Surgery Grand Rounds<br />Robert Wolfson, MD, MSHA<br />Healthcare Systems: History, Management & Policy <br />April 20, 2...
Comparative Analysis Of<br />National Healthcare Systems<br />www.wolfsonconsulting.com/grandrounds<br />April 20, 2009<br />
Healthcare Crisis!<br />&quot;Report puts U.S. health care with industrialized world&apos;s worst.&quot;<br />(Family Prac...
Healthcare Crisis!<br />&quot;Lack of health insurance causes 18,000 unnecessary deaths every year.&quot;<br />(Institute ...
4/20/2009<br />
What’s Going On Here?<br />Is This Problem Unique to the U.S.?<br />How Do Healthcare Systems Function In Other Comparable...
Topics<br />Define Terms & Methods<br />Evolution - Health Systems OECD Nations<br />Health System Models & Examples<br />...
Terms<br />OECD<br />Healthcare <br />Analytic Methods:  &quot;Systems Theory&quot;<br />Healthcare System<br />Individual...
I. OECD:<br />Organization for Economic Cooperation and Development<br />30 Countries Committed to &apos;Democracy & the M...
OECD - 30 Countries<br />20 Nations Initially: (1921)<br />Austria, Belgium, Canada, Denmark, France, <br />Germany, Greec...
II.  Healthcare<br />All Goods & Services Delivered <br />Designed to Promote Health <br />Including: <br /><ul><li>Preven...
Directed to Individuals & Populations</li></ul>4/20/2009<br />11<br />
III.  Methods<br />Healthcare Systems Can be Compared<br />Using Different Disciplines, or Methods:<br />Sociology: <br />...
Systems Theory:<br />&quot;The Study of the Nature of Systems <br />In Nature, Society and Science&quot; <br />A Framework...
Characteristics of Systems:<br />Separate Objects <br />Acting as an Integrated Whole<br />Often Reach Functional Equilibr...
IV.  Healthcare System<br />= All Resources Dedicated to Providing<br />Healthcare Services to Populations, Nations<br />I...
Healthcare Systems<br />Inputs: Funding, Patients, Physicans<br />Throughputs: <br />Healthcare Organizations, Treatments<...
Healthcare System Model<br />Feedback<br />Input:<br />$$$, Patients, Supplies,<br />Information <br />Output:<br />$$$, P...
Terms (cont.)<br />Individual, Employer Mandates:<br />Individual citizens are required to have health insurance, one way ...
Evolution of Health Systems<br />In U.S., Before & During World War II:<br />Labor Shortage, <br />Freeze on Prices and Wa...
Following World War II:<br />Western European Nations & Japan:<br />Had to Rebuild From Scratch<br />Developed National He...
U.S. Subsidies<br />Hospitals:<br />Hill Burton Act – Funding For Hospitals<br />Many Hospitals Granted Tax Exempt Status<...
Health System Models<br />National Health Service (NHS)<br />National Health Insurance (NHI)<br />Mixed Funding, Mixed Cov...
I. National Health Service (NHS)<br />&quot;Nationalization of Healthcare&quot;:<br />Including Providers, Facilities & Se...
Characteristics: NHS<br />Patients seen in Public Hospitals & Clinics<br />Physicians work for NHS<br />Countries Include:...
United Kingdom:<br />Population: 61 Million <br />Life expectancy at birth:79<br />Health spending as % GDP: 8.3%<br />Cov...
U.K.:Spending<br />Health Spending per capita per yr.: $2,580<br />$ 2,245 (87%) FromGovernment<br />$335 (13%) From Indiv...
U.K. (cont.)<br />Notable features: <br />Patients do not receive Bills: <br />Or Insurance Premiums <br />National Inst. ...
II.  National Health Insurance (NHI)<br />= Nationalization of Health Insurance<br />May be Single or Multiple Payers, But...
NHI: Japan, France<br />Individuals Buy Coverage: <br />From Government Plan or Private Insurers<br />Universal Coverage, ...
Those in Need
Small Businesses</li></ul>4/20/2009<br />29<br />
Japan:<br />NHI; Financing: Public & Private Insurance<br />Universal Coverage; <br />Individual & Employer Mandate<br />F...
Japan:<br />Population: 128 million <br />Life Expectancy at Birth: 82.1<br />Health Spending as % GDP: 8%<br />Coverage: ...
Japan (cont.)<br />Notable features: <br />Frequent Doctor Visits; Long Hospital Stays.<br />Insurers Must Cover Everyone;...
NHI, France:<br />Individual & Employer Mandate;<br />13.1% of Employees’ Salary Goes to NIH Fund <br />Income Tax Fund Co...
France:<br />Population: 61.7 Million<br />Life expectancy at Birth: 80.3<br />Health Spending as % GDP: 11.1% <br />Cover...
France: Notable Features<br />30 Chronic Conditions:<br />Including Diabetes:  Fully Covered<br />Broad Choice of Physicia...
France:<br />Physicians Organized into Unions<br />Government pays Fee-For-Service<br />Based on Negotiated Rates<br />Hos...
Canadian System:<br />NHI – of sorts.<br />Funded by Taxes From The General Fund<br />Single Payer System<br />Budgets on ...
Canada:<br />Population: 33 Million<br />Life expectancy at Birth: 81.1 yrs.<br />Health Spending as % GDP: 10.3% <br />He...
III.  Mixed Funding, Mixed Coverage<br />U.S.A. <br />Funding From:<br />Private Insurance, Individuals &Government<br /><...
No Individual or Employer Mandate
Coverage Not Universal</li></ul>4/20/2009<br />39<br />
United States:<br />Population:  302 Million<br />Life Expectancy at Birth:  78.1<br />Health Spending as % of GDP:  15.3%...
United States:<br />Highest Infant Mortality: in OECD<br />Coverage: Almost all people over 65 yrs. Old.<br />Approx. 80% ...
United States (cont.)<br />Notable Features:<br />Individual Choice; Very Expensive<br />Advanced Technology, Drugs and Fa...
Common U.S. Values and Opinions:<br />The ‘Rugged Individual’ Spirit<br />Anti-Entitlement <br />Anti-Government-Run Progr...
Cost of Care Per Capita<br />4/20/2009<br />44<br />
Cost of Healthcare - % of GDP<br />4/20/2009<br />45<br />
Health Spending/person %GDP<br />46<br />4/20/2009<br />
Life Expectancy & Ave. Annual Spending/Person<br />47<br />4/20/2009<br />
US Health Spending Projections<br />48<br />4/20/2009<br />
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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

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

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