Comparative Health Systems

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Comparison of Health Systems around the world.

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Comparative Health Systems

  1. 1. Surgery Grand Rounds Robert Wolfson, MD, MSHA Healthcare Systems: History, Management & Policy April 20, 2009
  2. 2. Comparative Analysis Of National Healthcare Systems www.wolfsonconsulting.com/grandrounds April 20, 2009
  3. 3. Healthcare Crisis! quot;Report puts U.S. health care with industrialized world's worst.quot; (Family Practice News, 2008) quot;The Coming Healthcare Collapsequot; Obama Health Plan Unafforable: Income tax to rise by 90%! (Robert McIntosh: 4/14/2009, A.P.) quot;The Healthcare Crisis in Americaquot; (Families USA – 2007) 4/20/2009 3
  4. 4. Healthcare Crisis! quot;Lack of health insurance causes 18,000 unnecessary deaths every year.quot; (Institute of Medicine, January 14, 2004) quot;To Err is Humanquot; (IOM, 1999, 2003) quot;44,000 – 98,000 People Die Each Year In Hospitals as a Result of Medical Errorsquot; 16%, or 43 Million Americans Have No Medical Insurance (CDC) 4/20/2009 4
  5. 5. 4/20/2009
  6. 6. What’s Going On Here? Is This Problem Unique to the U.S.? How Do Healthcare Systems Function In Other Comparable Nations? Where Should We Turn For Examples With Our Healthcare Reform Efforts? This Morning: Compare U.S. Healthcare System With Healthcare Systems In Other Nations 4/20/2009 6
  7. 7. Topics 1. Define Terms & Methods 2. Evolution - Health Systems OECD Nations 3. Health System Models & Examples 4. Consistent Differences 5. Current Healthcare Debate 6. Discussion 4/20/2009 7
  8. 8. Terms I. OECD II. Healthcare III. Analytic Methods: quot;Systems Theoryquot; IV. Healthcare System V. Individual Madate, Employer Mandate VI. Single Payer System 4/20/2009 8
  9. 9. I. OECD: Organization for Economic Cooperation and Development 30 Countries Committed to 'Democracy & the Market Economy' Began in 1921, Expanded in 1960's In the 20th Century, All OECD Countries Extended Government‟s Role in Financing & Organization of Health Services 4/20/2009 9
  10. 10. OECD - 30 Countries 20 Nations Initially: (1921) Austria, Belgium, Canada, Denmark, France, Germany, Greece, Iceland, Ireland, Italy, Luxembourg, Netherlands, Norway, Portugal, Spain, Sweden, Switzerland, Turkey, U.K., U.S.A. + 10 Later: Australia, Czech Republic, Finland, Hungary, Japan, Korea, Mexico, New Zealand, Poland, & Slav. Repuplic 4/20/2009 10
  11. 11. II. Healthcare All Goods & Services Delivered Designed to Promote Health Including: • Preventive, Curative & Palliative Interventions • Directed to Individuals & Populations 4/20/2009 11
  12. 12. III. Methods Healthcare Systems Can be Compared Using Different Disciplines, or Methods: 1. Sociology: Distribution of Care per Sociologic Group 2. Economics: Most Data Available 3. Systems Theory: The Most Comprehensive 4/20/2009 12
  13. 13. Systems Theory: quot;The Study of the Nature of Systems In Nature, Society and Sciencequot; A Framework by which One Can Analyze A Group of Objects, Working in Concert To Produce a Result Examples of Systems: Cell, A Method, quot;Cardiovascular Systemquot; 4/20/2009 13
  14. 14. Characteristics of Systems: 1. Separate Objects Acting as an Integrated Whole Often Reach Functional Equilibrium: (Closed Systems) 2. Objects in Systems are often Grouped into Categories: Input, Processing, Output, Feedback 3. Parts of Systems Have: Functional & Structural Relationships to Each Other 4/20/2009 Slide 14
  15. 15. IV. Healthcare System = All Resources Dedicated to Providing Healthcare Services to Populations, Nations Include: Patients, Providers, Methods, Treatments Institutions, Organizations, Buildings Acting as an Integrated Whole to Provide Healthcare Services to Populations &/or Nations 4/20/2009 15
  16. 16. Healthcare Systems Inputs: Funding, Patients, Physicans Throughputs: Healthcare Organizations, Treatments Outputs: Outcomes, Payments to Providers Environment: Physical Environment, Health Of Individuals & Community Feeback: Patient Health, Satisfaction, Health of Community 4/20/2009 16
  17. 17. Healthcare System Model Feedback Input: Output: Throughput: $$$, Patients, Suppli $$$, Patients In Pt. & Out Pt. es, Clinical Outcomes, Services, Information Information Information Environment People, Wellness, Illness, Risks 17 4/20/2009
  18. 18. Terms (cont.) V. Individual, Employer Mandates: Individual citizens are required to have health insurance, one way or another. Employers are required to provide health insurance to employees. VI. Single Payer System Payment for all Healthcare Expenses comes from a Single Source or Fund. 4/20/2009 18
  19. 19. Evolution of Health Systems In U.S., Before & During World War II: Labor Shortage, Freeze on Prices and Wages Employers Allowed to Offer Health Insurance As a Tax Deductable Benefit to Employees = Subsidy to Employers & Employees 4/20/2009 19
  20. 20. Following World War II: Western European Nations & Japan: Had to Rebuild From Scratch Developed National Health Systems Through Socialist Governments United States Chose Not to Build A National Health System, But Provided Subsidies to Their Healthcare System 4/20/2009 20
  21. 21. U.S. Subsidies Hospitals: Hill Burton Act – Funding For Hospitals Many Hospitals Granted Tax Exempt Status Training of Health Professionals Subsidized Through Governmental Grants Employer-Sponsored Health Insurance: Remained Tax Decuctible 1960's: Medicare, Medicaid 4/20/2009 21
  22. 22. Health System Models I. National Health Service (NHS) II. National Health Insurance (NHI) III. Mixed Funding, Mixed Coverage Pvt. Insurance + Government Funding Coverage is Not Universal 4/20/2009 22
  23. 23. I. National Health Service (NHS) quot;Nationalization of Healthcarequot;: Including Providers, Facilities & Services Universal Coverage, Single Payer Financing From: Income Tax, General Taxes & General Fund District Budgets Are Used to Control Spending 4/20/2009 23
  24. 24. Characteristics: NHS Patients seen in Public Hospitals & Clinics Physicians work for NHS Countries Include: Great Britain, Sweden, Norway, Finland, Spain, Italy, Greece Private Practices often Allowed 4/20/2009 24
  25. 25. United Kingdom: Population: 61 Million Life expectancy at birth: 79 Health spending as % GDP: 8.3% Coverage: Universal Management: Government Hospitals: Owned by Government Physicians: Paid Salary by Government Receive Fees from Private Insurance, Patients 4/20/2009 25
  26. 26. U.K.: Spending Health Spending per capita per yr.: $2,580 $ 2,245 (87%) From Government $335 (13%) From Individuals For Supplemental, Private Insurance, Payments to Doctors, Self Pay for OTC drugs Prescription drugs: 1/2 Population Receive Drugs for Free, Exemptions: Age, Disability and Pregnancy 4/20/2009 26
  27. 27. U.K. (cont.) Notable features: 1. Patients do not receive Bills: Or Insurance Premiums 2. National Inst. Health & Clinical Excellence: Advice For Treatments & Drugs to be Covered 3. Challenges: Inefficiencies, Old Infrastructure, Waiting Times, Unequal Distribution of Resources Among Districts. Professor Sir Bruce Keogh, 2/2/09 4/20/2009 27
  28. 28. II. National Health Insurance (NHI) = Nationalization of Health Insurance May be Single or Multiple Payers, But There is Universal Coverage with Employer &/or Individual Mandates Financing Comes From: Employment Taxes; Social Security Less „Budgeted‟ More Flexible form of Financing Private & Public Hospitals/Clinics Exist 4/20/2009 28
  29. 29. NHI: Japan, France Individuals Buy Coverage: From Government Plan or Private Insurers Universal Coverage, Individual Mandate Consumers Pay Insurance Premiums Government Provides Subsidies for: • Elderly • Those in Need • Small Businesses 4/20/2009 29
  30. 30. Japan: NHI; Financing: Public & Private Insurance Universal Coverage; Individual & Employer Mandate Funding: From Employment Taxes and Private Insurance Premiums ~ 4% of Salary => Nonprofit, Community-Based Insurance Plan. Public Assistance For Small Businesses, Elderly & Poor 4/20/2009 30
  31. 31. Japan: Population: 128 million Life Expectancy at Birth: 82.1 Health Spending as % GDP: 8% Coverage: Universal Spending/capita/yr.: $2474 $ 2053 (83%) From Government, $420 (17%) From Invividuals: Gov't. Controls on Pharmaceutical Prices 4/20/2009 31
  32. 32. Japan (cont.) Notable features: Frequent Doctor Visits; Long Hospital Stays. Insurers Must Cover Everyone; Can't Deny a Claim. Biggest challenges: Rapidly Aging Population. Overuse of Care. Highest Number of Hospitals/Person in the world. Shortage of Physicians in Many Specialties & Rural Areas. 4/20/2009 32
  33. 33. NHI, France: Individual & Employer Mandate; 13.1% of Employees‟ Salary Goes to NIH Fund Income Tax Fund Coverage for: Retirees, Unemployed, Disabled, Poor. 87% Have Supplemental Insurance: Private, for-profit Insurers Purchased by Employer or Individuals. 4/20/2009 33
  34. 34. France: Population: 61.7 Million Life expectancy at Birth: 80.3 Health Spending as % GDP: 11.1% Coverage: Universal Health Spending per capita/yr.: $3,300 $2,644 (80%) From Government, $440 (13%) From Individuals for Private Insurance, $220 Consumer Out-of-Pocket Expenses 4/20/2009 34
  35. 35. France: Notable Features 30 Chronic Conditions: Including Diabetes: Fully Covered Broad Choice of Physicians, Specialists Case Management: Pre/Post Natal Care, Cancer, Other Conditions Prescription Coverage: Co-pay Based on Demonstrated Effectiveness 4/20/2009 35
  36. 36. France: Physicians Organized into Unions Government pays Fee-For-Service Based on Negotiated Rates Hospitals: Government Sets Rates Challenges: Increasing Costs, Inefficiencies. 4/20/2009 36
  37. 37. Canadian System: NHI – of sorts. Funded by Taxes From The General Fund Single Payer System Budgets on a Provincial Level Most Hospitals: Self Managed, Private “Funding without Organization” Physicians: Salaried & Fee For Service Care is Publically Funded, Privately Delivered 4/20/2009 37
  38. 38. Canada: Population: 33 Million Life expectancy at Birth: 81.1 yrs. Health Spending as % GDP: 10.3% Health Spending per capita/yr.: $3460 $2, 422 (70%) From Government $1100 (30%) Private Spending Challenges: Increasing Costs; Waiting Times 4/20/2009 38
  39. 39. III. Mixed Funding, Mixed Coverage U.S.A. Funding From: Private Insurance, Individuals & Government • Multiple Payers • No Individual or Employer Mandate • Coverage Not Universal 4/20/2009 39
  40. 40. United States: Population: 302 Million Life Expectancy at Birth: 78.1 Health Spending as % of GDP: 15.3% 46 Million, or 16% Uninsured Medical Debt Is The #1 Cause of Bankruptcy Spending/capita/yr. = $7,000 $3220 (46%) From Government $3780 (54%) Employer-Employees, Individuals 4/20/2009 40
  41. 41. United States: Highest Infant Mortality: in OECD Coverage: Almost all people over 65 yrs. Old. Approx. 80% of people under 65 yrs.old. Total Health Spending/yr. = $3.16 Trillion Physician & Hospital Fees: Predetermined in Government Programs & Private Insurance No Price Controls for Uninsured: Charged approximately 200% 4/20/2009 41
  42. 42. United States (cont.) Notable Features: Individual Choice; Very Expensive Advanced Technology, Drugs and Facilities Insured Patients Choose Doctors & Hospitals Challenges: 1. The Uninsured 2. Discrepancy between Rich and Poor Access & Quality of Care 3. Increasing Costs, Quality Concerns 4. Dysfunctional Payment System 4/20/2009 42
  43. 43. Common U.S. Values and Opinions: The „Rugged Individual‟ Spirit Anti-Entitlement Anti-Government-Run Programs “U.S. Has the Best Healthcare the World” “Universal Coverage => Runaway Costs” “We‟re Different” 4/20/2009 43
  44. 44. Cost of Care Per Capita 7000 United States Germany Canada 6000 France Australia United Kingdom 5000 4000 3000 2000 1000 0 80 82 84 86 88 90 92 94 96 98 00 02 04 19 19 19 19 19 19 19 19 19 19 20 20 20 4/20/2009 44
  45. 45. Cost of Healthcare - % of GDP 16 14 12 10 8 6 United States Germany 4 Canada France Australia 2 United Kingdom 0 80 82 84 86 88 90 92 94 96 98 00 02 04 4/20/2009 45 19 19 19 19 19 19 19 19 19 19 20 20 20
  46. 46. Health Spending/person %GDP $7,000 18.0% 16.0% $6,000 14.0% $5,000 12.0% $4,000 10.0% 8.0% $3,000 Ave. Annual Spending/person 6.0% $2,000 Hlth. Spending 4.0% %GDP $1,000 2.0% $0 0.0% 4/20/2009 46
  47. 47. Life Expectancy & Ave. Annual Spending/Person $7,000 83.0 82.1 $6,000 82.0 81.3 $5,000 81.0 80.3 $4,000 80.0 79.4 Life Expectancy 79.0 79.0 $3,000 79.0 78.1 Ave. Annual $2,000 78.0 Spending/person $1,000 77.0 $0 76.0 4/20/2009 47
  48. 48. US Health Spending Projections National Health Expenditures (billions) $4,500 $4,000 $3,500 $3,000 $2,500 $2,000 $1,500 $1,000 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 4/20/2009 48
  49. 49. Consistent Differences Non U.S. Healthcare Systems: Are Significantly Less Expensive Have Acceptable (Better?) Outcomes All Have: 1. Individual &/or Employer Mandates 2. Universal Coverage 4/20/2009 49
  50. 50. What's Happening Here? I. Is There a Crisis? Characteristics of U.S. Healthcare System Are a Result Of: History, Structure, & Culture II. No System Is Perfect All Have Challenges, Problems III. Is it Less Expensive: To Mandate Participation? To Provide Universal Coverage? 4/20/2009 50
  51. 51. Reform Efforts: I. What Are Our Goals? Reduce Cost? Improve Quality? Cover the Uninsured? II. Can, or Should We Try To Accomplish All of Them Concurrently? How? 4/20/2009 51
  52. 52. What Are Our Options? I. Answers II. Questions 4/20/2009 52

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