International Health Care Systems Kao-Ping Chua Jack Rutledge Fellow, 2005-2006 American Medical...

International Health Care International Health Care SystemsSystems

Kao-Ping ChuaKao-Ping Chua

Jack Rutledge Fellow, 2005-2006Jack Rutledge Fellow, 2005-2006

American Medical Student AssociationAmerican Medical Student Association

Structure of systems Structure of systems

InsuranceInsurance DeliveryDelivery ExamplesExamples

National National health health serviceservice

Mostly publicMostly public Mostly publicMostly public U.K.U.K.

Entrepre-Entrepre-neurial neurial

Mostly Mostly privateprivate

Mostly Mostly privateprivate

U.S.U.S.

Mandated Mandated insuranceinsurance

Mostly publicMostly public Public and Public and privateprivate

GermanyGermany

The influence of values on systemsThe influence of values on systems

European social ethic: public good, social European social ethic: public good, social solidaritysolidarity

American individualistic ethic: individual American individualistic ethic: individual good, social fragmentationgood, social fragmentation

Three categories of analysisThree categories of analysis

Organization: insurance pools, Organization: insurance pools, public/private mixpublic/private mix

Quality, choice, and accessQuality, choice, and access

ProblemsProblems

OutlineOutline

I.I. U.S.U.S.

II.II. JapanJapan

III.III. GermanyGermany

IV.IV. FranceFrance

V.V. U.K.U.K.

VI.VI. CanadaCanada

THINK BIG PICTURE!!!

U.S.U.S.

WHO Ranking for Health Attainment: 24

WHO Overall Ranking: 37

% GDP spent on health care: 15% (OECD median 8.6%)

62%18%

15%

5%Employer-sponsored

Uninsured

Medicaid/otherpublic

Private non-group

US: Organization*US: Organization*

*This refers to the non-elderly population

US: Quality, choice, accessUS: Quality, choice, access

Quality: depends on plan – often gaps for Quality: depends on plan – often gaps for prescription drugs, dental, visionprescription drugs, dental, vision

Choice: Restricted choice of providersChoice: Restricted choice of providers

Access: Waiting lines relatively rare, huge Access: Waiting lines relatively rare, huge amount of uninsurance amount of uninsurance

US: ProblemsUS: Problems

45 million uninsured45 million uninsured

Skyrocketing health care costs Skyrocketing health care costs

Significant health disparities by race and Significant health disparities by race and incomeincome

JapanJapan

WHO Ranking for Health Attainment: 1

WHO Overall Ranking: 10

% GDP spent on health care: 7.9% (OECD median 8.6%)

Japan: organizationJapan: organization

Japanese healthcare

system

Employee health insurance Elderly (Roken)

Self-employed, retired, others

(Kokuho)

1800 Kenpo Associations

(largecompanies)

Seikan (small-mid companies)

Kyosai (public employeesand private-school

teachers)

Japan: organizationJapan: organization

Most providers and hospitals are in the private sector

Hospitals are the center of care

Japan: quality, choice, accessJapan: quality, choice, access

Quality: huge amount of technology, Quality: huge amount of technology, comprehensive benefitscomprehensive benefits

Choice: free choice of doctors and Choice: free choice of doctors and hospitalshospitals

Access: few waiting lists except at the very Access: few waiting lists except at the very best hospitalsbest hospitals

Japan: problems/reformsJapan: problems/reforms

Kenpo associations in debt (cross-Kenpo associations in debt (cross-subsidizations); rapidly aging populationsubsidizations); rapidly aging population

Over-prescription of drugsOver-prescription of drugs

High cost-sharingHigh cost-sharing

FranceFrance

WHO Ranking for Health Attainment: 3

WHO Overall Ranking: 1

% GDP spent on health care: 10.1% (OECD median 8.6%)

France: organizationFrance: organization

Multi-payer systemMulti-payer system

3 main payers are the 3 main payers are the “Sickness Insurance “Sickness Insurance Funds” (SIF’s) – cover Funds” (SIF’s) – cover most health care costsmost health care costs

Profession determines Profession determines which SIF a citizen is which SIF a citizen is automatically enrolled inautomatically enrolled in

85%

9%6%

Industrial,commerical,government

Farmers

Professionals,smallbusiness,craftspeople

France: organizationFrance: organization Most ambulatory care physicians are in private Most ambulatory care physicians are in private

practicepractice Sector I: charge at national fee schedule but get Sector I: charge at national fee schedule but get

government benefitsgovernment benefits Sector II: charge above fee schedule but don’t get Sector II: charge above fee schedule but don’t get

government benefitsgovernment benefits

Hospitals both private and publicHospitals both private and public

Complementary health insurance for cost-Complementary health insurance for cost-sharing (90% of the population)sharing (90% of the population)

France: quality, choice, accessFrance: quality, choice, access

Quality: very comprehensive, good safety Quality: very comprehensive, good safety net for the poornet for the poor

Choice: Free choice of doctorsChoice: Free choice of doctors

Access: Can usually see GP on same-dayAccess: Can usually see GP on same-day

France: problemsFrance: problems

Nursing and physician shortagesNursing and physician shortages

Increasing health expenditures, mainly Increasing health expenditures, mainly from drugs (19% of all expenditures)from drugs (19% of all expenditures)90% of physician visits end up with 90% of physician visits end up with

prescriptions!prescriptions!

GermanyGermany

WHO Ranking for Health Attainment: 22

WHO Overall Ranking: 25

% GDP spent on health care: 11.1% (OECD median 8.6%)

Germany: organizationGermany: organization

Multi-payer systemMulti-payer system ““Social Health Insurance” Social Health Insurance”

(SHI) network made up of (SHI) network made up of 192 private, occupation-192 private, occupation-based "sickness funds”based "sickness funds”

High-income may opt-out High-income may opt-out of SHI and purchase of SHI and purchase “voluntary health “voluntary health insurance”insurance”

Free government careFree government care

89%

9% 2%SHI

SubstitutiveVHI

Freegovernmentcare

Germany: organizationGermany: organization

Ambulatory physicians are mostly privateAmbulatory physicians are mostly private

Hospitals are both public and privateHospitals are both public and private

Germany: quality, choice, accessGermany: quality, choice, access

Quality: Extremely comprehensive benefitsQuality: Extremely comprehensive benefitsGenerous sick pay policiesGenerous sick pay policies

Choice: Free choice of GP and specialists, Choice: Free choice of GP and specialists, must use closest hospitalmust use closest hospital

Access: Waiting times not usually a Access: Waiting times not usually a problemproblem

Germany: problems/reformsGermany: problems/reforms

Expensive health care systemExpensive health care system

High cost-sharingHigh cost-sharing

Excessive numbers of physicians (60% of Excessive numbers of physicians (60% of areas are closed off to more doctors)areas are closed off to more doctors)

The United KingdomThe United Kingdom

WHO Ranking for Health Attainment: 14

WHO Overall Ranking: 18

% GDP spent on health care: 7.7% (OECD median 8.6%)

UK: organizationUK: organization

National health service (NHS):National health service (NHS): publicly financed publicly financed and deliveredand delivered

Supplemental private insurance for dental and Supplemental private insurance for dental and eye careeye care

Growing sector of substitutive private insurance Growing sector of substitutive private insurance

UK: Quality, choice, accessUK: Quality, choice, access

Quality: Comprehensive except dental and Quality: Comprehensive except dental and eyeeye

Choice: Free choice of doctorChoice: Free choice of doctor

Access: major problems with waiting listsAccess: major problems with waiting listsSpecialist (2.5 months)Specialist (2.5 months)Elective procedures (3 months)Elective procedures (3 months)

UK: problemsUK: problems

Underfunding: Underfunding: Waiting listsWaiting listsHealth care delivery capacity is insufficient for Health care delivery capacity is insufficient for

many servicesmany servicesFacilities need updatingFacilities need updating

CanadaCanada

WHO Ranking for Health Attainment: 12

WHO Overall Ranking: 30

% GDP spent on health care: 9.9% (OECD median 8.6%)

Canada: organizationCanada: organization Single-payer systemSingle-payer system

13 provincial/territorial 13 provincial/territorial governments administer governments administer health care plan health care plan (“Medicare”)(“Medicare”)

Federal government Federal government regulates the regulates the provincial/territorial health provincial/territorial health care plans by offering care plans by offering “transfer payments” “transfer payments” contingent upon pre-contingent upon pre-specified criteriaspecified criteria

Federal government

10 provinces 3 territories

Provincial health care plan

Territorial healthCare plan

Comprehensive

PortabilityPublic

administration

Accessibility

Universality

Canada Health

Act of 1984

Canada: organizationCanada: organization

Providers are mostly private; hospitals Providers are mostly private; hospitals mostly publicmostly public

Most Canadians have complementary Most Canadians have complementary private health insurance for non-covered private health insurance for non-covered servicesservices

Canada: Quality, choice, accessCanada: Quality, choice, access Quality: Coverage for “medically necessary” Quality: Coverage for “medically necessary”

servicesservices Gaps for dental care, long-term care, Gaps for dental care, long-term care, outpatient drugsoutpatient drugs

complementary private insurancecomplementary private insurance

Choice: Free to choose GP and hospitalChoice: Free to choose GP and hospital

Access: Access: No waiting lists for GP visits or emergenciesNo waiting lists for GP visits or emergencies Waiting times can be problematic for certain Waiting times can be problematic for certain

ELECTIVE proceduresELECTIVE procedures

Canada: Problems/reformsCanada: Problems/reforms

UnderfundingUnderfunding

Gaps in coverageGaps in coverage

Tension between provincial and central Tension between provincial and central governmentsgovernments

Points to remember, part 1Points to remember, part 1

Every country is dealing with increasing health Every country is dealing with increasing health care costscare costs

ANY system can have problems if it is ANY system can have problems if it is underfunded, no matter how good it is underfunded, no matter how good it is theoreticallytheoretically

Privatization exists to various degrees in each Privatization exists to various degrees in each system…but no country allows private elements system…but no country allows private elements to price people out of health care to price people out of health care

Points to remember, part 2Points to remember, part 2

UHC can be achieved while maintaining: UHC can be achieved while maintaining: Comprehensive benefits for everyone (every Comprehensive benefits for everyone (every

country but U.S.)country but U.S.)Free choice of providers (every country but Free choice of providers (every country but

U.S.)U.S.)High levels of technology (Japan, Germany) High levels of technology (Japan, Germany) Few waiting lists (France, Germany, Japan) Few waiting lists (France, Germany, Japan)

Parting thought Parting thought

The U.S. is the only industrialized countryThe U.S. is the only industrialized country

in the world without UHC…in the world without UHC…

……but we can achieve high-quality, affordable but we can achieve high-quality, affordable health care for EVERYONE if we used the vast health care for EVERYONE if we used the vast

amounts of money in our system more efficientlyamounts of money in our system more efficiently