Health Care Systems and Their Patients

An International Perspective

Marilynn M. Rosenthal

• Editorial: Routledge
• Año: 2019
• ISBN:
  9780429714665
• Edición: 1
• Categoría: Social Sciences
• Categoría: Sociology

This book provides an examination of the American health care system, a benchmark for cost-containment efforts, exploring two worlds: that of cost containment and that of the patient experience. It emphasises on the quality of care as perceived by the individual patient.

Part One
Introduction

The Struggle to Contain Health Care Costs: At What Price? The Current Worldwide Situation

Marilynn M. Rosenthal arid Marcel Frenkel

Health care systems in the industrialized world are facing the same problems: economic constraint and demographic pressure. Huge national debt, oil crises, weak economic growth, the unwillingness to raise taxes, and the fact that health care spending has been rising faster than the inflation rate have led to the need to reduce public spending and change the government's role in health care systems.

Populations in industrial and post-industrial societies are aging, with the fastest growing segment of the population that over 65 and particularly that over 85. In some modern nations, 15% to 17% of the population is 65 and older, and they consume 30% to 40% of health care resources. While we are living longer and healthier, aging populations will continue to put pressure on health care resources.

Other international trends confound the situation. Increasingly sophisticated medical technologies extend life at great cost, nursing shortages complicate staffing needs, fewer births 20 years ago mean fewer people coming into the labor force with intense competition for their services. All of this is compounded by the fact that health care systems everywhere are among the major employers in their countries. Modern nations everywhere have witnessed the erosion of the family, even the nuclear family. At the same time, there is increasing skepticism about the ability of large, centralized bureaucracies to address all these issues.

Everywhere countries are searching for techniques and strategies to slow the growth rate of health care budgets, from incentives for greater productivity and effectiveness to stimulating free-market competitive dynamics. Health care systems are in a period of challenge and transition. How they are meeting these challenges is the theme of this book.

The last 40 years have seen rapid developments in the scholarly study of comparative health care systems, an endeavor that has accelerated in the last 10 years. A variety of categorical frameworks has been utilized. Some of these have been geographical (Babson, Health Care Delivery: A Multi-National Survey, 1972, for example, although geography is often a proxy for similar organizational features), nature of ownership (Roemer, Health Care Systems in World Perspective, 1976), financing mechanisms (Anderson, The Health Services Continuum in Democratic States, 1989, who expresses this in terms of market maximizing and minimizing), convergence theory (Field, Success and Crisis in National Health Systems, 1989), and resource utilization (Kohn and White, Health Care: An International Study, 1976). And most recently, ability to control costs has been added (Ham, Robinson, and Benzeval, Health Check, 1990). Countries are increasingly compared statistically, particularly with reference to resource utilization and health status (OECD).

These categories are basically heuristic in intent as the central organizational, financing, and ownership features of health care systems are inexorably intertwined and reflective of particular cultural histories and political economies. Most of this work recognizes the importance of the political process and interest group politics.

What remains is the gargantuan effort to develop an integrated framework that takes into account all major features of systems and links them to resource utilization and quality of care. This book has a much more modest goal: to survey selected international trends in cost-containment strategies and to bring the patient experience more dramatically into international comparison.

Twelve Health Care Systems

We have included 12 health care systems representing different central organizing characteristics: insurance-based and integrated national health systems.

Health Care: Basic Organizational Structure

INSURANCE-BASED HEALTH SYSTEMS	NATIONAL HEALTH SYSTEMS
Private	Democracies
USA	Sweden
Social	New Zealand
Canada	Britain
France	Socialist
Germany	USSR
Australia	Hungary
Japan	PRC

While most of the country cases are from the post-industrial nations, second- and third-world countries are represented as well. Some have extensive central control and others relatively little; some command three times the proportion of gross national product as others. The concluding chapter of this book will discuss a number of comparisons. But the emphasis in this collection is on cost containment and the quality of care as perceived by the individual patient.

Problems in Comparative Study

There are dangers and problems in cross-country comparisons that are now well known; the comparability of statistics and data, complicated by different categorical definitions and collection techniques; the limitations in comparing countries of different sizes, economic development, and standards of living; the complexities and subtleties of systems that are forced into crude generalizations. Although we are at an early stage of comparative study, there is continuing interest in comparing performance in a variety of ways and examining the results of various organizational arrangements and strategies.

This is particularly true at this juncture with reference to cost-containment strategies. The United States has attracted unusual attention because of aggressive approaches to cost containment. As the only western industrialized nation without at least a universal national insurance system, it has not often been considered a model for others to follow. That situation has now changed with the recent "discovery" of market philosophies. The American experience is now of great interest and maybe said to have become a focal point of worldwide attention.

This book, therefore, begins with an examination of the American health care system, now a benchmark for cost-containment efforts. The next cluster of country histories is of those countries that have some form of mandated universal insurance: Canada, France, Germany, Australia, and Japan. These are followed by the national health care systems, first in the liberal democracies: Sweden, New Zealand, and Britain; then those in several socialist states: USSR, Hungary, and the People's Republic of China. In addition to being grouped according to this central organizing feature, the countries are listed, categorically, by percent of gross national product spent on health care, the United States spending the most and the PRC the least.

The Country Case Studies

Almost all the country case studies in this collection originally appeared in The Journal of Medical Practice Management. Each author has updated the original article, and in many cases, new developments in the early 1990s have been included. The Japanese chapter is reprinted from the New England Journal of Medicine. Authors are health policy authorities in their own countries or experts on the countries about which they write. Further information about them can be found in "About the Contributors" at the beginning of the book. They have followed roughly comparable formats, describing system characteristics, including brief histories, and focusing on recent problems and cost-containment strategies.

The Patient Experience

Twelve patient experiences are included in this book, one for each health care system discussed. Why include patient experiences in this study of health care systems around the world? How much can an individual experience tell us?

From a social scientist's perspective, the individual anecdote is limited because it is not generalizable. From a statistical point of view, not a single one of the patient experiences described in this book can claim it is representative of what patients experience in the health care delivery system of that particular country. Nonetheless, these patient stories present powerful portraits of the individual encounter, the personal perception of how a particular system worked for at least one consumer. They reflect microsocial involvement that personalizes the macro-social descriptions of the systems. They turn the reader's attention to a graphic description of what the larger system looks like as it functions for those for whom it is presumably organized, funded, and staffed. The patient articles force the reader to think about the health care systems in personal terms, the way each one of us as an individual experiences health care. This has rarely, if ever, been part of cross-cultural health care analysis.

The individuals who have contributed patient articles to this book are, not unexpectedly, overwhelmingly well educated and articulate. Three articles are written by professors, two of whom also wrote systems articles. Six other articles are written by individuals who are highly educated and professionals themselves. Two of the articles describe the experiences of working-class patients but are interviews, written and interpreted by professionally trained individuals. The majority of the articles concern experiences of patients over 55, and several describe encounters of over 20 years' duration. All of the articles were commissioned and only one, the British, has previously appeared in print.

There will be no attempt to generalize from the individual patient experience back to the single country system as a whole. However, it is possible to generalize from this particular collection of patient articles, from twelve different countries, themselves at different levels of economic development, with health care systems that differ in organizational characteristics, funding amounts and sources, role of government, and public-private mix. Are there any consistent themes? Satisfactions? Complaints? Which are the unique experiences? Do the patient articles provide clues for further research?

One of the dominant figures in sociology, C. Wright Mills, pointed out that the greatest social insight accrues from understanding the intersection of the individual and social structure at a particularly historical moment. The patient articles in this book provide just that.

Goals of the Book

This book explores two worlds: that of cost containment and that of the patient experience. What are these 12 countries trying to do to control soaring costs and shrink public budgets? Are there international trends? What are the individual patients experiencing and what are their perceptions of quality of care as they seek needed services in their various health care systems?

International Health Expenditure Trends: The United States Compared to Other Market-Oriented Countries

Dale A. Rublee

The expansion of resources devoted to health care in the U.S, is leading domestic commentators to recommend the introduction of a single-payer or a coordinated-payer system modeled along the lines of one of several market-oriented countries. U.S. health care expenditures have been increasing at a higher rate than the overall growth in the economy during the 1980s. For example, from 1983 to 1987 personal health care spending per capita grew at an average annual rate of almost 9%. In contrast, GNP per capita grew at an annual rate of 6.5%. This paper discusses patterns of health expenditures across several market-oriented countries over time, particularly as they relate to the U.S. Only industrialized countries are included because their statistical collection systems are more developed.

Overview of Financing Systems and Current Expenditure Levels

In the market-oriented countries, two broad models show themselves. On the northern and southern periphery of Western Europe we find centralized national health services where, on average, countries pay high levels of taxes and use those taxes to finance health systems that make small charges or no charges to patients. The paradigm of the national health service model is the structure found in Sweden. At the core of Western Europe and in North America and Japan we find decentralized insurance-based systems where tax levels are lower. Health expenditures are generally funded by insurance plans monitored and regulated by the government, although U.S. insurance plans are largely independent. The German health insurance system is the most straightforward example. Figure 1 displays total tax revenue ...