不住在医院附近，因此在很多方面我们无法获得医疗资源。
They don't live near a hospital usually, so we don't have access to care in many ways.
如果我们只是利用人工智能，让药剂师和全科医生能够发挥更高水平的职能，这本身就已经值回这个机会了。
If we just took AI and allowed pharmacists and doctors, GPs to function at a higher level, it itself would be worth the opportunity.
所以，我甚至不是在主张使用那些根本不了解你、我们无法控制的AI代理，也许其他国家会介入其中。
So I'm not even saying advocate at all to an AI agent that doesn't really understand you, we can't control, maybe some other country gets involved in it.
从最实际的层面来看，我们缺乏足够的医疗从业者。
At its very practical level, we do not have enough practitioners.
根本就没有足够的人手来照顾美国的农村地区。
There just aren't enough people to take care of rural America.
有六千万生活在农村的美国人无法获得心理健康服务。
60,000,000 Americans living in rural America don't have access to mental health services.
我们的退伍军人自杀率高得惊人，远超战争中的死亡人数，因为他们无法获得心理健康服务。
Our vets commit suicide at a crazily high rate more than we lose in war because they don't have access to mental health services.
其中许多人确实生活在农村地区。
Many of them do live in rural America.
因此，如果我们想要解决这类耗时的问题，你不可能指望公园大道的精神科医生去那里行医。
And so if we're going to fix those kinds of problems, which are time consuming, you're not going to get Park Avenue psychiatrist to go practice medicine.
每小时800美元。
At $800 an hour.
在阿拉斯加北坡的冬天，每小时800美元。
At $800 an hour in the North Slope of of of Alaska in the winter.
这根本不可能发生。
This is not gonna happen.
因此，我们国家刚刚投入的这500亿美元，只是总统推动并通过、国会支持的工薪家庭减税法案中的一部分，确实提供了实际帮助。
And so this $50,000,000,000 investment that we as a country just made, just just the money was part of the a real help the the working families tax cut cut legislation that the president pushed through and congress got behind.
500亿美元，这是我国机构有史以来对农村医疗最大的投资，但在年底之前就被放弃了。
$50,000,000,000, the largest investment ever made in rural health care through our agency, was given up by the end of the calendar year.
所有州长都拿到了这笔钱，我们要求他们为自己的社区带来改变。
All the governors have the money, and we charge them to make a difference in their communities.
你了解自己的社区。
You know your communities.
他们几乎都回禀了某种人工智能元素。
They almost all came back with some AI element.
他们都明白，要真正实现农村地区的医疗覆盖，必须对体系进行合理调整。
They all know to really be able to get health care in rural America, you've got to right size the system.
合理调整体系意味着，医院的运作方式将有所不同。
Right sizing the system means, you know, we have the hospitals are gonna work out differently.
医生们将以不同的方式协作，但人工智能是社会的核心要素。
Doctors will work differently with each other, but AI is the core element of social
这些微型医院就像人们在自家后院建造附属住宅单元（ADU），为祖父母多提供一个住所，或用作Airbnb。据我了解，现在有一批初创公司正在研发类似的微型医院——一个配备核心服务的房间，可能有一名执业护士常驻，再通过远程医疗提供支持。
And these micro hospitals, just like people are putting ADU units in the back of their homes to get an extra, you know, apartment for grandma and grandpa or as an Airbnb, my understanding is there's a bunch of startups working on the equivalent building a micro hospital, a room with the central services, perhaps a nurse practitioner who are there's more available, and then you telemedicine in.
将医疗服务带到这些地区，而无需建造大型医院，也是一种胜利。
Just bringing the medicine to those areas without having to build a giant hospital is also a win.
是的？
Yeah?
我认为这些微型诊所能提供顶级的医疗服务。
The micro clinics, I think, to are huge provide top tier care.
但这还远远不止于此。
But this goes beyond that.
我们有由人工智能支持的机器人，将在阿拉巴马州一些没有产科医生的地区进行超声检查。
We have AI supported robots that are gonna be doing ultrasounds in parts of Alabama where there are no OBs.
对。
Right.
我们使用无人机向阿拉斯加北坡地区运送处方药，那里没有公路。
We have drones delivering prescription medications to the North Slope Of Of Alaska where there are no roads.
我们还有智能药柜，可以自动发放药品。
We have we have the vending machines that can dispense smart dispensing of medications.
顺便说一下，这种事情在其他国家也在发生。
By the way, this is happening in other countries.
所以我们希望在美国也实现这一点，为什么不利用农村健康转型基金提供的巨额资金——500亿美元——来推动全国农村地区的创新工作呢？这些地区正是我们国家的根本所在。
So we want this to take place in America, and why not take advantage of an opportunity through with a huge massive inflow of money, which is Rural Health Transformation Fund does, the $50,000,000,000, to start to do some innovative work in rural parts of the country, which is the the foundational element of who we are as a nation.
这些价值观会惠及我们其他人。
Those values ripple up to the rest of us.
我也认为，现在各州之间的交流方式已经不同了。
I also think that states now are talking to each other differently.
既然现在有了可以改变世界的资金，它们开始以完全不同的方式谈论人工智能和技术。
Now now that you've got money that's out there that could be used to change the world, they start talking about AI and technology generally very differently.
现在这不再是零星的研究了。
Now it's not a it's it's it's not a sparse research.
我们生活在一个富足的世界里，如果我们正确使用人工智能，它会让这种富足更加显著。
We live in a world of abundance, and AI makes it that much more abundant if we use it correctly.
这不会今天就发生，但我们相信，当政府完成这项工作时，我们将彻底改变美国人如何在医疗系统中使用信息的方式。
And it's not gonna happen today, but we believe by the time the administration has completed this work, we will have dramatically changed the face of how Americans work with information in the health care system.
有些事情只是基础工作，正如你所说，要让电子病历公司不再封锁数据。
Some of it's just blocking and tackling, as you said, make medical record companies not data block.
有些事情是迫使医疗信息系统以更舒适、更优雅的方式，并以公平的价格共享数据。
Some of it's forcing health information systems to share data more comfortably and elegantly at a at a fair price.
其中一部分是我们向系统投入资金，并以正确的方式进行培育。
Part of it is us putting money into the system, seeding it the right way.
但最重要的是，要让人们敢于走出舒适区。
But the most important thing is to make it safe to go outside.
是的。
Yeah.
我们希望让人们在这些领域进行投资时，能够安心承担财务风险。
We wanna make it comfortable to take financial risk to invest in these areas.
这就是为什么有600家公司已经投资了。
That's why 600 companies have invested.
每个主要
Every major
这是正确的。
This is correct.
AI公司，每一家主要的基础技术公司，还有我承诺过的那些外科医生，他们都在纷纷涌入。
AI company, every major foundational technology company, but all a bunch of these surgeons that I that I promised, they're all rushing in.
企业家一直犹豫不决、不愿涉足的三个领域是：教育、住房和医疗保健。
The three places entrepreneurs have been reticent to take on to build new products and services, education, housing, health care.
这些领域恰好也是受监管最严、政府控制最多的领域。
These also happen to be the ones most regulated, most controlled by the government.
因此，只要你能给予他们更多准入机会并加快进程，事情就会成功。
So to the extent you can give them access and make it go faster, it's gonna work.
我们过去在这些领域所做的唯一投资，都是直接面向消费者的，因为我们知道，如果通过政府渠道，这些公司根本没有足够的资金和时间走到终点。
The only investments we've ever made in those spaces are ones that go direct to consumer because we know going through the government, there's just not enough runway for those companies to get to the other side.
让我问你关于
Let me ask you about
一件事。
one thing.
我们正常营业，趁我在这儿，得做个推广。
We're open for business, and I gotta make this plug while I'm here.
请。
Please.
我们希望与产业界合作。
We wanna work with industry.
我们相信私营部门会提出更好的想法来与我们合作，同时我们也在招聘人才。
We believe the private sector will come up with better ideas to come work with us, and we're also looking for people.
我们刚进来时有九名工程师。
We we we had nine engineers.
我们刚进来时有九名工程师。
Nine engineers when we came in.
整个CMS系统，也就是我们上世纪七十年代建立的基于COBOL的基础设施，现在缺乏工程师
All of CMS, the our COBOL based infrastructure built in the seventies, where we don't have engineers that
你是在说部门里，你
You're talking about in the department, you
在总共多少员工中，有九名工程师？
had nine engineers out of what's the denominator of employees?
6500名员工和40000名承包商。
6,500 employees and 40,000 contractors.
所以，基本上是政府的人力资源人员与公司里的政府事务人员在合作。
So there's you basically have an HR person in government working with a governor government affairs person at the company.
那里根本没有工程师。
There's no engineers there.
16个基点，
16 basis points,
大卫。
David.
我们削减了30亿美元的成本。
We took out we took $3,000,000,000 of cost out.
我们解雇了一家公司，他们向我们收取了2亿美元的费用，却连一行可用的代码都没提供。
There there was a company that we fired that had billed us $200,000,000, not a single usable line of code.
这才是精彩的部分。
And here's the good part.
当我们解雇他们时，你知道他们说了什么吗？
When we fired them, you know what they said?
什么也没说。
Nothing.
是的。
Yeah.
我们早就知道。
We knew it.
我们早就知道。
We knew it.
是的。
Yeah.
我们表现不佳。
We were underperforming.
没有问责制。
No accountability.
表现不佳。
Underperforming.
天啊。
God.
我们可以没完没了地谈欺诈，但我现在想问问你这种神奇药物。
We could go on about fraud forever but I wanna ask you about this wonder drug.
四年前，我听了我的朋友蒂姆·费里斯和凯文·罗斯的谈话，他们是生物黑客，总是走在这一领域的前沿。
Four years ago, was listening to my friend Tim Ferriss and Kevin Rose who are biohackers and they're always on the edge of this stuff.
他想减掉一些内脏脂肪。
And he wanted to lose some visceral fat.
凯文身材很好，他听说了一种治疗糖尿病的药物——司美格鲁肽，决定试一试。
Kevin was in great shape, and he heard about this diabetes drug, Ozempic, and that he was gonna give it a shot.
他把注射笔的剂量调到了最大。
He dialed the pen all the way up.
他吐了，把剂量调低，减掉了内脏脂肪。
He puked, dialed it back down, lost his visceral fat.
我听说过这个。
I heard that.
我当时四十岁，体重是二百一十三磅。
I was, like forty I was two thirteen pounds at the time.
我去看了医生。
Went to my doctor.
他说，我不知道你在说什么。
He said, I have no idea what you're talking about.
你不是糖尿病患者，但你确实胖。
You're not diabetic, but you are fat.
然后他说，你是个胖混蛋。
And then he said, you're a fat bastard.
我想我说过这句话。
I think I said that.
过去二十年里，我每年差不多长了两三磅。
And I had just gained like two or three pounds a year for twenty years.
是的。
Yeah.
我以前是个马拉松跑者。
And I used to be a marathon runner.
我以前体重是一百六十五到一百七十磅。
I used to be one hundred and sixty five, one hundred and seventy pounds.
现在是一百七十二磅。
So now one hundred and seventy two.
顺便说一句，你现在看起来像只瞪羚。
You look gazelle right now, by the way.
嗯，我之前也有一些肌肉。
Well, I had a little muscle too.
谢谢，医生。
Thank you, Doctor.
奥兹。
Oz.
你看起来也不错。
You look great too.
但这是一种奇迹药物。
But this is a miracle drug.
在我看来，现在理论上已经有数千万美国人体验过它了。
This, in my mind, we now have theoretically, tens of millions of Americans have experienced it.
它将以药片形式出现。
It's gonna be in pill format.
末日四骑士：心脏病、肾衰竭、肝病、痴呆。
The the four horsemen of the apocalypse, heart disease Kidney failure, liver disease, dementia.
痴呆。
Dementia.
这四种疾病都与肥胖有关，而这些GLP药物似乎正在对它们产生影响。
These are all four of four impacted by obesity, and these GLP ones seem to be impacting them.
我当时就想，你知道吗？
I was like, you know what?
如果特朗普总统直接宣布，任何想要这种药的美国人都能获得，我觉得他肯定能赢得选举。
If Trump just president Trump just gave a national anybody can get this drug if they want it, I think he'd win the election.
不过他本来就已经赢了。
He won anyway.
你觉得应该强制让这种减肥药对所有美国人开放吗？
What do you think about a mandate to make it available, to make the fat drug available for all Americans?
我很高兴你
Would that be So I'm glad you
今天来上班了。
came to work today.
大约两个月前，在椭圆形办公室里，总统实际上已经这么做了。
So about two months ago in the Oval Office, the president basically did that.
他说我们要降低这些药物的价格，目前许多美国人支付1200美元现金都买不起。
He said that we're gonna take the prices of these drugs, which are now prohibitively high for many Americans, $1,200 cash pay.
这太疯狂了。
It's crazy.
起价将约为200美元。
It's going to be a starting price of around $200.
很简单。
Easy.
而药片的价格是1.5美元。
And with the pills, it's $1.50.
首批获得FDA批准的药片将在本月上市。
The pills will come out the first FDA approved pills will start this month.
因此，我们认为每天只需1美元。
So we believe at that price $1 a day.
因为锌胶囊是对的。
Because zinc cap is right.
这基本上就像每天喝一杯咖啡。
It's basically, you get coffee a day.
在那个价格下，我们将在两年内向美国纳税人返还资金。
At that price, we will, within two years, return money to the American taxpayer.
通过减少高血压、糖尿病以及你提到的末日四骑士等继发性疾病，我们将节省大量资金。
It's going to save us so much money from reducing hypertension, diabetes, and the downstream illnesses, the four horsemen of the apocalypse that you mentioned, that we will save money.
我认为，我们在医疗保健上花费的超过一半的钱，都用于这些由肥胖引发的慢性疾病。
That we spend over half the money, we I believe, within health care on these chronic illnesses driven by obesity.
因此，无论直接还是间接，比如你因超重而伤了膝盖，或患上自身免疫问题，甚至癌症也与肥胖有关，因为你处于代谢活跃状态。
And so if they're directly or indirectly, because you hurt your knees because you're overweight or you get autoimmune problems or even cancer is linked to obesity because you have a metabolically active state.
所有这些疾病都将急剧下降。
All of these are gonna drop precipitously.
我们内部建模的数据对此有相当充分的依据。
We have pretty good data on this from an internal modeling.
我们已与两家主要公司——诺和诺德和礼来——就这些价格达成一致。
So we agreed to those prices with the two major companies, Novo Nordisk and Eli Lilly.
我们将于下周推出。
We will launch next week.
我不知道这个播客什么时候播出，但下周就要推出Trump Rx这些产品，让民众可以自费以完全负担得起的价格购买。
I don't know when this podcast airs, but launch next week Trump Rx with those products so you can cash pay at a price that is completely affordable.
这是个好消息。
And here's the good news.
每位联邦医疗保险受益人都只需支付50美元的共付额。
Every Medicare patient gets it for $50 co pay.
每位医疗补助计划受益人则完全免费。
Every Medicaid patient gets it for nothing.
太棒了。
Amazing.
因此，那些最需要这些药物的人——最脆弱的群体，当人们说总统不希望保护医疗补助计划，不珍惜联邦医疗保险时，这让我气疯了，因为他为服务不足的美国人所做的，比以往任何一位总统都多。
So the people who need it the most, the folks that are most vulnerable this is what it when people say the president doesn't wanna protect Medicaid, he doesn't love and cherish Medicare, it drives me bonkers because he's doing more for underserved Americans than any other president ever has.
为肥胖流行最严重的地区、服务不足的美国人、你知道的，那些依赖医疗补助计划的弱势群体，提供这些药物的零自付费用，真正实现了减肥治疗的民主化。
Giving Americans where the obesity epidemic lives, underserved Americans, you know, vulnerable Americans who are on Medicaid, access to these drugs for no out of pocket costs truly democratizes the weight loss issues.
因为现在，减肥药物使用量最高的邮政编码是哪个？
Because right now, what's the number one ZIP code for weight loss?
药物。
Drugs.
排名第一的邮政编码是曼哈顿上东区。
Number one ZIP code, Upper East Side Of Manhattan.
我正要说
I was about to
我说肯定是曼哈顿或洛杉矶。
say it's gotta be Manhattan or LA.
洛杉矶排第二。
LA is number two.
好的。
Okay.
对吧？
Right?
因为人们负担得起，或者
Because people can afford it or
人们很虚荣。
People They're vain.
他们很虚荣。
They're vain.
他们想减掉两磅，好参加女儿的婚礼。
They wanna lose two pounds for their daughter's wedding.
哦。
Oh.
而且他们负担得起。
And they can afford it.
1200美元，不过是小数目。
$1,200 a rounding error.
没什么。
Nothing.
是的。
Yeah.
对吧？
Right?
但对于那些收入不高的人来说，1200美元的价格，你根本不会去吃这种药，而正是这些人会早逝。
But $1,200 for someone that's not making money, you're not you're just not gonna take the drug, and they're the ones that die early.
美国农村地区的预期寿命，我再回到这些群体，弱势群体的预期寿命比你们在同一国家短了九年。
The life expectancy in rural America, I'll go back to them, in vulnerable populations, nine years shorter than yours in the same country.
这是突然冒出来的事情。
It's something that came out of left field.
这告诉我们，未来医学将会发生什么变化？
What does that tell us about what's gonna happen in medicine going forward?
因为GLP类药物，这条研发之路走了多久？
Because GLPs, how long of a journey has that been?
然后推向市场，再从糖尿病患者开始出现超适应症使用，这能告诉我们什么？我们如何在未来产生更大的影响？
And then getting to market and then, you know, this off label use starting with people with diabetes, what does that what does that how does that inform you of how we can make even more impact in the future?
我们如何再做出一个像GLP这样的突破，并像特朗普总统那样去推广它？
How do we make another GLP like discovery and implement it the way president Trump
有？
has?
嗯，这种药物实际上是一种有毒的化学物质，一种毒液，后来被破解并发现它能影响人体食欲系统中的某些核心细胞，而食欲是我们本质中非常根本的部分，是的。
Well, this know, the drug actually came it's a poisonous chemical, a venom, actually, that was deciphered and found to have an impact on some of these core cells in the in the the appetite system of the body, which is so fundamental to who we are Yeah.
要干预食欲非常困难。
That it's very hard to hack the appetite.
但GLP-1类药物只是冰山一角。
But GLP ones are just the tip of the iceberg.
我们正在发现越来越多更复杂的方法，不仅针对食欲，还针对成瘾和成瘾行为，这些都与GLP-1类药物有关。
There are more and more sophisticated ways for us to be able to address not just appetite but addiction, addictive behavior drops at GLP ones.
因此，新一代药物在这一点上会更加有效。
So the newer drugs are gonna be even more effective at that.
你指的是利拉鲁肽吗？
Reditrutide is the one you've
例如，红itrutide。
For example, reditrutide.
但我想说的另一点是，给药形式很重要。
But the other thing I would say is the form factor matters.
在炎热天气下，注射剂容易失效，造成大量浪费；如果你不清楚确切剂量，药片则能像其他药物一样提供更稳定的使用体验。
Sending someone an injection that goes bad in the warm weather, that a lot of wastage, if you don't know the exact dose, the pills make it like the most other drugs.
嗯。
Mhmm.
而且现在这些药物的价格也低了很多，因此我们更容易大规模向美国民众提供这些药物。
And now the drug the price point is much lower as well, so it's easier for us to deliver that at scale to the American people.
所以它确实让我们超越了当前的问题，这也是我们政府的一个重要主题。
So it does leapfrog us beyond today's problems, and this is a big theme of our administration.
如果你们正在构建的新世界根本不需要管道，那就别费心去修理今天破损的管道了。
Don't bother fixing today's broken pipes if the world you're building doesn't have pipes.
我们正在用司美格鲁肽和替尔泊肽（礼来公司的产品）这样做。
And that's what we're doing with drugs like semaglutide and and tirzepatide, is the the Lilly product.
我们还在促使这些公司将生产设施迁回国内，雇佣美国工人，保持创新。
We're also getting these companies to onshore their production facility, hire American workers, stay innovative.
这就是为什么总统不希望我们阻碍创新。
This is why, again, the president doesn't want us hurting innovation.
就在我们举行首个最惠国药物活动的同一天，我们发布了关于儿童癌症的行政命令。
With the same day we did the first most favored nation drug event, we had an executive order on childhood cancer.
二十个可爱的孩子，笑容灿烂，双眼明亮，他们本该都已成为亡魂。
20 beautiful children, smiley bright eyes, all of whom, all of whom should have been ghosts.
他们之所以能活下来，是因为获得了这些技术，而世界上其他地方并没有这些技术来维持他们的生命。
They survived because technologies were afforded to them, they don't exist in other parts of the world to keep them alive.
这就是我们的目标。
That's our goal.
但如果我做得不够好，那就太糟糕了。
But I need to I'd be poorly served.
我听到了钟声响起。
I hear the bell tolling.
如果我没有投入到另一件事上
If I didn't get into the other thing
我们并不知道是为谁。
For whom we don't know.
在我们要求之前
Before we ask for for
钟声为……而鸣
the bell tolls, for
当然。
sure.
致你，杰科。
To you, Jayco.
但我认为这一切都是针对那些不肯低头的制药公司。
But I think that's all I think that's totally for the pharma companies who don't bend the knee.
不。
No.
实际上但是
Actually but
目前困扰我们的问题是欺诈行为。
the the the issue right now that is consuming us is the fraud Fraud.
是的。
Yeah.
浪费和滥用。
Waste and abuse.
还有什么是
And What have
你发现了什么，奥兹医生？
you found, doctor Oz?
告诉我们吧。
Tell us.
对你来说最令人担忧的是什么？
What is the most concerning to you?
首先，如果没有更好的资金使用透明度——我们需要技术或审计来实现这一点——
Well, as a preamble, without a better visibility into where the money's spent, which we need technology to be able to do Or audits.
审计其实挺有意思的。
Well, audits are interesting.
你可以审计电子表格。
You can audit the spreadsheet.
但你无法判断电子表格的输入数据是否合法，除非亲自去实地考察，而各州并不愿意这么做。
You can't tell if the input to the spreadsheet was legitimate unless you actually go and do site visits, and states don't wanna do that.
所以让我直接说一下。
So let me just give it
是这些州在阻止吗？
to Are blocking it, these states?
当然。
Of course.
当然。
Course.
首先，让我告诉你为什么是这样。
First of all, let me just I'll tell you why yep.
这是个好问题。
That's a good question.
你为什么会允许欺诈发生？
Why would you let fraud happen?
根据联邦法律，联邦法律明确规定，如果你向患者提供福利项目，如SNAP或医疗补助，你必须同时给予他们注册投票的权利。
It is by federal law, by federal law mandated that if you give a patient a welfare program, SNAP, Medicaid, you must also give them the ability to sign up to vote.
所以，你在提供免费政府服务的同时，实际上也在招募选民，这可能会让你招募到不同类型的选民。
So you're basically recruiting voters at the same time you're giving them free government services, which then you might actually end up recruiting a different kind of voter.
比如，你并没有法律规定，如果你去参加全国步枪协会的大会，嗯，针对枪支倡导者，就必须让他们注册投票。
Like, you don't have a law that if you go to an NRA convention, right, for for, you know, gun advocates that you sign up voters.
对吧？
Right?
你可以参加那个活动，而不需要注册投票。
You can go to that event and not get signed up to vote.
显然，他们可能会偏向右翼。
Obviously, they will be probably skewing to the right.
所以这里确实存在问题。
So there is an issue there.
工会也扮演着积极的角色，尤其是在加利福尼亚，我们面临一个严重问题，因为根据我与基层人士交流所听到的情况，工会似乎已经介入了例如为家庭护理工作者和个人护理服务人员登记注册的事宜。
We also have an active role of unions, especially in California where we have a a major problem because the unions have seemed this is all what I'm hearing from talking to people on the ground, seem to have gotten involved in, for example, signing up home health care workers and and personal care services.
我认为，提供这些居家服务的美国人数量，可能比在美国零售业工作的人还要多。
There are more Americans, I believe, providing some of these home based services that maybe might exist in retail in America.
我们已经将整个就业经济转向了这些服务。
We've shifted the entire employment economy towards some of these services.
而这里的风险在于，如果你真的想理解为什么美国会出现欺诈行为。
And here's the risk, if you really want to understand why we have fraud in America.
当我们提供那些原本由你的家人给予你的东西时，欺诈就会发生。
When I give you things that your family used to give you, we are going to have fraud.
你的家人过去会开车送你去看医生。
So your family used to drive you to the doctor's office.
你的家人会在你出院回家后照顾你，确保你得到充分的营养和照料。
Your family would take you home after you got home back from the hospital to make sure you got well nourished and taken care of.
你的家人会帮你把杂货搬上楼。
Your family would carry the groceries up the stairs.
你的家人会帮你和房东谈判合同。
Your family would negotiate your contract with the landlord.
猜猜怎么着？
Guess what?
现在，健康人类服务公司会为你做所有这些事。
Healthy Human Services does all that for you now.
你只需要提出请求即可。
All you gotta do is ask.
在一些州，这件事太容易了，结果导致了严重的欺诈。
And in some states, it's so easy to do that you end up with significant fraud.
我们还发现，他们已经截获了这笔交易。
We also So they have intercepted the transaction.
因此，欺诈和骗术就发生在这里。
Therefore, that's where grift can occur in fraud.
而且政府也在为此付费
Well, also the government's paying for
是的。
it.
对。
Right.
当消费者用自己的钱支付时，他们有动力确保交易物有所值。
And so When the consumer's paying for it out of their own pocket, they have their own incentive to get value for the transaction.
但当政府支付时，谁真正有动力确保这笔钱换来了相应的价值呢？
But when the government's paying for it, who really has the incentive to make sure that value has been provided in exchange for that money?
是的。
Yeah.
这就是明尼苏达州发生的情况，那里出现了一个亚文化群体。
And this is what happened in Minnesota where you had a subculture.
主要是从数学统计上看，大多数指控都针对索马里人。
It was primarily you know, just the mathematically, most of the indictments are with Somalians.
所以索马里社区意识到，嘿。
So the Somalian community realized, hey.
天哪。
My goodness.
没人盯着呢。
No one's watching.
你知道有一句俗话，只有傻瓜才会在医疗欺诈中被抓，因为这太容易了。
Now there's an adage, you know, that only the morons get caught in health care fraud because it's so easy to do.
如果你在医疗保险或医疗补助中偷了500万美元，只会被判18个月监禁。
And if if you get you steal $5,000,000 in medic in Medicare, Medicaid, you go to jail for eighteen months.
我的意思是，对很多人来说，这简直太划算了。
I mean, for many people, that's a pretty good deal.
是的。
Yeah.
你可能会在监狱里待18个月，但不幸的是，让我给你大致讲讲情况。
You're gonna sit in the pen for eighteen months, but unfortunately, I'll just give you a lay of the land.
耐用医疗设备供应商的数量多了两倍。
There are twice as many durable medical equipment providers.
他们销售轮椅和膝关节支具。
They sell wheelchairs and knee braces.
在南佛罗里达，这类供应商的数量实际上是麦当劳的20倍。
There's actually 20 times more in South Florida than McDonald's.
我的意思是，你需要这么多吗？
I mean, how many do you need?
结果发现，他们几乎都是古巴人。
Turns out they're all Cuban pretty much.
他们似乎都飞回古巴，逃避执法部门的追查。
They all seem to fly back to Cuba and escape, you know, law enforcement.
他们虚报了数百万美元的费用。
They they bill millions of dollars.
他们却能逍遥法外。
They get away with it.
那解决方案是什么？
There's What's the solution?
一定有一个非常实际又简单的解决办法。
There's gotta be a really practical easy solution.
确实有，我会跟你们分享，但先让我告诉你们另外两个，因为你们会记住这些。
There there are, but and I'm gonna share that, but let me just give you two others because you will remember these.
加利福尼亚州的临终关怀机构多了七倍。
We have seven times more hospice in California.
临终关怀是为生命即将结束的人提供的。
Hospice is for people at the end of their life.
是五年前、六年前、七年前的七倍多。
Seven times more hospice than was there five, six, seven years ago.
是七倍多。
Seven times more.
加利福尼亚州并没有那么多人死亡。
We don't have that many people dying in California.
更重要的是，临终关怀的生存率——针对的是预计六个月内会去世的癌症患者。
And more importantly, the survival rates on hospice, again, designed for cancer patients dying within six months.
这些临终关怀中心的生存率高达百分之百。
The survival rate for most of these hospice centers is one hundred percent.
等一下。
Wait a second.
他们根本就不该去临终关怀机构。
They shouldn't have gone to hospice.
没错。
Exactly.
政府在为此买单吗？
Is the government paying for it?
是的。
Yes.
好的。
Okay.
但没人会死，因为你本来就不该去——当
That's But the no one's dying because you're not supposed to When
政府是什么时候开始为此付费的？
did the government start paying for that?
哦，四十年前。
Oh, forty years ago.
哦，明白了。
Oh, okay.
它原本是设计为
It was designed
而在过去七八年或十年里，欺诈行为突然增加了，主要有两个原因。
And then what happened in the last seven or ten that the fraud just went Two things.
自然的。
Natural.
政府介入了。
Governments got involved.
在洛杉矶，临终关怀服务由俄罗斯亚美尼亚帮派操控。
In LA, the hospice is driven by the Russian Armenian gangs.
他们都是外国公民。
They're foreign nationals.
他们飞回俄罗斯。
They fly back to Russia.
今年早些时候，我们针对这些人破获了一起高达150亿美元的大案。
We had a big $15,000,000,000 bust on these guys earlier in the year.
但这些人全都逃之夭夭了。
Again, they all escape.
另一件事是，没人关注，因为一旦进入这些行业，就有机会赚大钱，这让我想起一个关于举报人的真实故事。
The other thing is no one's watching because there's a opportunity if you get into these businesses to make a lot of money, and it becomes I'll give you I'll just tell you a true story about whistleblower.
我再次强调，我无法证实这一点，但这就是他所说的。
Again, I I can't prove this, but it's what he said.
他说，他正在建造一座豪华别墅。
He said that he he was building a beautiful mansion.
他拥有所有这些临终关怀机构。
He owns all these hospices.
他是个医生，但是个骗子。
He's a doctor, but he's a fraudster.
所以他建了这栋豪宅。
And so he built this pewser house.
水管工进来时说：嘿，听说你做临终关怀这一行？
The the plumber comes in and says, hey, you know, hear you're in the hospice space.
那人说：是的。
The guy says, yeah.
我靠临终关怀赚了钱。
I made my money in hospice.
然后水管工说：你知道吗，我还有个副业。
Then the plumber says, you know, I've got a side hustle.
我也拥有一家临终关怀机构。
I own a hospice too.
对吧？
Right?
然后木匠听到了，说：我也是。
Then the carpenter hears them and he says, me too.
是的。
Yeah.
我做的是临终关怀生意。
I'm in the hospice business.
我们都在做临终关怀生意。
We're all in the hospice business.
当然。
Absolutely.
于是那人说，好吧，他意识到自己必须赶在这些人前面。
So then the guy says, okay, well, he realized he's gotta get ahead of these guys.
所以他去了洛杉矶一家大型医院，那家医院的医生——是一家人人皆知的著名医院——说：嘿，听着，如果你每个月给我一千美元，我就把临终关怀病人介绍给你，这在洛杉矶就是这么操作的。
So he goes to a major hospital in LA, and a doctor at the hospital, very prominent hospital that everyone's heard of, says, hey, listen, if you give me a thousand dollars a month, I'll send hospice patients to you, which is how it's done in LA, by the way.
你拿钱，就把病人转过去。
You get paid, you send patients over.
所以那人说，好吧，那实际住院的病人呢？
So the guy says, Okay, but what about the actual inpatients?
就是那些住院的人，我能得到他们吗？
Like the people hospitalized, can I get them?
医生说，我不能这么做，因为董事会里有一些人拥有疗养院，他们希望病人去他们的中心。
And the doctor says, I can't do that because it turns out there are some members of the board that own hospice and they like the patients to go to their centers.
你看，腐败最初起源于有组织犯罪，但如果你对此放任不管，它就会毒害整个系统，这才是我们面临更大问题的根本原因。
You see that the corruption starts in in organized crime but if you tolerate it, it poisons the whole system and that's the bigger reason we've got a problem.
那我们该怎么做呢？
So what are we doing?
我们设立了一个反欺诈作战室。
We have a fraud war room.
我要对一些服务实施暂停。
I'm gonna put a moratorium on some of these services.
我们不会让新的人注册。
We're not gonna let new people sign up.
如果我们能证明各州没有履行其对美国人民的受托责任，我们将积极且坚决地停止支付医疗补助资金。
We're gonna actively and aggressively stop paying Medicaid if we can prove that states are not obliging their fiduciary responsibility to the American people.
由于各州负责管理医疗补助，而我负责在CMS支付账单。
Because states administer Medicaid, I pay the bills at CMS.
如果我们认为你们没有妥善管理资金，我们将停止为纳税人支付相关费用。
So we're gonna stop paying on behalf of the taxpayer if we don't think you're taking care of the money.
人们应该知道，有举报人法律，举报者可以获得所举报金额的一定比例，他们应该去了解一下。
And people should know there are whistleblower laws where you get a percentage of whatever's reported, and they should look into that.
而且我们现在政府中有这么多人在传达这样一个信息：嘿。
And the fact that we have so many people in the administration now communicating that, hey.
我们希望你们向我们举报欺诈行为，这已经改变了所有情况。
We want to have you report fraud to us has changed everything.
举报欺诈的人数一定大幅增加了。
The number of people reporting fraud must have gone up
从显著的角度来看，政府内部的这些人，这可能是对我来说最有成就感的部分。
since Dramatically, people in the government this is probably, you know, the part that's most rewarding to me.
许多政府工作人员是民主党人，可能是大多数。
Many government workers are Democrats, probably most.
他们一再告诉我的是，他们只是来政府工作而已。
What they tell me again and again is they just came to government to do their job.
他们只想做正确的事。
They wanted to do the right thing.
但他们被要求不要履行自己的职责。
And they were told not to do their job.
他们被要求不要关注欺诈行为，而要专注于让更多人注册。
They were told not to focus on the fraud, to focus on getting more people signed up.
但如果你不处理欺诈问题，这是一个重要的信息，你将会摧毁整个体系。
But if you don't take care of the fraud, this is an important message, you will kill the system.
最终，你会毁掉医疗补助计划，而我不会允许在我们任内发生这种事。
Eventually, you will destroy Medicaid, and I'm not gonna let that happen on our watch.
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