HSS1101E Determinants of Health

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HSS1101E Determinants of Health

• March 16, 2009 Health Care Around the World

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Health Sciences ProgramFaculty of Health
Sciences Poster Presentations

• You are invited to attend student
• research poster presentations
• for the course HSS4303 Introduction to
  Epidemiology
• Posters will be presented in the following areas
• Adult obesity in Canada
• Cancers of the reproductive system
• Mental health
• Canada international health
• Students in the HSS4900 research course and wish
  to participate please contact jgomes_at_uottawa.ca

WHEN Saturday March 28, 2009 800am to
200pm WHERE The Atrium Roger Guindon Hall 451
Smyth Road
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From Last Week

• Canada has a medicare system
• Canada Health Act spells out the financial
  responsibilities of the provinces with respect to
  medical insurance
• Public administration
• Comprehensiveness
• Universality
• Portability
• accessibility
• Health care accounts for almost 50 of Ontarios
  budget, and is rising

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Today well look at health care around the world
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What Are The Worlds Best Health Care Systems?

• In 2000, The World Health Organization has
  carried out the first ever analysis of the
  worlds health systems
• Using five performance indicators to measure
  health systems in 191 member states

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Indicators Used to Make Rankings
The following were employed by WHO in their 2000
rankings

• overall level of population health
• health inequalities (or disparities) within the
  population
• overall level of health system responsiveness (a
  combination of patient satisfaction and how well
  the system acts)
• distribution of responsiveness within the
  population (how well people of varying economic
  status find that they are served by the health
  system)
• the distribution of the health systems financial
  burden within the population (who pays the costs).

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Why Country Topped the List?

• France provides the best overall health care
  followed among major countries by Italy, Spain,
  Oman, Austria and Japan

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1 France 2 Italy 3 San Marino 4 Andorra 5
Malta 6 Singapore 7 Spain 8 Oman 9 Austria
10 Japan 11 Norway 12 Portugal 13 Monaco 14
Greece 15 Iceland 16 Luxembourg 17 Netherlands
18 United Kingdom 19 Ireland 20 Switzerland
21 Belgium 22 Colombia 23 Sweden 24 Cyprus
25 Germany
51 Dominican Republic 52 Tunisia 53 Jamaica 54
Venezuela 55 Albania 56 Seychelles 57 Paraguay
58 South Korea 59 Senegal 60 Philippines 61
Mexico 62 Slovakia 63 Egypt 64 Kazakhstan 65
Uruguay 66 Hungary 67 Trinidad and Tobago 68
Saint Lucia 69 Belize 70 Turkey 71 Nicaragua
72 Belarus 73 Lithuania 74 Saint Vincent and
the Grenadines 75 Argentina
26 Saudi Arabia 27 United Arab Emirates 28
Israel 29 Morocco 30 Canada 31 Finland 32
Australia 33 Chile 34 Denmark 35 Dominica 36
Costa Rica 37 United States of America 38
Slovenia 39 Cuba 40 Brunei 41 New Zealand 42
Bahrain 43 Croatia 44 Qatar 45 Kuwait 46
Barbados 47 Thailand 48 Czech Republic 49
Malaysia 50 Poland
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What Is Universal Health Care?

• the law says that everyone must have access to
  health care

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What Is Single Payer System?

• characterized by one provider being able to
  create a market power that would buy all goods
  and services in the healthcare market

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Again Canada

• Single payer system, provincially run, funded
  through general government revenues
• 10 of GDP expended on health care
• 100 of citizens are insured
• Most physicians are paid fee-for-service
• There are only 2.1 physicians per 1,000 people
  (less than OECD average of 3.0 physicians per
  1,000)
• No copayments
• Lengthy waiting lists
• Fraser Institute estimates that 800,000
  Canadians are waiting for treatment at any given
  time

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The Human Cost of Illness in the USA

• 45.6 of all bankruptcies involve a medical
  reason or large medical debt
• 326,441 families identified illness/injury as the
  main reason for bankruptcy in 1999
• An additional 269,757 had large medical debts at
  time of bankruptcy
• 7 per 1000 single women, and 5 per 1000 men
  suffered medical-related bankruptcy in 1999

Source Norton's Bankruptcy Advisor, May, 2000
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France

• Often seen by political liberals as an ideal
  system (according to The Economist)
• Universal health care with few waiting lists
• highest level of satisfaction with their health
  care among all European countries
• The General National Health Insurance Scheme
  covers 83 of French workers
• other occupational specific (e.g. for
  agricultural workers, for the self employed, for
  miners, etc.) cover the remainder

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France

• Copayment rates for most services are 10-40
• About 92 of French residents have complementary
  private health insurance
• unlike true single-payer systems, it employs
  market forces
• France is the third most expensive health care
  system (11 of GDP) in the world
• in 2005 the health care system ran a 11.6
  billion deficit and in 2006 the health care
  system had a 10.3 billion deficit

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France

• Most of the funding is from a 13.55 payroll tax
  (employers pay 12.8, individuals pay 0.75).
  There is a 5.25 general social contribution tax
  on income as well
• Private health insurances makes up 12.7 of
  French health care spending.
• French doctors are paid by the national health
  insurance system based on a centrally planned fee
  schedule, but doctors can charge whatever price
  they want
• The average French doctor earns only 40,000,
  although medical school is free for them and the
  French legal system is fairly tort-averse
• To sum up the French health care system clearly
  works better than most national health care
  systems. Despite some problems, France has
  generally avoided the rationing inherent in other
  systems. However, the program is threatened by
  increasing costs and may be forced to resort to
  rationing in the future. the Economist

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Italy

• While France may have the highest rated health
  care system in the world, Italy is second
  according to the WHO
• Despite the high rankings by the WHO, Italians
  are dissatisfied with the quality of their care
• Health care spending rose by 68 between 1995 and
  2003.
• Funding is based on a regressive payroll tax. The
  tax starts at 10.6 of income for the first
  20,660 and drops to 4.6 of income between
  20,51 and 77,480. The rest of the funding comes
  from federal and regional general taxation

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Italy

• Physicians are paid via capitation
• Italians have limited choice of their physician
  but more than in the UK or in Spain. They must
  register with a general practitioner (GP) in
  their area
• Inpatient and primary care are free. For tests,
  diagnostic procedures and prescription drugs,
  copayments are as high as 30. However, 40 of
  the population (e.g. the elderly, pregnant
  women, kids) are exempt from these copayments.
• Waiting times are fairly long for diagnostic tests

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Spain

• The Spanish have one of the most centralized
  health care systems in the world.
• Spain ranks 7 on the WHO health care rankings
  and the Spanish are the second-most satisfied
  with the quality of their health care in Europe
  (behind France).
• 98.7 of the population is insured
• About 12 of the population has private health
  insurance
• Most physicians are quasi-civil servants and are
  paid a salary based on seniority and credentials
• Spain has fewer doctors and nurses per capital
  than most OECD countries

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Spain

• There are few copayments except for prescription
  drugs.
• Waiting lists are a significant barrier to care
  in Spain. The average wait to see a specialist in
  Spain is 65 days
• Rehabilitation and convalescence are not covered.
  Those with terminal illnesses are generally the
  responsibility of the patients relatives.

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Japan

• Japan has universal health insurance based around
  a mandatory, employment-based insurance.
• Japan has very generous health insurance
  benefits, significant provider choice, and high
  quality medical technology, but costs are not as
  high in the U.S.
• One reason for this is a significant level of
  cost sharing. The average Japanese household
  spends 2300 per year on out-of-pocket health
  care expenses
• Another reason for lower costs is that the
  Japanese government sets a reimbursement fee
  schedule for all physician services. This has
  resulted in assembly line medicine where
  two-thirds of patients spend less than 10
  minutes with their doctor 18 percent spend less
  than 3 minutes.

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Japan

• The health insurance plans are funded by an 8.5
  (for large business) or an 8.2 (for
  small-businesses) payroll tax
• Those who are self-employed or retired must pay a
  self-employment tax
• Very few Japanese use private, supplemental
  insurance. Private supplemental insurance pays
  for less than 1 of health care costs

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Japan

• Hospital physicians are salaried employees but
  nonhospital physicians are paid on a
  fee-for-service basis
• hospitals and clinics are privately owned but the
  government sets the fee schedule, just as it does
  for private physicians.
• The fee-setting system, however, is very corrupt
  since there are over 3000 procedures whose price
  needs to be set
• In 2004, a group of dentists was indicted for
  bribing the fee-setting board

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Japan

• There are no restrictions on physician or
  hospital choice and no referral requirements.
• Copayments are 10 to 30, but generally closer
  to 30. Copayments are capped at 677 per month
  for the average family.
• Waiting times are a significant problem at the
  best hospitals. Since the best hospitals can not
  charge higher prices there will be a queue. Many
  hospitals have been known to accept under the
  table payment to see patients quicker.

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Norway

• All Norwegians are insured by the National
  Insurance Scheme. This is a universal,
  tax-funded, single-payer health system. Compared
  to France, Italy, Spain and Japan, Norway has the
  most centralized system.
• 100 of Norwegian citizens and residents are
  covered.
• Funded by taxes

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Norway

• Norwegians can opt out of the the government
  system and pay out-of-pocket. Many pay
  out-of-pocket and travel to a foreign country for
  medical care when waiting lists are long.
• Doctors receive a salary
• Patients choose general practitioners (GPs) from
  a government list. These GPs then act as
  gatekeepers for specialist services. Patients can
  only switch GPs twice per year and only if there
  is no waiting list for the requested GP.

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Norway

• There are no copayments for hospitals stays or
  drugs. There are small copayments for outpatient
  treatment.
• There are significant waiting times for many
  procedures. Many Norwegians often go abroad for
  medical treatments. The average weight for a hip
  replacement is more than 4 months
• Generous system that has been known to pay for
  spa treatments

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U.K.

• Centralized, single payer system (National Health
  System NHS)
• Health care spending is fairly low (7.5 of GDP)
• 100 of citizens are insured
• In 2006, system had a 700 million deficit
  despite the fact that health care spending
  increased by 43 billion over five years.
• 10 of Britons have private health insurance.
  Private health insurance replicates the coverage
  provided by the NHS, but gives patients access to
  higher quality care, and reduced waiting times.

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U.K.

• most physicians and nurses are mostly government
  employees
• In 2004, the NHS negotiated lower salaries for
  doctors in exchange for reduced work hours
• Few physicians are available at night or on
  weekends
• ecause of low compensation, there is a
  significant shortage of specialists

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U.K.

• Patients have very little physician choice
• There are no deductibles and almost no copayments
  except for small copayments for prescription
  drugs, as well as for optical and dental care.
• Waiting lists are a huge problem in Great Britain
• 750,000 are on waiting lists for hospital
  admission
• 40 of cancer patients are never able to see an
  oncologist
• there is explicit rationing for services such as
  kidney dialysis, open heart surgery and care for
  the terminally ill

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Case Study Tony Wilson

• Famous founder of Factory Records (see movie, 24
  Hour Party People)
• Died last year of cancer, after being denied
  expensive cancer drugs by NHS
• "I've never paid for private healthcare because
  I'm a socialist. Now I find you can get tummy
  tucks and cosmetic surgery on the NHS but not the
  drugs I need to stay alive. It is a scandal.

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Switzerland

• of all the countries with universal health care,
  Switzerlands is the most market-oriented
• Spends 11.6 of GDP on health care, yet the
  government pays for very little of this funding
• Still the 2nd most expensive system in the world
• 99.5 of citizens are insured
• Insurance is purchased by individuals. 
  Individuals generally must pay the full cost of
  premiums, but the government helps to finance
  insurance purchases for the poor.
• Idea is that no individual pays more than 10 of
  income on health

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Switzerland

• Physician compensation is negotiated between the
  insurance companies and doctors
• Switzerland has strong regulation with respect to
  non-physician health care professionals (e.g.,
  nurses, PAs, NPs,) and thus patients are often
  compelled to use expensive physicians even when
  this may not be medically necessary
• According to WHO, Switzerland ranks second only
  to the U.S. in terms of the ability of patients
  to choose their provider
• Short waiting times

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Germany

• All Germans with incomes under 46,300 are
  required to enroll in a sickness funds
  wealthier people can opt out
• There are 200 of these funds, private and
  non-profit
• Funded by payroll taxes (15)
• 99.6 of citizens are insured
• Approximated 9 of Germans have supplemental
  insurance
• Physician reimbursement is set through
  negotiation with the sickness funds
• Short waiting lines

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Germany

• A family doctor in Germany makes about two-thirds
  as much as he or she would in America
• German doctors pay much less for malpractice
  insurance, and many attend medical school for
  free
• Germany also lets the richest 10 percent opt out
  of the sickness funds in favor of U.S.-style
  for-profit insurance
• These patients are generally seen more quickly by
  doctors, because the for-profit insurers pay
  doctors more than do the sickness funds

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Thoughts

• Health insurance does not mean universal access
  to health care. In practice, many countries
  promise universal coverage but ration care or
  have long waiting lists for treatment.
• Rising health care costs are not a uniquely North
  American phenomenon. Although many other
  countries spend considerably less than both
  Canada and the USA on health care, both as a
  percentage of GDP and per capita, costs are
  rising almost everywhere, leading to budget
  deficits, tax increases, and benefit reductions.
• In countries weighted heavily toward government
  control, people are most likely to face waiting
  lists, rationing, restrictions on physician
  choice, and other obstacles to care.

Source The Grass Is Not Always Greener A Look
at National Health Care Systems Around the World
by Tanner, CATO Institute
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Additional Reading

• http//www.pbs.org/wgbh/pages/frontline/sickaround
  theworld/countries/
• Sick Around The World Five Capitalist
  Democracies and How They Do it
• http//www.cato.org/pub_display.php?pub_id9272
• The Grass Is Not Always Greener A Look at
  National Health Care Systems Around the World