決定 記錄生命的轉折點

2006年歲末冬寒,在遙遠的北國獨自生活,把工作網站維護的重擔放了下來,交給智邦代管。

未來除了檔案儲存和搜尋引擎的部份,因為空間的需求不能負荷外,其它的如 BLOG, Calendar, Port, Personal Information Database,Mail Server等等的工作,都不再自己維護。

不知道這種的動作,代表了對 Linux 的技術不再精進,或者只是一種生命追求的改變,現在不得而知。

但是很肯定的告訴自己,這樣的動作是對的,應該把更多的時間用來做研究,而不再了維持網路主機的不間斷,付出了高昂的代價,未來只保留研華 Advantech 那台主機,做為 Samba & Rsync 的 BackBone 透過 VPN Connect 和其它工作地點的連接,以 RAID 1 的方式,確保檔案的安全,而不再以多機同步的方式來做。

另外思考是否用簡單的 WordPress 來架設自己的 BLOG,但短時間也不能擺脫 MovableType 的系統。

未來的時間是屬於自己的,不再為主機的安危擔心受怕,希望有更多的空閒時間,做歡喜快樂的事情。

風險轉出和產品的選擇

治療某種疾病,有兩種方法,A 和 B

A 方法,風險高,療效差,但是成本較低
B 方法,風險低,療效佳,但是成本較高

這裏的風險是指病人接受治療上,可能導致的併發症的可能。

在保險的支付原則,是病人必須先接受A方法治療,如果 A方法治療無效時,保險才支付 B 方法,而但書是 如果醫師認為病人需要接受 B 方法治療時,付合某些條件,保險可以支付,但需要經過嚴格的審查,若未通過審查,則事後不給支付。

此時病人需要接受治療時候,醫師的選擇,採用 A 方法時,因為高風險的存在,可能會導致醫療糾紛的風險成本高,而採用 B方法時,如健保不能支付時,會導致醫師或醫療機構的財務風險。

在這種情況下,Path A 和 Path B 的選擇,
Path A: 風險高,保險若不能承擔風險發生所需要的成本,也就醫師要自己承擔風險成本,這時候醫師評斷風險成本,高過他可以付擔時,Path A 就會 Failure. 除非保險付擔了風險成本,Path A 才能夠被 Activate.

Path B: 風險低,療效高,但是醫師如果直接採 Path B 時,對於病人是相當好的,但是醫師會承受較高的財務風險,也就是治療病人後,保險不支付的情況。如果財務風險太高,而醫師無法接受時,Path B 則會 Failure.
解套的方式,病人自己負擔 Path B 的費用,讓醫師的財務風險轉出,移往病人,則 Path B 才能夠推動。

如果保險不願意支付 Path A 的風險成本,而病人不願意承擔 Path B 的財務風險,則醫師認為 Path A 和 Path B 的相關成本,則會拒絕此類病人的就醫,也就是逆選擇的行為

醫療的藍海策略

在1980年代 Michael Porter 提出了競爭理論,把競爭策略分為三種型態,分別為降價 Cost down,差異化 Differentiation & 分割Focus 三種方式,Cost Down 的策略就是控制成本,使得在眾家的競爭者中,能以低價的方式來取得更多的市場,這就是書上所謂的紅海,大家殺的火紅市場。

這種競爭的方式,因為傳統的產品,一定會有固定的市場存在,如果成本控制得宜,而品質與競爭者相距不多,你就可以擁有固定的客源,在經營上,這種產品收益少,但是相對Differentiation 的市場來說,風險也比較少。

一般的醫師所能想到差異化,如標示外使用(Off Label Use),在法律上往往無沒受到保護,也就是說會導致更高的風險,而另外一種是在非醫療品質上去努力,提昇醫院建築和內裝上提升,提供病人更舒適的就診空間,提供

而Differentiation 的經營方式,就是提出某種產品的變革,也就是新的產品,而這個市場是可能是競爭者無法快速進入,這種方式也就是所謂的藍海策略,差異化的策略,通常是代表一個高風險,新產品的市場接受度無法預測,相對於傳統產品市場來說,除非能快速替代傳統產品的功能,能接受新產品的人數少,市場可能較小,而且更能提出一個新的安全品質良好的產品,可能需要投入更多更高的成本,而這些產品是競爭對手無法快速趕上時,才能夠得到高利潤,相對於降價,差異化的策略代表的是一個高成本且高風險。

醫療產業,產品的更替率與其它的市場如3C來說,相對來說是低,而且醫療產業和市場的動向是保守的,產品的開發和病患的思維都是首重安全的,新的醫療產品的成本,新的藥品,新的儀器,密須要透過層層關卡和認證才能上市,這種成本可能是跨國藥品廠商,或者是以國家資本才有辦法做到的。

一般醫療機構或是醫師的差異化做法,醫師通常採用標示外使用(Off Label Use),也就是未經政府主管認證單位所許可的使用方式,但這類的藥品和儀器的使用,在糾紛發生的時候,承擔更高的風險,另一種的方式是提升更多的非醫療服務的品質,如更好的建築和內裝的服務,讓就醫病人能感受舒適的服務,而這些服務產生的風險和成本,並不能提升真正的醫療品質,相對上也會付出較高的成本。

To Solve the Problem of Unsupported AGP

Look at /etc/modules.conf. In Slackware you can add it a line as below

“options agpgart agp_try_unsupported=1”

and run update-modules. That way when you use modprobe (but not insmod IIRC) or “depmod -a” the option is added automatically.

Reboot then you will find there is no more “agp_unsupported” message

觀雲

看山看雲,看不盡紅麈痴嗔
觀星觀月,觀不清凡生眾相

灑脫中坐擁清閒
清悠裡細數山巒

風雲之際,笑看天下

醫療院所提供給病人服務產品的分類

產品可分為 Tangible & Intangible 的兩種服務

Tangible services can be divided into two categories.
One is that services is not manufactured or produced by hospital itself. Like the medications and health complementary, hospital gets from their upstream and dispenses them to its patients.
The other tangible services which is operated or created in the hospital by staffs’ esp. operation, laboratorial survey and other like facilities to treat peoples’ diseases.

There are also some intangible products like information supports like consultations, secondary opinion service and patients’ educations.

In the past, the strategy of hospital should be use the advantage of information asymmetry between physicians and patients to operate some tangible product demands. Under authorities, the physician persuades or suggests patients to take his opinions to be the treatment guide. By this kind of business model, patient should accept some operation and buy some medication recommended by physician. It means that patients come to hospital to acquire their medications and some tangible product but not the information. Intangible Information product is just embedded with those above tangible products sales. The intangible product information cannot be charged according to it is free in the concept of patients own. Then hospital can get better efficiencies if they have good bargain power with its suppliers. And it can provide more health service product which emerged from itself. In truth, information should be most important in patients’ therapy.

In recent, the information of health service becomes more accessible and popular via internet or mass media. The situation of information asymmetry had been alleviated. Patients can have more information about their diseases and claim their physicians to do the treatment as their own way, even challenge their physicians’ recommendation. Some chronic patients like diabetes, hypertension or some menopause patient can surf on internet and acquire something important for them. But there is less warranty of their information. They can easily get their medications from the chemists by doctors’ long term prescriptions about chronic diseases easily than before. The hospitals are not considered to be source of medications only. Many new hospitals have established, and the more competition existed. The skill of services like operation and facilities of each hospital become similar. There are no more speculations between them and patients won’t go to a specific hospital owing to the differentiation. How to sustain the capabilities for competition is the first intention of hospitals now. To provide patients with the precise information and make the intangible product fit for their expectation become the set points.

Why the patients choose the medical center in the place of elementary local clinics? The price variance between them maybe is first considered according to our literature review. Supposed there should be other consideration over the price variance. Doesn’t the local clinic give less information support than hospital? Are patients willing to pay more for the information while the medications and facilities are same?

第一種的服務是通路上的服務,這類的服務通常是藥品或衛材的需求,病人可以前往醫院獲得他所需要的藥品或衛材,而這種服務決定於醫院的通路能力,是否可以取得獨佔或比較高的議價能力。

第二種的服務是器材,檢驗和手術上的服務,這方面的服務,通常是屬實質的服務,所謂的 Last Mile的服務,而這種服務決定於醫院醫療器材的好壞,醫院醫師的手術能力。

第三種的服務是資訊的服務,這方面的服務是屬於一種非實質產服務,這種服務決定於醫師的表達能力,和醫院可以提供給醫師和病人資訊系統和醫病間溝通環境的規劃。