I continue the World Health Tour with a look at countries that made it to the top ten of the WHO health survey; Japan, Italy, and Spain. Despite high marks from the WHO none of these countries score well with their own people. We look at possible explanations for this disparity.
Great discussion last time. It was wonderful to hear from people in other countries. Thank you all for your responses. So lets go on with our tour:
Country | Japan | Italy | Spain | US |
WHO Rank | 10 | 2 | 7 | 37 |
%GDP | 7.2 | 8.4 | 7.8 | 14.6 |
Public Spending | 5.7 | 5.3 | 5.5 | 6.5 |
Per Capita | $1822 | $1783 | $1556 | $4178 |
MD’s/1000 | 1.8 | 5.8 | ?? | 2.7 |
Drugs | Yes | No | Yes | No |
Glasses | No | No | No | No |
Dental | Yes | No | No | No |
Co-pays | Yes | ~$10+drugs | ?? | Yes |
Insurance | Yes | Supplement | Yes | Yes |
Type | Multi-Payer | Single-Payer | Single Payer | Pvt insurance |
Gatekeeper | No | Yes | Yes | Some |
MD Paid | Fees | Capitation | Fees | Both |
% satisfied | 53% | 20% | 21% | 40% |
Infant Mortality | 4.0 | 6.1 | 4.0 | 7.2 |
DALE | 74.5 | 72.7 | 72.8 | 70 |
JAPAN:
Japan is ranked number 10 in the WHO list and has a very low infant mortality rate and the highest life expectancy in the world; and all at a very low cost. Some of this might be genetics, cultural differences in life style and food but Japan is still worth a look.
Surprisingly, the US ranks 6th in MRI machines per 1000 people. Japan is 1st in that regard. The health care in Japan is very advanced. They clearly have every technological and pharmaceutical advantage that Westerners have.
There is no rationing of health care. The care of the patients is left strictly in the health care providers hands. In fact by and large the doctor also dispense the medication! The care is very weighted toward prevention. They admit half as many people as we do, but when they do admit them they expect them to stay until fully recovered. They have the longest average hospital stay of any country. They do a quarter of the number of surgeries and half as many cesarean sections as we do. The average Japanese person sees the doctor an amazing 12.9 times a year. The visits are brief, though—6.9 min. (US--20 min.)
The system is financed like social security via a payroll tax. Employers pay 34.6% and employees pay 21.7% of healthcare expenditures in Japan. The average Japanese worker will pay 5.8-9.5% of his gross salary for their healthcare premium. The cost is based on his income and how many people live at home with him. The rest is paid by other government funds. There are multiple insurers but the amount collected and the fees paid to doctor are regulated by the government. The system is administered via "societies" which are made up of labor and management. They are regulated by a government agency made up of 5 doctors, 2 dentists, 1 pharmacist, 4 insurers, 2 labor reps, 2 reps from employers, 3 economists, and 1 lawyer. Note that there are more economists than representatives of big business or lawyers. That would never happen here!
The health care has no frills but includes outpatient care, hospitalization, extended care, dental and medications. Additionally the healthcare owns 3500 sanatoriums, 1000 gyms, and 300 health centers. The co-pays are higher than what I have seen in other countries but there is also a catastrophic clause which limits the amount that you can pay in any one year. By the way maternity leave in Japan is 100 days with 50% pay and you can take up to 18 month sick leave at 60% pay by law.
One of the problems with this system is that there is a set of clinical doctors that take care of you on an outpatient basis but do not see you if you are admitted to the hospital. Then there are hospital doctors who assume your care when you are admitted to the hospital. This separation makes continuity difficult.
The Japanese rarely ask questions of their doctors and the physicians are unaccustomed to giving answers. Pill bottles are frequently given to patients without labels telling them what is in them. Physicians make much less than in the states. The Japanese also seem to look at long term care with some disdain. There are fewer physical therapists in Japan and thus 34% of the elderly in care facilities are bedridden (6.5% in the US).
Lessons from Japan:
Again I have to give credit where credit is due. I was surprised to learn that a country which has a tradition of revering aged does not have very good therapy for the old and disabled. The physical therapists of our country deserve a round of applause.
Also, in every country that I studied that had a separation of the physicians who care for you in the outpatient setting and those who care for you as an inpatient there are serious problems. There is definitely a continuity problem with the care. Additionally, the patients do not appear to like it as much. The countries with this system, even when they have otherwise good health care, have lower approval ratings from their populations. I definitely think our system of primary health care providers who see you and manage your care whether you are inpatient or outpatient is the best method of care.
Once again, I am struck by the fact that gatekeepers and restriction of physician practices do not seem to keep costs down. Japan’s healthcare costs are low and so are their hospital admissions—despite their clearly very advanced and technological society. Yet they have a hands-off philosophy toward government control of healthcare. In some ways I understand this. There are only a few physicians that would operate on people who did not need it and only a few patients who would insist on care that was unnecessary. Overall, combing the system for those few people may cost more money than it saves.
Finally, preventative health care seems to pay for itself. The Japanese have made gyms and wellness centers freely available to their population like the US military does. Our military has discovered what the Japanese already know. The systems with the most outpatient contacts seem to operate at a lower cost and have less high dollar health care needs—even in places where the high dollar equipment is not hard to come by.
ITALY:
Italy ranked second in the WHO survey. Yet Italy has run away unemployment at 11.4%, and has the highest aged population in the world. It also has an extreme income disparity. Despite Italy’s high rank on the WHO survey they have a very low approval from their countryman—20%. Why?
Italy has mandatory single-payer health insurance. The constitution of Italy actually mandates that the government safeguard the health of its people:
The Italian National Health Services Principles:
Human dignity: Every individual has to be treated with equal dignity and have equal rights regardless of personal characteristics and role in society.
Protection: The individual's health has to be protected with appropriate preventive measures and interventions.
Need: Everyone has access to heath care and available resources to meet the primary health care needs.
Solidarity: Available resources have to be primarily allocated to support groups of people, individuals and certain diseases that are socially, clinically and epidemiologically important.
Effectiveness and appropriateness: Resources must be addressed towards services whose effectiveness is grounded and individuals that might especially benefit from them. Priority should be given to interventions that offer greater efficacy in relation to costs.
Equity: Any individual must have access to the health care system with no differentiation or discrimination among citizens and no barrier at the point of use.
(Ministry of Health of Italy)
What do you think? Instead of an amendment to the Constitution against gay marriage how about one that gives us all health care?
The health care is financed through federal taxes with a small amount of regional taxes thrown in. There is also a small amount of money made up by user fees and co-pays. The health care is administered via 20 regional centers. The federal government assures that a certain minimum of care is met and that there is a uniform amount of money available per capita to each region. It is also responsible for general health care planning, controlling drug quality and efficacy (like the FDA), improvements to the health of the entire population, and labor contract negotiations. The health care includes medication, essential medical care, hospitalization, acute care, long term care and laboratory work.
The regional centers promote efficiency and cost control. They also assure quality standards are met and patients are satisfied. They select and accredit health care professionals and also see to it that all laws are complied with. They make the fee schedule for hospitals and doctors. The regional centers are also responsible for distributing monies to "Local Health Agencies".
Local Health Agencies or LHA’s actually provide the health care services. Every citizen is required to sign up for one of these centers but patients are free to go to any LHA or doctor they wish. Doctors are limited to 1500 patients or 1000 pediatric patients. The also have limited hours. There is always one physician who is dedicated to just after-hours and holidays. The center includes a pharmacy which not only has prescription medications but dietary goods as well. There is a tiered drug system. The "A" drugs are free, "B" have a co-pay and "C" are out of pocket, although some patients with chronic illness are exempt from paying the extra money. Recently, a law rescinded the co-pays for drugs.
Providers compete with each other for patients and also provide a gatekeeper function. Directors for each clinic are appointed by the regional director every 5 years. These facilities provide a strong prevention and education component to care.
Although this might seem like a much better system than what the US has, the Italians do not think much of their care. The hospitals are frequently overcrowded and under funded. This has created long waiting lines.
SPAIN:
Spain was second on the WHO list but, like Italy, there was not a lot of satisfaction with the system in their own country. Unlike the Italians, the relatives of the sick or convalescent are expected to care for them. This does lower the health care expenditures somewhat. Additionally, the Spanish live well. They have a good diet and overall are fairly active. They have very low rates of coronary artery disease.
The health industry is paid for by social security and federal taxes. The premiums are compulsory and paid by employees. Seventeen regional centers administer the health care and they are required to provide indigent care, maternity care, psychology, and public health services. Doctors in clinics are paid a combined capitation and base salary. Hospital doctors are paid a salary only. Most doctors have a private practice on the side in addition to their public job.
Like Italy there is mandatory enrollment with an assigned primary care giver who fills the gatekeeper roll. There are house calls although not as commonly as France. Most houses are within 15 minutes of a health center.
Seventeen percent of the nation has private insurance which entitles them to a private doctor with more time and shorter lines and a private hospital when needed.
The Spanish feel that there is enough money but a great deal of waste in the health care system despite the minimal amount spent per capita. (Oddly the British feel dissatisfied with the low amount of money spent on the health care system and feel that the government should spend more even though the two countries spend about the same amount.)
They also rail against the bureaucracy and long lines for elective cases. Additionally there are long lines at clinics and doctors are very time pressured which means they do not spend much time with any one patient. The wait for some surgeries is about 6 months. Additionally, the distribution of care is very uneven. The rural areas get less than the urban areas and rich areas get more services than poor ones.
Lessons learned for Italy and Spain:
The care in all the nations we have examined thus far is very top down. The money comes from tax dollars and goes to the federal government and then it is filtered down through a hierarchy of bureaucracy to the patient. This does have several advantages. It actually keeps the overhead costs at a minimum. These countries spend the least to administer the health care of their countries. It also provides for a fairly even care. There are some differences in what you can get if you have more money (or live in the city) in these countries but not like the US. Here these differences could actually mean the difference between life and death or the difference between well controlled diabetes and a chronic decline or your condition.
The bills that are currently proposed that would actually really change the health care system in the US are all modeled under these systems. They all take a top down approach.
But while I was studying the health care of various countries I did notice something unusual. All of these countries have moderately low or very low approval from their own countrymen. The health care itself seems fairly good. Especially looking in from the United States.
It seems that when people lose any meaningful control over the decision making about things that intimately affect their lives, they feel frustrated and powerless. Who knew? Even when the health care outcomes are good, the care is managed well, and it is inexpensive, the frustration still exists.
In the next entry we will examine an approach to health care that govern from the bottom up.
If you are interested in this topic and want to read more may I suggest Ezra Klein's Site:
http://ezraklein.typepad.com/...
He has some great articles that go a little more in depth about each nation and he runs an excellent and informative site.