Healthcare systems

Question 1

HC in UK

Answer 1

Lord Beveridge model

• public funding, tax-based
• public control of hospitals; regulation of physicians
• GP are gatekeepers: set budgets & services, contract w/ specialists & hospitals, paid by gov funds via capitation, P4P
• private sector in UK: 12% of pop., specialists can practice in both public and private

Good news

• coverage universal & comprehensive
• Gov. sets budget -> effective cost control
• effective regionalized HC, population health focus

Some concerns

• Long wait times
• 8.7% GDP
• now decentralized

Question 2

HC in Germany

Answer 2

Social insurance (Bismarck) model

• insured thru mandatory, not-for-profit, regulated sickness funds
• funds are paid into by employer/employee
• funds are inclusive, no experience rating, rates are regulated & must offer all medically necessary care, plus prescription drugs, dental, preventive
• universal coverage
• concerted action of HC providers, hospitals, admin., gov. regulation, insurance company -> cost controls
• physicians bill FFS but regulated by expenditure cap of sickness fund
• hospitals paid by DRG
• Gov. now collects the contributions & allocates money to sickness funds

Good news

• cost control built in
• balance b/w physician specialties

Concerns

• Dispersed model
• 10.5% GDP

Question 3

HC in Japan

Answer 3

Social insurance model

• health insurance mandatory
• employers & employees pay premiums to finance health insurance plans: Large, smaller, community-based insurance
• no restriction on choice of hospitals or physicians
• payment for care
• strict gov. regulation of physician fees, hospital payments, meds
• population pays thru premiums, general taxes, and co-payments for care

Good news

• Low rates of hospitalization
• 8.1% GDP
• combination of strict regulation & room for physician relationship

Concerns

• underfunded health infrastructure
• costs are still a concern
• rapidly & heavily ageing pop.

Question 4

HC in Taiwan

Answer 4

National insurance model

• health insurance mandatory
• single gov. -run insurer
• working people pay premiums split with employer, others pay flat rates w/ gov. help (poor & veterans are fully subsidized)
• mix of Canadian & US hc systems
• no gate-keeper

Good news

• One of lowest admin. cost in the world
• 6.3% of GDP

Concerns
- like Japan, underfunded health infrastructure

Question 5

HC in Switzerland

Answer 5

Social insurance model

• universal coverage (mandatory coverage)
• Gov. provides assistance to those who can’t afford premiums
• universal coverage in a highly capitalistic society
• insurers negotiate w/ providers to set standard prices for services but drug prices are set by gov.

Good news
- low admin. cost

Concern
- 11.6% GDP

Question 6

HC in Grenada

Answer 6

• Ministry of Health (MOH) responsible for overall management of health sector
• MOH divided into 3 functional areas: admin, hospitals, out-Pt clinics
• 2-tier public (majority) & private system
• total expenditure on health per capital (2005): $561
• 7.2% GDP

Question 7

Types of Physician payment

Answer 7

1. FFS: private insurance, medicare payments, managed care (HMO), shifts financial risk from provider to payer.
2. Per patient (capitation): 2-tier (UK, USA) or 3-tier (w/ IPA)
3. Per episode of illness: shifts financial risk from payer to provider.
4. Per time: public sector docs (VA hospitals, state hospitals, community clinics) & staff model HMO

Question 8

Hospital payment types

Answer 8

1. FFS: Traditional model, Ex. Blue Cross
2. Per diem
3. DRG: Medicare pt, hospitals conduct utilization reviews to reduce costs for Medicare pt
4. Global budgets: staff model HMO, most European and Canadian hospitals
5. Capitation:

Question 9

Cost control mechanisms

Answer 9

1. Financing:
   - competition
   - regulation: Gov. regulating money in
2. Reimbursement
   - Price controls
   - Utilization controls: Pt cost sharing, reducing supplier induced demand with utlization reviews

Question 10

ACA

Answer 10

HC Reforms include:

• no denial of coverage based on pre-existing conditions
• no rescision of coverage based on illness
• no lifetime limits on coverage
• cap on co-payments & out-of-pocket payments
• donut hole filling
• PEP
• expansion of dependent coverage to age 26

Question 11

Medicare ABCD

Answer 11

Part A: Contributory Hospital insurance

• fed. insurance program
• pays hospital based on DRG
• administered thru social security: employer/employees (1.45% each); paid social security for at least 10 years
• 24 mo-waiting period after disability except for chronic renal disease and ALS (no wait)

B: Supplementary med insurance
- all medically necessary services including physician services, physical, occupational, speech therapy, medical equipment, dx testing

C: Incentives for managed care

• combines A & B under managed care
• medicare subsidizes plan premium rather than direct reimbursement to providers

D: Optional drug coverage
- Donut hole -> ACA 2011 allows 50% discount on brand drugs while still in donut hole

Question 12

Medicaid

Answer 12

Public assistance program for unemployed and children

• not contributory
• paid by general revenues & jointly administered by fed. and state gov.
• Medicaid expansion thru SCHIP
• coverage for kids in low-income families at or below 200% fed. poverty level.

Question 13

Legislation affecting access to HC

Answer 13

• COBRA (1985) Reagan admin: allows workers who recently lost jobs to continue under group insurance for 18 mo.
• EMTALA (1986): all hospitals receiving fed payments must screen & stabilise Pt presenting in ER; no requirement to admit Pt though
• ACA: health insurance mandate for all Americans (2014)