Overview US Health System Debate
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  • AUSTRALIA , AUSTRIA, BELGIUM, CANADA, CZECH REPUBLIC , DENMARK, FINLAND, FRANCE, GERMANYGREECE, HUNGARY, ICELAND, IRELAND, ITALY, JAPAN, KOREA, LUXEMBOURG, MEXICO, NETHERLANDS, NEW ZEALAND, NORWAY, POLAND, PORTUGAL, SLOVAK REPUBLIC, SPAIN, SWEDEN, SWITZERLAND,TURKEY, UNITED KINGDOM,UNITED STATES

Overview US Health System Debate Overview US Health System Debate Presentation Transcript

  • Surgery Grand Rounds
    Robert Wolfson, MD, MSHA
    Healthcare Systems: History, Management & Policy
    April 20, 2009
  • Comparative Analysis Of
    National Healthcare Systems
    www.wolfsonconsulting.com/grandrounds
    April 20, 2009
  • Healthcare Crisis!
    "Report puts U.S. health care with industrialized world's worst."
    (Family Practice News, 2008)
    "The Coming Healthcare Collapse"
    Obama Health Plan Unafforable: Income tax to rise by 90%!
    (Robert McIntosh: 4/14/2009, A.P.)
    "The Healthcare Crisis in America"
    (Families USA – 2007)
    4/20/2009
    3
  • Healthcare Crisis!
    "Lack of health insurance causes 18,000 unnecessary deaths every year."
    (Institute of Medicine, January 14, 2004)
    "To Err is Human" (IOM, 1999, 2003)
    "44,000 – 98,000 People Die Each Year
    In Hospitals as a Result of Medical Errors"
    16%, or 43 Million Americans
    Have No Medical Insurance (CDC)
    4/20/2009
    4
  • 4/20/2009
  • 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
  • Topics
    Define Terms & Methods
    Evolution - Health Systems OECD Nations
    Health System Models & Examples
    Consistent Differences
    Current Healthcare Debate
    Discussion
    4/20/2009
    7
  • Terms
    OECD
    Healthcare
    Analytic Methods: "Systems Theory"
    Healthcare System
    Individual Madate, Employer Mandate
    Single Payer System
    4/20/2009
    8
  • 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
    9
    4/20/2009
  • 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
  • II. Healthcare
    All Goods & Services Delivered
    Designed to Promote Health
    Including:
    • Preventive, Curative & Palliative Interventions
    • Directed to Individuals & Populations
    4/20/2009
    11
  • III. Methods
    Healthcare Systems Can be Compared
    Using Different Disciplines, or Methods:
    Sociology:
    Distribution of Care per Sociologic Group
    Economics: Most Data Available
    Systems Theory:
    The Most Comprehensive
    4/20/2009
    12
  • Systems Theory:
    "The Study of the Nature of Systems
    In Nature, Society and Science"
    A Framework by which One Can Analyze A Group of Objects,
    Working in Concert To Produce a Result
    Examples of Systems:
    Cell, A Method, "Cardiovascular System"
    4/20/2009
    13
  • Characteristics of Systems:
    Separate Objects
    Acting as an Integrated Whole
    Often Reach Functional Equilibrium:
    (Closed Systems)
    Objects in Systems are often Grouped into Categories:
    Input, Processing, Output, Feedback
    Parts of Systems Have:
    Functional & Structural Relationships to Each Other
    Slide 14
    4/20/2009
  • 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
  • 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
  • Healthcare System Model
    Feedback
    Input:
    $$$, Patients, Supplies,
    Information
    Output:
    $$$, Patients
    Clinical Outcomes,
    Information
    Throughput:
    In Pt. & Out Pt. Services,
    Information
    Environment
    People, Wellness, Illness, Risks
    17
    4/20/2009
  • Terms (cont.)
    Individual, Employer Mandates:
    Individual citizens are required to have health insurance, one way or another.
    Employers are required to provide health insurance to employees.
    Single Payer System
    Payment for all Healthcare Expenses comes from a Single Source or Fund.
    4/20/2009
    18
  • 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
  • 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
    20
    4/20/2009
  • 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
  • Health System Models
    National Health Service (NHS)
    National Health Insurance (NHI)
    Mixed Funding, Mixed Coverage
    Pvt. Insurance + Government Funding
    Coverage is Not Universal
    22
    4/20/2009
  • I. National Health Service (NHS)
    "Nationalization of Healthcare":
    Including Providers, Facilities & Services
    Universal Coverage, Single Payer
    Financing From:
    Income Tax, General Taxes & General Fund
    District Budgets
    Are Used to Control Spending
    23
    4/20/2009
  • 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
    24
    4/20/2009
  • 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
  • U.K.:Spending
    Health Spending per capita per yr.: $2,580
    $ 2,245 (87%) FromGovernment
    $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
  • U.K. (cont.)
    Notable features:
    Patients do not receive Bills:
    Or Insurance Premiums
    National Inst. Health & Clinical Excellence:
    Advice For Treatments & Drugs to be Covered
    Challenges:
    Inefficiencies, Old Infrastructure, Waiting Times,
    Unequal Distribution of Resources Among Districts.
    Professor Sir Bruce Keogh, 2/2/09
    4/20/2009
    27
  • 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
    28
    4/20/2009
  • 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
  • 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 AssistanceFor Small Businesses, Elderly & Poor
    4/20/2009
    30
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
    37
    4/20/2009
  • 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
  • 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
  • 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
  • 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
  • United States (cont.)
    Notable Features:
    Individual Choice; Very Expensive
    Advanced Technology, Drugs and Facilities
    Insured Patients Choose Doctors & Hospitals
    Challenges:
    The Uninsured
    Discrepancy between Rich and Poor
    Access & Quality of Care
    Increasing Costs, Quality Concerns
    Dysfunctional Payment System
    4/20/2009
    42
  • 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”
    43
    4/20/2009
  • Cost of Care Per Capita
    4/20/2009
    44
  • Cost of Healthcare - % of GDP
    4/20/2009
    45
  • Health Spending/person %GDP
    46
    4/20/2009
  • Life Expectancy & Ave. Annual Spending/Person
    47
    4/20/2009
  • US Health Spending Projections
    48
    4/20/2009
  • Consistent Differences
    Non U.S. Healthcare Systems:
    Are Significantly Less Expensive
    Have Acceptable (Better?) Outcomes
    All Have:
    Individual &/or Employer Mandates
    Universal Coverage
    4/20/2009
    49
  • What's Happening Here?
    Is There a Crisis?
    Characteristics of U.S. Healthcare System
    Are a Result Of:
    History, Structure, & Culture
    No System Is Perfect
    All Have Challenges, Problems
    Is it Less Expensive:
    To Mandate Participation?
    To Provide Universal Coverage?
    4/20/2009
    50
  • Reform Efforts:
    What Are Our Goals?
    Reduce Cost?
    Improve Quality?
    Cover the Uninsured?
    Can, or Should We Try
    To Accomplish All of Them Concurrently?
    How?
    4/20/2009
    51
  • What Are Our Options?
    Answers
    Questions
    4/20/2009
    52
  • Thank You!