cf_HSA546_W1_Ch1.pptChapter 1
International Physician and Health System Practice:
Can U.S. Reform Efforts Learn from Other Nations?
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- Egyptian Medical Practices
- Egyptians believed that medicine alone would only relieve suffering. When paired with magic, medicine allowed the patient to recover strength and vitality.
- The Egyptians employed physicians, at public expense, to care for workers building the pyramids, mines, and quarries.
Origins of Medical Group Practice
Origins of Medical Group Practice
- Greco-Roman Medical Practices
- Greeks emphasized the relationship between the healthy human body and the harmonies of nature.
- The early Romans did not practice rational medicine but relied on folk remedies.
- After the fall of the Roman Empire, physicians in the Islamic Empire established the hospital as a place to treat the sick.
- Organized labor, technology, dearth of hospitals in the late nineteenth century hastened the growth of medical group practice.
Origins of Medical Group Practice
Medical Group Practice in the U.S.
- How physicians are paid explains how the financing of healthcare services affects medical group practice.
- Fee-for-service: Physicians receive fees for services they provide from Medicare, Medicaid, and employer-based health insurance plans.
- Prepaid Health Plans: Health maintenance organizations (HMOs) pay physicians a per capita rate for the patients that they agree to serve.
- The German and Dutch healthcare systems are the most comparable to the U.S. system.
- Canada, Germany, the Netherlands, Sweden, and the United Kingdom have implemented various elements of managed competition.
- Canada’s tax-funded healthcare achieves universal access, high quality, and moderate costs.
Medical Group Practice in Other Nations
Lessons for the U.S. Healthcare System
- The U.S. healthcare system has been unique among high-income countries in relying on voluntary, employer-based health insurance for most of its population.
- The Patient Protection and Accountable Care Act of 2010 (PPACA) requires individuals to buy health insurance if they are not covered by employer-based insurance, Medicare, or Medicaid.
Lessons for the U.S. Healthcare System
- The PPACA established the Patient-Centered Outcomes Research Institute (PCORI), which identifies and conducts research that compares the clinical effectiveness of medical treatments.
- PCORI lacks any authority to restrict the proliferation of healthcare technology, a major driver of costs. An agency with such authority would be a proven way to limit the continuous health inflation that has plagued the U.S.
Reforming the Medical Liability System
- A recent Harvard University study estimates the medical liability system cost the U.S. about $55.6 billion in 2008.
- Most countries use a tort system of medical liability to compensate patients and to deter malpractice by physicians and other health care professions.
- Some countries have adopted no-fault compensation systems.
- Costs associated with defensive medicine (i.e., the costs of additional medical services to minimize the physician’s liability risks) are driven by physician perceptions about risk.
- Perceived risks of medical liability severely hamper the reporting of medical errors, undermining quality improvement efforts that would help mitigate medical liability.
Reforming the Medical Liability System
- It has been recommended that no-fault medical liability insurance be made compulsory for both physicians and hospitals to increase provider accountability.
Reforming the Medical Liability System
Tax Funded Models for Direct Provision
of Health Services
- The United Kingdom
- All residents are covered under the National Health Service (NHS), funded through national taxes.
- General practitioners may be independent contractors or salaried employees.
- Sweden’s National Health Service
- All citizens, immigrants and foreign residents are covered.
- Over 90% of physicians belong to the Swedish Medical Association (SMA), a union and professional organization that negotiates general employment conditions (e.g., salaries, benefits, working hours).
Tax Funded Models for Direct Provision
of Health Services
- Sweden’s National Health Service
- Physicians in private practice set their own fee-for-service rates, but must adhere to county and national guidelines if they are reimbursed by the NHS.
- Patients may receive care from physicians, district nurses and other mid-level providers.
Tax Funded Models for Direct Provision
of Health Services
- Canada
- Indirectly provides health services through a tax-funded public system, which is accessible by all Canadians.
- In 2009, there were about 2.4 physicians per 1,000 people in Canada.
- Most general practitioners and specialists are paid on a fee-for-service basis.
Tax Funded Models for Direct Provision
of Health Services
Compulsory Insurance Model for Indirect Provision of Health Services
- Germany
- Every German is eligible to participate in the statutory, social insurance system.
- The chief system for financing healthcare is through contributions toward statutory, social health insurance funds (SHIs).
- The unemployed, homeless, and immigrants are covered through a special sickness fund financed through general revenues.
- Germany
- The Federal Ministry for Health and parliament are in charge of healthcare at the national level.
- Most general practitioners and specialists are self-employed and paid based on fee-for-service.
Compulsory Insurance Model for Indirect Provision of Health Services
- The Netherlands
- All citizens are covered under the Algemene Wet Bijzondere Ziektekosten (Exceptional Medical Expense Act), which provides funding for long-term, disability, and chronic psychiatric care.
- Citizens are required by law to enroll in a plan of their choosing.
Compulsory Insurance Model for Indirect Provision of Health Services
Mixed Models for Provision
of Health Services
- Argentina
- Combines tax-funded, direct provision of health services through compulsory social and private health insurance with indirect provision of services.
- Brazil
- Relies on both a public and a private subsystem, covers 75% of the population through the public health sector. Relies on taxes to provide or contract for health services.
- Greece
- A combination of tax-funded, direct provision and social insurance-funded, indirect provision of care. State and national taxes fund the national health service.
- Indonesia
- A complex mix of private expenditures; tax-funded, direct provision, compulsory social insurance; and voluntary private insurance.
Mixed Models for Provision
of Health Services
- Mexico
- The System of Social Protection in Health (SSPH) is funded by federal taxes, contributions from municipal governments.
- Turkey
- In 2005, all healthcare facilities part of the Social Insurance Organization (SSK) were transferred to the Ministry of Health.
Mixed Models for Provision
of Health Services
- The United States
- The current system comprises a voluntary, employer-based private insurance subsystem, social health insurance for the elderly, and tax-funded, direct and indirect provision of care.
- The federal government is the single largest health-care insurer and purchaser.
Mixed Models for Provision
of Health Services
