Global Benchmarks

Global Benchmarks in Public Healthcare

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Operational models for public healthcare vary widely throughout the countries of the world, from the complete unavailability of government paid healthcare to complete coverage. Most developed nations of the world provide some level of support for their nation’s healthcare system, but the amount and nature of the support varies widely. The categories of support, used by the World Health Organization (WHO) as criteria against which to measure effectiveness, can be seen in who is covered, the financial extent of the coverage, and exactly what services are covered.

Government-provided, or public universal health care is a complicated proposition under the best of circumstances. Factors that contribute to complexity include, but are certainly not limited to social, cultural, political, and economic conditions within the country.Yet, governments attempt to mitigate the difficulties caused by these factors and compromise where necessary to achieve workable solutions for their citizens. No system has yet achieved perfection and the process to improve continues.

The factors of program designs are so numerous as to create an effectively infinite variety of systems. For purposes of analysis, however, designs of health care systems may be categorized four ways:

Out-of-Pocket

An “out-of-pocket” system is another way of saying the government is not involved in health care. Today, only a handful of the poorer nations have no public health care system. Those who can afford to pay for health care services do so, while others rely on private charity, payment-in-kind (barter for health care with whatever goods of value the consumer possesses), or do without access to hospitals and trained doctors, relying instead on traditional or folk medicine. One might find this system in use in rural parts of some countries in Africa, South America, and India.

The NHI Model

The National Health Insurance, NHI, system uses private-sector providers who receive payment for services from a government-run insurance program. Citizens pay into the program through taxes or other mandated fees. This program is relatively inexpensive and simple-to-manage because all parties involved operate on a no-compete, not-for-profit model.Costsarecontrolled, however,through limitations on the medical services that are paid, so some needed care may not be available through the healthcare system. The NHI system is found in Taiwan, South Korea, and Canada.

Bismarck Model

Named for Otto von Bismarck, this system is used in Germany, Switzerland, France, Belgium, Japan, the Netherlands, and other countries. A variation of it has recently been adopted by the US. In this system, purchasing health insurance is mandated by the government while health insurance and medical providers, even if private enterprises, are highly regulated. In this system, health insurance is normally a benefit of employment. For those who are self-employed, having a government-approved health insurance policy is a government mandate.

Beveridge Model

William Beveridge is given credit for the design of the system used in Great Britain, New Zealand, Spain, and most of Scandinavia. In this system, healthcare is a government service completely financed by taxes.The government owns most of the hospitals and employs most of the doctors. Those hospitals and doctors that remain private bill the government for their services, thus patients never receive a bill. The benefit this model is low cost per capita, but costs are controlled by limiting the services available to the public and the amount that doctors are allowed to charge for services.

WHO’s Top 5 Public Healthcare Systems

Based on these criteria, the WHO rated these countries as having the best healthcare systems.

Australia

According to the WHO, Australians can expect to live an average of 74 healthy years. In this country, healthcareis provided by a combination of services funded by the Commonwealth, State Government, and private health insurance.

The universal health insurance plan since 1984, Australia’s Medicare program provides treatment in public hospitals without feecharged to the consumer. Subsidized care is provided for vision, dental, and psychological care, as well as general practitioner consultations, specialist care, physician-prescribed tests, and most surgical procedures. The Australian government also provides special healthcare benefits to war veterans and their dependents.

Some of Medicare’s funding comes through an income tax surcharge to Australians earning more than a prescribed threshold.Benefits are based on agovernment-established fee schedule. While doctors are free to set their own consultation fees, they are encouraged to accept the Medicare benefitas full payment.The system itself comprises three programsin addition to a program specifically for the lowest income residents.The first is free healthcare to the general public. Another program covers conditions specific to military service-related conditions. A third program makes certain medicationsavailable at reduced rates tocitizens who are war veterans or senior citizens.For low-income citizens there are discountson medicines and concessions on certain health services.

A surcharge on high-income earners encourages these people to purchase private insurance. Those individuals then have a wider array of choices in doctors and health facilities; they can use doctors and public or private hospitals of their choice.Depending on the policy, income, and age of the policy holder, that person may be entitled to rebates on some medical costs.

Canada

The Canada Health Act was designed to ensure reasonable access to all necessary medical services. It discourages user fees and, through equalization payments, tries to ensure access to all by leveling the playing field between prosperous provinces and those that are less so. In remote areas, primary care and emergency services,community-based health programs, and non-insured health benefits programs are offered in collaboration with Aboriginal organizations and other provincial and territorial systems.

Canada’s federal government sets and administers the public healthcare system so that it meets national standards throughout the country. As mentioned above, it works with smaller governing organizations to coordinate the overall healthcare system so that it is equitable everywhere. The provincial and tribal units are responsible for local administration, hospital planning and funding, payment for and negotiation of pricing for professional services, and for the promotion of the general public health.

Primary care providersare the first point of contact, ensuring continued care and ease of movement throughout the system, even when the patient requiresspecialized services. This comprehensive service covers a range of areas—disease and injury prevention and treatment, emergency services,referrals to coordinatedand specialized care, etc. Private practice doctors are paid based on a fee-for-service schedule. Those in public practiceare paid salaries or blended payments.

Secondary or specialized care refers to care in hospitals, community, or long-term care facilities. In Canada, the majority of hospitals are managed by regional health authorities or voluntary organizations under the watchful eyes of a board of trustees. The government does not fund home-based medical care but it does pay for care in long-term care facilities, and it provides coverage to seniors, low-income patients, and children.

France

In France, healthcare is seen as so important that its national director is a cabinet-level government position. Employees pay for compulsory health insurance through a payroll tax; the self-employed pay the same tax on their income. Insurance companies are all non-profit organizations that negotiate annually with the government to set service fees and prices.

When visiting a doctor, the patient will pay a small fee for the initial office visit, but will receive reimbursement for most or all of that fee from the government. If necessary, the general practitioner willrefer the patient to a specialist or a hospital.Alternatively, the patient may go directly to a specialist, but the specialist will then only receive payment correspondent with the general practitioner rate. Virtually all medical practitioners in France have contracts with the national health insurance plan so fees for services are standard throughout the country.

Germany

The oldest national healthcare system, Germany’s is based on the aforementioned Bismarck model where universal healthcare is financed via mandatory health insurance. Insurance may be provided by private insurers or through the public insurance plan. Salaried workers and those earning below a government-mandated income threshold are automatically enrolled in one of the many “sickness funds,” while those who earn above the limit, students, and government employees have the option of private health insurance. Rates for the public system are determined by income level while private insurance premiums are actuarial, based on risk factors of the insured.

Benefits covered by Germany’s health insurance are of three basic types: basic health insurance, accident, and long-term care. Of these, accident insurance, covering injury at the work place and while commuting to and from work, is the responsibility of the employer.

Dental insurance is provided as part of health insurance, but not all procedures are covered by public insurance. If the procedure is deemed purely cosmetic, payment for the treatment may be denied. For this reason, some Germans carry additional private dental insurance.

Costs are maintained through regulation by the Federal Joint Committee which not only negotiates with doctors and hospitals to set rates for procedures and all other aspects of health care, but makes regulations governing all facets of health care in the country.

Netherlands

The Netherlands continues to take top honors in the Euro Health Consumer Index, earning the number one position in 2014, and has been in the top three countries in this index since 2005.

Health insurance in the Netherlands, as with other countries in our report, is mandatory. However, health insurance paid for by individual premiums covers common medical care, while costs associated with long-term nursing care are considered separate and paid for by the government from general taxes. Health insurance premiums are not based on risk factors, instead everyone is covered under the same risk pool, making insurance relatively more expensive for healthy individuals so that those with high risk profiles do not have to pay as much as they would under a risk-based pricing system. Those who cannot afford health insurance are subsidized through a system of allowances based on income.

Insurance regulators oversee the entire process, ensuring all insurance providers offer the same services and that collusion between insurers does not happen. Insurance companies receive forty-five percent of their income from consumer premiums, and so have incentive to compete on price. They can negotiate with hospitals and doctors to maintain costs in order to offer lower premiums. However, even with competition, insurance companies have no incentive to avoid payments to policy holders because the government will compensate insurers whose payouts exceed income.

WHO Public Healthcare Excellence Criteria

The World Health Organization is the directing and coordinating authority on matters of health care internationally in the United Nations. As such, it shapes the agenda of research into health-related topics and sets norms and standards of health care and wellness. Each year, WHO issues its report of the state of health care among member nations, focusing on a different topic in each annual report. Its goal is to provide information to policy-makers and influential organizations that provide funding for government and private health initiatives and influence decisions toward higher quality health care for an ever greater number of people.

Their measure of public healthcare systems of member countries uses five criteria to determine relative quality of care provided. These criteria are quality, access, efficiency, equity, and the extent to which citizens of member nations are able to lead healthy lives to a determined age, currently sixty.

Quality of Healthcare

Quality indicators for a country’s public healthcare system are measured with respect to effectiveness, safety, coordination of care, and the degree to which care is patient-centered. Other factors in the quality realm include the extent to which health information technology is improving, how much of the total health care resources are dedicated to prevention, and the monitoring and coordinating of patient care.

Access

Patient access to health care can be evaluated on cost concerns and whether primary and specialized care is received in a timely manner. Affordable care and timely care can be conflicting requirements, so the report takes a subjective look at the balance between these two criteria.

Efficiency

Efficiency is gauged on whether the right care is received for the patient’s needs. For example, it is deemed inefficient for a patient to be relegated to an emergency room, with its high cost structure and long waits, when the condition can be easily and quickly treated by a physician.

Equity

The WHO considers healthcare to be a public right; it should be available to everyone and anyone should be able to receive necessary health care without suffering financial hardship as a result.

Healthy lives

The WHO measures healthy lives using three main criteria: incidence of mortality that should have been prevented by medical care, infant mortality, and a healthy life expectancy to the age of sixty years.

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