Germany Universal coverage for all legal residents  Since 1883 (!) employers and employees have paid into “sickness funds” Social Health Insurance (90%)  Income about <$65,000 mandatory coverage and payment  Payroll tax of 15.5% (split btw employers and employees)  ~200 Sickness funds organized by companies, geographic area, trade guilds  If an employee retires or loses job, they retain membership in their sickness fund; gov’t pays their share Private health insurance (10%)  Over ~$65,000 can choose a voluntary  Pay providers higher fees; may lead to preferential treatment

Germany: Providers About 50/50 generalist/ specialist split Not employed by government Strict separation between Outpatient and Inpatient providers  Outpatient physicians are paid FFS  Members of Regional Physician Associations. These associations are paid lump sums by sickness funds, with expenditure caps  Inpatient providers paid by salary  Hospitals: global budgets, paid by similar system as DRGs in U.S.

Germany: Impact Access: universal for  Undocumented can get care during illness  76% report getting same- or next-day appt  90% received specialty appt <2 mos (U.S. 94%) Cost  5 th highest per capita expenditure; ~9% of GDP  Rose in 1990s, so increased co-payments, controls on drug prices  Since 2000, stable growth Quality  Lower scores on Care coordination, mortality after MI than U.S.  Better scores on immunizations, mortality from lack of access to care

Canada The famous “Single Payer” system: Medicare  1957 Hospital insurance  1966 Medical Care Act: included physician and other medical care  1984 Canada Health Act Administered at Province-level  1/3 rd Federal funding: CHA established conditions to receive funds. All Canadians receive same insurance  No link to employment  Private insurance can supplement, but cannot replace Providers are not employed by the gov’t  Half are Family physicians/ Primary care  Physicians paid mostly Fee-for-service, by a negotiated fee schedule Hospitals are heavily regulated,  Mandated to have global budgets; Need approval for capital spending

Canada: Impact Access  Wait times? Yes for certain specialty referrals and procedures  Wait Time Reduction Fund requires reporting to a central agency Health expenditures  $211 billion in 2013; 11.6% of GDP, slower growth rate than GDP  Drug costs fastest rising; hospital and physician costs have decreased  Smaller disparity btw Primary care and specialist payments  Administrative costs are 1/3 of U.S. per capita  Less technology: 15 MRIs per million; US: 35 per mil Quality:  High satisfaction rate among Canadians  By 2007, most family docs integrated in multi-specialty groups  Global budgets allow investments in population health

Canada: Single medical liability insurer: Canadian Medical Protective Association  Physician dues, partly by gov’t, 1/10 th the cost of U.S. insurance  Federal cap on damages;  $2.5 bil fund; paid about $249m in 2012

Innovation and Advocacy Innovation  Primary Care innovation  Oak Street Health, Iora, Caremore, Primary Care Progress  Behavioral health integration  Community Health Workers  Virtual and Telemedicine Advocacy  “Organized Medicine” AMA, AMSA, prof societies  Doctors for America (full disclosure!)  PSR, PHR, PNHP,