Category: US/World Health Care Policy

Sweden – 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

Sweden
• The Swedish system sounds very much like the truly socialized systems that we have come to expect from right-wing fear mongers. Everyone is covered, everything is covered, and virtually everything is funded by the government through taxes.
• There are some co-pays and the deductibles and routine dental care for those over 18 is not generally covered.
• Co-pays for visits amount to about $20 for a general practitioner and $40 for a specialist. There is an approximately $12 per day co-pay for hospitalization and there is a deductible of about $140 annually for prescriptions. Once you go over this amount then there is a scaled re-payment or reimbursement (the higher the expenditure, the higher percentage the state pays.)
• Out-of-pocket expenses account for approximately 14% of total health expenditure.
• Funding is through federal and local taxes.
• The federal government is mostly responsible for prescription drug costs.
• County governments are responsible largely for hospitals, mental-health care, provider reimbursement etc.
• Municipalities are responsible for skilled nursing facilities and the like, as well as home care and some other things.
• Private insurance covers approximately 25% of the population and accounts for less than 1% of total health expenditures.
• Physicians are paid largely through capitation with some fee-for-service. Half of primary care physicians are private and half are employed or salaried.
• Hospitals are mostly county owned and the hospital-based physicians are generally salaried.

The Netherlands – 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

Netherlands
• The Netherlands will be experiencing major changes that began in 2006 due to dissatisfaction with the prior dual system of competing public and private health care.
• All residents are required to buy health insurance.
• Health insurance is “statutory” but provided by private health insurers and regulated under “private law”.(?)
• Financing: statutory health insurance, or SHI or public insurance is funded by a 6.5% tax on taxable income up to €30,000. This 6.5% apparently must be reimbursed by the employer however.
• The self-employed pay a 4.4% rate of tax for their insurance on their income.
• The average annual premium as of 2006 was €1050
• The government completely covers children up to age 18.
• “Substitutive” private health insurance was abolished in 2006.
• The statutory health insurance fund distributes risk-adjusted funds to the insurers. These insurers also provide, for a fee, complementary/supplementary insurance. The premiums for these complementary policies are not yet regulated.
• Private insurers may be for-profit but must accept everyone in their geographic area. They are compensated for this by risk adjustment reimbursement by the government.
• 78% of total health care expenditure is public.
• The statutory health insurance covers usual healthcare and includes drugs but does not include routine dental care. The annual deductible is €150 per year.
• Out-of-pocket expenditures account for 8% of the total health expenditure of the Netherlands
• Physicians contract directly or indirectly with insurers. General practitioners income is a combination of capitation and fee-for-service and pay-for-performance is being tried. Specialists are two thirds self-employed even if hospital-based and one third are salaried.
• Hospitals are mostly private but not for profit.
• Cost controls: it sounds like they are working on a version of managed competition though I am not clear on that.

France – 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

France
• 79% of all care is publicly financed
• Employer and employee payroll taxes account for 43% of the funding. The employer pays 12.5% of payroll and the employee pays 0.75% of payroll.
• Part of the national income tax goes to funding health care and accounts for 33% of the funding.
• Tobacco and alcohol taxes supply another 8% and state subsidies and other social security taxes provide another 10%
• Coverage includes everything except dental and eye.
• Cost-sharing occurs through coinsurance and co-pays and extra/balance billing
• Out-of-pocket expenditures account for 7.4% of the total health expenditure
• Private health insurance accounts for 12.8% of the total health expenditure
• The public funding goes to public health insurance funds with membership based upon occupation
• Benefits/prices/cost-sharing levels are determined, since 2004, by the national Union of health insurance funds (UNCAM)
• Low income persons also get free complementary-supplementary coverage including dental and eye and they qualify for no balance billing
• Private insurance is like our supplemental policies. It reimburses for the cost-sharing elements of the national plan. This is usually provided by employment-based insurers called “mutuelles” . 90% of the population gets this. So far there is only a minimum competition in this market.
• Physicians, non-hospital-based, are self-employed and fee-for-service. Hospital-based physicians are salaried.
• Two thirds of hospital beds are either government-owned or nonprofit.
• One third hospital beds are private located in for-profit clinics and, I believe, in hospitals as well.
• Hospital reimbursement is moving to a DRG style system. Hospitals do get subsidies for research and teaching and emergency care.
• There are some cost controls in place. Controlling formularies a big issue at the present time according to my interview with Dr. C’alloch in Paris.

OECD Denmark 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

Denmark
• The health-care system of Denmark covers all regular healthcare
• Insurance is universal and compulsory
• Cost-sharing occurs in dental and corrective eye care and drugs
• Out-of-pocket costs account for 14% of the total health expenditure
• There is a safety net for the poor and the chronically ill to limit their expenses
• The system is publicly financed
• Federal tax of approximately 8% of taxable income goes into the fund; this accounts for 82% of total health expenditure
• Private or complementary insurance is available. 30% of the population buys this through not-for-profit Danish Health Reimbursement Scheme plus some others. This is often a fringe benefit for employees.
• The system is organized into five regions. Each region owns and runs hospitals skilled nursing facilities etc.
• The various regions finance the practitioners dentists and “pharmaceuticals” (? Pharmacists)
• It was not clear to me whether practitioners get fee-for-service or rates or if they are able to negotiate.
• Some professionals, I’m not sure which, our salaried-perhaps hospital and clinic-based.
• Hospital-based physicians are salaried.
• Other physicians have a capitation arrangement which accounts for approximately 30% of their income plus fee-for-service for the rest.

FRONTLINE: sick around the world: interviews: uwe reinhardt & tsung-mei cheng | PBS

FRONTLINE: sick around the world: interviews: uwe reinhardt & tsung–mei cheng PBS

Wow. I can’t say enough about this interview. It is so on the mark in so many ways, and it is a pleasure to hear knowledgeable people discuss comparative international healthcare like this.

There are great bits on the real meanings of “socialized” medicine, vs socialized insurance, the German (!) perspective on the dignity of every person, the Canadian perspective on humanism, the leadership of Tony Blair turning around a system on the rocks, how terrifically well America does in training its healthcare providers (especially doctors), but the best is Reinhardt’s take on “Consumer Driven Healthcare“, quoted here:

We’ve heard some people have proposed that a solution for America is something called consumer-driven health care. How does it work? What is it?

… Well, the name “consumer-driven health care” at this time is a deceptive marketing label. What we’re really talking about is an insurance policy with a very high annual deductible — up to $10,500 per family, and less for an individual — and then coupled with a savings account into which you can put money out of pretax income; you don’t have to pay taxes on such income.

Now, this has the advantage … that people faced with this deductible will think twice before going to the doctor for trivial issues or drugs they don’t need, etc. But of course the problem also is that they may not go when they should or may skimp on the drugs they should be using, like a blood pressure drug, so that one would have to be solved by saying preventive services will have first-dollar coverage. So you could solve that problem.

But then what I argue is, yes, it may have the economic effect of cost control, because you then would have to know the prices different doctors charge, and hospitals and pharmacies, and something about the quality. And that information at this time exists only in a few areas. The insurance companies are beginning to work on Web sites that will give you that, but it’s still very primitive and fairly unreliable information. So that is why I compare it really more like thrusting someone into Macy’s department store blindfolded and say, “Go around; shop smartly.” …

The other problem that I see with it, though, is it has ethical dimensions to it that people don’t appreciate. If I make anything tax-deductible, then a high-income person in a high tax bracket saves more than a poor [person]. So supposing a gas station attendant and I each put $2,000 into a health savings account, and we get a root canal — about $1,000, just the drilling. It costs me about $550 because I’m in the 45 percent bracket. The gas station attendant may, in fact, not pay federal income tax because the income is so low but may only pay Social Security, so he saves 8 cents on the dollar. So a root canal will cost me $550; will cost him $920. …

Secondly, think of a family of two professionals, each making $140,000, close to $300,000 income, and they have, say, a $5,000 deductible. Would they deny their child anything that they think the child needs over a lousy $5,000? … But think of a waitress who makes $25,000 with a $5,000 deductible, and her kid is sick. It will certainly make her think twice. She’s likely to say, “Maybe not.” So therefore we’re asking the lower half of the income distribution to do all the self-rationing through prices. …

And the third issue is this deductible. If you’re chronically healthy, you don’t actually ever spend as much as that; you have a tax-free savings account. If you are chronically ill, on five drugs, you’re going to spend that deductible year after year. So the proposal is to shift more of the financial burden of health care from the shoulders of the chronically healthy to the shoulders of the chronically sick.

And I would say, imagine a politician coming to the people with a platform that I just described in ethical terms. … You think that would sell? So they say, “We’ve got to find a better name. Why don’t we call it consumer-driven health care?,” and have all these deceptive labels that even George Orwell wouldn’t have thought of. That is what I find troublesome. Yes, it’s an approach to health care, but could you please describe it to the American people honestly, in all of its dimensions — not just economics but information and ethics? And that’s not done. …

One answer he gave about physicians income left me with more questions that when I started:

Yes, American doctors get paid more, relative to average employees, than doctors in other nations; that is true. It’s about five times average employee compensation, and in England it’s about two, and in Canada it’s about three. So that’s certainly true.

Given the unprecedented income disparity in this country, it is hard to know what to make of these figures. Comparison to the median would have been more helpful, but I think the most interesting would be to see in which decile physicians place in each country. I will try to find that data.

This Frontline Website is a gold mine. Thanks to the indispensable CPB.

Frontline: Sick Around the World

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.”

Britain’s health care amounts to malpractice – BostonHerald.com

Britain’s health care amounts to malpractice – BostonHerald.com

I don’t know of a person who advocates for universal health care in the US who advocates for a nationalized system such as Britain’s that the author holds up as his bogeyman. The discussion is about which type of single payer system or universal insurance coverage scheme we should adapt to the US. As Michael Moore has stated, we aren’t talking about blindly adopting another contry’s system wholesale, we are talking about having a policy discussion and creating a uniquely American system, emphasizing our strengths and remedying our weaknesses.

But what really prompted me to write this were a couple of absurd statements by the author.

First, “No one can complain that the NHS is underfinanced. This year’s budget is $210 billion – about $1.05 trillion if adjusted to match America’s population.” Really, no one? The Internets have this thing called “Google” and if you search for “NHS underfunded” you might find out that at least a few people (Tony Blair, for one) who believe it is underfunded. But more importantly, is there anyone who doesn’t get that we spend roughly twice as much per person on healthcare and get terribly shaky outcomes for it? Specifically, is there anyone writing a piece for a major newspaper who doesn’t know this?

And this: “A September 2007 Lancet Oncology article found 66.3 percent of American men alive five years after cancer diagnosis. Only 44.8 percent of Englishmen survived after five years. Across the European Union, 20.1 females per 100,000 under 65 died prematurely of circulatory disease. Among British women, that number was 23.6.”

Here’s an interesting table from that study, showing the UK NHS as the worst, except for Slovenia, Iceland, Poland and the Czech Republic. And I’ll say it again, nobody wants to replicate the British system here. And for more comparisons on US versus other countries healthcare outcomes, go here.

And, finally, my favorite, “Within this maze, patient needs often yield to the wants of pols and medicrats.” Go see Sicko, man! Are you kidding? You think we don’t have pols in the hands of Pharma and the health insurance and health care industries and “medicrats” at our insurers? Who do you think draws those multi-million dollar salaries at the Blues and Aetna and the rest?
Aren’t these people getting tired of flogging this dead dog? Probably not, because apparently that dog still hunts in the imaginations of some.

Cheers,

Boston herald:

I don’t know of a person who advocates for universal health care in the US who advocates for a nationalized system such as Britain’s that the author holds up as his bogeyman. The discussion is about which type of single payer system or universal insurance coverage scheme we should adapt to the US. As Michael Moore has stated, we aren’t talking about blindly adopting another contry’s system wholesale, we are talking about having a policy discussion and creating a uniquely American system, emphasizing our strengths and remedying our weaknesses.
But what really prompted me to write this were a couple of absurd statements by the author.
First, “No one can complain that the NHS is underfinanced. This year’s budget is $210 billion – about $1.05 trillion if adjusted to match America’s population.” Really, no one? The Internets have this thing called “Google” and if you search for “NHS underfunded” you might find out that at least a few people (Tony Blair, for one) who believe it is underfunded. But more importantly, is there anyone who doesn’t get that we spend roughly twice as much per person on healthcare and get terribly shaky outcomes for it? Specifically, is there anyone writing a piece for a major newspaper who doesn’t know this?
And this: “A September 2007 Lancet Oncology article found 66.3 percent of American men alive five years after cancer diagnosis. Only 44.8 percent of Englishmen survived after five years. Across the European Union, 20.1 females per 100,000 under 65 died prematurely of circulatory disease. Among British women, that number was 23.6.”
Here’s an interesting table from that study, showing the UK NHS as the worst, except for Slovenia, Iceland, Poland and the Czech Republic. And I’ll say it again, nobody wants to replicate the British system here. And for more comparisons on US versus other countries healthcare outcomes, go here.
And, finally, my favorite, “Within this maze, patient needs often yield to the wants of pols and medicrats.” Go see Sicko, man! Are you kidding? You think we don’t have pols in the hands of Pharma and the health insurance and health care industries and “medicrats” at our insurers? Who do you think draws those multi-million dollar salaries at the Blues and Aetna and the rest?
Aren’t these people getting tired of flogging this dead dog? Probably not, because apparently that dog still hunts in the imaginations of some.
Cheers,

Quebec commission makes recommendations

Quebec commission makes recommendations:

“Quebec – The Castonguay task force on health care proposes a $25 charge for every visit to a doctor and an increase up to one percentage point in the Quebec sales tax to help pay for medicare.

Claude Castonguay, the chair of the task force, notes that health care, as a share of the provincial budget is growing 5.8 per cent a year, while total government spending increases 3.9 per cent annually.

He proposes capping health spending at 3.9 per cent and making up for the shortfall with a new health-stability fund, financed by the $25 doctor’s charge and the sales-tax increase.

Extra billing for health care is currently illegal under the Canada Health Act, which Castonguay concludes ‘hampers the evolution of the provincial public health systems.'”

In keeping with the “warts and all” approach to comparing helathcare systems…

The feedback to the story was mostly negative.

In Holland, Some See Model For U.S. Health-Care System – WSJ.com

In Holland, Some See Model For U.S. Health-Care System – WSJ.com:

“The Dutch system features two key rules: All adults must buy insurance, and all insurers must offer a policy to anyone who applies, no matter how old or how sick. Those who can’t afford to pay the premiums get help from the state, financed by taxes on the well-off.”

Sound familiar? Go to the link to see the accompanying graphic comparing the Netherlands, Massechusetts and (proposed) California plans. They are not too different. What is different is the minimum wage in the Netherlands-about 1.8 times ours.

So in order to avoid the pesky problem of deciding among insurance, food, and heating your home, we’d have to do a much better job against low wages and poverty in general. Thiis couldn’t happen in most states, but I wonder if California could double its minimum wage and get away with it? Not a lot of egress from california, almost no matter what. So maybe that could be the state to experimant with a mandated living wage and mandated health insurance.

Cheers,