Comparative Health Systems
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Transcript of Comparative Health Systems
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
Criteria for comparison
Legitimation and Regulation Services and benefits Finances Eligibility Organization and administration Liabilities and benefits of parties to the
medical organization
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
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
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
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
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
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
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
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
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?
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
Other issues
Universal access Financial control Do we trust and respect the state? Industrial invasion of medicine—who can
stop it?
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
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
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
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
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
Italian system
Public Universal coverage Regional differences in quality based on cost Unrealistic expectations Can retire at age 50—no contribution while
using resources
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
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
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