Healthcare

Question 1

Private insurance

Answer 1

Some like the US have PI for those not covered by SI or who prefer PI (US, Netherlands)

Others use PI supplement SI (UK, Spain, Italy)

And some use PI to provide coverage for SI cost sharing provisions (Denmark, France)

In one country (Ireland) PI serves all three functions

Question 2

OOP costs

Answer 2

cost-sharing, with third party covering majority of cost (US, Denmark, France, UK)

Italy, Portugal, Spain OOP is used for direct payment of total fee for certain services

Question 3

Public/Private, SI/Taxes mixes

Answer 3

The closer to the lower left hand corner in the prior figure, the more private country’s HC system financing is (US, CH)

Closer to the hypotenuse, the more public

The left end of the HT is more tax-driven, the right is more SI

TAXES AND SI ARE RISK POOLING MECHANISMS

Question 4

Brand drugs

Answer 4

The US pays more for brand named drugs, far less for generic, our MDs are better paid than most, accept UK, specialists in the US

Question 5

Why is the US so much more costly?

Answer 5

1. Higher administrative costs-our system is far more complicated than that of other countries. PRIMARILY FFS
2. Higher ratio of specialists to PCP are paid more and use more expensive tests
3. More stand by capacity we have more capacity in reserve
4. Open ended funding- our insurance tends not to have limits, while other countries have budgets that limit them from spending a certain amount of money
5. Less social support
6. More malpractice suits
7. Higher brand name drugs
8. Higher physician incomes

Question 6

In which country are there Rx caps

Answer 6

Germany

Question 7

UK

Answer 7

Beveridge Model: government provides healthcare

Pretty much everyone is covered

All services are offered

84% public

OOP:10%

G.P are gatekeepers they have a certain amount of patients they are allowed to see

Benchmark standards for all provider comparison leads to better competition

HARD BUDGETS

Question 8

Canada

Answer 8

National Health Insurance Model

Only resident citizens are covered

No hospital costs for hospitals and MD services

Highly decentralized-Each “state” unique

government funded insurance from taxation pays for all

Not good quality care, have to wait a while to be seen

Benchmark is 2-29 weeks for bypass

SINGLE PAYER POWER
Generic drugs are more expensive than in the US

OOP:15%

Only 20% of private insurances are NFP

Question 9

Japan

Answer 9

Bismark Model

All insured through different mechanisms, benefits are identical, 33% public, through taxes

OOP: 15.8%

Patients seek out care without referral

Little formal requirements alot is based on what is culturally acceptable

DRG

PROFIT MARGIN REGULATIONS ACROSS HOSPITALS AND PROVIDERS

Question 10

Germany

Answer 10

THE BISMARK MODEL

Everyone is covered public or private except long term care

Any services are provided

77% public, 9.3% private

G.P and specialists are independent, paid by fees negotiated by regional associations

Very strict regulations

INTEGRATED CARE MODEL

Reference Pricing

Question 11

UK rich people

Answer 11

private insurance, limited access to dental care

Question 12

Canada rich people

Answer 12

supplementary insurance
dental and vision care

Question 13

Japan rich people

Answer 13

Not a big issue here
Limited access to ER care

Question 14

Germany rich people

Answer 14

Some private and little choice in insurer

Question 15

4 major sources of money

Answer 15

General taxation
Private insurance
Social insurance
OOP

Question 16

Social insurance

Answer 16

run by the government, may come out of pay

benefits are paid out

medicare is social insurance

Question 17

US system is passive

Answer 17

The “system” in the US is passive, from the provider’s point of view

Patient initiates contact with the provider

If not, may be considered quackery

MD goes door to door would be looked at suspiciously

Question 18

The lay referral system

Answer 18

lay person= not a healthcare professional

Ask for opinion and advice of others or listen to suggestions

Usually seek advice from those perceived to knowledgeable

Result in either it gets better or they need professional help

Question 19

Professional referral system

Answer 19

professionals use this system

advice from other professionals

not as clear cute as the public thinks

up to 50% of all MD office visits have no firm diagnosis

Question 20

Pharmacists role

Answer 20

consumer often thinks pharmacists as part of the lay referral system or a bridge between the two systems

depends on the quality and nature of the therapeutic relationship

easy access in community

“community triage”

Question 21

Health

Answer 21

health, like jazz is something that is very much defined socially and culturally

each society, has an internal conceptualization of what health is

Question 22

The dark side of “health”

Answer 22

so what happens when someone decides you’re sick?

social or political concept

your doctor can have you confined against your will

health and sickness can also be a form as social control

Question 23

Disease

Answer 23

state of dysfunction or departure from normality

defined by capital M medicine (MD)

capital medicine has invented new diseases

you cannot self diagnose a disease

Question 24

Illness

Answer 24

not feeling well and they tend to modify their normal behavior

both disease and illness are defined by standard of normality

disease by standard of MD
illness by standard of the individual

Question 25

The “worried well”

Answer 25

20-30% of population

need someone to talk to

way to get attention

Question 26

Social/cultural define disease and illness

Answer 26

some cultures simply do not recognize mental illness

some diseases are so common they are not considered departures from normality

Question 27

Standard of normality often relative

Answer 27

society shapes the healthcare process

within a society, the standard may vary according to your place in that society or culture

occupation, economic status, eduction, religion

Question 28

Illness behavior

Answer 28

trying to figure out what is going on

person only has to feel ill, not to have disease

seeks to define, that is, reduce uncertainty

driven in part by HBM

may use the lay referral system

OTC remedy

Question 29

Sick role

Answer 29

when you are dealing with illness you are not 100% normal

if you are doing this you are not filling your social roles because you don’t feel well

Question 30

Sickness impairs our ability to fulfill our roles

Answer 30

Role failure

Can’t rescind role status due to sickness, need a “temporary” role for sick person to enter into

allows them a special status to relieve them from other role responsibilities

Question 31

Talcott Parsons

Answer 31

developed by Talcott Parsons in the 1950s to explain people’s behavior when ill

Question 32

Freedom from blame for condition

Answer 32

people who are sick have the right

not the person’s fault

not to be blamed for not fulfilling other role obligations

not to be punished

Question 33

Exemption from normal duties and tasks

Answer 33

people have the right to be temporarily be excluded from home, work, and school responsibilities

Question 34

Claim on others for assistance and care

Answer 34

derived orm the idea of healthcare as a right

people who are sick have the right to go to someone for help

Question 35

Try to get well

Answer 35

people who are expected to recognize their condition is undesirable

they must want to get well and get better

Question 36

The future of Sick role

Answer 36

long-term treatment of chronic diseases places greater stress and cost on the HCS

most likely higher co-pays or “higher risk” insurance

we are seeing a shift from “healthcare as a right” to “individual responsibility”

Question 37

1. Physical and person intimacy

Answer 37

access to confidential information

right to touch and probe the body

can ask questions no one else can

Question 38

2. Initiation and direction of treatment

Answer 38

what to do and when
the patient is an individual and has right to input