We continue with the last leg of our health care journey. This time a look at Scandinavia.
This is the last stop on our journey. After this I will do a recap and then the Initiative.
Country | Sweden | Finland | Norway | US |
Ranking | 23 | 31 | 11 | 37 |
%GDP | 8.6 | 6.9 | 8.9 | 14.6 |
Public Spending | 7.2 | 5.2 | 6.5 | 6.5 |
Per Capita | $1746 | $1502 | $2425 | $4178 |
MD’s/1000 | 3.1 | ? | 3.6 | 2.7 |
Drugs | Yes | Yes | Some | Some |
Glasses | No | Yes | No | No |
Dental | No | Yes | No | No |
Co-pays | Yes $20 or less | Yes $15 or less | Yes total $43 | Yes |
Insurance | Sup | Yes | No | Yes |
Type | Socialized | Single payer | Socialized | Pvt insurance |
Gatekeeper | Yes | Yes | Yes | Some |
MD Paid | Capitate
or salary | Fees | Fees or
Capitate | Various |
% satisfied | 58 | 81 | ?? | 40 |
Infant Mort | 3.5 | 3.9 | 4.0 | 7.2 |
DALE | 73 | 70.5 | 71.7 | 70 |
SWEDEN:
I picked Sweden because they have a very low infant mortality rate and they do not spend very much per capita on health care.
The Swedish system is socialized like England’s. All the people get all the care they need but may not get all the care you want. They main criticism of the system is excessive wait times—months. The emergency departments rival America in wait times as well. The Swedes do have the choice of which doctor or hospital they will use. They provide dental care, home health care, nursing home care. About 2.3% of the population has supplemental health care to avoid the long waiting lines.
Primary health care is run by doctors that do not admit to hospitals. Hospitals have their own doctors. All hospitals are affiliated with teaching institutions and are therefore teaching hospitals. This means cutting edge care, but also means being seen by a herd of people every day that you are in the hospital.
The down side is that the system is run like an assembly line. There is no such thing as your own physician. If you are sick you go to the clinic and see whoever is available. If you are admitted you see a completely different doctor until you leave the hospital. There is no continuity of care.
The health care system is financed by taxes at the local level and administered at the local level as well. The primary physicians are paid via capitation which does not increase the efficiency of the system. Thus there are long lines. The waiting time for elective surgery can be in excess of 6 months. What Sweden and Canada are finding out is that waiting periods for these surgeries are costing them money. While the patients are being maintained on the lists they are using more medication and seeing the doctor more often than average.
Thirty years ago Sweden had some of the longest lines for health care and ran very inefficiently. They decided to put some aspect of the free market in the system. They encouraged nurses and health care professionals to open and run their own private clinics and hospitals. They then sold their services back to the government. Doctors that stayed with the government continued to be paid on salary. The doctors that left were paid on capitation and had to compete for patients. The result is that there is competition between government clinics and private clinics which has raised the bar in both sectors. In private sectors nurses and doctors feel that their suggestions are taken seriously and they get a profit share as the clinic does better. The other result is that there are more clinics in Stockholm then in all of California. Patients have a vast array of choice.
Lessons from Sweden:
Sweden reinforces some of the lessons we have already discussed. Wait lines and poor continuity of care are expensive and unpopular. A US system should avoid these pitfalls.
Many of these countries have hospital systems that developed in ways ours did not. Sweden’s teaching hospital system may be the reason for their very low infant mortality. They have their best and most educated doctors running all their inpatient programs. Our system is spread over too large a geographic area to feasibly do that at this time. Many Scandinavian hospitals also have hospitals that specialize in just one thing—like maternity care. This, too, in not possible with our large rural population. Both these things bear a closer look for future planning in the US.
Finally, I have to confess that I was caught off guard by one aspect of what I learned doing this study. I assumed that I was going to report that pure socialism was the way medicine should be organized. I knew pure capitalism clearly did not work well for health care. I was surprised to learn that pure socialism only works slightly better. Neither does that well. I should have known that in the real world the answer is neither all black nor all white. The answer is to successfully combine both aspects.
The system with the shortest or nonexistent lines for services integrated some competition for money into the system. The American system does not work because there is only competition. The systems that had some capitalist aspects also had very strong regulation of that capitalism and did not allow their citizens to drop below a certain foundation level of care. They did allow the rich a slightly better level of care, but not too much better.
Additionally, I would point out that the capitalism that the Swedish integrated into their health care was not American capitalism. In America one obscenely rich family owns the clinic and treats the staff and the patients like their surfs. Not so in Sweden. The clinics were owned by those who worked in them. All parties who supported the work benefited when the clinic did well. This is "cooperative" capitalism.
This is a lesson that America has yet to learn. In this era of deregulation, the thought that an unbridled free market can always do something better than the government has just plan been proven wrong.
FINLAND:
Finland is another single payer system. Like Denmark and the US, the Finns have some bad habits. They smoke, drink and eat a high fat diet. They have very high levels of coronary heart disease. They rank slightly above Denmark on the WHO but spend far less on their health care and still maintain high marks from their population.
In 2001 there was a doctor strike because health care professionals felt they did not have the resources necessary to do their job and keep the people healthy. This led to an overhaul of the entire system. Instead of the first come first serve "see which every doctor" scheme that they had been using they developed a family doctor program. They decentralized the health care placing the control of the clinics at the local level.
Forty three percent of the money for health care comes from municipal taxes. The health care became a combination of public and private sectors which appear to be working better than it is in Sweden. There is a federal Social Insurance Institute (KELA) which is public health insurance that will reimburse some of your expenses if you go to a private facility. It will also reimburse travel, rehab, and disability pay. KELA makes up 16% of the health care budget. Federal taxes account for 17% of health care spending while out of pocket expenses are 20% of the healthcare expenditures. Only 4% of the money comes from traditional insurance.
You can go to a public facility for free but many people choose the private providers. The result was 3000 private hospitals/health centers, 13,000 independent providers, with 7,000 private doctors and 2,000 private dentists. Many of the hospitals specialize in some particular type of surgery or care like orthopedic cases or inpatient mental health facilities. Regional tertiary centers are still controlled by regional governments, however. This is probably wise since they serve a larger number and geographically larger area.
The system is based around health care centers that are geared to providing care for 10,000 people a piece. There is usually one within 10 miles of every residence.
A public health centre provides:
Family planning
Maternal and child health services
School and student health services
Health care for the elderly
Home nursing
Home nursing care
Other preventive measures (screenings, vaccinations, etc.)
Primary outpatient medical and nursing services
Medical rehabilitation
Inpatient care
Dental care
Ambulance services
The basic working team typically consists of a public health nurse, a midwife, a general practitioner, a dental hygienist, and a dentist. Psychologists, physiotherapists, speech therapists, nutritionists and social workers also work with the teams if necessary. These teams go into action to assist anyone with a chronic illness, obesity, mental health issues, post partum depression, domestic violence or substance abuse.
There is a very strong prevention aspect to their health care and 40% of the money for health care is spent on primary care. Despite the Finn’s bad habits the government is trying to change things. There are classes for maternity and child care which are free. These include classes that discuss the effects of TV and computer safety. Mandatory home visits for everyone prior to the birth and after the birth of each and every child. The new mother must have a check up by a doctor prior to her 4th month or the antenatal care and delivery will not be paid for by the state. There is also a "maternity pak" which every mother is entitled to. It contains essentials for the baby. This is not a couple of bottles and some coupons commonly given in the US but everything you need for a new baby.
Get this; maternity leave is a whopping 263 work days. If both parents work one of them is entitled to shorter days until the child is in his/her 2nd year of school. You can even stay home with your child unpaid for 3 years without the fear of losing your job. Additionally, municipal daycare is available for a sliding scale based on the parents pay. There is extra money paid to parents called a child allowance until the child is 17 years old. And I just have to emphasize that all this is done at $1500 per capita!! The US during the same time period spends $4178 per capita and we are predicted to spend $7500 this year. All of this has paid off. Finland has the lowest infant mortality of any nation at 3.9/1000. Compare that with the third world numbers of the US 7.2/1000.
Mental health is mentioned throughout their literature. Not just care for people with severe mental illness but desirable development of children and adults. Children are examined for learning disabilities very early and throughout their development. Good bonding for couples is emphasized. Several peer groups are available at all health centers. These not only include alcohol and drug rehab groups but also groups of mothers who are expecting or just delivered. People caring for the elderly. People with children with serious or chronic illness and adults with chronic illness. Couples having problems with their relationship. The entire system is very focused on healthy family/community relationships.
I heard on NPR today that the committee examining the Virginia Tech massacre stated that there was no way to have prevented the killings. I disagree. There were 3 ways. We as a people missed all of them. The shooter was in the mental health setting and let go. Everywhere in the US I have practiced medicine, there has been inadequate money, personnel and facilities to treat the mentally ill. This includes the military. Secondly, Dennis Kucinich keeps discussing his Peace Dept. The corporate media always makes him look like a nut case when he does this but did you know that there are people who have gone to college and have spent their whole lives learning how to prevent things like the Virginia Tech shooting and the government continues to ignore them? Mr. Kucinich would give these people an advisory position on his cabinet. Finally, there is the Finish way. They see a child who is suffering and investigate the cause and treat it before it gets out of hand.
There is also an extensive school health care system. This system oversees PE, the nutrition of the school meals, programs to discourage smoking and drug use. There is a strong health education program. School problem behavior such as bullying, violence, smoking and illegal substances are handed to a health care team in the school. This team consists of a nurse, general practitioner, principal or teacher, psychologist, and social worker. They do not have school shootings. That alone would make the cost worth it to me.
A nurse sees the student every year for vision, blood pressure, posture, hearing, etc. At the same time the kids are asked questions about nutrition, smoking, drugs and other health questions. The nurses see this not only as an exam but as a time to educate the kids in healthy habits. A thorough exam is done every 3 years in the first 9 years.
NORWAY:
At 11th on the WHO Norway is the only Scandinavian country that did well on the WHO list. The health care system is supervised by the federal government and paid for by income tax and payroll taxes. It is universal and mandatory and, like Canada, no supplemental insurance is permitted.
There is a deductible, just like the US. The deductible is decided every year by the government. Last year it was $275. Not like the US. My family deductible was $7000 this year. This is in addition to the nearly $800 a month I pay in premiums. There are also many co-pays and user fees in Finland but there is a ceiling as to how much any individual can pay in any one year. There are no co-pays for children less than 7 years, maternity care, and work related injury. Doctors are all private practice with fee for service reimbursement.
Correction: On 8/31 DSPS Owl wrote in the comments:
My impression is that nearly all GPs are in private practice with fee for service and capitation. But that many specialists are employees of hospitals. Many GPs are also salaried one day a week when they work at schools, well-baby clinics etc.
There is a strong gatekeeper aspect to the care. Norwegians are encouraged to sign up with one PCP and maintain a relationship with that physician. Hospitals are paid by Diagnosis Related Groups or DRG’s. There are several specialized hospitals as well as public hospitals.
The health care is run by municipalities. It is provided through "First Aide" stations throughout the community. Each center must offer health promotion, prevention, diagnosis and treatment of illness, rehabilitation, long term care and psychiatric care. The regional centers are responsible for hospitals and specialized care and the federal government takes a regulatory roll similar to Finland and Denmark.
There is a very strong social services component to the care with 35% of the national budget being spent on healthcare and the social safety net. Dental care is provided to children and the economically disadvantaged. Transportation to and from the doctor is paid for as well. Medications are on a tiered system with some medications being subsidized while others are not. Additionally social services assist those with disability, help the elderly to get out and meet others, shelter abused women, and provide drug and alcohol rehabilitation.
DSPS Owl wrote on her Daily Kos blog,
Home nursing visited my elderly, mostly bedridden, downstairs neighbor five times a day. When all the windows and outside doors in this building were going to be replaced, a very noisy and chilly process, I informed her GP (coincidentally also my GP). Two days later she was moved to a nursing home for three weeks. (As usual after such visits, she came back somewhat fattened up and more mobile.)
http://www.dailykos.com/...
Prevention is taken very seriously in Norway as well as the rest of Scandinavia. Citizens are reminded to get their annual health check up by mail from the government, not their doctor. Mental health is mentioned frequently in the health care literature. Mental health assessments start in teen years and severely mentally ill are treated in deinstitutionalized center.
Again there are long lines for surgeries. Patients are waiting over 6 months for elective cases and 3 months for semi-urgent cases. Lately there have been wait list guarantees by the government but they are frequently violated. The latest development is that if a surgery can not be done within the time limit guarantee then the government will pay for it to be done at a private institution or a foreign country.
Lessons Learned:
The Scandinavian countries all have health centers which are kind of like department stores for health care. They provide these for every 10,000 people or so. This has created a great deal of availability in the system. It also gives people a wide variety of health care styles to choose from. Certainly this is something Americans should try to reproduce.
The big lesson learned from these countries is about prevention. Thirty-five to 45% of health care money is spent on prevention. They start early, at birth, and continue education on prevention to the grave. They involve the school system and consider health education more than just a filler or optional class. Additionally, they are not just discussing diet and exercise and avoiding smoking and drugs. There is a very strong mental health component to the prevention aspect.
In the movie "Sicko" there is a portion of the film after Michael Moore talks about patient dumping when he ask, "Who are we?" He then goes on to lament the "Me Generation" and the feeling in America that every one should be on their own and pull themselves up by their own boot straps. This portion of my blog is about to take a similar turn. Consider yourself warned.
When we see people who have suffered domestic violence, we focus on the victim. What may surprise you is that I think the offender suffers as much as the victim sometimes. The offender does not realize that the relationships that he has would be so much richer and fuller if he was able to deal with his partner and children on another level other than dominance and submission. Equal partnership would be so much better for both partners. If the violent partner does not get treatment and see the difference he is doomed to continue to have relationships that are all about where you are in the hierarchy and not about cooperation. The victim can frequently break this cycle and learn from her relationship and have a better relationship next time. The perpetrator on the other hand is doomed to constant anxiety and anger response and to never understanding anyone including himself on a deeper level. In the end all of his relationships will end in alienation. The cost to society of this one person’s behavior is huge. All the damage he does to the people around him both emotionally and physically, with law enforcement and divorce proceedings add up. It would be cost effective to intervene early on to train a child in other ways to relate to people if you saw the child developing this sort of behavior. Better for him but better for society as well.
Prevention pays for itself. If we could prevent the perpetrator of domestic violence from developing these types of relationships prior to his teen years, less money would get spent on hospital bills, law enforcement, and aid for families after they leave the relationship, and possible having to treat his sons and daughters for similar problems.
When you see people on the street muttering to people that are not there, sure they are mentally ill. But more than that the community that allows them to wander the street homeless, or arrests them for vagrancy is equally mentally ill. I am not saying that the whole town has mental illness. But the community is like its own entity and we have vast community mental illness. The community no longer functioning in society in a productive way. It is destructive to its members. The community has taken on the same problems as the abuser. If the community was treated and healed all the members of the community would benefit. We, as a nation, need remedial community building to be healthy as a society again. Just like the hierarchical models of dominance and submission do not serve either partner of a marriage, the ever man for himself world model does not serve the winners or the losers of the community. The rich will still suffer if the world undergoes global warming. The rich must still live in a situation where there is crime. Where the landscape is dominated by the same stores every where and where the variations culture and diversity have been wiped out. The rich students in a college room get killed as randomly as the poor when mental illness is not treated.
So that is the end of our world travels. Next we return to the US and devise a system that works for us.