Impact of Approaches to Funding on Health Care Systems - Assignment Example

Outline Introduction General Health Care Systems with general outline on world health care with focus on USA and UK. The study and Comparison of healthcare in UK and USA . Managemant : Institutions Healthcare in USA(Private) 1. Background 2. Organizational Structure 3. Healthcare Financing Mechanism and Health Expenditures 4. Quality of Benefits, Choice, and Access 5. Problems and Reforms Healthcare in UK (Bismark and Beveridge) 1. Background 2. Organizational Structure 3. Healthcare Financing Mechanism and Health Expenditures 4. Quality of Benefits, Choice, and Access 5. Problems and Reforms Conclusion: The current trend and investment in healthcare. Private vs Public Healtcare. The funding programs supporting the healthcare systems and their growth in present scenario. The outcomes and success. Does it matter how health care systems are financed? Compare two or more countries in a discussion of the impact of approaches to funding on efficiency, quality and/or access to health care Every country has a healthcare system which organizes and delivers the healthcare services to the citizens of the country. Worldwide there are three major healthcare systems prevalent depending on the nature of government and the vehicle of management. These variations are dependent on the government machinery, the options made by the people and the operating vehicle of healthcare options available in the country. The three main approaches to financing healthcare are: private insurance, public insurance (Bismark) and tax-based (Beveridge). Health care funding depends mainly on what the government of the country in harmony with the welfare of the citizens has adopted for healthcare. Health systems delivery systems can be divided into two broad categories: National Health Services (NHS) on the one hand and Social Security (based) Health care systems (SSH) on the other hand. Existing literature is inconclusive about which system performs best. The research is to improve the evidence-base for discussion about pros and cons of NHS-systems versus SSH-system for health outcomes, expenditure and population satisfaction. The study of international healthcare systems reveals stark contrasts, which have at their root an individual country’s unique set of economic and social values. The European countries, in particular, are testaments to both the economic and social significance healthcare systems carry, and any healthcare reform effort must consequently address this central duality (Saltman and von Otter 1995). Since there is a strong ethic of social responsibility within European cultures, protecting and promoting the “public interest” is a fundamental goal. Thus, it is not surprising that despite system-wide variation, these countries share a fundamental healthcare vision of solidarity, mandatory participation, strict public regulation, community-based fairness, and health valued as a social good (Saltman 2002). In turn, this has produced a European focus on micro-economic efficiency based on the principle of “social entrepreneurialism”: the idea that competitive reforms tempered with the ideals of solidarity can still increase efficiency (Saltman 2002). All healthcare systems occupy a distinct place on the “public versus private” continuum in terms of the financing and delivery of healthcare (Sanders 2002). Although distinctions blur, most systems tend to predominantly embrace a “national health service model,” “entrepreneurial model,” or “mandated insurance model.” 1 • Under a national health service (e.g. the United Kingdom and Spain), universal coverage is publicly financed through taxation. Healthcare delivery occurs via mostly public mechanisms; hospitals are publicly owned, and medical services are primarily delivered by government-salaried physicians (Sanders 2002). 2 • In an entrepreneurial model of healthcare (e.g. the United States), people voluntarily purchase employment-based or individual insurance, and the healthcare delivery mechanisms (providers and healthcare facilities) exist largely in the private sector. Financing can come from both private and public sources (Sanders 2002). • Between these two extremes lies the mandated insurance model, in which compulsory universal coverage is publicly financed and health care is delivered by both public and private entities (Sanders 2002). Within this category, systems can be further classified as following a national health insurance/single-payer model (e.g. Canada and Sweden) or a multi-payer health insurance model that relies on sickness funds to provide universal health coverage as in the case of Germany and France. (OECD 2003). Structure and organization, financing, quality, choice, access, and problems and reforms related to variety of funding options should be addressed to determine the outcome. The values underlying these systems are indirectly manifest through the choices that each country has made for its system (e.g. degree of privatization, equitability, comprehensiveness. The aim is to increase awareness of the diversity of ways by which countries have achieved healthcare, as well as to paint a picture of some of the challenges that countries across the world face in their attempts to balance increasing healthcare demand with limited resources. The challenge is also to present the curve which leans towards adoption of universal healthcare system, unlike US which still has in practice the private healthcare option. The United Kingdom Background Despite its reputation as an advocate of free-market capitalism in its economic policies, the United Kingdom funds a strong social welfare safety net for its population that includes the National Health Service (NHS), a health system characterized by market-minimization and government ownership/control (Fried and Gaydos 2002). The UK NHS represents true socialized structure in the sense that physicians work for the government and the majority of healthcare facilities are publicly owned; that is, both the financing and delivery of healthcare is predominantly public. The NHS was ranked 18th for overall health system performance, 26th-27th for level of responsiveness, and 14th in level of health attainment by the World Health Organization in 2000 (Gaydos and Fried 2002; WHO 2000). NHS costs represent a significantly smaller percentage of the UK’s GDP at 7.7% than the health systems of many of its European counterparts (WHO 2005; Dixon and Robinson 2002). Despite this, the NHS continues to be plagued by chronic underfunding, as it is perpetually caught in an “efficiency trap” – its vaunted cost-effectiveness allows more patients to be treated, but the increased number of patients simultaneously creates higher costs and a need for greater funding (Appleby 1993). Moreover, the NHS has experienced problems with long waiting times, restricted choice, poor access to specialists, and outdated facilities (Appleby 1993; Ranade 1998). Yet in the face of this growing list of complaints, NHS enjoys an unprecedented level of public support (57%) and has been relatively successful at keeping escalations in health spending in line with GDP growth (Anderson and Poullier 1999; Blendon, et al. 2001). Organizational Structure and Management Basic Structure, Delivery, and Administration Established in 1948 in the aftermath of World War II, the NHS has been guided by the principles of equity, comprehensiveness, and free access at the point-of-service since its inception (Gaydos and Fried 2002). While a small private insurance sector does exist in the British healthcare system, the NHS provides the majority of care for the UK’s inhabitants via government-salaried physicians and public hospitals. The private insurance sector, which has grown significantly in recent years, is generally sought to improve access to elective procedures and ease waiting times, but even these private insurees are still entitled to NHS care (Gaydos and Fried 2002). Much of the actual administration of care is in the hands of county health authorities funded by the government. These authorities identify the local population’s health needs and purchase services from providers including GPs and NHS hospital trusts (Gaydos and Fried 2002). Recently, administrative duties have increasingly fallen in the hands of so-called “primary care groups” or “primary care trusts”, which are groups of GPs other healthcare professionals that are given funding to plan health services for their local communities – a responsibility that traditionally had been in the domain of the county health authorities (Gaydos and Fried 2002; Dixon and Robinson 2002). For primary care, delivery occurs through public GPs who either work alone or in a group. The average GP is responsible for a patient list of 1900 enrollees, and every UK citizen has the right to register with a GP. GPs provide free primary care consultations to NHS-registered UK citizens and serve as gatekeepers to specialist care Gaydos and Fried 2002). GPs are prevented from treating patients on their NHS-registered list on a private basis and only approximately 200 private GPs exist in all of the U.K., most of them in London (Dixon and Robinson 2002). NHS walk-in centers provide similar services to GPs (Gaydos and Fried 2002). Hospitals in the UK typically exist as part of independent, self-governing entities (“NHS trusts”) that provide a wide range of medical services, from emergency to long-term care (Gaydos and Fried 2002). NHS trusts employ the majority of the NHS workforce. Healthcare Financing Mechanisms and Health Expenditures Taxation, Premiums, and Other Contributions General taxation funds approximately 80% of NHS costs, with additional contributions coming from national insurance contributions (12% of NHS costs), patient fees (4% of NHS costs), and miscellaneous (4% of NHS costs) (Dixon and Robinson 2002). General taxation includes a 17.5% value added tax, as well as a direct general tax of 10% on the first Great British Pound (GBP) 1880 of taxable income, 22% of remaining income up to GBP 29400, and 40% on any income left above that amount (Dixon and Robinson 2002). The UK National Insurance contributions additionally require employees to pay 10% of their weekly taxable income between GBP 87-575 and employers to pay an 11.9% payroll tax for earnings over GBP 87 (Dixon and Robinson 2002). Premiums for private medical insurance are risk-rated and vary between group policies (e.g. employer-bought private insurance) and individual policies, the latter of which tend to be more expensive in general. Approximately two-third of private medical insurance is bought by employers as part of an employee’s benefits package (Dixon and Robinson 2002). User Fees Although most medical needs are met freely at the point-of-service with no charges for GP consultations or inpatient hospital stays, the population often must pay out-of-pocket for long-term and private care, pharmaceuticals, dental care, and eye services (Gaydos and Fried 2002). For example, the prescription drug co-payment was GBP 6.20 in 2002. However, 85% of all prescriptions end up being exempt from this co-payment because they fit into one of the exception categories (e.g. pensioners, students, low-income populations, STD clinic visitors, etc.). Segments of the population who frequently require prescription drugs are able to pay for four-month or annual prescription certificates at GBP 31.90 and 87.60, respectively; these certificates cover their drug costs for that time interval. Eye exams cost between GBP 10-20, while consumers pay 80% of the costs of dental services, up to a cap of GBP 354 (Dixon and Robinson 2002). Reimbursement Hospitals generally operated via global budgets. While hospital physicians are salaried government employees, GPs are reimbursed by capitation in accordance to the number of patients enrolled in a practice and also the number of services rendered. Privately insured patients are typically billed on a fee-for-service basis (Dixon and Robinson 2002). Quality of Benefits, Choice, and Access There is no enumerated list of guaranteed benefits within the NHS, but the Secretary of State is accountable for providing necessary benefits based on the recommendations of the National Institute of Clinical Excellence (NICE). The so-called "British National Formulary" allows UK residents to look up which drugs are not covered by the NHS due to excessive costs or questionable benefits. In general, UK citizens are free to choose their GP (Dixon and Robinson 2002). Although the NHS consistently receives high marks for public funding of healthcare, population coverage, and cost control, it typically is ranked low in terms of rapid access to medical technology and patient responsiveness (Blank and Burau 2004). The UK has a low ratio of both hospital beds and physicians per 1000 population relative to the UK’s European counterparts (Fried and Gaydos 2002). With GPs spending under 10 minutes with each patient on average, poor communication and strained, impersonal relationships are a growing consumer complaint (Coulter and Magee 2003). Moreover, in an era where patients are seizing personal control of their health, the NHS is plagued by long waiting times after GP referrals for specialist appointments (average 2.5 months) and elective hospital procedures/treatment (average 3 months). It is worth noting, however, that first-contact access to primary care is good, as appointments can usually be made for the same day in extreme circumstances and within a week for normal requests. Nonetheless, in order to compensate for some of these access issues, recent attempts have been made to reduce waiting times for elective procedures by contracting with private, for-profit hospitals in France; similarly, UK residents also recently have had the opportunity to receive necessary treatments abroad in a more timely manner under three pilot programs (Dixon and Robinson 2002). Problems and Reforms The NHS has been in a continual state of flux during the past two decades, with reforms yielding mixed results. On the positive side, recent NHS reforms have prompted a shift away from acute hospital-based medicine towards primary care and community health initiatives; with this new emphasis on prevention and education, GPs have found their roles enhanced at the expense of hospital-based specialists (Ham 1997). The transformation of British healthcare has also had negative effects, such as increased administrative costs due to the fragmentation of the purchaser role between GP fundholders (now replaced by primary care trusts) and health authorities (Saltman and von Otter 1995). Additionally, the introduction of primary care trusts created a high number of small purchasers of healthcare, which in turn reduced the bargaining power used to obtain lower prices and wage costs (Appleby 1993). In recent years, the Labour government has enacted reforms that have reversed the trends towards greater competition in favor of increased cooperation between purchasers and providers. These reforms aim to create an environment conducive to the formation of innovative partnerships between primary and secondary care providers (Ham 1997). The NHS continues to struggle with underfunding in the face of rising healthcare expenditures. Recently, the government committed to increasing levels of funding for healthcare with its 19 billion GBP “NHS plan” of 2000. This plan represents a 10-year effort to modernize and improve the NHS system, including increasing the number of doctors/nurses/hospitals, decreasing waiting times, upgrading healthcare facilities, and improving care for the elderly. The plan will be implemented by ten Department of Health task forces and a new Modernization Agency, which will work with NHS trusts and others to insure maximal community responsiveness (Gaydos and Fried 2002). Finally, health disparities continue to plague the UK’s healthcare system. While the magnitude of gradients might vary depending on the measure and method used (i.e. occupational class, education, income, or ecological index to examine mortality, birth weight, morbidity, height, etc.), studies have consistently shown that individuals in lower social classes tend to die younger and suffer from a higher rate of disability during their lifetimes (MacIntyre 1997). Significant variations also exist according to geographical location and gender. Eliminating these inequities has become a more pressing concern, as the health disparities between higher and lower social classes are increasing today despite advances in medicine and science. The social class gradient in mortality and morbidity is getting steeper largely because the professional, non-manual labor classes are experiencing a faster rate of decrease in mortality rates than the lower, manual labor classes (MacIntyre 1997). Although life expectancies were improving for all five social classes during the period from 1931 to 1991, males from professional families were found to live almost 10 years longer than their counterparts born to parents who were unskilled laborers according to a 1992-96 study. Even more disturbing, during the 1980s individuals from the poorest regions experienced a 27% increase in “likelihood of death,” which then ballooned to 34% as compared to the rest of the population in the 1990s (Mackenbach and Bakker 2002). The United States Background The US fuses a heavy reliance on private, voluntary insurance obtained primarily through employers with a public system that provides services through Medicare and Medicaid (Sanders 2004). The US is a leader in groundbreaking biomedical technology and innovative life-extending procedures, and those Americans who are well-insured enjoy arguably some of the best healthcare in the world. Despite this, the US entered the new millennium with a healthcare system characterized by skyrocketing costs, administrative inefficiency, and significant health disparities by race and income. Perhaps most visibly from an international standpoint, the US remains the only industrialized country in the world without guaranteed healthcare for its citizens. Indeed, the number of uninsured Americans rose to 45 million (15.6%) in 2003, an increase of one million people from the previous year (Kaiser Commission 2004). Recent economic recessions have aroused middle-class fears over the tenuous nature of their health insurance, particularly as escalating costs prompt increasing numbers of employers to drop coverage (Ham 1997; Marmor 1998). The US system was ranked 37th for overall health system performance, 1st in level of responsiveness, 24th in level of health attainment, and 55th for fairness in financial contribution by the World Health Organization in 2000. The US healthcare system performs unevenly on various health indicators, which is significant given that the US spends far more per capita on healthcare than any other country in the world (WHO 2005). Among OECD countries, the US ranked 7th worst in infant mortality rate and 9th worst in life expectancy (Department of Commerce 2004; OECD 2003). In contrast, the US excels on other indicators, such as its high level of consumer responsiveness and easy access to technology; indeed, with the exception of Japan, the US possesses the most magnetic resonance imaging (MRI) units per capita, as well as the most computed tomography (CT) scanners per million population (Anderson and Poullier 1999). The unevenness of the US systems performance on these health indicators and the decline in satisfaction with the US system to levels hovering around 40% have created a political environment geared towards reform of the healthcare system. It remains to be seen whether the problems of the US healthcare system can be successfully addressed by incremental reforms that keep the current structure in place, or whether the problems can only be solved through fundamental reform of the system. Organizational Structure and Management Basic Structure, Delivery, and Administration The US healthcare system relies on a combination of private and public insurance. The majority of Americans purchase private health insurance (63% in 1999) through their employer (58%) or on an individual basis (5%) (Upshaw and Deal 2002). An employer may purchase insurance coverage for an employee, cover them through the employer’s own insurance company (self-funded plans), or help pay for health insurance coverage for the employee. The public insurance system includes entities such as Medicare and Medicaid. Medicare provides health insurance for 65 and over Americans and is funded through payroll tax contributions. Medicaid is an income-based health insurance program jointly administered by the states and federal government that covers low-income populations, the disabled, and the elderly. Other publicly funded programs such as the Veterans Health Administration and workers’ compensation fund health services for veterans and those who are unable to work due to occupation-related disability, respectively (Upshaw and Deal 2002). Both for-profit and not-for-profit private insurance companies operate within the US. In general, health services are delivered in both public and private settings, with a predominance of physicians and hospitals in the private sector. Healthcare Financing Mechanisms and Health Expenditures Taxation, Premiums, and Other Contributions Contributions to healthcare funding in the US are made by individuals, employers, federal and state governments, and charitable organizations (Upshaw and Deal 2002). In 2002, government expenditures accounted for 44.9% of healthcare costs, and private expenditures represented the remaining 55.1% in the form of prepaid plans (65.7%) and out-of-pocket expenses (25.4%) (Sanders 2004; WHO 2005). The government finances Medicare, Medicaid, the Veterans Health Administration, and workers’ compensation largely out of general federal/state/local taxes (Upshaw and Deal 2002). Medicare Part A is additionally financed through a Social Security payroll tax, and Medicare Part B is additionally financed through monthly premiums. Both state and federal governments finance Medicaid, with the federal government providing states with matching funds for Medicaid expenditures according to a set formula (Upshaw and Deal 2002). User Fees 48% of Americans covered by private employer-based insurance obtain coverage through preferred-provider organizations (PPOs), which typically offer incentives to enrollees to choose certain contracted providers in the form of lower coinsurance rates. 23% of those covered by employer-based health insurance are enrolled in health maintenance organizations (HMOs), which subject enrollees to monthly premiums and co-payments (average $10) when they visit their physician. 22% are covered by point-of-service/indemnity plans that allow free choice of providers, although choosing contracted providers is usually rewarded in the form of more extensive benefit coverage. Finally, 7% have traditional fee-for-service plans that require enrollees to pay a monthly premium (often with employer contributions). Their insurance company then pays providers for services rendered each month. These plans, however, often have deductibles ranging from $250-500 as well as co-insurance requirements (Upshaw and Deal 2002). By federal law, states are not allowed to charge premiums to most Medicaid beneficiaries, but recently, states have been obtaining waivers that allow them to charge higher premiums to an expanded number of Medicaid beneficiaries. Cost-sharing in the form of deductibles, co-payments, or co-insurance has also increased recently. Certain groups of individuals are not allowed to be targeted for cost-sharing (e.g. children and pregnant women). Nonetheless, a total of 29 states imposed new or higher co-payments in Medicaid in fiscal years 2004 and 2005 for other groups (Artiga and O’Malley 2005). Reimbursement Reimbursement within the US healthcare system occurs via several different mechanisms: fee-for-service, capitation, and prospective payment. Indemnity plans tend to favor fee-for-service remuneration, while managed care plans often rely on capitation. Prospective payment mechanisms are also favored by health maintenance organizations (Upshaw and Deal 2002). Quality of Benefits, Choice, and Access Medicare Part A provides for limited hospitalization and home health costs for all Medicare enrollees who have made payroll contributions throughout their lifetime; Medicare Part B, on the other hand, offers a more generous benefits package extending to certain outpatient services and medical equipment (Upshaw and Deal 2002). Medicaid enrollee benefits vary by state, but the federal government mandates that certain medical services be covered, with other services (such as dental services) left to the state’s discretion (Upshaw and Deal 2002). In the US, there are large disparities in healthcare according to gender, race, age, region, education, and socioeconomic status (Schuster, et al. 1998). For example, despite possessing a large number of physicians (particularly specialists), 46 million Americans resided in areas experiencing primary healthcare professional shortages in 2000 (Upshaw and Deal 2002). As another example, uninsured individuals are more likely than insured individuals to experience difficulty accessing care and also tend to have worse health outcomes; indeed, the Institute of Medicine estimated that there are 18,000 preventable deaths a year related to a lack of health insurance coverage (IOM 2004). Even with these barriers to access, US patients are generally informed, savvy consumers of healthcare in comparison to many of their European counterparts. Particularly in today’s Information Age, patients are finding a wealth of information at their fingertips. Conversely, the increasingly specialized medical profession is struggling to stay up-to-date with recent developments; thus, physicians rarely possess more than a topical knowledge of areas outside of their specialty, which serves to level the playing field between doctors and the information-armed patients and to promote mutual participation in the decision-making process (Freidson 2004). Problems and Reforms The US is plagued by high administrative costs, and studies have estimated as much as 31% of all healthcare costs in the US go to administration (Woolhandler, et al. 2004). Health insurance premiums continued to grow at unsustainable rates; from 2003 to 2004, premiums increased 11.2%, a much faster rate than inflation (2.3%) and wage increases (2.2%). Overall, the US devoted 14.6% of GDP to healthcare in 2002, which is significantly higher than the OECD average of 8.1% (Reinhart, et. al 2004). The increasing number of uninsured individuals and skyrocketing health insurance premiums continue to be the most visible problems within the US healthcare system. With such a strong reliance on employer-based health insurance in the US, it is noteworthy that only 63% of jobs offered workers health insurance (Kaiser Family Foundation 2004). As health costs continue to soar, employers feel increasing pressure to drop healthcare coverage for workers, shifting many people onto public health insurance programs such as Medicaid (Kaiser Commission 2004). The US has embraced an element of planning/regulation during the past two decades, transforming itself from a fee-for-service system to one in which over 50% of the population is now part of a managed care plan (Appleby 1993). Although HMOs have achieved a degree of success in reducing unnecessary treatments and increasing consumer/provider accountability through deductibles and incentives, these accomplishments have often been at the expense of low-income populations, the elderly, and people with pre-existing health conditions; thus, coverage has improved little in the US during this era of managed care because HMOs cannot afford to take on such high-risk populations (Appleby 1993; Saltman and Otter 1995). Problems also exist regarding the quality of healthcare in the US. Various studies have shown that not only are a mere two-thirds of acute/chronic patients receiving proper care in the US, but American patients receive many unnecessarily “intensive treatments” that fail to produce appreciable gains in health outcomes on a consistent basis (OECD 2003; McLoughlin and Leatherman 2003). These problems are further compounded by the continued use of treatments proven ineffective by research studies, such as the prescription of antibiotics for viral infections, as well as the extensive underuse of necessary treatments, such as the under-prescribing of β blockers to decrease the likelihood of future attacks in heart attack patients (McLoughlin and Leatherman 2003; Schuster, et al. 1998). Nevertheless, it is important to note that outstanding medical treatment is provided for well-insured individuals, who have quick access to cutting-edge technology and a plethora of innovative treatment options (Sanders 2004). The central challenge facing the US healthcare system is extending this excellent healthcare to all of its citizens, not just those who can afford it. As the baby-boomer population has aged and worker tax bases have dwindled, governments have struggled to efficiently utilize available resources in order to fund an equitable level of care for their citizenry (Appleby 1993; Blank and Burau 2004). Understanding the nature of these struggles and the current environment for healthcare reform across the world requires a basic understanding of the structure of international healthcare systems as well as the values underlying each system. Work Cited Appleby, J. Financing Health Care in the 1990s. Buckingham, OU: 1993. Artiga, S and O’Malley, M. “Increasing Premiums and Cost Sharing in Medicaid and SCHIP: Anderson, Gerard F., and Jean-Pierre Poullier. “Health Spending, Access, and Outcomes: Trends in Industrialized Countries.” Health Affairs: 18 (3), 1999. Blank, Robert, and Viola Burau. Comparative Health Policy. Hampshire, Palgrave Macmillan: 2004. 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