The AAPM is comprised of members with great diversity and with origins from many parts of the globe. There are some things about the culture in the United States that are no doubt unique and bewildering to those who have not grown up in the United States. One such peculiarity is the way hospital and other healthcare costs are paid. Many of us who are US natives will freely admit we can offer no logical reason why the situation is the way it is. Those of us who have taken the time to study the structure and history often come away no closer to understanding the swirl of money in healthcare than before. As someone who was involved in healthcare economic issues more than most in our organization, I will offer an introductory perspective to our diverse colleagues who have come to call the US their home.

My first real employment was in a hospital in 1969. I wanted to work in the kitchen, delivering food trays to patients. However, there were no openings, and instead I was offered a position as a radiology orderly, transporting patients from their hospital patient rooms to the x‐ray department and developing films in the dark room. (My introduction to medical physics was when two gentlemen came to visit one day per year to provide performance tests for our equipment.)

During the summer, I worked full time, and I noticed a pattern. Patients would check in on a Sunday and be scheduled for an array of morning procedures. One was performed on Monday, a second on Tuesday, and a third on Wednesday. Usually, these x‐ray tests were the intravenous pyelogram, the GI/gallbladder, and the barium enema. Always sequential and in this order. It did not take me long to think something was amiss with this arrangement. Could all of these patients have a medical disorder that would require all of these procedures? I also began to notice that the patients would return periodically for the same series of tests. When I asked the patients why they were here, they often replied: I am here for a rest. I began to wonder, who is paying for all of this? The short answer was hospital insurance, often Blue Cross and Medicare.

The origins of Blue Cross are found in Dallas, TX in 1929. Justin Ford Kimball, while he was vice president of Baylor University's healthcare facilities in Dallas, Texas, developed a plan to provide hospital coverage to teachers for up to 21 days for $6 per year. Before long, groups of hospitals were banding together to offer plans that were honored at all participating institutions, giving subscribers a choice of which hospital to use. This became the model for Blue Cross, which first operated in Sacramento, California, in 1932. An analogous type of plan and coverage was later extended to employees in lumber and mining camps of the Pacific Northwest to include coverage of physician costs; this was known as Blue Shield. (https://en.wikipedia.org/wiki/Blue_Cross_Blue_Shield_Association); (https://imprimis.hillsdale.edu/short‐history‐american‐medical‐insurance/). These are the earliest examples of employer‐paid health insurance.

Hospitals are very expensive to operate. The personnel, real estate, and operations are expensive; the equipment is not only very costly, but also becomes obsolete very quickly. Cash flow is always a problem because often patients require time to pay their bills. Hospital insurance provides a solution to this cash flow problem by providing reliable funds on an ongoing basis. No wonder this idea for hospital insurance proved popular with employees and spread very rapidly. It also had the benefit of generating steady and increasing demand for hospital services as they were already paid for. Additionally, the money does not return to the individual, as with most insurance; rather the funds are distributed directly to the hospital. While this obviously benefits the health institutions, it provides a perverse incentive. If patients do not care about the costs of their healthcare, they do not create a climate of competition between healthcare providers. There is no barrier from consumers of healthcare to keep costs in check. Physician care costs followed a similar economic model and patients were free to select mostly any physician regardless of the cost, unless the associated procedure was not covered or only partially covered.

In 1965, Congress proposed legislation to cover hospital and physician services, and what came of it were Medicare and Medicaid. President Lyndon B. Johnson signed it into law as part of his Great Society Legislation, capping 20‐yr of congressional debate. When the two programs were finally enacted, they were structured much like Blue Cross and Blue Shield, only with the government picking up much of the tab. In many states, the government actually hired Blue Cross/Blue Shield to administer the Medicare and Medicaid programs. The two new systems greatly increased the number of people who were eligible for advanced medical care, and the incomes of medical professionals soared, roughly doubling in the 1960s. Reimbursement for both hospitals and physicians were based on a fee‐for‐service procedure model. (https://en.wikipedia.org/wiki/Blue_Cross_Blue_Shield_Association); (https://imprimis.hillsdale.edu/short‐history‐american‐medical‐insurance/). This history explains much of my experience in 1969; some of the structure is still with us, in a modified form.

This structure sets the stage for the following dynamic: The government wants to pay less for hospital and physician services, so it does where it can. Hospital and physician groups band together to become large enough to negotiate directly with the carriers. The results of these negotiations are not public information. The financial well‐being of healthcare institutions becomes based more on the size of the population it serves than the cost and quality of its services. In days past, there was a robust relationship between community leaders and the hospitals, which were under the control of local boards. Religious‐based hospitals received support from churches and other community organizations. Sadly, this local interest and enthusiasm no longer exists for many hospitals and local boards often have little power over important decisions. Therefore, there is also a necessary loss of local community control of hospitals and associated healthcare delivery.

There is much additional complexity to master: the growth of HMOs and PPOs, the motivation behind capitation for services, the expansion of the power of state governments over healthcare and hospitals, and the significance of malpractice, and other litigation in the healthcare arena.

What should happen next? It is necessary to get consumers to care again about their personal healthcare costs. Some mechanism should be found to make the entire system transparent as to costs and charges. Consumers must bear responsibility for healthcare purchases, which means that they should be responsible for some portion of the costs, and it should be proportionate to the newly transparent charge and fee schedules in order to promote competition among providers.

What will all this mean for medical physicist salaries and program support? My magic 8‐ball says the answer is unclear; try again later.

AAPM由成员组成，成员来自世界各地，具有很大的多样性。对于美国文化而言，有一些事情无疑是独一无二的，对于那些在美国未曾长大的人来说，这是令人困惑的。这样的特点之一就是医院和其他医疗费用的支付方式。我们中的许多美国原住民都会自由地承认，我们无法提供合理的理由说明这种情况。我们当中那些花时间研究结构和历史的人往往比以往更加远离了解医疗保健中的金钱漩涡。作为一个比我们组织中大多数人参与医疗保健经济问题更多的人，我将向来我们这里以美国为家的各种同事提供介绍性见解。

我的第一份真正工作是在1969年在一家医院里。我想在厨房工作，为病人提供食物托盘。但是，这里没有空缺，而是为我提供了有序的放射学职位，将患者从他们的病房转移到X射线科，并在暗室中冲洗胶片。（我对医学物理学的介绍是，每年有两位先生来一天访问，为我们的设备提供性能测试。）

暑假期间，我全职工作，并注意到了一种模式。患者将在星期日检查，并安排进行一系列早晨检查。一个在星期一进行，第二次在星期二，第三次在星期三。通常，这些X射线检查是静脉肾盂造影，胃肠道/胆囊和钡剂灌肠。始终按此顺序进行。不久之后，我就认为这种安排不对劲。是否所有这些患者都患有需要所有这些程序的内科疾病？我也开始注意到患者会定期返回进行相同系列的检查。当我问病人为什么在这里时，他们经常回答：我在这里休息。我开始怀疑，这一切由谁支付？简短的答案是医院保险，通常是Blue Cross和Medicare。

Blue Cross的起源于1929年在德克萨斯州的达拉斯发现。贾斯汀·福特·金博尔（Justin Ford Kimball）担任贝勒大学在德克萨斯州达拉斯的医疗机构副总裁时，制定了一项计划，为教师提供长达21天的住院服务，费用为每人6美元年。不久之后，各医院集团联合起来，提供所有参与机构都认可的计划，使订户可以选择使用哪家医院。这成为Blue Cross的典范，该模型于1932年在加利福尼亚州的萨克拉曼多首次运营。类似的计划和承保范围后来扩展到了西北太平洋地区的木材和采矿营地的员工，包括了医师费用的承保；这就是所谓的蓝盾。（https://zh.wikipedia.org/wiki/Blue_Cross_Blue_Shield_Association）；（https：//imprimis.hillsdale。edu /短期历史美国医疗保险/）。这些是由雇主支付的健康保险的最早例子。

医院的运作非常昂贵。人员，房地产和运营费用昂贵；设备不仅非常昂贵，而且很快就会过时。现金流始终是一个问题，因为患者通常需要时间来支付账单。医院保险通过持续提供可靠的资金来解决这一现金流问题。难怪这种医院保险的想法在员工中很受欢迎，并且迅速传播。由于已经支付了费用，它还带来了对医院服务的稳定和不断增长的需求。此外，与大多数保险一样，钱不会退还给个人；而是将资金直接分配给医院。虽然这显然有益于卫生机构，但却提供了有害的激励措施。如果患者不关心自己的医疗保健费用，那么他们就不会在医疗保健提供者之间形成竞争气氛。医疗保健消费者没有任何障碍可以控制成本。内科医生的护理费用遵循类似的经济模型，并且无论费用如何，患者几乎都可以自由选择任何医生，除非相关的医疗程序没有被承保或仅被部分承保。

1965年，国会提出了涵盖医院和医师服务的立法，其中包括医疗保险和医疗补助。总统林登·约翰逊（Lyndon B. Johnson）将其签署为法律，作为他的《大社会立法》的一部分，并限制了20年的国会辩论。当这两个程序最终制定时，它们的结构非常类似于Blue Cross和Blue Shield，只是政府承担了大部分费用。在许多州，政府实际上雇用了Blue Cross / Blue Shield来管理Medicare和Medicaid计划。这两个新系统大大增加了有资格获得高级医疗服务的人数，而且医疗专业人员的收入猛增，在1960年代几乎翻了一番。医院和医师的报销均基于服务收费程序模型。（https：//zh.wikipedia。org / wiki / Blue_Cross_Blue_Shield_Association）；（https://imprimis.hillsdale.edu/short-history-american-medical-insurance/）。这段历史解释了我在1969年的大部分经历；某些结构仍以修改后的形式存在于我们中。

这种结构为以下动态奠定了基础：政府希望为医院和医师服务支付更少的费用，因此它会尽其所能。医院和医生团体团结在一起，规模足够大，可以直接与承运人协商。这些谈判的结果不是公开信息。医疗机构的财务状况更多地取决于其服务的人口规模，而不是其服务的成本和质量。在过去的几天里，社区领导者与医院之间存在着牢固的关系，这些地方都受到地方委员会的控制。宗教医院得到了教会和其他社区组织的支持。令人遗憾的是，许多医院已不再具有这种对当地的兴趣和热情，而且地方委员会通常对重要的决定也无能为力。因此，

还有很多需要掌握的复杂性：HMO和PPO的增长，人为化服务背后的动机，州政府对医疗保健和医院的权力扩大，医疗事故的重要性以及医疗领域的其他诉讼。

接下来应该怎么办？有必要让消费者再次关心他们的个人医疗保健费用。应该找到某种机制使整个系统对成本和费用透明。消费者必须对购买医疗保健产品承担责任，这意味着他们应对部分费用负责，并且应与新近透明的收费计划相称，以促进医疗服务提供者之间的竞争。

这对医学物理学家的薪水和计划支持意味着什么？我的魔术8球说答案还不清楚。稍后再试。