Germany – The Moral Healthcare Blog

Swiss Model for Health Care Is Gaining Admirers – NYTimes.com

Swiss Model for Health Care Is Gaining Admirers – NYTimes.com:

ZURICH — Like every other country in Europe, Switzerland guarantees health care for all its citizens. But the system here does not remotely resemble the model of bureaucratic, socialized medicine often cited by opponents of universal coverage in the United States.

Swiss private insurers are required to offer coverage to all citizens, regardless of age or medical history. And those people, in turn, are obligated to buy health insurance.
That is why many academics who have studied the Swiss health care system have pointed to this Alpine nation of about 7.5 million as a model that delivers much of what Washington is aiming to accomplish — without the contentious option of a government-run health insurance plan.

In Congress, the Senate Finance Committee is dealing with legislation proposed by its chairman, Max Baucus, Democrat of Montana, which would require nearly all Americans to buy health insurance, but stops short of the government-run insurance option that is still strongly supported by liberal Democrats.

Two amendments that would have added a public option to the Baucus bill were voted down on Tuesday. But another Senate bill, like the House versions, calls for a public insurance option.

By many measures, the Swiss are healthier than Americans, and surveys indicate that Swiss people are generally happy with their system. Switzerland, moreover, provides high-quality care at costs well below what the United States spends per person. Swiss insurance companies offer the mandatory basic plan on a not-for-profit basis, although they are permitted to earn a profit on supplemental plans.

And yet, as a potential model for the United States, the Swiss health care system involves some important trade-offs that American consumers, insurers and health care providers might find hard to swallow.

The Swiss government does not “ration care” — that populist bogeyman in the American debate — but it does keep down overall spending by regulating drug prices and fees for lab tests and medical devices. It also requires patients to share some costs — at a higher level than in the United States — so they have an incentive to avoid unnecessary treatments. And some doctors grumble that cost controls are making it harder these days for a physician to make a franc.

The Swiss government also provides direct cash subsidies to people if health insurance equals more than 8 percent of personal income, and about 35 to 40 percent of households get some form of subsidy. In some cases, employers contribute part of the insurance premium, but, unlike in the United States, they do not receive a tax break for it. (All the health care proposals in Congress would provide a subsidy to moderate-income Americans.)

The German system also does fine without a “public option,” and is my favorite model, but this type of advance will take us a few years, but I think we will get there eventually. Having a successful public plan pulling the private insurers, including the not-for-profit-in-name-only ones, into some sanity will help tremendously. The bold, italicized part above is really the key to real reform and universal access: “Swiss insurance companies offer the mandatory basic plan on a not-for-profit basis, although they are permitted to earn a profit on supplemental plans.”

Another interesting tid-bit:

As in the United States, practitioners typically are paid on a fee-for-service basis, rather than on salary. But they make less than their American counterparts. According to the O.E.C.D., specialists in Switzerland earn three times more than the nation’s average wage, compared with 5.6 times for American specialists. General practitioners in Switzerland make 2.7 times more than the average wage, versus 3.7 in the United States.

So specialists:PCP income here in the US is $1.51: $1
Switzerland is $1.11:$1.00
Interesting…

Health Care in Germany

Health Care in Germany:

This is from a British source, The Institute for the Study of Civil Society

First, Germans are free to visit any doctor they like. They may either walk in off the street, or ring for an appointment that will invariably be booked for the same morning or afternoon. Consumers can and do penalise bad service. Our recent study of German consumers commonly produced reactions like this: ‘I saw a long queue, so hopped on the tube and went to a different practice’; ‘she was rather ill-tempered so I never went back’; ‘the facilities were drab, so I went to a different one next to my office’; ‘I felt rushed at his practice so didn’t go back’.

Second, Germans do not have to see a GP before visiting a private specialist. GPs do act as gatekeepers to German hospitals, but about half of all specialists practice outside the hospitals. German hospitals provide few out-patient services. Instead, there are a large number of independent clinics, invariably with the most sophisticated diagnostic equipment. Most Germans have a favourite GP, although many maintain a relationship with more than one – just in case – but if they need to see a specialist they would not waste time seeing a GP first.

Third, there are plenty of specialists. Germany has 2.3 practising specialists for every 1,000 people, compared with only 1.5 in the UK.

What problems are there in Germany? The German media is not excited by the subject. There are no patients lying on trolleys in A&E. Germany suffers no real rationing. Yes, problems occur from time to time. Just at the moment, there is a shortage of nurses, and many Germans feel that care is expensive, but serious complaints are few. Nevertheless, reform is in the air. Since January 2004 members of the statutory insurance plan have had to pay 10 euros per quarter to see a GP.

The reforms also saw the introduction of charges for non-prescription drugs, and an end to free treatments such as health farm visits and to free taxi rides to hospital. This is expected to allow for a reduction in premiums from an average of 14 to 13 per cent of annual gross wages.

German satisfaction rates in 1996, the latest Eurobarometer survey, showed that the German are far more satisfied with their system than we are with the NHS. About 11 per cent of Germans said they were ‘very or fairly dissatisfied’, compared with 41% per cent here. And when asked whether their system needed ‘fundamental
changes’ or a ‘complete rebuild’ 19 per cent of Germans said ‘yes’, compared with 56 per cent of Britons.

Does the German healthcare system deliver an acceptable standard of care for serious illness to all members of society? Do the poorest in society benefit from a higher standard of healthcare provision than those in the UK? The answer to both of these questions is an emphatic, ‘yes’.

RAND | (Technical) Reports | Possibility or Utopia?: Consumer Choice in Health Care: A Literature Review

RAND (Technical) Reports Possibility or Utopia?: Consumer Choice in Health Care: A Literature Review:

This literature review examines consumer choice in health insurance plans against the background of the German health system in order to inform the questions: What are models of consumer choice and their effects?, and: If consumers want lower cost health care, what instruments can insurers use to provide it and what are the likely effects of those instruments? The review looked at experiences in other industrialized countries, especially the United States, for consumer choice options such as co-payments, reimbursement/bonuses, and deductibles, as well as organizational designs such as gatekeeper systems and selective contracting. In addition to cost-containment measures, the review also examined what was known about effects on health status, satisfaction, fairness and the macro-economic situation. The review describes the health economics theory of consumer choice, the methodology for the literature review, the German health system, and studies on consumer choice of insurers and providers, and reflects on their relevance on the German system. This literature review examines consumer choice in health insurance plans against the background of the German health system in order to inform the questions: What are models of consumer choice and their effects?, and: If consumers want lower cost health care, what instruments can insurers use to provide it and what are the likely effects of those instruments? The review looked at experiences in other industrialized countries, especially the United States, for consumer choice options such as co-payments, reimbursement/bonuses, and deductibles, as well as organizational designs such as gatekeeper systems and selective contracting.

The full document is here.

Germany – OECD Summary

Summaries of summaries of healthcare systems based on the Commonwealth Fund reports.
Author(s) of the originals are:
Karsten Vrangbaek, Isabelle Durand-Zaleski, Reinhard Busse, Niek Klazinga, Sean Boyle, and Anders Anell

Germany
• Germany’s system is based on public or social health insurance (SHI)
• SHI is mandatory for those with income less than €48,000 (this is about 75 to 80% of the population)
• The top quintile of income earners can opt in or out of SHI; 75% of these high earners opt in. (This matches up interestingly with the quintiles in the US, with the top 5% in Germany opting out of SHI it sounds like.)
• Also civil servants and the self-employed are excluded from SHI and make up the bulk of the 10% of privately insured individuals. (I don’t understand the rationale of excluding the self-employed or, for that matter, civil servants except that I presume they just get these benefits paid for by the government anyway.)
• SHI covers the usual healthcare plus dental and drugs and more.
• Cost-sharing occurs through co-pays for outpatient visits, drugs and dental care. Apparently this is new since 2004. Cost-sharing max-out is 2% of income. Out-of-pocket expenses account for 13.8% of total health expenditure.
• SHI is operated by over 200 competing health insurers and these are called “Sickness Funds”.
• The Sickness Funds are all autonomous and nonprofit but regulated.
• Funding comes from the employer at 8% of gross up to €43,000 and from the employee at 7% of gross.
• For those not in SHI, the sickness funds set rates but in 2009 the government will collect and regulate this as well. After 2009 the government will distribute to sickness funds based upon risk adjustment mix of their clients.
• Interestingly, private health insurance rates cannot change once you have been accepted into the plan.
• Private health insurance accounts for less than 10% of the total health expenditure of Germany.
• Physicians receive fee for service plus “fees per time period” (the latter sounds like capitation). Just a note here to refer to the NPR story about the fee-for-service money running out towards the end of every quarter
• Hospital-based physicians are salaried.
• Hospitals are split up into about 1/2 public, 1/3 private nonprofit and 1/6 private for-profit. The latter for-profit segment is apparently growing at this time.
• Hospital reimbursement is now a DRG based.

Health Care System Profiles

Health Care System Profiles:

“The work of the Commonwealth Fund’s international program highlights the valuable lessons the U.S. can learn from the health care systems in other industrialized countries. These country profiles provide overviews of the health care systems of several countries, including Denmark, France, Germany, the Netherlands, Sweden, and the U.K. Each profile includes descriptions of how each country organizes, finances, and delivers health services and highlights quality, efficiency, and cost-controlling policy initiatives and reforms”

Follow the link to this page at the Commonwealth Fund website to download individual country profiles or the whole thing.

Here is a remarkable slide presentation from the Commonwealth Fund aggregating in PowerPoint form, a large quantity of data on systems around the world.

Continuing my education in international comparative health policy…

Keeping German Doctors On A Budget Lowers Costs : NPR

Keeping German Doctors On A Budget Lowers Costs : NPR:

“How Doctors Get Paid

Nearly all hospital-based doctors are salaried, and those salaries are part of hospital budgets that are negotiated each year between hospitals and ‘sickness funds’ — the 240 nonprofit insurance companies that cover nearly nine out of 10 Germans through their jobs. (About 10 percent, who are generally higher income, opt out of the main system to buy insurance from for-profit companies. A small fraction get tax-subsidized care.)

Office-based doctors in Germany operate much like U.S. physicians do. They’re private entrepreneurs who get a fee from insurers for every visit and every procedure they perform. The big difference is that groups of office-based physicians in every region negotiate with insurers to arrive at collective annual budgets.

Those doctor budgets get divided into quarterly amounts — a limited pot of money for each region. Once doctors collectively use up that money, that’s it — there’s no more until the next quarter.

It’s a powerful incentive for doctors to exercise restraint — not to provide more care than is necessary. But often, the pot of money is exhausted before the end of the quarter.”

Interesting piece from over the Fourth holiday. It was mostly about the last paragraph above: Namely that physicians have to decide whether to continue to provide service until the end of the quarter when the budget is already exhausted. Seems bizarre to physicians here, except that we do the same thing, only play the game differently.

The way we do it is not quarterly, but on an ongoing basis. Most of our patients have insurance that pays us (more or less) what we expect, but a certain percentage have Medicaid or are uninsured altogether or have crappy insurance that doesn’t cover whatever you just took care of, and so on. So the net effect is similar.

But another intersting tidbits is the salaried nature of hospital based physicians. It would be interesting to see what the contracts look like in terms of benefits, vacation, salary, etc.

FRONTLINE: sick around the world: five capitalist democracies & how they do it | PBS

FRONTLINE: sick around the world: five capitalist democracies & how they do it PBS:

“Each has a health care system that delivers health care for everyone — but with remarkable differences.”

Summaries of the five countries covered in the Frontline episode: UK, Germany, Japan, Taiwan and Switzerland.

Frontline: Sick Around the World

Lots to digest, and I’ve only begun to explore the web extras, so I post now for convenience’ sake. Overall, though, TR Reid did a terrific job all around.

From the physicians’ perspective, I, of course would have liked more but they only chose to do an hour. Frankly, this would have been another good use of an extended format Frontline, as they did with “Bush’s War.”