Introduction How Much Money does the United States Spend on Health Care? What Types of Government-Supported Health Insurance Are Available? What Types of Employment-based Insurance are Available? What Are the Extent and Consequences of Being Uninsured and Underinsured in the U.S.

Introduction How Can We Describe the Healthcare Systems in General and the U.S. Healthcare System? How Can We Describe the Healthcare Systems in Canada and the United Kingdom? What Conclusion Can We Reach from These Descriptions of the U.S., Canadian and U.K. Healthcare systems?

Introduction How Can a Healthcare System be Scored? Using the National Scorecard, How Does the U.S. Healthcare System Compare to Other Developed Countries? How Can the Costs of Health Care Be Controlled in the United States?

Scenarios Health Care Systems The politicians seem to agree that health care is too expensive. However, some argue for greater regulation while others argue for less regulation. You ask yourself: what are the options for controlling costs and what are the consequences?

Scenarios Health Care Systems You take a job right out of college and need to select from among your company’s health care options or alternatively choose not to be insured. The choice seems quite complicated and none of them seems just right for you. How can you go about choosing between health insurance options?

Scenarios Health Care Systems You decide to take your chances and refuse the expensive health insurance offered by your employer. What are the consequences of not having insurance?

Scenarios Health Care Systems Members of the Smith family live in the U.S., Canada, and the United Kingdom. They have the same inherited disease. The recommended treatment is quite similar in the three countries and can be delivered as part of primary care. How might the delivery of care and the payment for care differ between the three countries?

Scenarios Health Care Systems You wonder how the U.S. ranks in terms of the performance of its health care system. You’re surprised when you find out that the U.S. is not #1 or even near the top. Why is that, you ask yourself?

Prototype Health Insurance Options Fee-for-Service Classic Mixed ModelHMO Classic Monthly cost to employee $400 Individual $1000 Family of 4 $1000 yearly deductible per person $200 Individual $600 Family of 4 $500 yearly deductible per person $100 Individual $400 Family of 4 No yearly deductible Choice of physician No restrictions–full coverage Physicians paid "prevailing fee“ No restrictions, but 20% copayment for Non-network Physicians paid lower discounted fee for service Staff physicians Only Full coverage Physicians paid through capitation

Prototype Health Insurance Options Fee-for- Service Classic Mixed ModelHMO Classic Access to specialists including OB- GYN Access without referral–full coverage Access with referral–full coverage Access without referral–20% copayment Access with referral only DrugsFull coverage as ordered $20 copayment for generic or approved/ formulary drugs $20 copayment for generic or approved/ formulary drugs

Prototype Health Insurance Options Fee-for- Service Classic Mixed ModelHMO Classic HospitalFull coverage as authorized by physician 80% coverage if preauthorized by plan 100% coverage if preauthorized by plan Skilled nursing Full coverage if ordered by physicians 80% coverage if found necessary by plan 100% coverage if found necessary by plan

Prototype Health Insurance Options Fee-for- Service Classic Mixed ModelHMO Classic Hospice100% coverage based on physician authorization 80% coverage based on plan authorization 100% coverage based on plan authorization Preventive services Not covered100% coverage in network 20% copayment out of network 100% coverage in network Emergency Department and out-of-area services 100% coverageRequires prior authorization except in emergencies as defined by “reasonable person” [J1] [AU – need “on”?] ok as edited[J1] [J2] [AU – need “on”?]Ok as edited[J2]

Describing the U.S. Healthcare System CategoryDescription Financing Cost over 16% of GDP and rising rapidly; Complicated mix of federal, state, employer and self-pay Type(s) of insurance and reimbursement Employment-based insurance plus government insurance through Medicare and Medicaid provide most insurance; Mix of fee-for-service, capitation, and salary with incentives are the most commonly used methods

Describing the U.S. Healthcare System CategoryDescription Delivery of care Mix of practice types with private practice dominant; Physicians: 1/3 Primary Care; 2/3 Specialists; Primary care increasingly based upon nurse practitioners and physician assistants; Hospitalists increasingly provide inpatient care; Need for better continuity of care between institutions and between clinicians Comprehensiveness of insurance 15% uninsured plus half again as many underinsured; Drug benefits included for elderly and those with comprehensive insurance; Preventive services increasing, but not comprehensive

Describing the U.S. Healthcare System CategoryDescription Cost and cost containment Over 16% of GNP and rising; Emphasis on competition as means of controlling costs, plus cost sharing by patients Patient choice Considerable choice of primary care and often direct access to specialty care; Greatly increased access for those with comprehensive insurance Administrative costs High: 25–30% of total costs including administrative costs of health insurance, clinicians and institutions, but this does not include time administrative spent by patients and their families

Describing the United Kingdom’s Healthcare System CategoryDescription Financing Budget about 7–8% of GDP has been rising Tax-supported comprehensive and universal coverage through National Health Service Private insurance system with overlapping coverage purchased as additional coverage by ~15% of the population with perception of easier access and higher quality Type(s) of insurance and reimbursement National Health Service is single payer with capitation, plus incentives for General Practitioners, i.e. physicians responsible for panel of patients Specialists generally salaried in National Health Service and often earn substantial additional income through private insurance

Describing the United Kingdom’s Healthcare System CategoryDescription Delivery of care Governmental system of healthcare delivery in National Health Service including government- owned and administered hospitals Emphasis on physicians Primary care general practitioners~ 2/3 Specialist physicians~ 1/3 General practitioners generally do not admit to hospitals Comprehensiveness of insurance National Health Service comprehensive with little cost sharing plus may cover transportation costs Incentives to provide preventive services and home care

Describing the United Kingdom’s Healthcare System CategoryDescription Cost and cost containment Overall limit on national spending (“Global budgeting”) Negotiated rates of capitation and salary with government as single payer within National Health Service having considerable negotiating power Patient choice National Health Service provides limited choice of general practitioners Waiting lines for services in National Health Service especially specialists and high-tech procedures Referral to specialists generally needed Greater choice with private insurance Administrative costs Greater than Canada, less than U.S.

U.S. health system performance as compared to best-performing countries Area of performanceU.S. score (out of 100) Healthy lives72 Quality71 Access58 Efficiency53 Equity71 Overall score65