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Healthcare System Models

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Elana Lowell

on 14 October 2014

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Transcript of Healthcare System Models

Four basic healthcare models
Oral Healthcare Systems
Which model is best?
Beveridge model
Oral healthcare models in Europe
Economic, social, and demographic climate in Europe has change
Increase in average life expectancies
Decline in the fertility rate
Led to an extension of non-employment and dependency periods
More expensive medical services and technology

Social insurance contributors must support an increasing number of people who no longer contribute
The Bismarck system did not envision this
The Beveridge system is also under financial pressure
Financing of the healthcare system must compete for tax allocation with other policy areas

Example of convergence
France (Bismarck)
Imposed broad-ranging tax to finance their healthcare system in 1997
Contribution sociale generalisee
The provision of oral healthcare often operates outside the general healthcare system and the role of private services is more significant.
Example: Italy
Private oral healthcare system, but a public NHS for general healthcare
Healthcare system models
Measuring oral health complicated
There is no general, standardized measure
Like quality-adjusted life year (QALY) used for general health
The decayed, missing, and filled teeth (DMFT) index in 12-year old children is a proxy for the dental health of children
Most dental care provided by independent dentists in contract with the NHS
Contract regulates prices and treatment profiles, average income, and pensions
Growing proportion of oral healthcare is being provided outside the NHS under private contracts
Team dentistry plays an increasing role in the provision of care with dental hygienists, therapists, and clinical dental technicians
Each of the four countries within the U.K. has a national CDO
Each nation’s healthcare system is a reflection of its:
National values
While all systems vary to some degree, they all share common principles.

These organizational principles are rooted in four basic healthcare models.
Named for the Prussian Chancellor Otto von Bismarck
Invented the welfare state as part of the unification of Germany in the 19th century
Introduced statutory health insurance in 1883
Germany, France, Belgium, the Netherlands, Japan, Switzerland, (Latin America)
Mixed Model
Out-of-Pocket Model
Named after William Beveridge
Social reformer who designed Britain’s National Health Service (NHS) in the 1940s
Single-payer system
Includes the entire population
Healthcare is provided and financed by the government
Through tax payments
Medical treatment is a public service
There are no medical bills
Low costs per capita
The government, as the sole payer, controls what doctors can do and what they can charge
Some doctors are public (government) employees
Others are private doctors who collect their fees from the government
Many (but not all) hospitals and clinics are owned by the government
Social health insurance
National health service
"Beveridge" Tax
Has elements of both Beveridge and Bismarck
Payment comes from a government-run insurance program that every citizen pays into
Simpler administrative costs
No need for marketing, no financial motive to deny claims, and no profit
Single payer has considerable market power to negotiate lower prices (e.g., pharmaceutical prices)
Control costs by limiting the medical services they will pay for, or by making patients wait to be treated
Providers are private
National health insurance
Only developed, industrialized countries have established healthcare systems
Most nations are too poor and too disorganized to provide any kind of mass medical care
Most medical care is paid for by the patient, out-of-pocket
No insurance or government plan
Beveridge or Bismarck
Bismarck model
Characterized by significant government involvement
Government has central role in guidance and supervision
Combines elements of both Bismarck and Beveridge models
Eastern European model
(in transition)
Heterogeneous group
Characterized by universal sickness insurance
Oral healthcare is financed through compulsory social insurance
Insurance system is subject to close regulation by the government
Statutory sickness insurance that reimburses some or all of the costs of dental care
Agreements cover most restorative dental care
Financed by employers and employees
National or regional sickness funds negotiate with dental associates about fees
Dentist working independently as private practitioners
Very small public sector
Clinical auxiliaries rarely used
No appointed dentist as a national Chief Dental Officer (CDO)
Most central European countries
Austria, Belgium, France, Germany, and Luxembourg
Finance care through general taxation
Some salaried public dental services located in community and hospital clinics
Free care for children and subsidized care for adults
U.K. (England, Northern Ireland, Scotland and Wales)
Nordic model
General or local taxation
Private sector subsidized through public health insurance
A well-developed salaried service
Widespread use of clinical auxiliaries
Dental team is well-developed
Some aspects of oral healthcare are provided by dental hygienists and clinical dental technicians
Nationally appointed CDOs
Denmark, Finland, Norway, Sweden
Exception: Iceland has no public dental service
Southern European model
(mixed systems)
Some limited clinical auxiliaries
Dental hygienists (except in Greece)
Government appointed CDOs
Italy, Portugal, Spain
(Greece, Cyprus and Malta)
There used to be free public oral healthcare
Since political changes in 1989, public sector provision has been reduced
Dentists were salaried public employees
Oral health facilities were publicly owned
Distribution of personnel, clinics, treatments and materials was planned
Increasing privatization
Dental hygienists work in these countries
Nationally appointed CDOs
Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Slovakia, and Slovenia
Hybrid systems
Include a mixture of elements from a few models

Iceland, Ireland, and the Netherlands

Iceland and the Netherlands
Dental professionals are private
Public/private mix
Sickness funds (insurers)
Multi-payer model
Insurance plans cover everyone, and do not make a profit
Financed jointly by employers and employees through payroll deduction
Doctors and hospitals are mostly private
Analogy in U.S. system
Working American who get employer-sponsored insurance
Sickness & Pepto-"Bismarck"
Analogy in U.S. system
Veteran Affairs
U.K., Spain, most of Scandinavia, New Zealand, Hong Kong, Cuba
Canada, Taiwan, South Korea
Analogy in U.S. system
Analogy in U.S. system
The 50 million Americans without health insurance
Most of Africa, India, China, most of South America
No country follows either of the two systems in its pure form and the deviations among individual benefits can be significant
Convergence of the two systems has occurred
Private provision and finance of oral healthcare
Some public services are available free to children and to treat emergencies
Funded from local or regional taxation
The majority of oral healthcare is now provided in the private sector
The oral healthcare system models modulate the relationship between oral health and the oral health system
By means of funding, and increasing or decreasing access to dental professionals
But many factors come into play
Some conclusions
Council of European Chief Dental Officers (CECDO) database

The former communist countries of Eastern Europe are the poorest and have the highest (worst) DMFT scores
Though there has been great improvement
Nordic countries have the best outcomes

Dental workforce
No significant difference among oral healthcare models and the proportion of human resources
No correlation between DMFT and the availability of dental healthcare professionals
So what does influence oral health (lower DMFT in 12-year old children)?
The significant parameters:
Educational level
Total healthcare expenditure
Income (GNP per capita)
In part because costs of dental treatment vary in accordance with differences in GNP per capita
But there is no difference in average expenditure among models of oral healthcare systems
To be continued . . .
Final thoughts
General vs. oral healthcare
General healthcare
Bismarck systems are ranked higher than single-payer Beveridge systems
Oral healthcare
The Nordic model along with the Beveridge-Hybrid model have a lower DMFT index than other models (e.g., Bismarck)

Cross-national comparisons
Differences vs. similarities
"American exceptionalism"

Importance of healthcare system models as a conceptual framework
Full transcript