Both public and private including for profit hospitals exist, though the public hospitals account for about half the beds.
Hospitals tend to use salaried physicians, and unlike the United States physicians in private practice generally do not have admitting privileges.
Thus, many doctors have invested in elaborately equipped clinics to compete with hospitals by being able to perform a wide range of procedures. The German experience is especially relevant to the United States.
Coverage is provided through a large number of relatively small and independent plans. In this sense, the delivery of health care is similar to that found in the United States where, for the most part, large numbers of employee groups, independent insurers, and providers reach agreements without direct government intervention.
Many Americans propose mandated coverage for the working uninsured. Germany relies on a mandated approach where coverage for certain conditions is required by law. Germany also introduced cost controls similar in principle to prospective payment under the U.
DRG mechanism. In the German health care system, each level of government has specific responsibilities. The central government passes legislation on policy and jurisdiction. State governments are responsible for hospital planning, managing state hospitals, and supervising the sickness funds and physician associations. Local governments manage local hospitals and public health programs. Decentralization is extensive. The sickness funds and physician associations have considerable administrative autonomy.
Despite this autonomy, government intervention is extensive and has been increasing steadily. As a result, the Cost Containment Act of introduced a fixed budget for payments by the sickness funds to the physician associations.
In essence, this program is similar to prospective payment schemes developed in the United States. The Health Care Reform Act of introduced more major changes.
These were directed at attempts to further reduce the growth of health expenditures through means familiar to those in the United States. The act also attempted to control hospital costs through reductions in hospital capacity, hospitals inpatient admissions, and hospital expenditures on capital equipment 2. As costs continued to rise for the sickness funds at a rate faster than the rise in incomes, the call for reform continued. In the Health Care Reform Act was passed which introduced supply- side competition.
These reforms gave members the freedom to choose among a range of sickness funds whose revenues would be determined by the risks of their members. The reforms further changed the hospital payment system from a per diem payment to a DRG — styled prospective payment basis.
By linking medical expenditures to the income of sickness fund members, the success of the strategy depends upon the continued growth in wages and salaries and the success of the negotiations between the sickness funds and medical practitioners.
The cost containment measures have resulted in a dramatic decrease in the relative salaries of primary care physicians, which have fallen from 5. More than , students attend one of the 29 medical schools run by the state. After completing the six-year curriculum, physicians must first practice in a hospital setting for five years before they are allowed to enter private ambulatory practice. Hospitals also have less high technology diagnostic, therapeutic, and surgical equipment than is available in the typical urban hospital in the United States.
Germany has The one area where Germany has more technology is CT scanners, where they have The German system suffers from several problems that bring into question its ability to contain costs over the long term. Possibly the biggest problem with the system is its reliance on third party payment providing virtually no role for the cost — conscious consumer. Patients have no incentive to limit their demand and medical providers have no incentive to limit their supply. Nothing would lead competitive forces to reduce costs.
The only competition is among medical practitioners to attract more patient volume. The ability of the system to control costs depends solely on the relative bargaining power between sickness funds and medical providers.
Another problem with the system is its tendency to use resources inefficiently. Incentives promote the provision of invasive acute care procedures and discourage the provision of personal services. Based on the latest available OECD figures, Germans see their doctors more often, are provided more prescription drugs, have a higher hospital admission rate, and stay in the hospital longer than citizens of the major developed countries in the OECD.
The average lengths of stay in the hospital are much longer in Germany than in the United States Significant excess capacity in the number of hospital beds relative to the population means 9. After examining the performance of the German system, we may question whether it is the United States or Germany that has the better system.
Surveys of public opinion indicate that Germans by and large are satisfied with their health care system as opposed to the U. The German health care system also faces additional cost pressures from having a much older population than the United States does. Germany has achieved a favorable rating along other criteria. It has a publicly funded system with virtually universal coverage but has avoided queues and extensive government intrusion.
Both patient and provider have considerable autonomy. Germany has managed to achieve cost control by establishing an explicit trade off between volume and price. When utilization is higher than anticipated, fees are lowered proportionally. In addition, spending caps instituted in the mid s as a temporary cost containment measure have become permanent.
Even with all these new changes, support for the system remains high, in part because wealthy Germans have a private insurance safety valve and the ability to buy more physician time and better services.
On the other hand, the German health system faces a new challenge. The German population is aging rapidly, causing a demographic change that will place severe pressure on its social security and health care programs 4. The United States has no single nationwide system of health insurance.
Health insurance is purchased in the private marketplace or provided by the government to certain groups. Private health insurance can be purchased from various for — profit commercial insurance companies or from non — profit insurers.
Employers voluntarily sponsor the health insurance plans. Rather than purchasing an insurance policy from an external party commercial insurance company employer and employee premiums sometimes fund an internal health insurance plan.
In either case, the firm usually contracts with a third party to administer the health insurance program. Even these plans provide some type of utilization management program e. Traditional plans differ depending on the medical services that are covered and the co-payment and deductible amounts. Rather than enroll employees in a traditional insurance plan, most employers have turned to managed care health insurance plans. About 70 percent of employees are currently enrolled in MCOs.
HMO is a health care delivery system that combines the insurer and producer functions. HMOs are pre — paid and in return provide comprehensive services to enrollees. PPOs are a third party payer that offers financial incentives such as low out — of — pocket prices, to enrollees who acquire medical care from a preset list of physicians and hospitals.
The two major types of public health insurance, both of which began in are Medicare and Medicaid. Medicare is a uniform national public health insurance program for aged and disabled individuals.
The Medicare plan consists of two parts. Part A is compulsory and provides health insurance coverage for inpatient hospital care, very limited nursing home services and some home health services. Part B the voluntary or supplemental plan provides benefits for physician services, outpatient hospital services, outpatient laboratory and radiology services and home health services. The Medicare patient is also responsible for paying a deductible and a co-payment for most part B services and for long-term hospital services under part A.
Many Medicare recipients also choose to purchase Medigap insurance, a private health insurance plan offered by commercial insurance companies that pays for medical bills not fully reimbursed by Medicare Hoffman et al.
The second type of public health insurance program, Medicaid, provides coverage for certain economically disadvantaged groups. Medicaid is jointly financed by the federal and state governments and is administered by each state.
Coverage under Medicaid varies because states have established different requirements for eligibility. Individuals who are elderly, blind, disabled or members of families with dependent children must be covered by Medicaid for states to receive federal funds. Additionally, although the federal government stimulates a certain basic package of health care benefits e. Following that, individuals in certain states receive a more generous benefit package under Medicaid than those in others.
Medicaid is the only public program that finances long — term nursing home stay. However, another category of individuals exists: those who are uninsured. This does not mean these individuals are without access to health care services. Many uninsured people receive health care services through public clinics and hospitals, state and local health programs, or private providers that finance the care through charity and by shifting costs to other payers.
Nevertheless, the lack of health insurance can cause uninsured households to face considerable financial hardship and insecurity. The uninsured often find themselves in the emergency room of a hospital after it is too late for proper medical treatment. The U. Government, not — for — profit, and for — profit institutions all play a role in health care markets.
Primary care physicians in the United States function in the private for — profit sector and operate in group practices, although some physicians work for not — for — profit clinics or in public organizations.
In the hospital industry, the not — for — profit is the dominant form of ownership. Not — for — profit hospitals control about 70 percent of all hospital beds. A different picture can be seen in the nursing home industry, where 70 percent of all nursing homes are organized on a for — profit basis Santerre and Neun 52 5. Up to the early s most insured individuals had full choice of health care providers in the United States.
Consumers could choose to visit a primary care giver or the outpatient clinic of a hospital, or see a specialist if they chose to. The introduction of various Managed Care Organizations and such new government policies as selective contracting a situation when a third party contracts exclusively with a preselected set of medical providers have limited the degree to which consumers can choose their own health care provider.
For example, those individuals belonging to a staff HMO must receive their care exclusively from that organization; otherwise they are fully responsible for the ensuing financial burden.
The primary care giver acts as a gatekeeper and must refer the patient for additional care. The lower premiums of a staff HMO compensate consumers at least to some degree for the restriction of choice.
Even those individuals belonging to the less restrictive PPO face a financial penalty when choosing health care providers outside the network.
Unlike in Canada and Europe, where a single payer — system is the norm, the United States possess a multiplayer system in which a variety of third — party payers, including the federal and state governments and commercial health insurance companies are responsible for reimbursing health care providers. Reimbursement takes on various forms depending on the nature of the third party payer. The most common form of reimbursement is fee — for — service, although prospective payment a method of payment used by third — party payers in which payments are made on a case by case basis and prepaid health plans are becoming more popular.
Most traditional health insurance plans reimburse health care providers on a fee for service basis. Health care providers contacting with most MCOs are paid on a fee — for — service basis. Physician services under Medicare and for the most part Medicaid as well are also reimbursed on a fee for service basis, but the fee is fixed by the government.
This means the fee was limited to the lowest of the three charges: the actual charge of the physician, the customary charge of the physician, or the prevailing charge in the local area. The RVS is transformed into a schedule of fees when it is multiplied by a dollar conversion factor and a geographic adjustment factor that allows fees to vary in different locations Santerre and Neun Under both Medicare and Medicaid, the physician can choose to accept assignments of patients.
If the physician accepts the assignment, he or she agrees to accept the government determined fee in full and cannot charge the patient an additional amount beyond the normal 20 percent co-payment. The physician must also agree to treat all Medicare patients for all services. A physician who does not accept assignment can charge patients a price higher than the Medicare fee and accept patients on a case-by-case basis.
In contrast to the fee — for — service method, some health care providers are paid on a fixed — fee or prospective basis. For example, the consumer prepays the staff HMO, and physicians are paid on a salary basis. The consumer also prepays the individual practice association HMO, however, health care providers are usually paid on a fee — for service or capitation basis.
Since , the federal government has reimbursed hospitals on a prospective basis for services provided to Medicare patients. A prospective payment is established for each DRG.
The prospective payment is claimed to provide hospitals with an incentive to contain costs. Beginning in the early s, many states instituted selective contacting, in which various health care providers competitively bid for the right to treat Medicaid patients. Under selective contracting, recipients of Medicaid are limited in the choice of health care provider. The advanced state of technology is the greatest strength of the U. Premature babies for example, face relatively good chance of surviving if they are born in the United States because of the state of technology.
A relatively high life expectancy after age 80 is another reflection of the advanced state of health care technology in the United States. People 80 years and older in the U. Also the United States continues to be the world leader in pharmaceutical innovation.
These products save, extend and improve the quality of lives. Unfortunately, the U. For all the local variations, health care systems tend to follow general patterns. There are four basic systems:. In this system, health care is provided and financed by the government through tax payments, just like the police force or the public library.
Many, but not all, hospitals and clinics are owned by the government; some doctors are government employees, but there are also private doctors who collect their fees from the government.
In Britain, you never get a doctor bill. These systems tend to have low costs per capita, because the government, as the sole payer, controls what doctors can do and what they can charge.
Countries using the Beveridge plan or variations on it include its birthplace Great Britain, Spain, most of Scandinavia and New Zealand. Hong Kong still has its own Beveridge-style health care, because the populace simply refused to give it up when the Chinese took over that former British colony in Named for the Prussian Chancellor Otto von Bismarck, who invented the welfare state as part of the unification of Germany in the 19th century.
Despite its European heritage, this system of providing health care would look fairly familiar to Americans. Unlike the U. Doctors and hospitals tend to be private in Bismarck countries; Japan has more private hospitals than the U. Although this is a multi-payer model — Germany has about different funds — tight regulation gives government much of the cost-control clout that the single-payer Beveridge Model provides.
Health insurance protects you from owing a lot of money to doctors or hospitals if you get sick or hurt. In exchange, the company agrees to pay some, or all, of your medical bills.
Learn more about health insurance. Your new PCP could be a nurse practitioner or a physician. You will see your PCP when you need a physical exam or lab test, when you are sick, or if you need care for an ongoing condition, like diabetes or high blood pressure. Learn more about PCPs. You will usually need an appointment to get medical care.
When you call, you need to explain why you need the appointment. If you are sick or hurt, you will get an appointment very soon.
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