This document summarizes a presentation on comparing the US healthcare system to systems in other developed nations. It defines key terms like OECD and healthcare systems. It describes different models like the National Health Service (NHS) and National Health Insurance (NHI) used by countries like the UK, Canada, Japan, and France. It analyzes spending, coverage, and challenges faced by each country. Consistently, other nations spend less per capita and get better outcomes. The US faces a crisis due to its mixed funding model without universal coverage. Reform efforts aim to reduce costs, improve quality and cover the uninsured, but the best path forward is unclear given US history, structure, and values.

1. Surgery Grand Rounds Robert Wolfson, MD, MSHA Healthcare Systems: History, Management & Policy April 20, 2009

2. Comparative Analysis Of National Healthcare Systems www.wolfsonconsulting.com/grandrounds April 20, 2009

3. Healthcare Crisis! "Report puts U.S. health care with industrialized world's worst." (Family Practice News, 2008) "The Coming Healthcare Collapse" Obama Health Plan Unafforable: Income tax to rise by 90%! (Robert McIntosh: 4/14/2009, A.P.) "The Healthcare Crisis in America" (Families USA – 2007) 4/20/2009 3

4. Healthcare Crisis! "Lack of health insurance causes 18,000 unnecessary deaths every year." (Institute of Medicine, January 14, 2004) "To Err is Human" (IOM, 1999, 2003) "44,000 – 98,000 People Die Each Year In Hospitals as a Result of Medical Errors" 16%, or 43 Million Americans Have No Medical Insurance (CDC) 4/20/2009 4

5. 4/20/2009

6. What’s Going On Here? Is This Problem Unique to the U.S.? How Do Healthcare Systems Function In Other Comparable Nations? Where Should We Turn For Examples With Our Healthcare Reform Efforts? This Morning: Compare U.S. Healthcare System With Healthcare Systems In Other Nations 4/20/2009 6

7. Topics Define Terms & Methods Evolution - Health Systems OECD Nations Health System Models & Examples Consistent Differences Current Healthcare Debate Discussion 4/20/2009 7

8. Terms OECD Healthcare Analytic Methods: "Systems Theory" Healthcare System Individual Madate, Employer Mandate Single Payer System 4/20/2009 8

9. I. OECD: Organization for Economic Cooperation and Development 30 Countries Committed to 'Democracy & the Market Economy' Began in 1921, Expanded in 1960's In the 20th Century, All OECD Countries Extended Government’s Role in Financing & Organization of Health Services 9 4/20/2009

10. OECD - 30 Countries 20 Nations Initially: (1921) Austria, Belgium, Canada, Denmark, France, Germany, Greece, Iceland, Ireland, Italy, Luxembourg, Netherlands, Norway, Portugal, Spain, Sweden, Switzerland, Turkey, U.K., U.S.A. + 10 Later: Australia, Czech Republic, Finland, Hungary, Japan, Korea, Mexico, New Zealand, Poland, & Slav. Repuplic 4/20/2009 10

12. Directed to Individuals & Populations4/20/2009 11

13. III. Methods Healthcare Systems Can be Compared Using Different Disciplines, or Methods: Sociology: Distribution of Care per Sociologic Group Economics: Most Data Available Systems Theory: The Most Comprehensive 4/20/2009 12

14. Systems Theory: "The Study of the Nature of Systems In Nature, Society and Science" A Framework by which One Can Analyze A Group of Objects, Working in Concert To Produce a Result Examples of Systems: Cell, A Method, "Cardiovascular System" 4/20/2009 13

15. Characteristics of Systems: Separate Objects Acting as an Integrated Whole Often Reach Functional Equilibrium: (Closed Systems) Objects in Systems are often Grouped into Categories: Input, Processing, Output, Feedback Parts of Systems Have: Functional & Structural Relationships to Each Other Slide 14 4/20/2009

16. IV. Healthcare System = All Resources Dedicated to Providing Healthcare Services to Populations, Nations Include: Patients, Providers, Methods, Treatments Institutions, Organizations, Buildings Acting as an Integrated Whole to Provide Healthcare Services to Populations &/or Nations 4/20/2009 15

17. Healthcare Systems Inputs: Funding, Patients, Physicans Throughputs: Healthcare Organizations, Treatments Outputs: Outcomes, Payments to Providers Environment:Physical Environment, Health Of Individuals & Community Feeback: Patient Health, Satisfaction, Health of Community 4/20/2009 16

18. Healthcare System Model Feedback Input: $$$, Patients, Supplies, Information Output: $$$, Patients Clinical Outcomes, Information Throughput: In Pt. & Out Pt. Services, Information Environment People, Wellness, Illness, Risks 17 4/20/2009

19. Terms (cont.) Individual, Employer Mandates: Individual citizens are required to have health insurance, one way or another. Employers are required to provide health insurance to employees. Single Payer System Payment for all Healthcare Expenses comes from a Single Source or Fund. 4/20/2009 18

20. Evolution of Health Systems In U.S., Before & During World War II: Labor Shortage, Freeze on Prices and Wages Employers Allowed to Offer Health Insurance As a Tax Deductable Benefit to Employees = Subsidy to Employers & Employees 4/20/2009 19

21. Following World War II: Western European Nations & Japan: Had to Rebuild From Scratch Developed National Health Systems Through Socialist Governments United States Chose Not to Build A National Health System, But Provided Subsidies to Their Healthcare System 20 4/20/2009

22. U.S. Subsidies Hospitals: Hill Burton Act – Funding For Hospitals Many Hospitals Granted Tax Exempt Status Training of Health Professionals Subsidized Through Governmental Grants Employer-Sponsored Health Insurance: Remained Tax Decuctible 1960's: Medicare, Medicaid 4/20/2009 21

23. Health System Models National Health Service (NHS) National Health Insurance (NHI) Mixed Funding, Mixed Coverage Pvt. Insurance + Government Funding Coverage is Not Universal 22 4/20/2009

24. I. National Health Service (NHS) "Nationalization of Healthcare": Including Providers, Facilities & Services Universal Coverage, Single Payer Financing From: Income Tax, General Taxes & General Fund District Budgets Are Used to Control Spending 23 4/20/2009

25. Characteristics: NHS Patients seen in Public Hospitals & Clinics Physicians work for NHS Countries Include: Great Britain, Sweden, Norway, Finland, Spain, Italy, Greece Private Practices often Allowed 24 4/20/2009

26. United Kingdom: Population: 61 Million Life expectancy at birth:79 Health spending as % GDP: 8.3% Coverage: Universal Management:Government Hospitals: Owned by Government Physicians: Paid Salary by Government Receive Fees from Private Insurance, Patients 4/20/2009 25

27. U.K.:Spending Health Spending per capita per yr.: $2,580 $ 2,245 (87%) FromGovernment $335 (13%) From Individuals For Supplemental, Private Insurance, Payments to Doctors, Self Pay for OTC drugs Prescription drugs: 1/2 Population Receive Drugs for Free, Exemptions: Age, Disability and Pregnancy 4/20/2009 26

28. U.K. (cont.) Notable features: Patients do not receive Bills: Or Insurance Premiums National Inst. Health & Clinical Excellence: Advice For Treatments & Drugs to be Covered Challenges: Inefficiencies, Old Infrastructure, Waiting Times, Unequal Distribution of Resources Among Districts. Professor Sir Bruce Keogh, 2/2/09 4/20/2009 27

29. II. National Health Insurance (NHI) = Nationalization of Health Insurance May be Single or Multiple Payers, But There is Universal Coverage with Employer &/or Individual Mandates Financing Comes From: Employment Taxes; Social Security Less ‘Budgeted’ More Flexible form of Financing Private & Public Hospitals/Clinics Exist 28 4/20/2009

31. Those in Need

32. Small Businesses4/20/2009 29

33. Japan: NHI; Financing: Public & Private Insurance Universal Coverage; Individual & Employer Mandate Funding:From Employment Taxes and Private Insurance Premiums ~ 4% of Salary => Nonprofit, Community-Based Insurance Plan. Public AssistanceFor Small Businesses, Elderly & Poor 4/20/2009 30

34. Japan: Population: 128 million Life Expectancy at Birth: 82.1 Health Spending as % GDP: 8% Coverage: Universal Spending/capita/yr.: $2474 $ 2053(83%) From Government, $420 (17%) From Invividuals: Gov't. Controls on Pharmaceutical Prices 4/20/2009 31

35. Japan (cont.) Notable features: Frequent Doctor Visits; Long Hospital Stays. Insurers Must Cover Everyone; Can't Deny a Claim. Biggest challenges: Rapidly Aging Population. Overuse of Care. Highest Number of Hospitals/Person in the world. Shortage of Physicians in Many Specialties & Rural Areas. 4/20/2009 32

36. NHI, France: Individual & Employer Mandate; 13.1% of Employees’ Salary Goes to NIH Fund Income Tax Fund Coverage for: Retirees, Unemployed, Disabled, Poor. 87% Have Supplemental Insurance: Private, for-profit Insurers Purchased by Employer or Individuals. 4/20/2009 33

37. France: Population: 61.7 Million Life expectancy at Birth: 80.3 Health Spending as % GDP: 11.1% Coverage: Universal Health Spending per capita/yr.: $3,300 $2,644 (80%) From Government, $440 (13%)From Individuals for Private Insurance, $220 Consumer Out-of-Pocket Expenses 4/20/2009 34

38. France: Notable Features 30 Chronic Conditions: Including Diabetes: Fully Covered Broad Choice of Physicians, Specialists Case Management: Pre/Post Natal Care, Cancer, Other Conditions Prescription Coverage: Co-pay Based on Demonstrated Effectiveness 4/20/2009 35

39. France: Physicians Organized into Unions Government pays Fee-For-Service Based on Negotiated Rates Hospitals: Government Sets Rates Challenges: Increasing Costs, Inefficiencies. 4/20/2009 36

40. Canadian System: NHI – of sorts. Funded by Taxes From The General Fund Single Payer System Budgets on a Provincial Level Most Hospitals: Self Managed, Private “Funding without Organization” Physicians: Salaried & Fee For Service Care is Publically Funded, Privately Delivered 37 4/20/2009

41. Canada: Population: 33 Million Life expectancy at Birth: 81.1 yrs. Health Spending as % GDP: 10.3% Health Spending per capita/yr.: $3460 $2, 422 (70%) From Government $1100 (30%) Private Spending Challenges: Increasing Costs; Waiting Times 4/20/2009 38

43. No Individual or Employer Mandate

44. Coverage Not Universal4/20/2009 39

45. United States: Population: 302 Million Life Expectancy at Birth: 78.1 Health Spending as % of GDP: 15.3% 46 Million, or 16% Uninsured Medical Debt Is The #1 Cause of Bankruptcy Spending/capita/yr. = $7,000 $3220 (46%) From Government $3780 (54%) Employer-Employees, Individuals 4/20/2009 40

46. United States: Highest Infant Mortality: in OECD Coverage: Almost all people over 65 yrs. Old. Approx. 80% of people under 65 yrs.old. Total Health Spending/yr. = $3.16 Trillion Physician & Hospital Fees: Predetermined in Government Programs & Private Insurance No Price Controls for Uninsured: Charged approximately 200% 4/20/2009 41

47. United States (cont.) Notable Features: Individual Choice; Very Expensive Advanced Technology, Drugs and Facilities Insured Patients Choose Doctors & Hospitals Challenges: The Uninsured Discrepancy between Rich and Poor Access & Quality of Care Increasing Costs, Quality Concerns Dysfunctional Payment System 4/20/2009 42

48. Common U.S. Values and Opinions: The ‘Rugged Individual’ Spirit Anti-Entitlement Anti-Government-Run Programs “U.S. Has the Best Healthcare the World” “Universal Coverage => Runaway Costs” “We’re Different” 43 4/20/2009

49. Cost of Care Per Capita 4/20/2009 44

50. Cost of Healthcare - % of GDP 4/20/2009 45

51. Health Spending/person %GDP 46 4/20/2009

52. Life Expectancy & Ave. Annual Spending/Person 47 4/20/2009

53. US Health Spending Projections 48 4/20/2009

54. Consistent Differences Non U.S. Healthcare Systems: Are Significantly Less Expensive Have Acceptable (Better?) Outcomes All Have: Individual &/or Employer Mandates Universal Coverage 4/20/2009 49

55. What's Happening Here? Is There a Crisis? Characteristics of U.S. Healthcare System Are a Result Of: History, Structure, & Culture No System Is Perfect All Have Challenges, Problems Is it Less Expensive: To Mandate Participation? To Provide Universal Coverage? 4/20/2009 50

56. Reform Efforts: What Are Our Goals? Reduce Cost? Improve Quality? Cover the Uninsured? Can, or Should We Try To Accomplish All of Them Concurrently? How? 4/20/2009 51

57. What Are Our Options? Answers Questions 4/20/2009 52

58. Thank You!