12. International

Question 1

Current Obesity trends in the US?

Answer 1

A bunch of major cities are leveling off obesity levels

Question 2

Overall trend between US and the rest of the world?

Answer 2

MEDICAL SPENDING ALONE DOES NOT DRIVE OUTCOMES. While US spends a shitload more on health care, it spends less on social service supports (unemployment, housing subsidies, early childcare, job training)….Other countries seem to spend less and get better life population health outcomes, partly cuz they?re spending more on social services

Question 3

Cultural differences between nations?

Answer 3

Culturally specific differences on how we perceive disease. Comparisons of differences in medical practice based on these cultural traits turns out…it?s true.

Question 4

What tends to slow cost increases? Implications?

Answer 4

Global budgeting! Price controls!

Question 5

Primary care organization in world?

Answer 5

Primary care is similarly organized in most countries. PCPs are independent practitioners still practicing in relatively small solo organizations. Most recent data show rapid movement into larger partnerships in US (small movement internationally)…but basic model in US and most other countries is small ?cottage industry?

Question 6

PCP role - ROW?

Answer 6

Internationally PTs are expected to register with PCP who serves as gatekeeper. Gate keeping disappeared 2000-2010 in US. You gotta register…you’re MY DOC.

Question 7

Who owns hospitals - ROW?

Answer 7

Most hospitals publically owned internationally…separate small for-profit systems and private systems are showing up where people have opted out of public insurance

Question 8

Who owns hospitals - US?

Answer 8

IN US, most hospitals are not-for-profit, some owned by govts (state university), some have hospital districts, relatively small are private, for-profit (even though they participate in public funding schemes)

Question 9

PCP payments ROW? Difference between US?

Answer 9

Most PCPs in MOST countries are FFS. In some countries it?s mixed with capitation or salary. HOWEVER, in most of these systems there?s a national fee schedule (instead of docs setting fees)

Question 10

Hospital payments ROW?

Answer 10

Global budges determine what hospitals get every year

Question 12

Specialists in ROW v. US?

Answer 12

Some salaried by hospital (incorporated into global budgeting); mix of private ffs (and public system). US is either FFS or salaried (based on a MEDICAL GROUP THAT CHARGES FFS). Again, voluntary in the US, but nationally enforced fee schedules in ROW.

Question 13

Why does US stick to private so much?

Answer 13

Distribution Economic/political forces, inertia, insecurity of what would really work

Question 14

Government’s role in ROW? (3)

Answer 14

1) Half have a national health service (which has assumed full responsibility for financing the health care system - even though it’s by different routes). 2) Some have REGIONAL govt responsibility (like, provinces in Canada, Switzerland, etc). 3) Some have mandatory coverage through different insurance mechanisms (either centered around employment or NON-COMPETITIVE INSURANCE SYSTEM)

Question 15

Example of country in non-competitive insurance system?

Answer 15

Japan.

Question 16

Govt role in health system, in general?

Answer 16

Mixed bag. Public v. private. Insurance rules regulated at STATE level, although ACA is beginning to set national standards

Question 17

Financing, ROW? (3)

Answer 17

National consumption taxes (that’s why shit’s a lot more expensive elsewhere), general taxes, earmarked taxes (stays out of national budgeting process, just goes directly to system)

Question 18

Financing, US?

Answer 18

MCARE Payroll tax goes into a MCARE trust fund, general tax revenue, premiums

Question 19

Premiums in ROW?

Answer 19

Not usually. May have copays associated with insurance, but very few pay a premium out of pocket.

Question 20

Role of private insurance, ROW?

Answer 20

Not part of the CORE usually, but it may be used for private facility coverage, dental, fancy shmancy stuff.

Question 21

Preventable deaths between US and ROW?

Answer 21

When compared to other countries, the US has a higher level of preventable deaths. Also, US is improving slower than the other countries.

Question 22

Preventable deaths?

Answer 22

Deaths which could have been prevented if the pt had timely access to appropriate medical care

Question 23

Health care spending per capita in US v. ROW, between 1980 - 2010?

Answer 23

Twice as high in 1980 too, although we?re bunched more closely together then. The rate seems to have risen a shitload between 2000 - 2008. Costs are going up dramatically everywhere, just not as dramatic as in US.

Question 24

What happened between 2000 and 2008?

Answer 24

A lot more Rx drug use (MCARE D), new technologies, prices went up more rapidly, reimbursement….80s and early 90s, had some cost-containment programs (through HMOs, constricted networks and rules). Docs hated this shit, rebelled….told pts to get out of most restrictive networks. Then the economy took off in the 2000s, and there was a pushback against restraint (new technologies, raise prices, health planning disappeared)

Question 25

How does OOP v. private v. public spending look for US v. ROW?

Answer 25

For the most part, other countries are spending sort of close to what we?re spending wrt public spending. However, PRIVATE is significantly different in US (insurance, and out of pocket)

Question 26

Pharmaceutical spending, US v. ROW?

Answer 26

US is highest spending per capita for pharma. Why? Cuz there?s national price setting and price control for pharmaceutical products. Pharma companies don’t have a say in price control like they do in the US.

Question 27

Comparative/cost effectiveness research in US v. ROW?

Answer 27

In other countries we have comparative/cost effectiveness research (in US, no cost-effectiveness analysis). There are National Review processes (such as NICE in UK, which uses QUALY’s) for determining relative efficacy/cost of new therapies

Question 28

Hospital discharges (measure of hospital stay)…US v. ROW?

Answer 28

We’re on the low end, and we don’t stay that long there. Germans use hospitals a lot more frequently than most countries (spend more about cardiac care stuff than most other countries). HOWEVER, we depend a SHITLODA more IN hospitals than others (cu we get more tests while inpt)

Question 29

Number of physician visits per capita…US v. ROW?

Answer 29

US has fewer doctors than most countries ? maybe having fewer doctors has something to do with what we pay our doctors?get better salaries cuz there are fewer

Question 31

Fees for procedures/medical specialty equipment?

Answer 31

Process is the SAME, but physician fee is just a lot more expensive…dramatically different for private payers. Not much control/no referrals for imaging procedures, and we use imaging for many more conditions than we need to. We also may seem to pay more for diagnostic imaging than in other countries.

Question 32

US v. ROW…DM treatment?

Answer 32

We have a shitload more DM, and are way more aggressive with treatments (like amputation), this can be correlated with obesity, worse preventative care because of lack of access

Question 33

US v. ROW … in hospital mortality after MI?

Answer 33

U.S. performance was middling. Our mortality rates were better than in five countries but worse than in five others.

Question 34

US v. ROW…drugs prices?

Answer 34

Prescription drugs are more expensive in the U.S. than in other countries ? even though drugs are pretty much the same in whichever country they?re taken: we?re just paying more for them.

Question 35

Physician incomes…us v. ROW?

Answer 35

We’re getting paid more than ROW..a little more in PCP, WAY more in specialties. EVEN THOUGH PCPs all over the world are living off FFS

Question 36

DOC Dissatisfaction of pay and time to spend per patient?

Answer 36

We’re pretty average for income from practice (France is PISSED), and pretty average for time spent per patient (UK is PISSED)

Question 37

EMR in US v. ROW?

Answer 37

Most countries have EMR and we don’t, BUT that EMR is pretty primitive. AND the US is rapidly increasing EMR use.

Question 38

After hours care - US v. ROW?

Answer 38

We have really shitty after-hours care wrt other countries.

Question 39

Price/Unit service equation - general picture for US?

Answer 39

We?re really good at driving up volume, AND price per service?all efforts to change this hasn’t succeeded very hotly. Instead move to other side of the equation to the other side.