CANADA
Policy and Management
The Canadian provinces and territories set much of their
own health care policy and manage their own health services delivery, although
the federal government oversees care for certain components and populations.
Canada’s health care system is highly decentralized. The country’s ten
provinces and three northern territories are primarily responsible for health
care in Canada, collectively called the Medicare systems. They set social
policy regarding health, education and social assistance, and other social services.
The provinces and territories also govern their respective single-payer systems
for universal hospital and medical services, paying for hospitals either
directly or through global funding for regional health authorities. In
addition, the provincial governments negotiate physician fee schedules with the
provincial medical associations. However, rarely do the provinces directly
deliver health care. Most of the health services organization and delivery in
Canada are through the regional health authorities.
The
federal government does retain jurisdiction over certain aspects of the health
care system, notably regulating prescription drugs and financing and
administering health benefits for indigenous peoples, the armed forces and the
Royal Canadian Mounted Police, veterans, and inmates in federal penitentiaries.
Health Canada, the federal department of health, also plays a critical role in
health services research and public health and protection.
Financing
Canada
finances its health system primarily through tax revenues, but copayments and
reimbursements from private insurance also make a significant contribution.
Tax revenues at the provincial, territorial and federal governments account for
nearly 70% of total health expenditures. These general revenue funds generally
come from income, consumption, and corporate taxes. The provincial and
territorial governments set the tax rates of their respective jurisdictions.
Patient out-of-pocket copayments and private insurance reimbursements cover
much of the remainder at 15% and 12%, respectively. The final 3% comes from
myriad sources, including social insurance funds, such as workers compensation,
and charitable donations.
In
2004, the C$130 billion spent on health care went to:
•
43% on hospital (30%) and physician (13%) services
•
23% on provincial social service programs
•
30% on private health care services
•
4% to direct federal services
Canada
spent approximately C$4548 per capita on health care in 2006. However, spending
varies throughout the country. Per capita spending in Alberta and Manitoba in
2006 was higher than in any other province or territory at C$4924 and C$4901,
respectively. Yet Prince Edward Island and Québec spent the least per
capita in 2006, only C$4225 and C$3976, respectively.
Payors
Regional
health authorities purchase most health services, but private insurance pays
for services that Medicare does not cover. The
regional health authorities have become the primary payor
of health care services. The regional authorities organize services and
allocate a global budget for the defined population. Funding methods vary among
the provinces and territories. Regional authorities have great freedom in
allocating funds to best serve the particular needs of their population.
Private
health insurance mostly covers goods and services not covered by Medicare.
Private insurance covered 33.8% of all prescription drugs, 21.7% of all vision
care, and 53.6% of all dental care in 2004. Six of the provinces—British
Columbia, Alberta, Manitoba, Ontario, Québécois and Prince Edward
Island—go so far as to outlaw insurance that attempts to provide alternative or
faster access to health care already covered by Medicare. Most private health
insurance is group-based, sponsored by employers, unions, or other like
organizations. Although employer-based insurance is part of the benefits
package, this insurance is mandatory and thus most provinces do not tax those
benefits.
Providers
General
practitioners as well as regional health authorities act as providers in the
Canadian system. The regional health authorities manage the
delivery of care. They hire salaried staff at a majority of acute care
facilities. They also contract with some private providers for specialized
ambulatory care services. However, most of Canada’s 1.5 million general
practitioners and specialists work under fee-for-service arrangements.
Fee-for-service payments account for 79.5% of physician income. Providers are
discouraged from performing services in both the public and private spheres, although
it is not illegal to do so.
Hospital
funding comes from global budgets transferred by regional health authorities.
Although hospitals historically have been private, not-for-profit institutions,
hospitalization has created a substantially integrated relationship between
hospitals and provincial governments. Most hospitals rely almost entirely on
the global budget monies allocated by the regional health authorities.
Access
Canada
provides universal, medically necessary care for its residents free of charge,
but its essentially single-payor
system has created a bottleneck for timely access to services.
The Canada Health Act makes all residents of a province or territory eligible
for medically necessary services without charge. Insured services include
virtually all hospital, physician, and diagnostic services as well as primary
care services covered under the provincial Medicare plans. Although financial
barriers to care have essentially disappeared with the elimination of most
Medicare user fees, access to timely care is a problem with which the
provincial and territorial governments continue to struggle. On the one hand, a
single-payor system is much more administratively
efficient than a multi-payor one. On the other hand,
it can create a bottleneck for access to services. Organizations within the
country, such as the Western Canada Waiting List Project and the Canadian
Medical Association, have developed waiting time benchmarks. Under the federal
Wait Time Guarantee Trust Fund, each province and territory had to specify a
patient wait time guarantee in order to qualify for federal funding.
Other
Health-Related Social Welfare Services
Canadian
provinces and territories provide long-term care and other social services
benefits to their populations. Options range from
residential care facilities, which provide some assisted-living services, to
chronic care facilities, which provide intensive services for patients with
high-needs. Home-based care is also available in both the public and private
sectors.
Systemic
Challenges
Canada
struggles with administrative efficiency and service quality.
Waiting lists are a point of dissatisfaction with care and erode public
confidence in the system. The country as a whole also must address the rising
costs of health care to ensure the sustainability of its programs.
FRANCE
The
French government provides health care for all 64 million residents under its
jurisdiction, nearly 60.9 million of whom live in France proper; the remainder live
in French Guiana, Guadeloupe, Martinique, and Réunion.
France has implemented several statutory changes in the past decennial that
have substantially changed its health care system. First, the 1996 Juppé reforms changed the funding scheme from a tax
on earned income to a tax on total income. In addition, the reforms increased
the oversight of the parliament, which set definitive health policy and finance
goals, and created regional hospital agencies (agences
regionales hospitales).
France now provides universal health coverage to all its residents.
Policy
and Management
Responsibility
for health services is split between the national, regional, and departmental
levels of government. At the state level, the
parliament sets the national ceiling for health insurance expenditures every
year and adopts new provisions regarding benefits and regulation through the
Act on Social Security. The Ministry of Health regulates much of the health
care system. See Figure 3 for a list of its most important functions. At the
regional level, regional hospital agencies are responsible for allocating funds
to public hospitals, adjusting taxes for private for-profit hospitals, and
planning for all types of hospitals. These agencies report to the Minister of
Health. Finally, the general councils provide social, health, and public health
services at the departmental level.
Financing
Tax
revenues from a variety of sources fund the bulk of the French health care
system. The vast majority of health insurance revenue,
88.1% in 2000, came from the general social contribution tax and the
contributions of employers and employees. Contributions to the social security
system differ according to the source of the income. Each resident pays a
general social contribution (contribution sociale général) based on total income. The
health insurance rate for earned income, capital gains, and gambling winnings
is 5.25%, while benefits such as pensions or social allowances are taxed at a
rate of 3.95%. Earnings-based contributions are levied at 0.75% of gross
earnings. The remaining funds are provided through state subsidies and
specifically earmarked taxes, such as car usage and alcohol and tobacco
consumption. Pharmaceutical companies also contribute, mainly via a tax on
advertising. See Figure 4 for a breakdown of the source contributions in 2000.
Payors
French
insurance schemes are organized according to employment type.
Working together under the umbrella of the national union health insurance fund
(Union nationale des caisses
d’assurance maladies—UNCAM), three insurance
funds make up the French health care system: (1) the national health insurance
fund for salaried workers (Caisse nationale d’assurance maladie des travailleurs salariés—CNAMTS); (2) the agricultural scheme (Mutualité sociale
agricole—MSA); and (3) the national health
insurance fund for independent professionals (Caisse
nationale d’assurance maladie des professions indépendentes—CANAM).
Each national health insurance fund distributes monies to regional and local
funds. The funds contract for services with self-employed providers and
negotiate the level of charges.
CNAMTS
covers approximately 85.6% of the population.
Members include both employees in commerce and industry and their families
(84%), as well as those eligible under the Universal Health Care Act (1.6% as
of 2001). The agricultural scheme, MSA, covers farmers and agricultural
employees, amounting to approximately 7.2% of the population. Non-agricultural
self-employed people, about 5% of the population, are covered under CANAM.
Under
the statutory health insurance plan, the reimbursement of health care costs
accounts for 84.9% of total expenditures. The remaining 15.1% is paid out as
cash allowances for maternity, illness, work-related injuries, or disability.
Reimbursements are made either to the patient, who paid out-of-pocket, or to
the provider. Increasingly, pharmacy and laboratory benefits are being paid
directly by the insurers.
To
cover the cost of “copayments”—i.e., the cost of coverage that is not
reimbursed under the statutory health insurance scheme, 86% of the population
purchased voluntary health insurance in 2000. However, only 43% opt for
voluntary insurance of their own initiative—employers purchase most coverage
through a group contract.
Providers
The
French health care system supports both public and private providers.
Approximately 4000 hospitals operate in France. Public hospitals account for
about 25% of all hospitals (1000). Non-profit private
hospitals number 1400, about one-third of all French hospitals. Private
for-profit hospitals are most numerous at 1750, but tend to specialize in
particular medical, surgical, or obstetric procedures.
Although
all hospitals receive a per diem, the services covered in that rate vary based
on hospital type. Public hospitals receive a single per diem rate that covers
all services provided, while private for-profit hospitals bill medical fees and
other items, such as prostheses, separately. Patients also contribute ˆ10.67
per day of hospital stay.
The
number of general practitioners and specialists in France is almost evenly
split—of the 194,000 physicians in France in 2000, 51% were specialists and 49%
provided primary care.
One-half
of specialists and 29% of general practitioners are salaried, both working mostly
in the hospital setting. Notably, private general practitioners in France still
make home visits, which account for about 25% of their care activities.
Providers receive payment from patients at the time of service; thus, providers
negotiate with insurance schemes over the unit value to apply to the fee
schedule to determine the rate of each procedure.
Access
French
residents may consume as much health care as they like; however, to increase
their price sensitivity, they pay for their care upon receipt and do not
receive full reimbursement. Although France provided
nearly all of its residents with health insurance prior to 2000, the Universal
Health Care Act (Couverture Maladie Universelle) expanded
coverage to all French residents. Single residents whose taxable income falls
below a certain amount per year (ˆ8774 for 2008-09) are entitled to free
coverage
The
system is quite liberal in that patients may choose to see any licensed
practitioner at any time without limit. The French average 4.7 contacts with a
general practitioner, and not necessarily the same one, each year. To make
consumers price sensitive at the time the service is provided, most patients
pay the full cost of services out-of-pocket and request reimbursement from the
statutory plan, with the exception of those requiring hospitalization and
low-income beneficiaries under the Universal Health Care Act. Typically,
patients receive only partial reimbursement and thus pay the equivalent of a
copayment for services. Patients without supplementary insurance typically
receive a reimbursement rate of 70% for physician and dentist services and 60%
for auxiliary and laboratory services. There are exemptions for patients with a
certain chronic or debilitating health status, those receiving a certain type
of care, or due to the status of the patient (such as pregnant women or those
injured in the workplace). Out-of-pocket payments accounted for 11.1% of total
health care expenditures in 2000.
Social
Welfare
France
also provides services for other health-related services.
France provides expansive coverage for those with mental illness and addictions
as well as for the elderly and disabled. The local authorities have the primary
responsibility for administering these types of services.
Systemic
Challenges
Like other health
systems, the French scheme must overcome issues related to increasing health
care costs and increased demand due in part to the aging population. The WHO has ranked
France as the best health care system in the world. Yet even France must
address challenges relating to sustainable financing and meeting growing demand
due to aging populations.
GERMANY
The German system,
known as the Bismarck model, is the oldest in the world and was established in
1883. Although it has undergone many substantial changes since then, the basic
structure remains. Within this framework, Germany enacted another significant
reform (Gesundheitsreform) to its healthcare
system in 2007. The reform had four target goals: (1) mandatory universal
health insurance coverage; (2) improvement of medical care; (3) modernization
of sickness funds; and (4) reform of the health fund, the base of health care
financing in Germany. As different parts of the reform will take effect at
different times, this section describes both the previous system and the impact
of the new reform.
Policy and Management
The German government
controls most of health policy development and health care delivery. The Ministry of
Health (Bundesministerium für Gesundheit) introduces
and executes health policy for the country. Major policies require approval of
both houses of government—he First Chamber (Bundestag or Parliament) and
the Second Chamber (Bundesrat, which
represents the German states or Länder).
The current policy emphasizes solidarity, i.e., the idea that all citizens
should have equal access to high quality health care, regardless of ability to
pay. he Ministry also administers the health
solidarity fund, which will be reorganized as of January 1, 2009, under the
2007 reform. The Social Health Insurance system, a coalition of sickness funds
that provide a standardized package of benefits, also falls under government
regulation.
Financing
The German model is
currently in a state of transition, reorganizing its internal subsidy model to
be more streamlined. Health care financing in Germany currently
follows an internal subsidy model. In this system, consumers pay both their
solidarity tax and health insurance premium directly to the applicable sickness
fund. The sickness fund then remits the solidarity fund contribution to the
government health fund, while the solidarity fund distributes premium subsidies
to the sickness funds. At present, the government subsidizes premiums for
certain low-income or special classes of residents, in keeping with the
solidarity principle. Basically, the total government subsidy to the sickness
funds equals the difference between the aggregate solidarity contributions and premium subsidies. The model is illustrated in
Figure 6 below.
Under this current model, both employees and
employers pay their contributions directly to the applicable sickness fund.
Contributions are calculated based on a percentage of wage or salary, and
differ among sickness funds. At the individual level, employers and employees
divide the contribution payment equally. On average, though, employees
contribute 7.6% of their salary for health insurance and employers contribute
6.6%. Premium subsidies are available for workers who earn less than US$60,000
per year, retired persons, students, and those who are unemployed, disabled, or
homeless.
The 2007 reform will reorganize the financing
system. Rather than a progressive percentage based on income contributed to a
sickness fund, individuals and their employers will contribute a flat
percentage rate directly to the health fund (Gesundsheitsfonds)
starting on January 1, 2009. Federal subsidies also will be paid directly to
the new fund. The fund will then distribute monies to the insurance plans on a
capitation basis; however, payments will be risk-adjusted based on age, sex,
and disease status. Well-managed, efficient insurance plans can remit excess
monies back to the insured or provide additional benefits not included in the
standard package. Insurance plans that run at a deficit have the option of
levying an additional premium on the insured, but it is capped at 1% of gross
income. However, if the plan imposes the second premium, the insured is
immediately free to change plans. The 2007 reform model is
displayed at Figure 7 below.
The 2007 financing reform has several goals.
First, it attempts to increase transparency for consumers. It also standardizes
the contribution rate for the mandatory insurance program. Flat rate
contributions already exist for long-term care, retirement, and unemployment
insurance; now they will exist for the mandatory insurance program. The reform
also tries to ensure equitable risk-sharing by risk-adjusting capitation
payments. More importantly, the reform increases competition among insurers.
For example, insurers have additional tools, such as discount negotiation
rights and optional contribution rates, to increase their ability to economize.
Further, the expansion of consumer-choice through the immediate ability to
change plans if the company imposes additional costs also incentivizes
companies to use monies efficiently.
Payors
Germany offers
residents coverage through the statutory system with the option to purchase
supplemental private insurance. Germany had 253 nonprofit sickness funds in
Access2006, which is a substantial decrease from more than
To contain costs,
patients may shoulder costs in addition to the premium and solidarity fund
contributions. Copayments and direct payments are not uncommon, and are still
allowed under the 2007 reform.
Providers
Health care in Germany
is delivered in both the public and private sectors. Both public and private
providers deliver in-patient hospital care. The majority of hospitals are
enrolled in a hospital plan, which means that hospitals receive funding through
the same mechanisms no matter the ownership (except psychiatric care, which is
reimbursed on a per diem schedule). There are two primary channels of hospital
financing. Sickness funds provide approximately Access93% of the total funds,
covering recurrent expenditures and maintenance costs. In addition, the sixteen
state governments plan investments in hospitals, which are financed by both the
state and local governments. These investments cover the remaining 7% of
hospital financing. Hospital reimbursements are based on the German
diagnosis-related groups. DRG over- or underpayments are adjusted marginally,
at 65% withholding in the subsequent year and 60% reimbursement at years end,
respectively. Private, for-profit providers deliver ambulatory care in Germany.
German physicians number Access133,000; of those,
118,000 are authorized providers in the Statutory Health Insurance system. Half
of these providers are family practitioners, while the other 59,000 provide
specialty care. Presently, seventeen regional associations of social insurance
physicians (Kassenärztlichevereinigungen)
negotiate annual contracts for ambulatory care on behalf of their members. Each
association receives a lump sum, which it then parses into two funds—one for
the primary care providers and one for specialists. Individual physicians
receive payment based on an invoice of total services provided and calculated
according to a relative value scale. The morbidity risk adjustment of the 2007
reform will decrease the disparity between services provided and reimbursement
levels, but will not likely significantly change overall provider
reimbursements.
Access
The 2007 reforms
mandate universal coverage but look to past coverage to determine how
individuals satisfy the mandate. Currently, certain classes of citizens are
insured by law. Workers who earn less than US$60,000 per year as well as
pensioners, students, and persons who are unemployed, disabled, poor, or
homeless are covered under the Social Health Insurance system. All insured in
this system have equal access to benefits and services—in fact, statutory plans
cannot refuse any applicant.0 Benefits include inpatient and outpatient care, all
necessary medication, rehabilitation therapy, and even dental benefits. These
plans include family insurance, so unemployed spouses and children of workers
are coinsured for no additional charge.
Access to private
insurance is limited. Individuals who have made more than US$60,000 per year
for three consecutive years or the self-employed may opt-out of social
insurance and purchase private insurance instead. Civil servants are eligible
for a 50% reimbursement on their health care costs if they purchase private
insurance to cover the remainder. However, choosing private insurance coverage
may be disadvantageous. In addition to risk-based premiums for all family
members, opting for private coverage makes reenrolling in the social system
difficult.
The German mandate for
universal coverage takes effect intermittently. Plan eligibility depends on the
type of plan the uninsured person was eligible for prior to coverage
termination. Those eligible for the Social Health Insurance plans must have
re-enrolled by April 1, 2007. Those who previously had private health insurance
were guaranteed eligible for private health insurance starting July 1, 2007,
and must have minimum coverage by January 1, 2009. The 2007 health reform also
excludes children from the social insurance plans; however, children are not
abandoned.
The reform merely
switches funding for dependents to a different source —from social insurance
financing to subsidies derived from federal taxes. The reforms attempt to keep
solidarity ideals intact. Standard social insurance benefits will be similar to
current ones. All eligible applicants must be accepted, and physicians have an
obligation to treat. If patients are unable to pay their premiums, the welfare
system will cover the payments. In addition, private insurance premiums will be
capped at the average maximum contribution in the statutory system.
Systemic Challenges
The transition to the
universal mandate poses the most immediate challenge to the German system. Germany must
vigilantly monitor the progress of the 2007 health reform implementation.
Unexpected and unintended consequences may arise, and the health ministry must
be prepared to meet unanticipated challenges. In addition, the Organization of
Economic Cooperation and Development has criticized the plan for not doing
enough to alleviate the rising costs of health care in Germany to the detriment
of the population.
The American health care system
Introduction
Like many of our institutions, the U.S. health care system relies on a
wide variety of public and private resources. Health care is provided in
several ways: by physicians in private practice; by municipal, county, state
and federal institutions, such as the Veterans Administration; and by
hospitals, which may be owned by religious orders or profit-making
corporations, or may be financed through charitable or community efforts. The
United States has more than half a million physicians, and they practice in a
variety of settings: in solo, partnership or group practice; in prepaid clinics
and organizations (HMOs); as hospital or governmental employees; and in surgicenters, immediate care facilities and emergency
rooms. Health care may be financed by the individual, by private or
employer-employee insurance plans, through Medicare and Medic-aid, or through
other governmental programs.
The American health care system is large,
employing more than 5 million people, handling more than 3.5 million patients a
day, and absorbing over 10 per cent of our annual Gross National Product.
For more than a quarter of a century the number of physicians per 100,000
population has been increasing and the common measurements of health - infant
mortality, life expectancy at birth, and so forth - have been improving. As a
result, the United States is today one of the healthiest among large nations
with heterogeneous populations. And, scientifically, American medicine is
often regarded as the best in the world.
This section contains answers to these questions
and many more that you might ask. Reading it will help you maximize the benefits
that the fine health care system of this country has to offer.
Voluntary care
organizations
These
voluntary associations are usually, but not always, nation-wide, state-wide or
regional, with local chapters in cities and large towns. The activities of
these groups include services such as providing the public with information
about various conditions, working toward related legislation, providing
information for patients and families, providing research funds, and supporting
programs that supplement care already available.