International Health International Health Care Systems Care Systems Kao-Ping Chua Kao-Ping Chua Jack Rutledge Fellow, 2005- Jack Rutledge Fellow, 2005- 2006 2006 American Medical Student American Medical Student Association Association
International Health Care Systems Kao-Ping Chua Jack Rutledge Fellow, 2005-2006 American Medical Student Association.
Dec 22, 2015
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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
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