Health systems Flashcards
6 WHO building blocks for health system
Service delivery Health workforce Health information Medical products, vaccines, and technologies Financing Leadership and governance
3 main elements of universal health coverage
equity of access to health services: those who need services should get them
the quality of health services is good enough to improve health
financial risk protection: the cost of care should not create financial hardship
give 5 examples of issues with health systems
Level of population access
System organization
Position and priority for primary care, and how primary care works
Gatekeeping and direct access to specialists
Strength of health promotion and disease prevention
Functioning of primary and secondary care
Method of financing
Level of public sector financing
Out-of-pocket payments and catastrophic expenditure
options for healthcare funding (5)
pay as you go savings account risk based insurance social insurance national/local taxation
reasons why the normal market doesn’t work for individually rated health insurance
Individual rating-people with high predicted medical costs will have high premiums
May be unaffordable and people go without care or take chance on emergency care when needed
Healthy individuals have incentives to be free riders
Administrative costs of individual health insurance are high-40% of medical claims or more
Insurers may choose not to cover high risk individuals or per-existing conditions
Insurers make contracts difficult to avoid easy price comparisons
General principles of the NHS
Universal coverage
Funded from taxation
Free at the point of delivery (with small exceptions)
Functional separation between general practitioners and hospital doctors
Gate-keeping by GPs i.e. no direct access to specialists
Team working between GPs and other health professionals
Extended primary care covers health promotion, disease prevention and chronic disease management
examples of financing of different components of the US healthcare system
Public Health Activities Care for the Uninsured Government Programs Hospitals Community Health Centers Free Clinics Private Physician Offices Medical Groups TriCare/CHAMPUS/Military Employer-based Insurance Individually-Purchased Insurance Indian Health Services HIV/AIDS-related care Insurance Companies Veterans’ Affairs (VA) Health Care Workers’ Compensation Children’s Health Care
problems with the US healthcare system
Prior to 2007 47 million people were uninsured
Many private providers will not accept them
Difficult to find “medical home”
The burden is placed on community health centers, public hospitals, and emergency rooms
Some considered uninsurable due to pre-existing conditions, but could not qualify for Medicaid
Cannot afford full cost of visits: this can lead to medical bankruptcies and foreclosures. There is some evidence that cost-shifting has resulted in the uninsured being billed for full charge, even higher than commercially insured patients
difference between US medicaid and medicare
Medicare is “social insurance”: Designed for people with disabilities or the elderly who meet specific requirements, lifetime benefit
Medicaid is a “welfare program”: Designed for needy people who are categorically eligible (not a guaranteed benefit)
Medicare, Medicaid, and SCHIP are all aimed at insuring people who cannot afford coverage or would otherwise be unable to get insurance due to disability, age, medical needs, and overall cost. They represent almost half of the health care expenditures for the population.
What was the US affordable care act 2010
The Affordable Care Act is made up of two acts:
Patient Protection and Affordable Care Act (Public Law 111-148)
Health Care and Education Reconciliation Act of 2010 (Public Law 111-152 )
Key elements:
- A reform of the health insurance system, not the health care system
- Employer-based health insurance system remains.
- Individual mandate
- An extension of health insurance coverage through public subsidies to increase eligibility for Medicaid and encourage purchase of private insurance for those with incomes over 133% of federal poverty level.
- An extension of health insurance regulation as counterpart of increased market share for private health insurance.
- Strategy to reduce rate of increase of Medicare expenditures
- New taxes for health care financing
- Impact on health care system indirect
- Some current difficulties with enrollment and insurance company participation
- Dome undermining of ACA by current administration
Main changes from the Affordable Care Act 2010
Health insurance exchanges
Ban on pre-existing condition discrimination
Rescission outlawed
Preventive services included compulsorily
Expanded coverage for young adults up to 26
Ban on lifetime coverage limits
Funding for more community health centers
US citizens and legal residents required by law to have health insurance, or pay a fee.
If you are a woman insurance companies will not be able to discriminate and charge more
American Recovery and Reinvestment Act provides financial incentives for physicians and hospitals to use electronic health records
The ACA provides policy and financial support for primary health care and primary health care physicians
Describe the Canada Health act 1984
5 key principles Public administration Comprehensive Universal Accessible Portable
Explicitly prohibited user fees/co-payments
Provincial plans must meet 5 conditions:
Universality: entire population must be covered
Comprehensiveness: all “medically necessary” medical and hospital services must be covered
Accessibility: in practice, no user fees
Portability: benefits must be portable from province to province.
Public administration: plans must be operated by a public (governmental) agency.
Give some characteristics of German health insurance
Health insurance mandatory from 2009, under income ceiling
Those with higher income not required to be covered. Publically financed scheme covers 88% of population
Scheme funded by compulsory contributions based on wages-average 8% of gross wage.
Benefits and contributions are primarily earnings related
Financing is by wage taxes levied on the employer and the employee with some additional financing by the state
Private risk-rated health insurance available by choice above a certain income level, covers 10%
Reimbursement made directly to the provider (rather than to the consumer after deduction of co-payments)
Public sources of finance accounted for 77% of all health expenditure
Basic principles of the German healthcare system
System administered by non-state actors-the sickness funds (SFs)
The SHI package covers preventive services, hospital care, physician services, mental health care, dental care, prescription drugs, medical aids, rehabilitation, sick leave compensation
Sickness funds and doctors negotiate fee schedules through collective bargaining arrangements-doctors associations
Direct access to specialists and no formal “gate-keeping”
Portability of coverage and eligibility for benefits. Some co-payments
No individual risk rating and automatic access to cover
Pros and cons of the german healthcare system
Achievements
High quality care provided on an almost universal basis (0.1% of Germans carry no health insurance)
During 80s and 90s Germany kept health care expenditures under control (8.4% of GDP in 1980, 8.1% in 1990)
Doctors have largely retained clinical and professional autonomy
Issues
Priority for health promotion and disease prevention
Integration of ambulatory (primary) and hospital care
Ambulatory care for the elderly included in health insurance from 1995
Public health control under the care of local authorities and relatively weak
