We are on a roll. We continue our tour of World Health systems with Germany and Denmark. These countries organize their care from the bottom up. Unlike the countries that are traditionally mentioned in the universal health care debate. They have significantly higher patient satisfaction and no waiting lines.
I grew up on a dirt road in a small rural town in Michigan. When I was a child we had a "party line" telephone. When you picked up the phone you waited to start dialing to see if any of your neighbors were using the line. There were about 8 families on our line. You just listened and if someone was talking you very quietly hung up the phone.
So the internet still blows me away. I find it astonishing that I have gotten comments from Spain, Canada, Norway and France. My Dad used to yell at me if I called the next county and talked for more than 5 minutes.
I want to thank all of you and I would like you to know that I read all of the comments. I have actually gone back into the initiative that I am writing and changed the wording to reflect some of the concerns in the comments section. Most recently I was alarmed by the hospitalist discussion and continuity issues that were raised. I have since change my initiative to reflect that. I have included primary care providers (PCPs) charged with organizing the patient’s care but not mandated to be gatekeepers.
So I can hardly wait to read your comments for this part of the World Tour:
Country | Germany | Denmark | US |
Ranking | 25 | 34 | 37 |
%GDP | 10.6 | 8.3 | 14.6 |
Public Spending | 8.3 | 6.7 | 6.5 |
Per Capita | $2424 | $2133 | $4178 |
MD’s/1000 | 3.7 | 2.9 | 2.7 |
Drugs | Yes | Yes | No |
Glasses | Yes | Yes | No |
Dental | Yes | Yes | No |
Co-pays | Yes | <$5 for all <br>Drug only | Yes |
Insurance | Yes | Sup | Yes |
Type | Sick
Funds | Socialized
(Locally) | Pvt insurance |
Gatekeeper | ?? | Yes | Some |
MD Paid | Fees | Fees | Both |
% satisfied | 58 | 91 | 40 |
Infant Mort | 4.9 | 5.2 | 7.2 |
DALE | 70.4 | 69.4 | 70 |
GERMANY:
This is the one of two systems I looked at that does not have 100% coverage. But unlike America where 1/5th of the population do not have coverage, the German system covers 92% of its people. The military, the rich and the very poor are not included. The very rich opt out and go for private insurance only. Public insurance is mandatory for everyone below a certain income level. The remainder are the very poor who get public assistance and the military who have their own system.
The German system is different than any of the other systems I have looked at so far. It is not nationally run. There are 1200 nonprofit "sick funds". They are administered by regional councils elected by the insurance payers. They are financed by a complex system of taxes and insurance premiums. The premiums go up if you join later in life—like American life insurance—so once Germans join they keep that insurance forever. The cost is based on a percentage of gross income, about 6.5-16% with a median 12%. If you become unemployed it is picked up by your former boss. That’ll teach him. Retired—paid out of a pension fund. About 11% have private supplemental insurance.
The federal government in Germany takes a more regulatory role. It mandates a rapid response and short wait time so that there are no lines in this system. It also mandates choice of doctor and hospital. It taxes rich neighborhoods and gives it to poor neighborhoods so that the care is fairly level throughout Germany. It also mandates that the sick funds must be nonprofit, they can not discriminate, and which services must be carried. The German system is very technologically advanced. They also ensure drugs are covered and that the insurance is portable (you can take it to your next job). The actual funds have local administrators and are made up of a 50/50 mix of workers and company reps.
The sick funds negotiate with the doctors for a fee schedule every year. They also negotiate other things like maternity leave, (six weeks prior and 8 weeks after delivery—paid), home health, dental health, medications, and 1 month at a health spa every few years.
There are down sides to this system. Because there are so many different sick funds that are then coordinated by the government, the administrative costs are high—7.5%. The public health care administrative cost for the US is only 3.1%. (However, the administrative cost of the private insurance industry is an outrageous 31 %!!) Canada’s administrative cost is only 0.8% and the French only let go of 0.2% to administer their health care.
Additionally, the German system is slow to respond and change. Although it is heavy on prevention they have not responded with the same speed as other countries have to obesity and smoking to improve the overall health of their citizens.
DENMARK:
The Danes are the most satisfied with their medical care of any of the industrialized nations, despite the fact that they rank barely above us on the WHO list and below us in life expectancy. Is it the availability of psychoactive drugs that just makes them happy? No. It is local control of their health care and the ability to see where the money is going.
The Danes administer their health care through the county or city governments. The federal government coordinates all these smaller councils and sets the rules, such as equal access and free choice of physicians. The municipal council that runs the health care is chosen by election every 4 years. The money is raised via local taxes. Private expenses such as co-pays etc. constitute 17.8% of health care cost. About a third of Danes purchase insurance for glasses, dental work and help with co-pays, but they do not use the money for cutting in line for services. There is no rule that says they can not do this; it is just that Danes see that as immoral. God love ‘um. Although this may also be because the waiting periods are only 1-2 months—the same as the US. The rich by enlarge get the same care as the poor.
They pay their doctors a mix of capitation and fee for service. What research there is on this subject shows that this is the most advantageous to the patient. Gatekeepers are used to access higher levels of care (i.e. referrals to specialists).
The low wait time may also reflect the fact that health care is a local political foot ball. Politicians win points by promising lower wait times. The Danes also leverage their wishes for their health care at election time so the system is very responsive to people's needs.
Despite this, the Danes do have some pretty bad habits. They smoke, have a high fat diet, don’t exercise and drink a lot. The Danes have some serious health issues. The amount of obesity in Denmark increased 75% in the last 10 years. They are one of the largest consumers of sugar in the world. Their diet may actually be worse than ours.
The government estimated that diseases linked to obesity were costing the Danish 3 billion US dollars a year. So it was time to take drastic action. They started "Denmark on the Move" to encourage exercise in the country and in 2006 the same organization that gave them such low marks i 2002 in health care (the WHO) awarded them a prize for counter acting obesity.
Denmark was the first nation to make it illegal to sell a food with more than 2% trans fats. So in Denmark you can buy marijuana—no problem. But if you sell a food that causes obesity—you will pay a stiff fine or do prison time. I am absolutely serious, that is the way it is in Denmark. (I have changed my mind, I no longer want to move to England.) They were able to drop their heart attack rate by a remarkable 20% with just this one action. Coronary illness is one of the more pricey health care costs so the savings to the country must have been astronomical. In America, on the other hand, you can market poison as a food as long as the label says "May contain poison."
Additionally, you can exercise in a gym owned by the Danish government and provided to you through your health agency. You can even get a personal trainer. The school system also got involved. They started teaching old physically active games that the kids had forgotten—like kick the can. Now in the middle of reading lessons or math class the kids get out of their seats and do 10 minutes of exercise. They march in place, do crunches or dance. As a result not only are kids more fit, but they discovered that the kids focus better and actually learn better too.
Lessons learned:
These systems actually started in the Middle Ages. They started with Guilds. You remember Guilds from high school history—a bunch of craftsmen got together to train younger members and regulate their craft. There were weaving guilds, masonry guilds, etc. The Guilds eventually pooled their money and started "death funds" which paid for the burial of their members and a small salary to the widow. This eventually became "sick funds" that paid doctors to treat the members who became ill. Finally the sick funds, instead of being centered around professional guilds converted to municipalities as their focus.
Great idea! There is virtually no hope that meaningful health care reform will come from the federal government in this country. So what. The Germans and the Danes didn’t use the federal government to create universal care. They did it at the city level. One city at a time.
Additionally, they have local financing and control of their health care. They have direct and very democratic control of their health care system and thus the wait times for procedures are comparable to what you see in the US. The federal government got involved late and only in national concerns—leveling the money between municipalities, creating programs to help the population as a whole and assuring that no person or group gets left out.
Even when the health care is very good, sometimes the population of the country is dissatisfied (France). The Danes teach us that being able to see where the money goes and having some control on where the money is spent increases the satisfaction with the system even if the care is only so-so.
The big downside to these systems is the administrative costs and the layers of bureaucracy. They are not flexible and can not change quickly if new research shows advantages to certain methods or for overall health benefits of the entire population.
These disadvantages can be overcome, as in Denmark, with a strong regulatory capacity at the federal level of government. Also by integrating networks between the isolated municipal funds as the funds are created. In the way you create a system that can be more limber. This would create a hierarchy similar to corporations that sell directly to the consumer (i.e. Avon) that could move the whole network in one direction when necessary.
Hope you enjoyed this leg of our journey. Next entry will be about the Scandinavian systems that many people feel are the best systems. Then at long last I think I will have a reasonable rough draft of my initiative ready for your perusal.