Health Systems

What is the best way to compare the HOW much countries are spending on health?

% of GDP? per capita?

NHS: what is a conflict of interest? also, does it have a gatekeeper??

1. COI--> doctors cant contract doctorsa 2. has gate keepers, this is a key to control volume and costs. idea being that GPs make the best decision, and this controls costs.

Health financing summary, who are all the agents? (3)

1. Govt (taxes, social health insurance, direct expenditures by govt) 2. Private (OOP, private insurance, NGO) 3. Extenal (donors)

Other mechanisms to control costs? (3)

1. Institute a budget (for hospitlas) 2. Share costs w/ patients (copay, deductables, uninsured services) 3. Improve efficency (EMR, P4P, competition

Health and Health risks in middle income, how do they vary?? 1) Life expectancy 2) U5mR 3) MMR

1. Life expectancy: varies greatly, 60 in ghana, 79 in chile 2. U5MR, Ghana 121, indonesia 29 3. MMR: 25 in chile, 220 indonesia

Contribution of OOP, private pre-paid, and govt health expednitures in 1) Low growth health economies 2) rapid growth health economies 3) high expedntirue health economies

1. Poor counties have HIGHER OOP costs, lower govt health expenditure and lower pricate pre paid health expenditure 2. rapid growth in the middle 3. Counties w/ high health expenditures have LOW OOP, and HIGH govt health expenditures and HIGH private pre paid

Desribe NHI of Taiwan: Was it a single payer? Financed? Enrollment? Benefits? Gatekeeper?

1. Single Payer 2. Financed through premiums and TAXES 3. Mandatory enrollment, 96% 4. Service delivery: private (fee for sevice), and public 5. COmprehensive benefits: inpt, outpt, druvs, dental, traditional chinese med, organ tx 6. NO GATEKEEPER

Taiwain Smart Card: what it does, how they deal w/ over utilization

1. Tracks every visit 2. Govt comes to ur door if u have too many visits....they then see maybe what SOCIAL services u truly need. 3. use is monitored, walk in swipe card, all the info comes up-> improves treatment, reduces claims processing, admin costs DELCINE. CONCERNS: confidentiality???

US Govt Role in health care (3)

1. VA system 2. Medicare/Medicaid 3. Regulator of private insurance

Main mechanisms to control costs...How to Limit volume?

1. capitation, waitlists, limits on choice, physician supply policies

What are 6 principles that countries like UK, canada and france share about govt-financed health systems?

1. comphrensivnesS: for a large amount of health problems 2. universality: everyone gets it 3. solidarity/equity: the better off help take care of the less off 4. portability: always take it with u, not tied to ur job or where u live 5. accessability/affordability- everyone can get it 6. Choice of providers

OOP, pros and cons

1. discourages over use 2. prevents poor people from getting eessential health care (regressive) *she thinks they are bad, and u want them to be low so as not to discourage use*

What are the system weaknesses for Taiwan NHI? 4

1. fee for service= over utilizaotin 2. dont have a systemic way to monitor and improve quality of care 3. via legistlative procecesses, rejected provision to adjust premiums when NHS depletes its reserves. 4. result is running on a defecit--> results in cutting fees which adversly impacts the QUALITY>

Main mechanisms to control costs...How to control prices?

1. fee schedules 2. price set by state

Why do healthcare systems need govt intervention? (5 examples)

1. for markets to function fairly and efficiently one needs perfect competition and info, BUT, health care has several market failures which prevent optimal function w/o PROPER OVERSIGHT: 1. Externalities 2. Adverse Selection 3. Moral Hazard 4. Agency (information assymetry) 5. Monopolies

How did Japan approach cost containment?

1. govt set the fees like BISMARK model, the people/employers all payed and the govt paid, services purchased..

Survey of cost related access problems in the last year, how did US compare to peer nations

1. highest % of 'didnt fill rx' 2. highest % didnt go to doc when had an issue 3. highest % skipped a tx or follw up

Goals of Health Systems (3)

1. improve health of the popualtion 2. respond to peoples non-heath expectations 3. provide financial protection against catastrophic cost of care Other goals--> function as a social instititution, equity, efficency, etc

Results of NHI in Tawian?

1. increase in use 2. Health info highly evolved and tracked utilization 3. Expedntures ROSE

Private insurance

1. mandatory or volunatry 2. premiums may be risk rated, community rated- (risk transfer between sick and healthy), income rated (risk transger between sick and health and rich and poor) 3. private for profit or NON for profit 4. can be princpal coverage or supplementary (i.e. dental in canada)

How to contain costs? 4 methods

1. premiums increased from 4.25% of salary to 4.55% 2. provider payements decreased if reasonable patient volumes are exceeded 3. efforts to reduce provider profits 4. negotiated w/ pharm companies5

How does the ACA move us closer to those 6 principles?

1. provide coverage to pre-existing conditions 2. protects choice of docs 3. ends arbitaray w/drawl of insurance, ends lifetime limits 4. removes barriers to emergency care 5. reviews permium increases 6. restricts annual dollar amount limits on coverage

UK, NHS, what are the 2 major recpieints of funds

1. public health of england ( pub health, clean air, immunizations) 2. Personal health serivices (NHS teams, clinical commision groups)

WHO's Health system building blocks (6)

1. service delivery 2. Health workforce 3. Information 4. medical products/vaccines, tecnologies 5. FINANCING 6. leadershup and governance

Governance (6)

1. setting priorities for what services are provided 2. distributional issues 3. regulations.laws for private sector 4. spending decisions 5. organization of healthcare system (who controls resources) 6. managing money and ino

HIV/AIDS in middle income

1/4 botswana

Taiwan: what was their health system prior? % covered?

10 diff public insurance covering 60%, and 40% uninsured MANY uncovered, elderly and children

What % of GDP do most countries pend on healthcare?

6%

WHO's Health system Goals and outcomes (4)

Access/Coverage and Quality/Safety: 1. Improved health (level/equity) 2. Social and financial risk protection 3. Responsiveness 4. Improved Efficiency

Public confidence, vs peer nations

Also not great

Germany, what is the name of their model?

BISMARK

German Bismark model, payment model, is it single payer? what happens if unemployed?

Funding: germans pay permium based on INCOME, into sickness fund (SS fund) No changes if loose ur job or health increased risk of illness if unemployed, so you KEEP ur insurance WHo pays?? employers/employees Money comes off paycheck REDISTRIBUTION: rich take care of poor NOT a single payer Sicknessfunds---> highly regulated insurance companies (controlled by the governemt) So how do the companies compete.... they have individual incentives, ceo makes money, pay is higher if company does well....incentive to keep a patient for a long time SO leads to incentive to keep patient health.

Ex of nations w/ social insurance

Germany Grance Austria Israel

if i want to know that size of governments investment in health care

Govt expenditure of health as % of total expenditure of health

Consequence to NHI implementation

MORAL HAZARD. incrase in use. the uninsured now doubled care/admissions/ER GDP growth rate was fluctuating up and down, National health expenditures were rising. NHE/GDP rose from 4.5--> 6.8 NHE rose from 221--> 891 per capita 1324-->20,290

Classic Typology of Health Systems:Mixed

Majority of health systems today Combination of tax, social insurance, and OOP e.g. US

do we have the best QOL or life expectancy compared to peer nations

NOPE, in the middle

do our breast cancer pt do much better than peer natoins?

Nope , similar

financial burden of health care payments on the average family, what stat?

OOP

Classic Typology of Health Systems: Unregulated, define, what type of countries?

OOP at the point of care. govt isnt doing anything really most LOW income nations

Classic Typology of Health Systems: BISMARK, define, progress or regressive, country example

Social security system (money deducted from paycheck) where employers and workers contribute to health funds generally progerssive (can be mildly regressive where there are ceilings on income contributions) GERMANY

How do values shape health systems

Societal values greatly impact health systems:

Where do we do more than other countries??

Table shows MRI unites, MRI exams, CTs, tonsillectomys CABG, Knee replacements, c-sectoins we pay specialists more, but GPs similar

Health systems in middle income countries: two case studies

Taiwan and Thailand

Define TOTAL Expenditures on health

Total money per yearr on health

Ex of nations w/ Tax based

UK canada Denmark

Mixed exmpels

US Switzerland

Examples of tax based nations

Uk , canada (income tax)

Thailands Health financing (5)

Unlike Taiwain, financing was incrememtntal..... 1. user chargeres waived in 1975 for poor fams 2. Civil servants and familes: tax financed medical care 3. Formal sector private insurance: payroll tax financed social health insurance scheme 4. Subsidized volunatry health insurance for near-poor rural families in 1983. 5. 2001 univeral health insurance to cover reamining 30%

Asthma hopsital admissions

We do terrible!!! we have more than average number of damissions, and more COPD admissions too. compared to peeer nations and OECD

Can u have similar health stats and diff GDP

YEs~ mexico vs vietnam

What is a health system

all activities that primary purose is to promote restore or maintain health. more narrowly, the provision of and investment in health services (preventive, curative, palliative)

UK: The NHS what values were in this?

all those 6

How important is wealth to health?

as u increase spending, life expectancy goes up After about 3K/person, the bang for ur buck levels off. SO how do u argue that u need more money? Also, this doesnt measure QOL

Of those 6, which are embraced by the US

choice of providers comprehnsive affodable/accessible

Good health services

deliver safe/effective quality health inteveventions to those who need them minimum waste

NHS England and Area Teams, what is it?

directly buys - specialists services and primary care NOT throught he CCGS Contract w/ hosptials and specialists

What is driving the costs?? What isnt driving the costs

everyones costs are gong up.... we spend mor eper capita Do we have sicker people? more smokers? more specialists... more technology? NOPE. BUT we do have more obesity, So what is driving the costs?? THE PRICES WE PAY FOR THE SERVICES... we arent tough of pharm companies. Vs single payers that set prices.

What is a negative consequence of not being able to set prices?

example of private oncology clinics, they cant make money, but hospitals get better reimbursements bc they have PURCHASING POWER.

Low middle income: what is the total health expedntirue PER CAPITA?

from low 30$ to 1K in brazil

Classic Typology of Health Systems: Beveridge, define, progressive or regressive, example nation

general tax based fund collected, where tax systems are progressive, health contributions are thus progressive *taxes---> a percent of taxes goes to health care 1. UK, Canada

general govt expenditure on health as % of total govt expenditure

govt has a budget (edu, clean air, health) % of total governemnt spending on health

IMplementation of NHI. initial response from docs and patients

govt just did it initial reactin: confusion and choas from docs and providers PUBLIC LOVED IT, DOCS HATED it

What is a clinical commissions group?

groups formed of docs, nurses, healt providers community srevives, mental health, and hospital services *they look at the health in their area and say this is what we need: GPs, specialists, clinics, etx. they then purchase what they need.

South africa is rich on the surface but....

health stats resemble poorer nations

Monopolies

high capital costs for buildings and equipment means that hospitals function best at a certain size (economies of scale), or by specializing in one line of treatment ( economies of scope, imposing high barriers for entry of competitors e.g. hospitals are relatively free to set their own prices

Total expenditures on health as % of GDP

how much per proportion. How big is health sector as a piece of the whole GDP pie

As public spending increases, what happens to ability to collect taxes?

increases

Health is determined by more than health care, ex: penicillin

infanr mortality trends were already declining when penicillin was introduced Really what was influencing this was housing improvements, santiiaton, etx

Taiwan Case Study: how did the plan for their National Health iNsurance program?

long time, 7 years of planning and international input

Define hi, low, middle income

low < 1,1025/person per year middle 1026-4035 upper middle 5036-12475 hi > 12476

Thailand: basic info about the country

middle income robust economic growth for 2 decades growth in income inequlity and poor health stats LE:72 years U5MR: low 8/10000

UK, the NHSH

money: taxes--> congress-->dept health--->deciions how its spend

doctor satisfacation in US

not great

what nation has LOW adult litearacy

pakistan this is a driver(women edu)--->MMR

Agency

people cant treat themselves, rely on a doctor. this can result in over treating e.g. areas w/ more surgeons have more surgery

Extrenalities

people pay for treatment they need, yet many disease affect other people e.g. free markets would underpurchase vacciantiosn bc they underestimate social benefit

Moral Hazard

people w/ insurance will consume more, doctors will treat things they know they will get reimbursed for e.g. increase in hi tech procedures as soon as covered by insurance

What is more related to under 5 mortality: health spend per capita or health spend as % GDP?

per capita % of GDP doesnt tell u how much ur spending (if u have a small GDP, then a % of that isnt enough)

What health stat tells u whether ur likely to find a CT scanner in ur hospital?

per capita health expedntirue

How is % of govt health spending associated w/ gross national income?

positive correlation "first law of health economics" as $ economy goes up, health spending goes up. Health care spending goes up as country gets richer.

Cost =

price X quantity

Adverse Selection

price of health insurance may rise too high for most people to afford as companies estimate risk based on previous health/age/risk/behavior e.g. history of having cancer => hard to get new insurance

Health information system

production analsysis and dissemination of reliable and timeely info

Well Performing Health Workforce

responsive, fair, effiicient, mix of staff, fairly distributed

High middle income: what is the total health expedntirue PER CAPITA?

starts areoun 200$ up to thousands

3 main approaches to financing health care systems

tax based social insurance mixed

Classic Typology of Health Systems: Semashko, define, examples

tax funded, central planning, docs are govt employees, universal covrage, free service, salaried workers, little or no private sector participation ex: old eastern europe, Cuba

Tax Based: define, pros, challenges

taxes on incomes, sales of goods/services/properites/capital gains. MANDATORY particpation Pros: Benefit from scale economies in administration, purchasing power (fee set) and risk management promotes equity bc contributions are NOT based on health need one authority is easier than 50 Everyone is in it--> solidarity Challenges: assumes political support for redistribution, lessens personal responsibility, lessnes accountability of providers to patients

Inverse Care Law, when is it exacerbateD?

the availability of good medical care tends to vary inversely w/ the need of the population served. This law operates more completely where medical care is most exposed to MARKET forces, and less so where such is exposure is reduced.

Effect of OOP spenidng on financial catastrophe and impoverishment

the lower the OOP the lower the catasopthes and improvershiment Ideal goal < 20% of OOP

Per capita expenditure on health

total expenditure / total population how much u spend per person. Ex: US spends 8K/person. Other peer nations spend 1-5K

size of health care industry overall, what stat?

total expenditures on health as % GDP size of industry = relative to other industry. so % of GPD is best.

Tawain: exploring the notion of choice

two types of freedom 1. choice of insruance or choice of provider Tawain: says yah you DONT have a choice of insurance but you DO have a choice of provider.

OOP, Private and Public spending, peer nations are they similar or diff

vary greatly overall trend is public spending > OOP > Private but in the US.... US: public=private> OOP (we have a large private cost compared to 0thers) *even when our public spending is comparable to toher nations, remmeber, we DONT cover everyone, just VA/Medicare and caid, etx... so spending a decent amount and covering a smaller proportion of our natoin

Middle Income: examples

very HETEROGENOUS lower middle- ghana, egypt india upper middle, russia, china, thialand

Context for push for NHI

w/ growing wealth comes pressure from public to expand pressure, cover the vulnerable, this persisted DESPITE economic downturn in 1998

Cost related acccess barrier and OOP issues, how does US do?

we have the highest rate of people experiencing cost related access probs highest % of people spending more than 1K OOP

Government expenditures on health as % of total expenditure on health

what proportion of all the countries health spending does the govt pay for

Social Insurance: define, pros and challenges

workers/self employed/enterprises and govt pay contributions into health insurance fund based on workers salary Mandatory participation (but opt out is availbable for hi income in germany/netherlands govt contributes for unemployed and low income Pro: risk independent (pre-existing condition doesnt impact how much u pay), transparent contributions Sickness or social insurance funds are payers/purchasers- can be geopgrahic, political, religiously based same benefits for all all providers and pham suppliers have contracts w/ sickness funds and have the POWER TO NEGOTIATE directly (this keeps costs down). choice of provider and sometimes choice of sicknes funds