Comparative Health Systems

1. Comparative Health Systems • Why compare? • We have problems and others have different and perhaps better solutions • What kind of comparison? • Scientific enterprise • Inefficiency, efficacy, inequity and cost • Repair versus prevent

2. Criteria for comparison • Legitimation and Regulation • Services and benefits • Finances • Eligibility • Organization and administration • Liabilities and benefits of parties to the medical organization

3. Other modes of comparison • Outcomes • Equity • Disease versus prevention and public health

4. Mutual aid model • Communal risk and communal cure • Minimize financial risk • Emphasize prevention • Power local and communal • Team oriented care delivery • Patient not educated except in prevention

5. State model • Strengthen state control • Minimize cost, and disease prevalence • Universal access • Centered on governance and control • Not patient or physician centered • Primary care, basic care • Financed by state taxes

6. Professional model • Professional core delegated the responsibility and the power to provide medical care, finance it and decide who gets it • Best care, compassionate care • Professional associations control • Less primary care, more specialized care • Private finance, risk pooling if able • Expensive, secret and less equity

7. Corporatist model • Medicine as industry, buyers and sellers • Minimize conflict • Cost versus provider interests at issue • Institution is the corporate body of medicine • Negotiated between unequal negotiators • Finance depends on the intervention of the state • Inequity and cost high

8. Canada • National system with central finance and regional control of allocation • Cost controls • Indirect care availability controls • 12.5% of GNP instead of 20.3% in U.S. • 8.5% of Canada’s budget instead of 22% in U.S. • Preserved D/P relationship, emphasis on primary care • Small population

9. Will it work here? • Entitlement mentality • Cost, technology focus • Powerful professions • Government and insurance industries would suffer in the bargain—balance of power would have to shift

10. Downsides to our System • Red tape—actually less administrative red tape and paper work • D/P relationship—we have managed care and too much non-patient contact compared to freeing the doctor to see patients and interact • External control to care

11. Downsides to their System • Long lines for elective procedures—reason we have no lines is because people know not to get in lines here—financial penalties too onerous • Must admit our addiction to technology and make social changes to our own behavior • Lower quality a myth—outcomes and health measures as well as satisfaction BETTER in Canada

12. Downsides • Rationing versus allocation • Communal responsibility for allocation of care NOT individual right • ONLY prisoners in the US have a RIGHT to care, no one else does—has this changed? • In Canada everyone has a right to care that is limited—is this more fair? Equitable?

13. Downsides • Presumed exodus of physicians—actually doctors happier in Canada because the paperwork is less, more patient contact and less direct oversight, negotiation • If money really matters then they move

14. REAL downsides • The availability of technology • Portability • Esoteric care • Social control issues

15. Other issues • Universal access • Financial control • Do we trust and respect the state? • Industrial invasion of medicine—who can stop it?

16. German system • Insurance cost based not care based • Subsidy of the old by the young • Subsidy rich for poor • Office/hospital dichotomy • Drugs expensive • L.E. dropped 9 years in last 15 years

17. British systems • Differentiate the financial control (Canadian system) and financial and organizational control (UK) • 1948—took control of finances and organization– made doctors employees and eliminated private medicine • NHS as state model

18. Strengths • Universal access • Cost control – 6-10% of GNP • Better public health and prevention • Better control of research and outcomes • Less drugs, more health, more education and self-reliance

19. Weaknesses • Regional inequalities • Less technology • Class variations in use • Waits for invasive care

20. Restructuring NHS • Began in the 1980’s • Managerial and regional control • Performance indicators, quality control • Localization of internal markets • Empowering the consumer—the return of private medicine and open markets • Detailed lists of wait times and outcomes

21. Restructuring • Welfare pluralism • Public and private funding returns • Flexible firms with more local control and less reliance on government funding • A result of social action groups • Result of flat technology advances, sameness of care

22. Italian system • Public • Universal coverage • Regional differences in quality based on cost • Unrealistic expectations • Can retire at age 50—no contribution while using resources

23. Concepts of prevention • Less harm, less disease with better health • Prevention is better than cure and easier • And less costly • Public health and its separation in US medicine—unlike the rest of the world

24. Refocusing the Debate over Health • Health comes from prevention in a world where chronic illness predominates • Health is preferable to disease • Disease treatment is short term and temporizing • Health promotion is long term and lasting • There is futility in both approaches

25. Refocus • NOT battle between makers of disease and health workers • Political economy of health—we make an industry of illness and the viability of that industry is dependent on lack of health • So get healthy, prevent harm • Concept of PERSONAL moral health entrepreneurship • Need hierarchies—survival and beyond

26. Issues • Social Justice • Universal coverage • Who pays • How much • Access to care • Have we solved these issues with reform?