Health Systems: Global

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72 Terms

1
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What is capitation in physician payment?

A set payment per patient per time period.

2
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What is risk adjustment in capitation?

Higher payments for patients with higher expected needs.

3
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What is fee-for-service?

Payment to providers for each service delivered.

4
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What is per diagnosis payment?

Bundled payment based on a diagnosis, e.g., pregnancy or pneumonia.

5
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What is a Diagnosis-Related Group (DRG)?

Set Medicare payment for expected care based on diagnosis.

6
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What is salary-based physician payment?

Fixed annual amount regardless of services or volume.

7
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What are key metrics for evaluating a health care system?

Access, cost, satisfaction, quality, and equity.

8
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What is a regional care model?

System with local primary care, regional hospitals, and national tertiary care centers.

9
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What is single payer health care?

One public payer (often government) pays all health care costs.

10
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What are advantages of single payer systems?

Lower admin costs, price negotiation, and universal coverage.

11
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What type of system does Germany use?

Mixed social insurance and public assistance.

12
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What are sickness funds in Germany?

Employer-based insurance funds retained if unemployed.

13
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Can Germans purchase private insurance?

Yes, for extra services or preferential access.

14
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Are sickness funds allowed to use experience rating?

No, only community rating.

15
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How are contributions to German sickness funds collected?

Through a central government-run fund.

16
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How are German physicians and hospitals paid?

Physicians have billing caps; hospitals receive set rates.

17
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Do primary care providers in Germany work in hospitals?

No, they work in outpatient settings.

18
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How is a 42-year-old employed person covered in Germany?

Employer-based sickness fund with shared premium (~15% of income).

19
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How is a 27-year-old unemployed person covered in Germany?

Ex-employer’s fund, employee portion paid by government.

20
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How is a 70-year-old retired person covered in Germany?

Funded by pension (40%) and active workers’ contributions (60%).

21
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How is a 5-year-old child covered in Germany?

Covered under parent’s fund; receives Kindergeld child benefit.

22
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What type of health care system does Canada have?

Universal, tax-financed, single payer system.

23
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Who is the payer in Canada’s health system?

Provincial governments.

24
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Is employment required to get health care in Canada?

No.

25
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Can private insurance pay for covered public services in Canada?

No, it is prohibited.

26
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How are Canadian hospitals funded?

Global budgets (not per service).

27
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How are most Canadian physicians paid?

Fee-for-service at negotiated rates.

28
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What other payment models are emerging in Canada?

Capitation and pay-for-performance.

29
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How are drug prices and new technologies managed in Canada?

Government regulates prices and purchases.

30
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How do Canadian primary care providers interact with hospitals?

They admit patients.

31
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What is a concern in Canada’s system?

Long wait times and quality concerns.

32
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How is a 42-year-old employed person covered in Canada?

Tax-financed provincial health plan.

33
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How is a 27-year-old unemployed person covered in Canada?

Tax-financed provincial health plan.

34
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How is a 70-year-old retired person covered in Canada?

Tax-financed provincial health plan.

35
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How is a 5-year-old child covered in Canada?

Tax-financed provincial health plan.

36
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What is the UK’s national health care system called?

National Health Service (NHS).

37
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How is the NHS funded?

General taxation.

38
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Can people purchase private insurance in the UK?

Yes, for faster access to the same services.

39
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What role do GPs play in the UK system?

Gatekeepers to specialist care.

40
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How are UK GPs paid?

Capitation + carve-out fee-for-service for prevention.

41
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How are UK specialists paid?

Salaried, some also do private fee-for-service.

42
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Where do GPs work in the UK?

In the community, not hospitals.

43
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What is pay-for-performance (P4P) in the UK?

Payment tied to quality, access, safety, and experience.

44
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What is a key feature of UK cost control?

NHS budgeting, capitation, and limits on specialists and services.

45
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How is a 42-year-old employed person covered in the UK?

NHS, may buy private insurance.

46
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How is a 27-year-old unemployed person covered in the UK?

NHS, possibly exempt from contributions.

47
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How is a 70-year-old retired person covered in the UK?

NHS, may pay more for long-term care.

48
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How is a 5-year-old child covered in the UK?

NHS, no contributions required.

49
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What kind of health care system does Japan have?

Universal public insurance with employer-based and national plans.

50
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What is “society-managed” insurance in Japan?

Large employer-based plans for employees and dependents.

51
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What is citizens’ health insurance in Japan?

Government-managed plan for small business workers, self-employed, and retirees.

52
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How is health insurance for older adults funded in Japan?

Through premiums and taxes.

53
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Can Japanese patients see specialists directly?

Yes, no gatekeeping required.

54
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What is unique about physicians in Japan?

They dispense medications and profit from them.

55
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How does Japan control health care costs?

Government-regulated fee schedules.

56
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What are concerns about Japan’s system?

Aging population and sustainability of financing.

57
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How often do Japanese people visit physicians?

Frequently—physicians may see up to 60 patients/day.

58
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What is Japan’s average life expectancy?

~85 years (one of the highest globally).

59
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How is a 42-year-old employed person covered in Japan?

Employer-based or government-managed insurance with shared premiums.

60
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How is a 27-year-old unemployed person covered in Japan?

Citizens’ health insurance.

61
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How is a 70-year-old retired person covered in Japan?

Citizens’ health insurance or Long Life Medical Program if 75+.

62
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How is a 5-year-old child covered in Japan?

Through a parent’s insurance plan.

63
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What contributes to higher health care costs in the US?

Higher prices for nearly all services and medications.

64
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What percent of US health care spending is administrative?

Estimated 15–30%.

65
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What are administrative cost drivers in the US?

Multiple insurers, complex billing, prior authorizations, credentialing.

66
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How do under- and un-insurance raise costs?

Lead to delayed care, sicker patients, and higher acute care needs.

67
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How do social programs affect US health care costs?

Less investment in social supports (e.g., child care, paid leave) worsens health outcomes.

68
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What role does technology play in US costs?

High use of expensive technology, especially at end of life.

69
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Why can’t the US negotiate lower prices?

Limited ability to negotiate with drug and equipment companies.

70
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How does malpractice contribute to costs?

Defensive medicine and malpractice insurance drive spending.

71
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What demographic trend affects US costs?

An aging population requiring more care.

72
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How does primary care underinvestment affect cost?

Less prevention and more expensive downstream care.