Healthcare Flashcards
Private insurance
Some like the US have PI for those not covered by SI or who prefer PI (US, Netherlands)
Others use PI supplement SI (UK, Spain, Italy)
And some use PI to provide coverage for SI cost sharing provisions (Denmark, France)
In one country (Ireland) PI serves all three functions
OOP costs
cost-sharing, with third party covering majority of cost (US, Denmark, France, UK)
Italy, Portugal, Spain OOP is used for direct payment of total fee for certain services
Public/Private, SI/Taxes mixes
The closer to the lower left hand corner in the prior figure, the more private country’s HC system financing is (US, CH)
Closer to the hypotenuse, the more public
The left end of the HT is more tax-driven, the right is more SI
TAXES AND SI ARE RISK POOLING MECHANISMS
Brand drugs
The US pays more for brand named drugs, far less for generic, our MDs are better paid than most, accept UK, specialists in the US
Why is the US so much more costly?
- Higher administrative costs-our system is far more complicated than that of other countries. PRIMARILY FFS
- Higher ratio of specialists to PCP are paid more and use more expensive tests
- More stand by capacity we have more capacity in reserve
- Open ended funding- our insurance tends not to have limits, while other countries have budgets that limit them from spending a certain amount of money
- Less social support
- More malpractice suits
- Higher brand name drugs
- Higher physician incomes
In which country are there Rx caps
Germany
UK
Beveridge Model: government provides healthcare
Pretty much everyone is covered
All services are offered
84% public
OOP:10%
G.P are gatekeepers they have a certain amount of patients they are allowed to see
Benchmark standards for all provider comparison leads to better competition
HARD BUDGETS
Canada
National Health Insurance Model
Only resident citizens are covered
No hospital costs for hospitals and MD services
Highly decentralized-Each “state” unique
government funded insurance from taxation pays for all
Not good quality care, have to wait a while to be seen
Benchmark is 2-29 weeks for bypass
SINGLE PAYER POWER
Generic drugs are more expensive than in the US
OOP:15%
Only 20% of private insurances are NFP
Japan
Bismark Model
All insured through different mechanisms, benefits are identical, 33% public, through taxes
OOP: 15.8%
Patients seek out care without referral
Little formal requirements alot is based on what is culturally acceptable
DRG
PROFIT MARGIN REGULATIONS ACROSS HOSPITALS AND PROVIDERS
Germany
THE BISMARK MODEL
Everyone is covered public or private except long term care
Any services are provided
77% public, 9.3% private
G.P and specialists are independent, paid by fees negotiated by regional associations
Very strict regulations
INTEGRATED CARE MODEL
Reference Pricing
UK rich people
private insurance, limited access to dental care
Canada rich people
supplementary insurance
dental and vision care
Japan rich people
Not a big issue here
Limited access to ER care
Germany rich people
Some private and little choice in insurer
4 major sources of money
General taxation
Private insurance
Social insurance
OOP
Social insurance
run by the government, may come out of pay
benefits are paid out
medicare is social insurance
US system is passive
The “system” in the US is passive, from the provider’s point of view
Patient initiates contact with the provider
If not, may be considered quackery
MD goes door to door would be looked at suspiciously
The lay referral system
lay person= not a healthcare professional
Ask for opinion and advice of others or listen to suggestions
Usually seek advice from those perceived to knowledgeable
Result in either it gets better or they need professional help
Professional referral system
professionals use this system
advice from other professionals
not as clear cute as the public thinks
up to 50% of all MD office visits have no firm diagnosis
Pharmacists role
consumer often thinks pharmacists as part of the lay referral system or a bridge between the two systems
depends on the quality and nature of the therapeutic relationship
easy access in community
“community triage”
Health
health, like jazz is something that is very much defined socially and culturally
each society, has an internal conceptualization of what health is
The dark side of “health”
so what happens when someone decides you’re sick?
social or political concept
your doctor can have you confined against your will
health and sickness can also be a form as social control
Disease
state of dysfunction or departure from normality
defined by capital M medicine (MD)
capital medicine has invented new diseases
you cannot self diagnose a disease
Illness
not feeling well and they tend to modify their normal behavior
both disease and illness are defined by standard of normality
disease by standard of MD
illness by standard of the individual
The “worried well”
20-30% of population
need someone to talk to
way to get attention
Social/cultural define disease and illness
some cultures simply do not recognize mental illness
some diseases are so common they are not considered departures from normality
Standard of normality often relative
society shapes the healthcare process
within a society, the standard may vary according to your place in that society or culture
occupation, economic status, eduction, religion
Illness behavior
trying to figure out what is going on
person only has to feel ill, not to have disease
seeks to define, that is, reduce uncertainty
driven in part by HBM
may use the lay referral system
OTC remedy
Sick role
when you are dealing with illness you are not 100% normal
if you are doing this you are not filling your social roles because you don’t feel well
Sickness impairs our ability to fulfill our roles
Role failure
Can’t rescind role status due to sickness, need a “temporary” role for sick person to enter into
allows them a special status to relieve them from other role responsibilities
Talcott Parsons
developed by Talcott Parsons in the 1950s to explain people’s behavior when ill
Freedom from blame for condition
people who are sick have the right
not the person’s fault
not to be blamed for not fulfilling other role obligations
not to be punished
Exemption from normal duties and tasks
people have the right to be temporarily be excluded from home, work, and school responsibilities
Claim on others for assistance and care
derived orm the idea of healthcare as a right
people who are sick have the right to go to someone for help
Try to get well
people who are expected to recognize their condition is undesirable
they must want to get well and get better
The future of Sick role
long-term treatment of chronic diseases places greater stress and cost on the HCS
most likely higher co-pays or “higher risk” insurance
we are seeing a shift from “healthcare as a right” to “individual responsibility”
- Physical and person intimacy
access to confidential information
right to touch and probe the body
can ask questions no one else can
- Initiation and direction of treatment
what to do and when
the patient is an individual and has right to input
