Back from vacation and time for the biggie.....the UK National plan.

United Kingdom

Britain’s public provider of health care is known as the National Health Services (NHS). Services provided by the NHS include hospitals, family doctors, specialists, dentists, chemists, opticians and the ambulance service.

Not all services provided by the NHS are free of charge. Unless exempt, patients pay (subsidised) fixed costs for prescriptions, sight tests, NHS glasses and dental treatment. Hospital treatment, the ambulance service and medical consultations remain free.

The UK’s NHS was the first state organisation in the world to provide free universal healthcare. Today, it is an organisation with some severe structural problems, which means that waiting lists for treatments even for urgent operations have grown and the standard of treatment in some hospitals has deteriorated. Many Britons in the higher income bracket purchase private health insurance and there is a growing number of employers providing private cover as standard to their employees.[1]

Private Health

CarePrivate medical treatment in Britain is amongst the best in the world, with London having some of world’s most skilled specialists. Within the country, most people go private to avoid NHS waiting lists for non-emergency specialist appointments and non-urgent treatment. Around a quarter of all operations are performed privately.

There is almost always no difference in quality between private and NHS doctors. Indeed, you will often end up seeing the same specialist privately as you would have seen through the NHS. The difference will be when you get the appointment and how quickly you are treated, i.e. a heart bypass operation may be diagnosed for and completed in a couple of weeks with private treatment, but through the NHS this could take two or three months. Many employers also provide their workers with private health insurance, which is definitely worth finding out about if interviewing for different positions or negotiating a package.[2]

NHS to allow ‘private’ drugs for cancer

Patients may soon be allowed to pay for “top up” drugs on top of their NHS care under a major reform to Britain’s healthcare system expected next month.

Approval of top-up payments for cancer and certain other treatments is being widely anticipated from the review being conducted by Professor Mike Richards, the Government’s national cancer adviser, despite fears that it could introduce a two-tier NHS.

Medical organisations have accepted that the change is inevitable in a health service that champions patient choice and is increasingly driven by consumer demand. But there is little enthusiasm for the move, which is seen as difficult to implement and would pose a long-term threat to a comprehensive NHS.

The review was ordered by Alan Johnson, the Health Secretary, in June after protests from NHS cancer patients who were told they could not pay privately for cancer drugs that had been rejected, or not yet assessed, by the National Institute for Clinical Excellence.[3]

Life prolonging cancer drugs to be banned because they cost too much

Thousands of patients with terminal cancer were dealt a blow last night after a decision was made to deny them life prolonging drugs. The Government’s rationing body said two drugs for advanced breast cancer and a rare form of stomach cancer were too expensive for the NHS.

The National Institute for Health and Clinical Excellence is expected to confirm guidance in the next few weeks that will effectively ban their use.  The move comes despite a pledge by Nice to be more flexible in giving life-extending drugs to terminally-ill cancer patients after a public outcry last year over ‘death sentence’ decisions. Leading campaigners last night said NICE had failed the ‘acid test’ of whether it really intended to give new priority to people with just a few months to live. [4]

Cost Containment has created problems in the NHS

FILTHY hospitals in Kent have led to the death of 90 patients - and now you can find out if your local hospital has been affected too.

Appalling hygiene at Kent and Sussex Hospital, Pembury Hospital and Maidstone Hospital saw the killer Clostridium difficile bug C.diff directly linked to 90 deaths.

Almost every hospital in England has suffered C.diff outbreaks and MRSA scares.[5]

Find out how your hospital has been affected by using our interactive map. Just click on the link below.[6]

Hard-up hospital orders staff: Don’t wash sheets – turn them over

Cleaners at an NHS hospital with a poor record on superbugs have been told to turn over dirty sheets instead of using fresh ones between patients to save money. Housekeeping staff at Good Hope Hospital in Sutton Coldfield, have been asked to re-use sheets and pillowcases wherever possible to cut a £500,000 laundry bill.

Posters in the hospital’s linen cupboards and on doors into the A&E department remind workers that each item costs 0.275 pence to wash. Good Hope reported a deficit of £6million last year and was subject to a report by the Audit Commission because of its poor financial standing.

It recorded 36 cases of MRSA from April last year to January, while cases of clostridium difficile have more than doubled in less than a year to 327. A Government hit squad was drafted in to solve the infection problems last year but the trust is still failing to hit MRSA targets.

Tony Field, chairman of Birmingham-based MRSA Support, said: ‘Is that all the safety of a patient’s life is worth? 0.275 pence? ‘It is utterly disgraceful and tantamount to murder because hygiene like changing sheets is essential to protect patients.

“It proves beyond all doubt that cost- cutting is directly contributing to hospital acquired infections.” The scheme is one of many ways that cash- strapped trusts are trying to save money.

Staff at West Hertfordshire NHS Trust were amazed to receive a memo urging them to save £2.50 a day by:

Prescribing cheaper medicines,

1. Reducing the number of sterile packs used
2. Cutting hospital tests
3. Asking patients to bring drugs in from home
4. Epsom and St Helier Trust in South London has removed every third light bulb from corridors[7

The NHS cost containment can be deadly

Dying woman refused chemotherapy by the NHS Tuesday 3^rd June 2008

A widower has demanded a change in the law after his wife was denied chemotherapy for bowel cancer on the NHS because she paid privately for life-extending drugs.

Linda O'Boyle, 64, and husband Brian, 74, both retired NHS workers, decided to pay for drug cetuximab in addition to NHS treatment after her consultant said it might prolong her life.

The decision meant she was considered a private patient and had to pay for her NHS treatment as well, because the Government has banned patients mixing public and private care. Mrs O'Boyle died on March 26 this year. Mr. O'Boyle, who was a health manager for 30 years before his retirement, blames the Government and South West Essex Primary Care trust for the system which saw them paying out £11,000 for private treatment, including cetuximab and chemotherapy.

Mr O'Boyle said he and Linda, who was an assistant occupational therapist, were angry at the decision.

He blames Health Secretary Alan Johnson, who last year issued guidance to NHS trusts telling them not to permit patients to pay or additional medicines. Mr. Johnson claims co-payment would create a two-tier NHS, with preferential treatment for patients who buy extra drugs.

"Linda told me they just did not think she was worth helping and had put her on the dump and sent her to die. "That was her initial reaction. It was a huge shock."

He added: "I still think it extended her life by three months, so don't regret doing it, but the system needs to be changed."

Comments on the page:

In 1997 when it was discovered that my Dad had lung cancer, he wasn't offered any sort of chemotherapy or radiotherapy at all.  Maybe it was because it was too far gone to do anything, or maybe it was because he was 80 years old, although he only looked about 65 and was still full of life. He died six months later.

1:15pm Tue 3 Jun 08

A tragic decission from the PCT but then again they wont even give school kids the TB vaccine (not British ones anyway)so therefore this case don't surprise me unfortunately. My heartfelt wishes go out to her family.[8]

Cost Containment – waiting times

Friday 8 June 2007 – One in eight NHS hospital patients still has to wait more than a year for treatment, the government acknowledged yesterday in its first attempt to tell the full truth about health service queues in England.

A Department of Health analysis of 208,000 people admitted to hospital in March showed 48% were wheeled into the operating theatre within 18 weeks of a GP sending them for hospital diagnosis. But 30% waited more than 30 weeks and 12.4% more than a year.

The inpatient clock started when the consultant decided hospital treatment was needed and stopped when the patient was treated. The maximum inpatient delay is six months. Until now, the NHS did not measure the time patients waited after the first outpatient appointment before going on the inpatient list. This “hidden” delay could last months.

Some primary care trusts ordered hospitals to go slow in March to avoid overspending. The analysis measured the waits of people who were treated during the month without estimating the extra waiting experienced by those still in the queue.

Norman Lamb, the Liberal Democrat health spokesman, said: “Behind the statistics, thousands of sick people are still waiting more than a year for hospital treatment. This is a daily tragedy.”[9]

Operations cancelled as NHS runs out of money – January 4, 2007

Patients are being denied basic operations, including treatments for varicose veins, wisdom teeth and bad backs, as hospitals try frantically to balance the books by the end of the financial year.

NHS trusts throughout the country are making sweeping cuts to services and delaying appointments in an attempt to address their debts before the end of March. Family doctors have been told to send fewer patients to hospital, A&E departments have been instructed to turn people away, and a wide range of routine procedures has been suspended.

In one example of the cash-saving strategies, seen by The Times, a primary care trust in Yorkshire has told hospitals that they will not be paid for some non-essential operations, while patients will not be given a hospital appointment in under eight weeks. Similar tactics have emerged at hospitals in Norfolk and Surrey, while dozens of trusts have resorted to closing beds and offering voluntary redundancy in recent months. Devon Primary Care Trust has offered voluntary redundancy to all 5,000 staff.

The cuts are widespread, although there are no central records to provide definitive figures. Among the most comprehensive plans are those from North Yorkshire and York Primary Care Trust, which faces a deficit of £24 million this year.

A letter from its chief executive, Janet Soo-Chung, says that all non-urgent admissions must be approved by an assessment team or they will not be paid for. A&E departments in Harrogate, Scarborough, South Tees and York have been told that they will not be paid for treating patients with minor ailments who could go elsewhere.

No patients will be given a hospital appointment in less than eight weeks, and none admitted for elective surgery unless they have waited a minimum of 12 to 16 weeks. Those treated quicker will not be paid for.

The trust also announced the immediate suspension of treatments for varicose veins, wisdom teeth, X-rays of the back, operations for carpal tunnel syndrome, bunions, arthroscopy of the knee, and grommets for the ear, among others. “We fully appreciate the difficulties that the introduction of these measures entail,” Dr Soo-Chung’s letter says. “However, the financial position of the PCT is such that there is absolutely no alternative to this programme if we are to avoid even more difficult decisions in the near future.”

Norfolk PCT has issued similar instructions, telling hospitals not to treat patients who have waited less than 17 weeks — expected to rise to 18 weeks by February. Hilary Daniels, the interim chief executive, told hospitals to work out how many patients could be deferred until next financial year, and said that the trust would not pay for elective operations on smokers until they had attended smoking clinics.

In a report published this week, the think-tank Reform said that NHS deficits were deepening. It called for a one-off repayment of debt followed by a more rigorous financial regime and immediate administration for failing trusts. But the idea was rejected by the Department of Health.

Last year the NHS returned a net deficit of £512 million, a fraction of the total budget. But the scale of the problems was concealed by strategic health authorities saving large amounts of money largely by cutting education and training budgets.[10]

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[1] http://www.justlanded.com/english/UK/UK-Guide/Health/National-Health-Service

[2] http://www.justlanded.com/english/UK/UK-Guide/Health/Private-healthcare

[3] http://www.independent.co.uk/life-style/health-and-wellbeing/health-news/nhs-to-allow-private-drugs-for-cancer-927102.html

[4] http://www.dailymail.co.uk/health/article-1159506/Life-prolonging-cancer-drugs-banned-cost-much.html Life prolonging cancer drugs to be banned because they cost too much

[5] http://www.thesun.co.uk/sol/homepage/news/article334708.ece

[6] http://extras.thesun.co.uk/flash/mrsa/index.html

[7] http://www.dailymail.co.uk/health/article-448395/Hard-hospital-orders-staff-Dont-wash-sheets–turn-over.html

[8] http://www.echo-news.co.uk/news/2313704.dying_woman_refused_chemotherapy_by_the_nhs/

[9] http://www.guardian.co.uk/society/2007/jun/08/health.politics

[10] http://www.timesonline.co.uk/tol/news/article1289215.ece

Netherlands and Sweden

In both countries, the majority of the population buys supplemental policies, often purchased from the insurer providing basic coverage. Insurers providing supplemental coverage are subject to fewer (Netherlands) or no (Switzerland) risk-rating restrictions. This has had complex effects on competition and mobility of the insured in the supplemental insurance market.

An additional 1.5 percent is insured but behind on premium payments—a policy concern in both countries. Both countries subsidize premiums for low-income households, with about 40 percent receiving such premium assistance.[1]

Netherlands

• Compulsory social insurance for people earning an income below a certain income level
• Private insurance available for people earning above a certain income level

Sweden

Sweden attaches high priority to the provision of health services to the entire population paid for through

• National taxes
• Regional taxes.[2]

Netherlands – The Health Insurance Act of 2006

The Health Insurance Act of 2006 was the culmination of several years of Dutch legislation and policy aimed at achieving universal health care coverage. It requires all people who legally live or work in the Netherlands to buy health insurance from a private insurance company. Insurers are required to accept each applicant at a community-rated premium regardless of preexisting conditions.

As discussed, insurance companies are required to accept each applicant for basic insurance coverage. Individuals can choose from among 14 private insurance companies and several related subsidiaries. The Dutch government has set up a Web site where consumers can compare all insurers with respect to price, services, consumer satisfaction, and supplemental insurance, and compare hospitals on different sets of performance indicators.

The plan is financed with individuals’ annual income-based contributions to the tax collector. Employers are required to compensate their employees for these contributions.

• In addition, all adults are required to pay premiums directly to the selected insurer, which sets its own community-rated premium. It is estimated that 1.5% are uninsured[3]

In the Netherlands, the government is not in charge of the day-to-day management of the healthcare system.

• Private health suppliers are responsible for the provision of services in this area.
• The government is responsible for the accessibility and quality of the healthcare.

Since January 1^st 2006 there is a new healthcare insurance system in the Netherlands and you should be aware of the requirements before you leave for the Netherlands.

If you are living in the Netherlands or you are paying income-tax in the Netherlands you are required to purchase a health insurance at a Dutch insurance company. In the past there was a difference between public and private healthcare in the Netherlands. This however has been changed and everybody is now required to purchase basic health insurance.

Fees of the basic package

The fees for the basic health insurance package are annually determined by the health insurance companies and are normally approximately €95 per month. Although the Ministry of Health ( Ministerie van Volksgezondheid, Welzijn en Sport) determines a standard premium, the insurance companies determine the additions fee you will have to pay in the end by charging a certain rate and a no-claim charge. It is with these additional fees that the insurance companies compete with each other. There are various health insurance companies and a new law will make it easier to change between health insurance companies.

If you are required to purchase health insurance and are earning a salary, you will also pay a supplementary contribution from your income (rated 6.5% up to the first €30,000 of earnings; 4.4% for self-employed individuals). [4]

In the Netherlands, for example, people must buy supplementaryinsurance for health care such as cosmetic surgery, non-rehabilitative physiotherapy, or more comprehensive dentistry. Costs have been cut, quality driven up, and fees are far from prohibitive; infact 93% of the population have bought some form of supplementaryinsurance.[5]

“Have you recently moved to the Netherlands? “Remember to take out health insurance. Obligatory health insurance Health insurance covers the costs of medical care. Residents in the Netherlands are obliged by law to take out health insurance, for themselves and for their partners and children. Even if you already have a health insurance policy, you are still obliged to take out a new policy in the Netherlands.[6]

The Netherlands operates a national insurance market for its 16 million residents. Plans may operate on a for-profit or nonprofit basis.

Plans typically offer coverage in all areas of the country and include all providers, although selective contracting is allowed. Children are covered in full through public funds. Premiums charged for adults represent 50 percent of the expected annual costs. Netherlands has notably low cost-sharing, with additional protections for the chronically ill. [7]

The right to health care in the Netherlands

As for the waiting lists, their existence is as such acceptable, but only depending on the required treatment. And in this respect, it must be said that waiting lists in the Netherlands are sometimes unacceptably long. For example, there are huge shortfalls in appropriate care for children with mental and behavioural disorders, which is a growing problem in the Netherlands.

On occasion, the length of the waiting list has led to a situation where people have died because they could not get the treatment they needed on time.

The waiting lists are partly caused by shortfalls in personnel. There is a particular shortage of general medical practitioners, GPs in short. Although in the Netherlands everyone is supposed to have access to a GP, which is a worthwhile objective, a fair amount of people are still without recourse to this type of general medical care. The shortage is most visible in areas where it is less attractive for GPs to set up their practice.

As a result of the waiting lists, people are increasingly seeking medical care across the border, especially in Germany and Belgium. Although this takes the pressure off, the government fears that this practice will endanger the return on its investments in the national health care sector.

The following groups are vulnerable to exclusion from health care services: immigrants, the elderly, women in certain cases, people with chronic diseases, including HIV/AIDS, and people with physical or mental disorders.

There is, however, one group in the Netherlands that is particularly susceptible to exclusion from medical services and they are illegally residing immigrants. Due to the so-called ‘Matching Act’, only people with legal status are covered by the sickness fund. This means that illegal aliens are excluded from access to the health care package provided under the fund. In order to prevent inhumane situations from arising, the Matching Act provides that people without legal status may claim subsidised medical help in cases of ‘medical necessity’. This means that they have access to a limited health care package. What should be provided under this package has been heavily debated in the Netherlands. As part of the discussion, before the term ‘ medical necessity’ was introduced, the term ‘ emergency medical care’ was applied, which is stricter than ‘ medical necessity’.  A practical implication of the system is that, in practice, people without legal status do not have access to treatment for HIV/AIDS.

Switzerland

The Swiss health care system has gained a reputation of being one of the best in the world. There is an extensive network of hospitals and doctors, waiting lists for treatment are rare and medical facilities have the latest technology. However, as with most things in Switzerland, there is a price tag attached to this quality!

Hospitals ( Krankenhaus, Spital/hôpital) can be recognized by a white “H” on a blue background and are listed in the yellow pages under Spitäler or hôpitaux. Except for emergencies, you usually have to be referred to a hospital by a doctor. You normally have to visit a hospital in the canton where you are residing, although there are exceptions to this.

Depending on your insurance scheme, you will either be put in a

1. Standard cover – general ward with two to four beds
2. A two-bed room (half private)
3. A single room (private)

Note that standard cover does not give you the right to choose your doctor, this may be important as not all doctors may speak your language.

Hospitals in Switzerland aren’t cheap! All hospital fees have to be paid for either by you or your insurance company. There is no such thing as ‘free treatment’ in Switzerland (even in the case of emergencies). If the decision is up to you whether or not to go into the hospital, you should first talk to your insurance company.

After visiting a hospital or doctor, you will receive a bill which you should pay within the specified period (usually around 30 days). You then send a copy to your insurance company, which will reimburse the percentage covered by your insurance scheme. If you are not resident in Switzerland and don’t have any sufficient health insurance, hospitals can require a deposit upon your admittance, which may range from CHF 2000 to 10,000.

Health insurance – Public and private health insurance in Switzerland

According to the Health Insurance Act ( Krankenversicherungsgesetz – KVG) every person living in Switzerland is obliged to take out a basic health insurance policy ( Grundversicherung). Note that in Switzerland, sickness insurance will normally not be arranged by your employer. You have the responsibility of contacting providers and arranging the insurance yourself. Only if your employer has an agreement with a specific insurer and pays part of your premiums (which rarely happens), will you be forced to choose a specific provider.

Health insurance premiums in Switzerland are:

1. Not dependent on income
   
2. Calculated based on your personal risk profile 
3. Swiss Confederation subsidizes premiums for low-income individuals/families

Swiss insurance schemes only cover individuals, not families as in some other European social security schemes. You will therefore have to insure each household member, including children.

If you only have a compulsory basic insurance scheme, you are obliged to make a contribution towards your total annual medical cost, up to a certain limit per year. This ‘franchise’ is calculated as a percentage of your total annual medical costs and capped at a yearly limit.

About 40% of the Swiss population chose to top-up their insurance cover. This is commonly in order to have more comfortable accommodation during a hospital stay or wider choice of treatments.[8]

The Swiss have operated with a mandate since 1996. Uninsured rates are low (estimated at below 1 percent in Switzerland). An additional 1.5 percent is insured but behind on premium payments.

Switzerland imposes much higher cost-sharing, including deductibles and coinsurance than the Netherlands.

The Swiss insurance system (7.5 million people) is highly decentralized, with plans operating and setting premiums at the canton level (26 divisions). In Switzerland, only nonprofit insurers may participate. The 10 largest of some 85 carriers insure 80 percent of the population. Swiss insurance risk equalization efforts adjust only for age and sex factors at the moment. Currently, Swiss premiums vary widely by health risks of insured pools across the country and within regions.

Switzerland, 12 percent of the population is enrolled in HMOs or other managed care plans. However, savings have been limited because most of these enrollees are in the least integrated plans, and plans have no ability to negotiate prices with providers. Outside such plans, Swiss patients have open access to physicians and can self-refer to specialists. Swiss provider fees are generally set by negotiations between provider associations and insurance associations.

Hospitals are mostly paid per diem rates, although a large fraction has already changed to prospective reimbursement.

Aside from emergency care health care or care that can not be acquired, you must be use providers that are located in your resident Canton.

A nationwide diagnosis-related group (DRG) system (SwissDRG) will be introduced in 2012. Cantons finance more than 50 percent of hospital costs either directly or through DRGs.[9]

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[1] http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2009/Jan/The-Swiss-and-Dutch-Health-Insurance-Systems–Universal-Coverage-and-Regulated-Competitive-Insurance.aspx

[2] http://content.healthaffairs.org/cgi/reprint/13/5/106.pdf

[3] http://www.commonwealthfund.org/Content/Publications/In-the-Literature/2008/May/Universal-Mandatory-Health-Insurance-in-The-Netherlands–A-Model-for-the-United-States.aspx

[4] http://www.justlanded.com/english/Netherlands/Netherlands-Guide/Health/Healthcare

[5] http://www.bmj.com/cgi/content/full/bmj.39563.453183.AD

[6] http://www.minvws.nl/en/folders/z/2008/obligatory-health-insurance1.asp

[7] http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2009/Jan/The-Swiss-and-Dutch-Health-Insurance-Systems–Universal-Coverage-and-Regulated-Competitive-Insurance.aspx

[8] http://www.justlanded.com/english/Switzerland/Switzerland-Guide/Health/Introduction

[9] http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2009/Jan/The-Swiss-and-Dutch-Health-Insurance-Systems–Universal-Coverage-and-Regulated-Competitive-Insurance.aspx

Who is Brigit Toebes

Germany

Ask Germans about their own system and they are usually quick to judge it wanting. One survey conducted by the Commonwealth Fund, an American health care foundation, found that 55 percent of Germans thought the system needed fundamental reform.

Americans on the other hand, rate the system better. More than 50 percent of Americans rate the US health-care system as “excellent” only 35 percent of Germans would give their own system such high marks.

Health-care reforms enacted over the past several years, which introduced a nominal co-pay for doctor’s office visits and made some changes to drugs covered by public health plans, have unleashed widespread anger among the populace and only deepened public dissatisfaction

Right now, the system is supported for by contributions from workers, who generally pay around 14 percent of their wages for health care. But Germany’s stubbornly high unemployment rates have meant less money is going into the system.

Uninsured in Germany has risen above the 200,000 mark, with some suggesting that number could reach as high as 250,000.

Germany will be applying higher co-payments and more services will not be covered by insurance plans in the future.[1]

Most agree that Germany’s creaking health care system needs reform. Cries have gotten louder that the system of public and private insurance providers has created two classes of health care.

Privately Insured and preferential treatment

When Peter Stegman calls to set up a doctor’s appointment, he usually gets what he wants. The 37-year-old Berlin resident who works in the mobile phone industry is insured privately, and if he wants an appointment on the next day, he almost always gets it.  ”You just get treated better when you have private insurance than if you have the public kind,” he said. “The service is better and you have more choice.”

Before coming to Germany from Finland two years ago, he investigated the country’s insurance system and was told that if he could afford it, private insurance was the best option, since people on the public plans get lower priority with many doctors. “They have problems getting appointments quickly; it takes a lot more time,” he said.

Anecdotal evidence abounds about difference in service between those insured under private health care plans in Germany and those with the state system. The newspaper Bild conducted a test of 100 doctor’s offices around Germany, calling each to set up appointments.

In each case, one caller would claim to have private insurance, another to be insured under the public system. In the majority of cases, the privately insured individual got appointments much sooner than did publicly insured pretend patients, if they got appointments at all.

“Private patients are preferred, publicly insured patients are brazenly turned away, just gotten rid of,” Heinz Windisch, president of VKVD, an interest group for both privately and publicly insured individuals, told the newspaper.

People who earn less than 46,800 euros ($54,850) per year are obligated to enroll in one of Germany’s public health plans. Their contributionsare determined by their income and range from12.7 to 15.5percent, half of which their employer pays.

In addition, patients must pay a 10 euro quarterly office fee, five to 10 euros for medicines, pay for shared rooms in hospitals and generally cover 50 percent of the cost of dental prostheses.

Private patients on the other hand:

1. Generally have much more choice regarding doctors
2. Have long lists of services covered
3. Not required to pay a quarterly office fee
4. Can receive medicines or eyeglasses without additional charges.
   

“Those who pay more in Germany get better service,” said Kai A. Konrad, a professor specializing in health system economics at the Institute of Public Finance and Social Policy at Berlin’s Free University. “They are like two different products.”[2]

German hospitals are coming under increasing pressure to cut costs, and are seeking concessions from their medical staff. Doctors working in hospitals are paid roughly the same salary as an elementary school teacher, despite having to endure work weeks that often amount to more than 60 hours.[3]

Striking German Doctors Shed Light on System Ills

Some 20,000 doctors at German state-run hospitals lay down their stethoscopes this week demanding better pay and work conditions. Can the country afford to pay its doctors more—and can it afford not to?

Indeed, a 2004 study by UK economic research group NERA showed German hospital physicians at the rock bottom of a list of 11 western countries in terms of compensation, earning between 35,000 and 65,000 euros ($41,000 to $77,000) per year. A similar OECD study showed German physicians earning 15 percent less than their counterparts in the UK, and 40 percent less than US doctors. The problem with physicians’ pay is not recent. “It has been a political problem for the past 20 years, but it’s been ignored,” Henke said.[4]

You may opt for private health insurance (Private Krankenversicherung or PKV) instead of joining the government health plan if you can show that your gross annual salary is presently more than 48,150 Euros and has been more than 47,700 Euros per year for each of the past three years. For those seeking to upgrade their medical coverage, for instance the right to consult a private doctor, to homeopathic remedies, a private room in hospital and higher dental reimbursements, supplemental insurance coverage is available which can top up the government system benefits.

Generally, private health plans cover a wide choice of medical and dental treatment and provide broad geographical coverage. Private patients generate higher earnings for medical professionals and will usually be treated by senior doctors. A private patient can also request and will often get, doctors who speak their native language. Germany has an extensive network of pharmacies.

• National health prescription plan: Reimbursement for generic drugs, with a copayment

Prescription drugs for children have no co-payments.

• Private health prescriptions: brand-name medication will be covered.[5]

Health Insurance Options in Germany – 2008

Germany has a reputation for having one of the best health care systems in the world, providing its residents with comprehensive health insurance coverage. Approximately 85% of the population are mandatory or voluntary members of the public health scheme while the others usually have private health insurance. The health insurance reform of 2007 now requires everyone living in Germany to be insured for at least hospital and out-patient medical treatment.

The costs of the German health care system are immense and rising due to demographics as well as long-term unemployment rates.

Recent government reforms have attempted to make hospitals more competitive and thereby reduce costs for the state health insurance providers (Gesetzliche Krankenversicherung or GKV).

1. Reduced benefits for dental work
2. Increased out-of-pocket payments
3. Additional 0.9% insurance premium above and beyond regular income tax

Efforts to cut the social security cost for employers and reduce the monthly cost for state health insurance members were controversial and after a very long and drawn out political battle, a further health reform compromise was reached which went into effect in 2007.

The cost of government health insurance is currently approx. 15 % (the rates depend on the provider “Krankenkasse” you choose) of your eligible gross salary to a maximum monthly income of 3,600 Euros. If you earn more than this you do not pay a higher insurance premium. Assuming you pay a monthly premium of 530 Euros as an employee earning at or above the threshold and are therefore a voluntary member, your contribution is approx. 280 Euros and your employer pays approx. 250 Euros.

The benefits include

1. In-patient (hospital) care as a ward patient with doctor on duty at your nearest hospital
2. Out-patient care with registered doctors (Kassenärzte) and basic dental care.
3. Generally no coverage for private doctors or surgeons, a private room in hospital, alternative/homeopathic medical care, dental implants, vision products for adults or benefits outside of Europe.
4. Your non-working dependents living at your address in Germany are presently insured at no additional cost and are simply to be registered with the “Krankenkasse“.[6]

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[1] http://www.dw-world.de/dw/article/0,2144,1973312,00.html

[2] http://www.dw-world.de/dw/article/0,,1788172,00.html

[3] http://www.dw-world.de/dw/article/0,,1574252,00.html

[4] http://www.dw-world.de/dw/article/0,,1942544,00.html

[5] http://www.howtogermany.com/pages/insurance.html

[6] http://www.howtogermany.com/pages/healthinsurance2.html

France

The French have not solved all health-care riddles. Like every other nation, France is wrestling with runaway health-care inflation. It has led to

• Some hefty tax hikes
  
• France is now considering U.S.-style HMO's to rein in costs
  

Still, some 65% of French citizens express satisfaction with their system[1]

Subscription to the general French social security system (except in some specific cases) gives rights only to the basic health insurance coverage which reimburses usually only part of medical expenses. [2]

Regardless on whether you are insured in France or in your home country, you are generally required to pay medical expenses as they occur, e.g. when visiting a doctor, buying prescribed medicines and for medical tests. Then you can ask to be reimbursed by your health insurer.

A general doctor may charge from €20-25 for a consultation, a specialist €25-30. Fees will be higher at night or the weekend – a home visit will also cost more.

Types of payment vary: doctors usually prefer payment by check and some organisations might not accept cash. Only in some cases – such as some hospitalisations or if you are covered by specific heath coverage – you may be exempt from advance payment.

If you are subscribed to the French social security, you need to send a completed form (feuille de soins) to your CPAM (Caisse Primaire d’Assurance Maladie). Reimbursement takes usually 2-3 weeks and you can check on-line on www.ameli.fr (you should receive access information in the documentation provided by CPAM). If you have a Carte Vital and the doctor (or a healthcare organization) is linked to the social security system, it is possible you may only pay the non-reimbursable part instead of having to claim it back afterwards.

For some medical costs (e.g. dental or orthopaedic prostheses), you must get prior approval from your CPAM to ensure subsequent reimbursement.  This is why most people – nearly 85% of the population in France – choose to take a complementary private insurance (mutuelle, assurance complémentaire). This additional coverage covers partly or completely the percentage of medical costs not paid for by the general social security system. Some employers pay for some or all of an employee’s supplementary coverage. In our directory, you find a list of some mutual heath insurance organizations. [3]

French Healthcare is ‘Badly Run

France must make big changes to its health system in order to cut waste and increase efficiency, a government-commissioned report is warning. The report says citizens must pay more and doctors must alter their behaviour. Failure to do so could add 66 billion euros a year to France’s public budget deficit by 2020, it adds. The warning comes after thousands of health workers protested on Thursday over staff shortages and the “creeping privatisation” of the health system. The report was written by the High Council for the Future of Health Insurance, an advisory body set up by the government as it prepares to introduce healthcare reform legislation in June. [4]

The council also highlights the CSG welfare levy – a charge paid by workers, the unemployed and pensioners – as an area for possible reform. “The High Council is unanimous in its refusal to turn to massive indebtedness to cover the growth in health insurance expenditure,” the report said. Problems in the French health system were exposed last year, when a heat wave killed around 15,000 mostly elderly people. There was also a bed shortage in hospitals in December, when a nationwide flu and bronchitis epidemic broke out. [5]

To make all this affordable, France reimburses its doctors at a far lower rate than U.S. physicians would accept. However, French doctors don’t have to pay back their crushing student loans because medical school is paid for by the state, and malpractice insurance premiums are a tiny fraction of the $55,000 a year and up that many U.S. doctors pay. That $55,000 equals the average yearly net income for French doctors, a third of what their American counterparts earn. Then again, the French government pays two-thirds of the social security tax for most French physicians—a tax that’s typically 40% of income.

Specialists who have spent at least four years practicing in a hospital are free to charge what they want, and some charge upwards of $675 for a single consultation.

Many French doctors, in fact, earn more by

1. Increasing their patient load
2. Prescribing more diagnostic tests and procedures
3. A technique, also popular in the U.S., that inflates health-care costs.

So far France has been able to hold down the burden on patients through a combination of price controls and increased government spending, but the latter effort has led to higher taxes for both employers and workers.

That’s why France is gearing up to make changes. It already requires patients to register with a general practitioner before visiting a specialist, or else agree to a lesser reimbursement, much like many U.S. insurance plans.[6]

French doctors go on strike to demand reintroduction of compulsory out of hours work

Emergency services at public and university hospitals in France last week began a “general and unlimited” strike, organised by the French Association of Hospital Emergency Doctors. Joined by nurses, administrators, and ambulance drivers, the striking doctors are asking not only for more staff, better working conditions, more beds, and more money but a revamp of France’s entire emergency and out-of-hours care system.

They are also complaining that doctors with private practices do not carry out enough out-of-hours work during evenings, weekends, and holidays, forcing patients to use hospitals instead. They want to see a system introduced whereby most general practitioners with private practice are obliged to do out-of-hours work. Doctors complain that on-call work adds to an already burdensome 55 to 58 hours of work a week, according to the Private Doctors Union. [7]

The public health insurance system covers about 75% of total health expenditures.

Half of the outstanding amount is covered by patients’ out-of-pocket payments and the other half is paid by private health insurance companies.

These supplementary health insurance policies can be taken out by individuals or groups. For example, patients must pay 30% of Social security’s tariff for a physician’s visit, moreover, roughly 40% of specialists and 15% of GPs are allowed to charge more than the tariff. Copayments are also high for dental prostheses and eye-ware. This tended to deter the poorest citizens (few of whom had supplementary insurance) from seeking care.

Once varying depending on the fund, disparate reimbursement rates were replaced by uniform rates. The funds are financed by employer and employee contributions, as well as personal income taxes. The latter’s share of the financing has been ever-increasing in order to:

• compensate for the relative decrease of wage income
• limit price distortions on the labor market,
• and more fairly distribute the system’s financing among citizens.

Most health insurance funds are private entities which are jointly managed by employers’ federations and union federations, under the State’s supervision. The joint labor/management handling has always sown discord within the funds’ boards, as well as between the boards and the State. [8]

We pay high tax, but get a reliable health care system FRANCE

Income: £40,000

Income tax: £3,500

National insurance: £8,000

Private health insurance: £200 a year

Secu is funded by national insurance payments amounting to about 20 per cent of any worker’s salary, deducted at source.

Almost everybody in France, have private health insurance [called a mutuelle].

“A mutuelle is an absolute must, because there are some black holes which social security hardly covers at all.”

“A visit to the paediatrician with one of the children costs about £30,” and the state covers only £11, so if we didn’t have private insurance each visit would cost us about £20.”

Such dependence on private health insurance in France has created a huge market for mutuelles. For young people in good health they are often reasonably priced and tariffs may be reduced further as companies invest in group plans for their staff.

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[1] http://www.businessweek.com/magazine/content/07_28/b4042070.htm The nation’s system isn’t quite as superb as Sicko maintains, but it’s pretty good

[2] http://www.justlanded.com/english/France/France-Guide/Health/Introduction

[3] http://www.justlanded.com/english/France/France-Guide/Health/Medical-costs

[4] http://news.bbc.co.uk/2/hi/europe/3423159.stm France must make big changes to its health system

[5] http://news.bbc.co.uk/2/hi/europe/3423159.stm

[6] http://www.businessweek.com/magazine/content/07_28/b4042070.htm

[7] http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=556187

[8] http://www.medicalnewstoday.com/articles/9994.php

Canada

Spending on health care to reach $5,170 per Canadian in 2008

November 13, 2008—Canada’s health care spending is expected to reach $171.9 billion in 2008, or $5,170 per person, according to new figures released today by the Canadian Institute for Health Information (CIHI). This represents an increase of $10.3 billion over estimated expenditures for 2007, or a growth of 6.4%. These figures are featured in National Health Expenditure Trends, 1975 to 2008, Canada’s most comprehensive source of information tracking how dollars are spent on health care in this country.

When looking at health care spending as a proportion of Canada’s overall economy, health expenditure is expected to reach 10.7% of the gross domestic product (GDP), the highest share ever recorded. This rate has climbed gradually, from 10.0% in 2002, to an estimated 10.6% last year.

Since 1997, the public and private sector shares of total health expenditure have remained relatively stable, with governments accounting for 70% of total spending and the private sector (including privately insured and out-of-pocket expenses) for 30%. In 2008, public-sector health care spending is expected to reach $120.3 billion (70.0% of total spending), compared to $51.6 billion spent by the private sector (30.0% of total spending).

Spending on health varies from province to province.

Canada’s spending :

1. Alberta and Manitoba, at $5,730 and $5,555, respectively
2. Quebec ($4,653)
3. British Columbia ($5,093) [1]

Seismic shift in cancer drug funding to private payers

The Cancer Advocacy Coalition of Canada reveals steady shifting of cancer drug costs from public to private insurers, leaving employers and individuals to shoulder the increasing burden of cost.

“Expenditures for oral, take-at-home therapies now represent approximately half of the total for all cancer drugs,” says Dr. Kong Khoo, a B.C. medical oncologist and lead author of the study. “Employers and insurers should be made aware of the magnitude and pace of these shifts.”

Private insurance plays a critically important role in assuring access to medically necessary prescription drugs. The CAC says the bigger issue is that a reasonable on a $60 average drug becomes unaffordable when the drug costs $25,000 or more and suggests that pooling high cost drug claims — often catastrophic to patients and their families — is an idea whose time is long overdue.[2]

Private Health Insurers’ Roles To Expand As National Healthcare Costs Soar, Projects PricewaterhouseCoopers

31 October 2006 – Governments around the world are looking to expand the role of private insurers as a source of funding the delivery of healthcare, according to a new report issued today by PricewaterhouseCoopers. The report entitled “Healthy Choices: The Changing Role of the Health Insurer,” forecasts that the threat to governments’ fiscal objectives from rising public sector health expenditures will drive the expansion of private sector contributions, and this trend will reshape the health insurance business model globally. Risk sharing will grow as consumers pay more of the cost of their care and efforts to control health costs focus on the reduction of frivolous healthcare claims and over-usage.[3]

Critical Illness Private Insurance in Canada

TORONTO, March 4 2009 – 61 per cent of Canadians admit they have no plan ready in the event they are diagnosed with a critical illness, reveals a recent survey of more than 1,600 Canadians by Ottawa-based polling firm, Redfern Research.

Many are concerned about the time it takes to see a specialist, and then get the necessary tests done. And a growing number see the need for critical illness insurance to cover costs the healthcare system doesn’t cover. Bottom line, Canadians believe their healthcare system will be there for them if they do become critically ill – but many feel under protected. [4]

Private sector health care spending continues to increase while access to non-emergency surgery has improved in recent years, according to the Canadian Institute for Health Information’s Health Care in Canada 2008 report. Total private-sector health care spending – which includes payments by health insurance providers as well as individual Canadians’ out-of-pocket expenses – was an estimated $47 billion in 2007, up 5.7% from $45 billion in 2006. [5]

While health care spending is on the rise, it appears that wait times for elective surgery are down slightly. In 2007, 32% of Canadians reported waiting less than a month for elective surgery, compared with 15% in 2005, according to a Commonwealth Fund international survey cited in the CIHI report. [6]

Small drop in median wait times for surgery

The median wait time for Canadians seeking surgical or other therapeutic treatment dropped to 17.3 weeks in 2008 from 18.3 weeks in 2007, according to new research recently published by The Fraser Institute.

This year’s report shows the main decrease in wait times occurred in the time between a referral from a general practitioner and consultation with a specialist, which decreased to 8.5 weeks from 9.2 weeks. [7]

This nationwide improvement in access reflects waiting-time decreases in 7 provinces, while concealing increases in waiting times in Saskatchewan, Nova Scotia, and Newfoundland & Labrador.

Waiting for diagnostic and therapeutic technology The waits to see a specialist and to receive treatment were not the only delays facing patients in 2008.

Patients also experienced significant waiting times for various diagnostic technologies across Canada:

1. Computed tomography (CT),
   
2. Magnetic resonance imaging (MRI), and
   
3. Ultrasound scans
   

The median wait for a CT scan across Canada rose slightly to 4.9 weeks from 4.8 weeks in 2007.

Alberta and Ontario had the shortest wait for computed tomography (4.0 weeks), while the longest wait occurred in Prince Edward Island (19.0 weeks).

The median wait for an MRI across Canada fell to 9.7 weeks from 10.1 weeks in 2007.

In 2000-01, Statistics Canada data showed that an estimated 4.3  million Canadians had difficulties

1. Obtaining routine care,
2. Health information or advice
3. Immediate care for minor health issues
4. Other first contact services

Approximately 1.4 million Canadians had difficulties (Sanmartin et al., 2002).

1. Gaining access to specialist visits,
2. Non-emergency surgery,
3. Selected diagnostic tests

Twenty percent of those who waited for the latter three specialized services indicated that (Sanmartin et al., 2002).

1. The wait affected their lives;
2. Most of these people experienced “worry, stress, and anxiety, pain,
3. Diminished health as a result of waiting”
4. Over 20 percent of the 1.4 million also indicated that their waiting time was unacceptable

Polls regularly show that Canadians are concerned about wait times and the general state of the health care system.[8]

We’re finally getting an MRI scanner, but it’s only a base unit. Upgrades are essential

It’s about time!” says Chief of Neurosurgery Dr. Brian Hunt. “Lions Gate Hospital has been performing neurosurgery since the 1960s, yet unbelievably we are one of the only neurosurgical units in North America that doesn’t have an MRI scanner.” [9]

Interactive webpage map for health care costs of each Province

The provinces and territories also provide some groups with supplementary health benefits not covered by the Act, such as prescription drug coverage. The level and scope of coverage for supplementary benefits varies between jurisdictions.[10]

Access to Insurance Coverage for Prescription Medicines

Under the Canada Health Act, all necessary drug therapy administered within a Canadian hospital setting is insured and publicly funded. Outside of the hospital setting, provincial and territorial governments are responsible for the administration of their own publicly-funded prescription drug benefit programs.

Most Canadians have access to insurance coverage for prescription medicines through public and/or private insurance plans. The federal, provincial and territorial governments offer varying levels of coverage, with different eligibility requirements, premiums and deductibles. The publicly-funded drug programs generally provide insurance coverage for those most in need, based on age, income, and medical condition.[11

As one Canadian doctor described when and why his support changed for the Canadian Plan

Originally the Canadian doctor was appalled by the American health care system.  He gradually changed his views on the Canadian health system. The most important lesson he learned was not taught in the classroom. It was taught to him one cold morning  in Winnipeg.  The good doctor decided to take a shortcut through emergency room. Opening the door,  he stepped into a nightmare.   The room was filled with elderly people lying on stretchers, awaiting admission. The air had the odor of sweat and urine.   That is the moment that the Canadian reconsidered his support of the Canadian system.

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[1] http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=media_13nov2008_e Spending on health care to reach $5,170 per Canadian in 2008

[2] http://ebnc.benefitnews.com/news/seismic-shift-cancer-drug-funding-private-2667721-1.html Seismic shift in cancer drug funding to private payers

[3] http://www.insurance-canada.ca/market/canada/PWC-Private-Health-Insurers-611.php

[4] http://www.insurance-canada.ca/profproducts/health-critical/Right-Choice-Insurance-online-solution-903.php

[5] http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=media_13nov2008_e Spending on health care to reach $5,170 per Canadian in 2008

[6] http://ebnc.benefitnews.com/news/private-sector-health-spending-rise-says-1237961-1.html

[7] http://ebnc.benefitnews.com/news/small-drop-median-wait-times-surgery-722001-1.html

[8] http://www.fraserinstitute.org/commerce.web/product_files/WaitingYourTurn2008.pdf

[9] http://www.lghfoundation.com/files/pdf_documents/rapport-news_fall-01.pdf

[10] http://www.hc-sc.gc.ca/hcs-sss/delivery-prestation/ptrole/index-eng.php

[11] http://www.hc-sc.gc.ca/hcs-sss/pharma/acces/index-eng.php

[12] http://www.ramq.gouv.qc.ca/en/citoyens/assurancemedicaments/factures/fact_adulte.htm