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和魂と洋才と医療の崩壊(下)

随分間が開いてしまったが、前回と前々回で、日本社会の評判メカニズムが機能しなくなると、社会のあちこち(温泉であったり、救急医療だったり)が綻んでいく、と書いた。しかし、ここで話を〆てしまうと、結局「昔は良かった」というご老人の繰言と大差がなくなってしまう。そこで今回は、前回に引き続き医療を例に取りながら「じゃぁ、どんなシステムならうまくいくのか?」ということを考えてみたい。

こちらの記事によると、医療サービスで未払いが多いのは産科と外科(救急)なのだそうである。理由としては所持金不足や経済的理由(所得不足)が挙げられているのだが、本来所持金不足は理由になるわけがない。経済的に困窮していないのであれば、手持ちのお金が足りないなら後で払えばいいのである。これは単に借金を踏み倒しているだけのことだ。

とりあえず産科に議論を絞ると、ひとつの理由として考えられるのは、産科と患者とはほとんどの場合「一期一会」だということだ。人生で3回以上出産をする人は日本では少ない。つまり、世話になった産科の先生の心象が悪化したところで、人生で彼・彼女と再び出会う可能性は非常に低いわけで、これはやりたい放題が保証されているに等しい。一般の内科でこれが起こりにくいのは、「今健康を崩して病院へ行く」ことは「将来も同じ病院を利用する可能性がむしろ高まる」から。出産すればもう一度出産する確率が低下する産科とは真逆なのだ。更に、産科に比べて内科の診療費は低いので、診療費を踏み倒すべく引越しをする、という戦略がうまくいかないということもあるだろう。

つまり、産科医療では、恐らく銭湯や救急医療以上に、評判メカニズムは機能しない。とすれば、評判メカニズムに支えられた性善説的な行動を患者に期待すること自体が間違っているということになる。「正しいやり方で」産科を利用しない妊産婦を最近は「野良産婦」と呼ぶらしいが、自分の期待するやり方で産科サービスを利用してくれない人たちを非難しても意味がない。彼らには彼らの道理があるのだから。まずは彼らの道理が存在することを認め、それを前提にサービスの在り様を再検討する必要がある。病院関係者はギルド社会的な患者への期待を捨て、洋才社会の知恵を借りて医療システムを立て直すしかないのではないだろうか。


洋才型アプローチその1:サービスの有料化

さて、需要サイドである患者の側でギルド型の「自制」が働かない場合、ユーザーの医療サービスの使い方をコントロールする責任は供給側たる病院(厚生労働省なども含む)に移る(注1)。自制の効かない(自称)患者が大挙病院に殺到すれば、医療サービスは確実に崩壊する。人的にも金銭的にも、医療資源には限界があるのだから。自然、サービスのコントロールとは、この限られた医療資源をどのように分配すべきかということになる。

言うまでもなく、この手の「限られた資源」を効率よく分配するひとつの方法は価格メカニズムに頼るやり方だ。経済学お得意のやり方である。「患者がどれだけのお金を喜んで支払えるか」は、症状の深刻さを測る上で非常に有用なパラメータだ。特に、「それほど深刻な症状はないけど、タダならとりあえず救急車を呼んでおこうかな」と言った、不届きな連中を排除する上では極めて有効といってよい。

アメリカを含め、多くの国で採用されている救急車の有料化はこの理屈の上で実行されている。当然、産科医療の問題もこのアプローチで改善することは可能だ。まず、未払いの問題は前金制で解決する。患者の要求が厳しすぎる?サービスを松竹梅とかに分けて、料金別に利用可能なサービスを設定してしまえばよい。もしその患者が本当にあらゆるリスクを避けて(可能な限り)安全な出産を行いたいと思うなら、彼らは喜んでそのお金を払うはずである。有料化は患者の「本当の気持ち」を洗い出す

と、ここまで読んでストレスを感じた人は結構多いかもしれない。「所得が足りなくてその金を支払えない人はどうすればよいのか。金を払えない人は自宅で何のサポートも受けずに産めとでも言うつもりか」と。結論から言うと、最適な医療システムを考える上で、「低所得者をどうするか」という点を考慮する必要はない。医療システムを考える上での要点は「必要な人に適切な医療サービスをどう提供するか」だけだ。有料化で低所得者が割を食うならば、そしてそれが社会的に問題であるならば、それに対処するのは政府の責任である。低所得者を救う責任は病院にはなく政府にこそあるのだという、ごく当たり前の視点を昨今の医療問題の議論であまり見かけないように思うのは筆者の気のせいだろうか。

もし妊婦の中に低所得で困っている人がいるならば(そもそも出産は多くの場合まだ所得の低い20代30代で行われるわけで、そういう人は当然多い)、彼らは(その利益を代弁する人を含め)政府にこそその要求を突きつけるべきなのだ。バウチャー制で政府が出産費を肩代わりするとか、方法はいくらでもある。納税者が、少子化の問題を少しでも軽減したいとか、出産の安全性は当人の所得に関わらず保証されるべきだと考えるならば、彼らは喜んで税金を払うはずである。有料化のメリットは、システムの効率性と、社会福祉の向上(所得格差の是正を含む)を完全に別個の問題として考えられる点にある、と言っても良い。


洋才型アプローチその2:日常的トリアージ

医療システムの効率とは、「限られた医療資源の最適な分配」のことだ、と上で書いた。言い方を変えれば、医療サービスを使う必要のない人間をいかに排除するか、が問題なわけだ。ギルド型の社会では「不適切な行動を取ると村八分にするぞ」という脅しで、アメリカでは「サービスを使いたいなら金を払え」という仕組みで、それぞれ「不適切な需要」をコントロールしている。

これらのアプローチはひとつの回答ではあるが、唯一の回答ではない。有料化のひとつの問題点は、「患者は自分の病状の深刻さを自分では理解できるとは限らない」という点にある。患者が自分の症状を過大評価してしまう可能性もあるし、過小評価してしまうこともある。どちらも、医療システムの効率を損なう可能性がある。

イギリスのやり方はこの点において優れている。イギリスでは、誰が「今」医療サービスを必要としているかは病院が判断する緊急を要する患者が優先され、それ以外の患者は後回しになる。その代わり、医療は原則として無料(薬代などは有料らしい)。医療費によって不適切な需要を排除する必要がないからだ。専門医の時間を無駄にしないため、患者はまずGP(General Practitioner)と呼ばれる診療所に行くことを要求される。そこで重症であるという判断が下されると、初めて専門病院が紹介されるわけだ。救急車についてもこの原則が適用される。救急車も無料だが、その患者を受け入れるかどうかは救急隊員が判断する。隊員が軽症だと判断したら、救急車には乗れない。

なんだか良さそうな仕組みに見えただろうか。ユーザー側から見ると、この仕組みは有料化と違って個々人の追加負担がなく、また納税者の一人として「どこまで妊婦にお金を払うか」といった選択を突きつけられることもないため、比較的受け入れられやすい。しかし、Googleで「イギリス 医療」で検索をかけてみてほしい。出るわ出るわ批判と不満の山。

特に多いのが、「病気にかかったのに延々と待たされる」というものだ。そもそも重症患者以外は後回しにするのがシステムの大前提なので、比較的軽症であれば当然待たされることになるわけだが、問題なのはその期間である。こちらのページを見ると、2000年の段階で4分の1の患者が実に半年以上待たされている。1年を超えて待たされた患者すら数千人はいたというから恐れ入る。ブレア政権以降の医療改革の進展で待ち時間はだいぶ改善されたが(過去5年間で医療関連予算は倍増している)、平均で2ヶ月以上、最長で半年以内と言ったところで、これをもって問題が解決されたといっていいのかどうか。そもそも、肝心の救急医療ですら、5年前までは4分の1の患者が4時間以上待たされている。現在は4時間以上待たされるケースはほぼなくなったようだが、これも4時間以内ならいいのかと言えば、そうはいえないだろう。

たとえ無事に入院できたとしても、病院側による優先順位の設定は当然軋轢を生む。適当に検索をかけて見つけた記事だが、こちらでは産婦の4分の1が出産時に一人で放置された経験があるというアンケート調査が紹介されている。プライオリティを明確にするという原則がある以上、この手の問題は避けて通れない。もちろん、高い金を払って保険対象外の医療サービスを受けることは出来るが、出産関連で200万円くらいかかるのだそうだ。

そもそも、患者の分別を病院側で全て行うこの仕組みは病院にかかる負担が大きい。今後更に医療費をつぎ込んだとしても、「病院にいけば治療してもらえる」日本のような仕組みは望むべくもないだろう。


それぞれの社会のそれぞれの制度

だいぶ違って見えるアメリカ型とイギリス型の医療制度だが、ひとつの共通点がある。医療サービスを受けるべき患者と、そうでない患者とを分別する仕組みがあるということ。そして、その仕組みにはコストがかかるということ。前者の場合は所得格差を是正する政策を新たに構築する必要がある(脚注に詳しく書いたが、患者の分別を適切に行いつつ、低所得者にも利用可能にするには、かなり政治的に受け入れられがたい政策を必要とする)。後者の場合は長大な待ち時間に耐えなければならない。

和魂と洋才とユダヤの商人」で書いたように、ギルド型社会のひとつのメリットはこれらの社会的なコストがかからないという点にある。日本社会はそれゆえに「効率が高い」社会なのだ。または、社会だった。もし日本のムラ社会が消滅しつつあるなら、我々は「低コストで手厚い医療サービス」という理想をあきらめなければならない。これは過去においては決して幻想ではなかったが、我々の社会構造が変化してしまったのならば、もはや追い求めてはいけない幻なのである。

次回、補論として、幻として消えそうなギルド社会型のシステムを取り戻す方法を考えてみたい。


本日のまとめ

ギルド型社会では、患者自身が「自分が医療サービスを受けるべきかどうか」を判断する。

評判メカニズムが機能しない社会では、有料化なり病院サイドの「トリアージ」なりで、適切な患者を分別せねばならない。

このような社会では、今までの日本以上に医療サービスには(金銭・非金銭両面での)コストがかかるようになる。


*イギリスについては英語版のウィキペディアを参考にした。なかなかの労作なので興味のある方には一読をお勧めしたい。


注1:正確に言えば、ギルド型の社会では、サービスの使い方をコントロールするのは病院ではなく、ムラ社会それ自体ということになる。このルールは明文化されるものではなく、美意識とかモラルという言葉で表現されることが多い。

注2:上では産科の例だけを挙げて所得格差の問題は別途解決可能だ、と書いた。ただし、より幅広く医療サービス全体を考えるなら、これはバウチャーだけで解決できるような問題ではない。例えば、救急車利用券のようなバウチャーを配ることには意味がない。バウチャーは特定のサービスを利用してもらうために配るものであって、使ってもらいたくないサービスのバウチャーを配るのは逆効果以外の何者でもない。むしろ、低所得者にはいざというときの救急車代として現金をこそ配るべきなのだ。彼らがそのお金を救急車ではなく、それ以外のサービスに使ってくれたほうが、社会の効率は高まるのだから。もし彼らがそのお金を浪費したのなら、救急車を使わずに野たれ死んでもらわなければならない。または、バウチャーを「使わなかったら換金可能」にしておく、という手もある(こうすることで浪費を防ぐことが出来る)。どちらにせよ、納税者の負担は高まる。さもなければ、低所得者の負担が高まる。

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Comments

hospital

私は基本的には有料化が望ましいと思っています。
コストを全て料金に転嫁させるというよりは、タクシーより若干高くなる程度の料金に設定したらどうでしょうか。

貧困者を切り捨てるのか、という議論もあるでしょうが、後払いにし、超低所得者の場合は申請によって支払い免除、もしくは減額措置が受けられるようにします。

Posted by: のびい | April 03, 2008 at 07:00 PM

イギリスの医療制度に関連して、今日のGIGAZINEにこういう話がありました。このおばあちゃんは緊急を要しないと判断されたのでしょうか?

http://gigazine.net/index.php?/news/comments/20080407_pull_own_teeth/

Posted by: Baatarism | April 07, 2008 at 04:54 PM

救急車有料化して、無料であった時代を忘れかける頃になったら、そのうちマスコミが「救急車事業赤字」とか騒ぎ出すのに10ペソ。

ジェノヴァ型社会になれば、やがて馬車馬さんのような理性的な議論が主流になる日がくるってことはあるんでしょうかねぇ…。

Posted by: Cru | April 09, 2008 at 11:45 PM

のびいさん、コメントありがとうございます。

私も原則として有料化のほうが望ましいと思います。次のコメントでもう少し詳しく書きますが、イギリス方式は医療供給側にかかる負担が大きすぎ、あまり現実的ではないのではないかと。一方で自己診断による間違いを防げるという点では「予算さえ潤沢であれば」優れたシステムなのですが。

おっしゃるとおり、低所得者に対しては免除の仕組みを作り、その代わりそのための手続きに極端に時間がかかったり、多量の書類を作らねばならなかったりといったシステムにすればいいのではないかと思います。要するに、金がない人間は金を払う以外の苦痛を感じてもらおうということですね。

Posted by: 馬車馬 | April 10, 2008 at 08:13 AM

Baatarismさん、コメントありがとうございます。

なんとも壮絶な話ですが・・・。このケースがどう判断されたのかはどうともいえませんが、本文でも紹介したとおりイギリスのGPシステムは崩壊寸前にあります。特に歯医者は保険の利くところ自体が少なくなってきている、という致命的な状態にあるようですから、それこそ顔の形が変わるくらいに腫れ上がらないと優先順位が上がらない、というケースはあると思います。また、単純に誤診、または事務手続きのミスという可能性もあるでしょう。ざっと情報をあさった感じ、無料のGPだけにこだわっていれば当然ありうる結末、という感じすらしてきます。とんでもない話ですが。

個人的には、やはり優先順位の判断を全て医者に委ねるという仕組みは時間的にも(または金銭的にも)コストがかかりすぎるのが問題だと思います。更に、当然誰しも誤診はするわけですが、その責任をすべて医者側が負うのもストレスは大きかろうなと。イギリスの医療問題は1に待ち時間の長さ、そして2に医療関係者への暴力だそうですが、私はこの2つの問題は日常的トリアージを介して密接につながっているように思えます。

Posted by: 馬車馬 | April 10, 2008 at 08:22 AM

Cruさん、コメントありがとうございます。

・・・なんだか微妙に笑い話になりきってないような・・・というか私なら10ドルは賭けます。

実のところ、ジェノア型の社会にも色々と苦労がありまして、なかなかどうしてうまくはいかない、という話は4回くらい先でするつもりです。というか、そこまで行ければこのシリーズもほぼ終わりが見えてくるんですけど。

Posted by: 馬車馬 | April 10, 2008 at 08:26 AM

外科(救急)業なんですが、
このような仕組みになってほしいと思います。

近くの救命センターで未払いを防ぐため
夜間は預かり金をもらうことにしたんです。
(夜間は会計が出来ないため)

急患は半減したとか
その分がこっちに押し寄せてきました

ある患者さんは
「あっちでは金を取るんだ」と大声で、、、

以前、事務に調べさせたところ
一族で3年間120万くらい、
すべて救急受診で1円も払っていない
家系が見つかりました。

やる気がうせました。


Posted by: ossanpower | April 13, 2008 at 08:18 AM

前回のコメントの >療業界全体が日本社会から村八分に遭っているからではないかと思うことがあります。実際、過去(数十年前)に「医者の態度が悪い」「医療過誤の隠蔽」といったことは実際にあり、そしてそのさい医療業界がそれに対して適切に対処してきたとは正直思えません。

は反省すべき妥当な意見だと思います。 お年寄りの先輩などの話を聞くと20-30年ほど前の医療は、非科学的かつ相当傲慢、荒稼ぎだったようです。(そのころの医療がまだ経験則だけで科学と無縁だった気もしますが)そのころの話を持ち出して医者をたたきたがっていたテレビ屋さんも知っています。実際、今でもお年寄りの医者にはすごく威圧的な人がいますしね。医者も業界の品質維持のためには同業者にさくっとペナルティを与えるべきなんですが、それが制度上はあっても実際には機能していないのが医者の文字通りギルド社会というか何というか。急速に医療経済も患者の意識も変わっているわけですが、上で運営している団塊の(元)お医者さんは逃げ切り済みというか根性論しかぶちませんしね。これだけ激変すると医者の世界にも世代間闘争が明確にあるはずです。最近ちらほら見かける勤務医vs開業医という構図も、医者人生ゲームのあがりのひとつが開業医であるわけで、世代間抗争にも見えます。医療法人を経営のプロではなく医者が運営するか、医療法人は会社と違うという縛りがじゃまをしているような気もします。現場的には「チキンゲームに突入もよし」「『税金を取ってください』とお願いするまで行政をスリム化」というのも過渡期の混乱を気にしなければありなのかなあ、という空気も。

Posted by: ぷー | April 17, 2008 at 11:44 AM

トリアージですが、これは日本ではイギリス以上に厳しいと思います。イギリスに比べても自分の判断でリスクをとる、リスクの結果に責任をとる、自分が他人に優先度付きで評価される、なんてことになれていない平等国の国民ですから。実際、外来で明らかに具合の悪そうな人を先に診察するというのは実はタブーでして。夜間救急外来ですら「順番をとばすな!」って平等万歳小学校の学級委員じゃないんですから・・・ orz みたいなことがあったり。アメリカで子供を小児科で連れて行こうとしたことがありますが、まずナースが電話に出て、自分で病院に行くと言っても向こうが「病院に来る必要性がない」と判断すれば「来るな」と言えるんですよね。あれがとてもいいシステムとも思えませんが、日本でやるとえらいことになるでしょうね。

そうそう。この前、教育水準とルール破りに相関がないという話をしましたが、夜間に無理矢理駆け込んでくる中産階級の人ってそれはそれでせっぱ詰まっているんですよね。「会社の仕事をどうしても休めないから熱を下げろ」とか「お昼に病院に行く時間はとれないから」とかなんとか。会社は会社で社員が病気になるリスクをヘッジするのに必要な余裕もないんでしょうね。してみると医者は彼らの無理を聞かざるをえない下請け工場みたいな立場でしょうか。ただしお金の踏み倒しは明らかに低所得者階級に多いです。彼らと話をして思うのは、長期計画をしないんですね。朝三暮四でよろこぶというか、生活保護のお給金を目の前の娯楽費やら食事やらに使うとか、飲酒制限をかいくぐるとか。アメリカの「貧乏人ほどデブ」というのも原因と結果がどちらなのかなあ、と思います。
個人でリスクをとるぶんにはかまわないのですが
大阪の釜ヶ崎・あいりんのあたりだと結核が多いわけです。結核は強制収容・治療なんですが、彼らは症状が治まると完治しないうちに逃げ出すから、そのたびに多剤耐性結核菌が強くなる一方。で、調子が悪くなると共産党の親切な方が病院に連れてくると・・orz 人権もいいのですが他人に迷惑をかける場合、朝三暮四の人にもわかりやすい強いペナルティをかけられないものですかねえ。

Posted by: ぷー | April 17, 2008 at 12:09 PM

長々と他人のコメント欄で書いてすいませんが
http://business.nikkeibp.co.jp/article/life/20080415/153068/
似たような話が出ていて興味深いですね。

>ただし、日本人の集団主義的な価値観は、ある条件下のもとで優位を占めているにすぎない、というのが著者の言いたいことだ。

 その条件を著者は「安心社会」と呼ぶ。「安心社会」とは、〈メンバーがお互いを監視し、何かあったときに制裁を加えるメカニズム〉が埋め込まれているムラ型の社会のことだ。こうした社会では、〈社会そのものがそこに暮らすメンバーたちに正直さや、律儀さを強制するような仕組みになっている〉ため、人はいやがおうにも、集団を優先した行動をとらざるをえない。

 しかしこのことは、「安心社会」という条件を外してしまえば、日本人は個人主義的にふるまうことも同時に示している。実際、著者がおこなった社会心理学の実験によれば、アメリカ人より日本人のほうが、他者一般への信頼が薄く、個人主義的な行動に出る傾向が強いそうだ。

Posted by: ぷー | April 17, 2008 at 12:57 PM

ossanpower さん、コメントありがとうございます。リプライが遅れてすみません。仕事に余裕が出来そうだなと思って仕事の幅を広げてみたら、同時に本業が忙しくなってしまい、大変なことになっておりまして・・・。

預かり金制度が適用可能なら、全病院で一斉にやらないといかんということですね・・・。しかし、120万とかになったら差し押さえとか出来ないんでしょうか。100万を超えれば法的コストを考えてもなんとかペイするのではないかと思うのですが。法的にちゃんとした債権になってないと駄目なんでしょうか。

「支払いが出来ないなら帰れ」(事前処置)と言えないのなら、代わりに「ちゃんと支払わないとひどいぞ」(事後処置)はきちんと整えないと駄目だと思うんですが。出来れば、事前処置がコストが低いのでお勧めなのですが。

Posted by: 馬車馬 | April 27, 2008 at 08:09 AM

ぷーさん、コメントありがとうございます。
私のところは長文コメント歓迎のスタンスですのでお気になさらず。大体、私のコメントが一番長いですし。

本来、ギルド社会は「適切かつ容赦ない処罰」によって成り立つものですから、駄目な人を放逐できなかった医療ギルドには社会としての問題を抱えていたのかもしれません。但し、ギルドは「自分の職域を侵すものには徹底的に対抗する」という役割もありますから(元々はそのために生まれたといっても過言ではありません。貴族は売ったはずの特権を取り上げたり、適当に税金を課したり、やりたい放題でしたので)、忠告をギルドへの攻撃と勘違いしてしまったのかもしれませんね。(この話は先のほうでちゃんと書くかもしれません。今のところ没原稿ボックス入りを果たしているのですが・・・)。

チキンレースの結果ですが、一部の医療が海外に移転するという結末になりそうな気がします。タイとかやる気満々ですし。この件は数ヵ月後に書く予定です。

しかし、救急外来でも順番どおりですか・・・ただ、そこで親が文句を言うのはある意味当然(これ自体非常に洋才っぽい考え方ですが)で、それを適当に受け流したり無視したりするスキルが必要になるのかもしれません(で、イギリスのように暴力を振るう人も増えるのかもしれませんが・・・)

長期計画をしない人、出来ない人というのはいつでも社会の悩みの種ではあります。評判メカニズムは「これをやらかしたら将来こんな不利益を蒙る」ということを全員が理解できることを前提に成立します。それが出来ない人間はギルドに入れません。来る者を拒めない洋才社会では刑務所に放り込んだり、場合によってはこの世から放逐する必要が生じます(つまり、一度は「やらかす」ことを洋才社会は防げません)。

特に流行り病を持ち込むような人の場合は、放っておくだけでも害悪ですから、積極的に社会から隔離する必要が出てきます-少なくとも、理論的には。実社会ではpolitically incorrectな発言ですが・・・。私は、人権というのは(少なくとも、社会によって守られるべき人権は)より良い社会を構築していくという目的意識を持って定義されるべきであると思っています。その点を無視して人権を定義しても、まさに流行り病のケースのように、ある人の人権を守ることで他の多くの人の人権が損なわれ、結局は状況が悪化してしまいます。その辺り、人権擁護を唱える人にはマクロの視点が欠けるケースが散見されるように思います。

面白いページを教えていただいてありがとうございます。私は経済学でよくある「意思決定は意識ではなく、無意識の産物である」という仮説を支持する立場(ちなみに、経済学者にはこれに強く反論する人もいますが、意識を明示的に扱う理論はまだ構築されていないようです)ですので、アンケート調査の結果には少々懐疑的です。ですが、個人の行動が社会、または他の人との関わりの中で決まってくることが、アンケート調査からすら示されるというのは大変面白いですね。

ちなみに、無意識の意思決定の話はこの辺でも話題になっていましたね。
http://slashdot.jp/science/article.pl?sid=08/04/15/041236

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