Medical Professions Across Nations final

All problems that countries face

• cost

• patient satisfaction

• choice

• ageing population

Methods all countries have

• DRGs

• increase premiums

• payment systems HMOs

• HMOs

NHS

• universal nation health system funded by general taxation

• health is a public good

• largest public sector

• not all services are funded by the public

General practice in England

• GPs are independent contractors in private services

• GPs are gatekeepers because of HMOs and share interests with the NHS

• more power than specialists like Denmark, Canada, and Norway

• gov’t has interest in them

Two-way access in England

GP or emergency room

Payment systems in England

• capitation

• performance based

• fee-for-service

• locums

locums

extra money if you work weekends or overtime

What are the problems in England with capitation?

• undertreatment

• people might not show up

England before reform

• NHS owned hospitals

• all services were provided by the government

Problem with England before reform

• no incentive to be efficient

• patients complain

• costs

• lack of coordination of care

• long waiting lists

Reform in England

privatize hospitals similar to Sweden in order to increase efficiency, patient choice, and competition

Problems with long term care

• ageing population is increasing

• U.S. should have private Medicare to decrease the dependency on the working class

• Singapore: have citizens have money to put into retirement accounts as soon as they begin working

Problems in English system

• shortage of nursing home care

• long delays

• long waiting lists

• shortage of manpower

• lack of coordination between GPs and specialists

• less patient choice

Patient satisfaction in England

very high

Germany Health Care

• insurance-based like Switzerland and Netherlands

• very efficient

• requires employers to provide insurance

• government subsidies to help poor people pay for health care

• sickness funds= insurance companies

• basic universal coverage for all

• have special fund for chronic illnesses

• privatized ambulatory services

• decentralized

Physicians and specialists in Germany

have freedom

Germany payment systems

• fee-for-service

• capitation

• DRG

• performance-based

Germany reform

• introduce program similar to Medicare

• Increase out of pocket payments on co-payments

• allow people to pay generic drugs

• all sickness funds have GPs as gatekeepers

Challenges in Germany

1. excessive number of hospital beds and hospitals

2. lack of coordination and bad with disease management

3. need more nurses/ health personal

4. high number of sickness funds with same services so no competition or incentives to make changes

5. people that make more money pay less taxes

6. increase in ageing population

Switzerland cantons

• like regions

• need to meet certain requirements to provide health coverage

• provide specific private insurance companies

Switzerland health care

• insurance-based

• basic universal coverage

Switzerland individual mandates

• everyone is required to buy insurance

• penalty if you don’t

• governmental subsidies

Switzerland 4 plans

• high deductible which decreases premiums by paying more first

• managed care which has GPs as gatekeepers

• higher deductible

• bonus plan which allows people to decrease premiums the following year

Switzerland outcomes

• high patient satisfaction, number of hospital beds, and quality doctors

• access and choice are plentiful

• higher stroke morality rates

Switzerland demand side

• access demand

• ability to change physicians increases the patients’ leverage in making physicians doing what they want

Switzerland regressive nature of premiums

people who are poorer are paying more and have less benefits

Switzerland problems

• little competition between companies since they are all very similar

• big GDP on health care

• swiss doctors are highly paid

• ageing population

• lack of coordination

• fee-for-service creates a perverse incentive

Swedish Health Care

• similar to Denmark and Norway

• universal coverage

• 21 county councils/ regions provide health care

• mulpalicities provide social services and long-term care

• GPs are not gatekeepers, so they are weak

• privatized hospitals owned by county councils

• more hospital care

Swedish Challenges

• cost, pay a lot of taxes

• lack of coordination

• lack of incentives

• long waiting lists

Stockum Model goals

• address problems in Sweden

• help with inefficiencies

Stockum Model outcomes

• create more competition in hospitals

• give hospitals more money to increase efficiency

• put GPs into private practice to increase competition

Why is the medical profession being undermined?

• insurance company role

• increased power of personal below physicians

• HMOs decrease autonomy

Republican views on Medicare

increase premiums and to make it mean-based

Democratic view on Medicare

focus cuts on hospitals and physicians fees

Medicare benefits tension

• gap between the promise of Medicare to protect elderly from devasting costs

• commitment of federal government to pay medical bills by letting medical providers control billing

Medicare finances tension

shifting to alternate form of financing to private system (part C)

Chapter 2- history of Medicare

• idea of the federal gov’t providing health insurance to its citizens was brought up by German which was disliked by America

• socialized medicine was introduced after WW1

Support of Medicare

• popular

• political power of organizations can resist changes

• political strength of Medicare consensus

• limited scope of coverage

Medicare consensus

to oppose Medicare could lose your seat in Congress

Medicare problems

• not account for mental health

• home health and nursing homes were covered short term

• drugs were not coverage in original model

How Medicare is financed

A is free through payroll taxes and B is financed through general revenues and people pay premiums

Medicare proposals

• introduce general revenue for part A

• increase cost of A with cost-sharing

• increase Medicare’s income by increasing payroll taxes

• PSROs and DRGs to regulate program payments for medical providers

• raise retirement age

• make Medicare based on need

• privatize Medicare

PSROs (The Professional Standard Review Organization)

• doctors and accountants

• created to regulate costs of Medicare

Medicare Fee Schedule

Negotiations with hospitals physicians that Medicare only pays 80 percent

Medicare Interest groups

physicians, hospitals, patients, and insurance companies

New Trends in Medicare- The Inflation Reduction Act of 2022

• Medicare could negotiate prescription drugs

• amount of money elderly pay for prescription drugs should not exceed 2000

• efficiency in Medicare by expansion ACA

• provide incentive for companies to change due to inflation

Problems with demand and supply

• patients are sicker

• ageing population

• long waiting lists

• burnout

• physician shortage

• lack of integration of care

• lack of hospital beds

Health planning

making decisions that relate into the future for health

Why plan?

• lack of resources and need to make wise choices

• have to account for power structures and core values

• need gov’t to intervene for inefficiencies in market system

activity planning

timetables

allocative planning

decisions that we make with resources that we have

Quantitative

gather information, valid, rational, numbers

Qualitative

interviews, observations, case study, evaluate all different ways to get information

Rational model

• scientific research

• top-down approach

• evidence

• focused on facts

The Incremental Model

• don’t have the facts

• open-minded

• critiques rational model

• interviews

• different views

Mixed scanning

cursory search on many different sources and draw conclusions

Garbage-can model

• everyone brings different ideas and plan based on that

• create policy after combining all different ideas

class analysis/ Marxian approach

how someone’s economic class affects their ability to access health care

Pluralism

different interest groups will have different agendas

Corporatism

how interest groups undermine medical profession

Social construction of reality

• how we get information

• your reality is not the same as mine, different interpretation of what we see

• justify reality is important

What you need to do to form policy

understand:

• communities, institutions, and personal

• know what people need and what we have

interest groups in policy formation

• mass media force government to respond

• external factors

• professional lobbyists

• non-governmental organizations

• UN organizations

Staff HMOs

physicians with very low autonomy

group of HMOs come together to form a group

• can negotiate with health plans to decide payments

• negotiate with both private and public health plans

• more autonomy and control

Reforms for countries

private want to go more public and public want to go more private

how to compare health systems

• service delivery

• manpower shortages?

• equity or universal care?

• stewardship

• drugs

• risk pooling (vulnerable groups)

• mechanism of financing

Top-down planning

experts make decisions, rational model

bottom-up planning

start with community

stakeholder analysis

• have goal, come together with different ideas or interests

• whose agenda will be used?

• power involved

• bottom-up or top-down

autonomy in right to die cases

listen to wish of patient

In order to pull plug

• patient must be clear they want it

• there must be more than one doctor that agrees

• must be evidence that the patient will not make it

What necessitated the Patient Protection and Affordable Care Act of 2010

• democratic congress and president

• reconciliation act

• cost of health care

• many people uninsured

• fragmented private insurance

• goal was to extend health care to the uninsured

Federal role in ACA

• give money to states to expand Medicaid (happened)

• contract with insurance companies to expand coverage (did not happen)

State role in ACA

expand Medicaid if they decide to

insurance company role in ACA

• have certain requirements for benefits and services

• cannot deny coverage to pre-existing conditions

• have certain lifetime or cap

• can no longer cap

• 200 or more employees than required to provide care (repealed)

• on board because they got more money

health care provider role in ACA

• GPs and specialists got paid similarly which made specialists mad

• more preventative care

physicians, patients, pharmacies and providers were _____ the ACA

on board

individual mandates in ACA

employers provide coverage or pay a fine (could be cheaper)

The Accountable Care Organizations

control Medicare costs

outcomes of ACA

• increase in taxes

• 10 states did not expand Medicaid (have more minority groups)

• expanded to 31 million

• Thermerican Rescue Plan (covid)

• Inflation Reduction Act

• If subsidies are not expanded, many will lose coverage

What is a professional?

Someone with

• expertise

• monopoly over knowledge that is checked

• education in a certain field

• ethics and standards

• license

• autonomy

• own to a professional body or association

• self-regulation

What is power?

ability to compel someone to do something against their resistance

Why are doctors powerful?

have knowledge over the patient

Authority

power that is legitimized or there are recognition and consent that someone has power over you

What is the relationship between medicine and science?

• gather information

• decisions are made based on facts and expertise

• always a logical reasoning

What factors led to the rise of the medical profession?

• science

• way patient is seen

• moved from homecare to institutions

• more qualifications

• non-clinical field need supervision of doctors

old system before managed care

• too costly because of fee-for-service

• patient choice and physician autonomy

• no coordination of care

• waste of resources

• overtreatment

• demand was too high because insurance covered everything

managed care

• single payment per month

• GP as gatekeeper

• networks of physicians and hospitals

• reduce costs, organization, coordination, integration, and capacity to learn

• capitation

• preventative care

HMO

• group, staff contract w/ exclusive network

• contract w/ individuals who have multiple contracts at the same time

• lock in patients

• POS: patients seek care from doctor outside of network

• physicians are under a lot of pressure

PPO

• fee-for-service payment to physicians

• in network for CHEAP, out of network money

• more choice of provider for more money

• make more money when they do more

Selective contracting

• use threat of not contracting to achieve favorable payment rates

• improve quality

• limited networking with physicians

• coordination and community of care

UM and Preauthorization

physicians recommendation for complex and costly services are evaluated by nurses to see if there is a way to save money

How to improve managed care

• practice guidelines and review boards

• demand management

• chronically ill

• disease management

• specialty benefit carve-outs

How does the medical profession change in different societies?

• Are GPs gatekeepers?

• private has generally more physician power

• public= less physician power but can be powerful with large professional body (Sweden has weak one)

• are they paid by insurance companies? -more power, fee-for-service

• are they paid by gov’t?- less power, capitation

• cost containment decreases power

• financial incentives

• increase of non-clinical professionals decrease power

1st amendment

freedom of association from exercise of religion

4th amendment

• permits searches and seizures unless certain conditions exist

• cannot take life without evidence the patient wants it

Griswold V. Conn (1965)

• Planned Parenthood

• contraception (birth control) is allowed

Roe V. Wade

gave abortion rights

The common law doctrine of informed consent

will and deciding what happens if you die