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Nephrol Dial Transplant (1999) 14 [Suppl 6]: 3-9 IMephrology Dialysis...

Nephrol Dial Transplant (1999) 14 [Suppl 6]: 3-9 IMephrology Dialysis Transplantation Healthcare systems — an international review: an overview N. Lameire, P. Joffe1 and M. Wiedemann2 University Hospital, Gent, Belgium, 'Renal Division, Holbaek County Hospital, Holbaek, Denmark and 2Baxter Deutschland GmbH, Munich, Germany Downloaded from https://academic.oup.com/ndt/article/14/suppl_6/3/1829904 by guest on 05 September 2024 Abstract Based on the source of their funding, three lowest in access and is close to lowest ranking in main models of healthcare can be distinguished. The quality parameters. first is the Beveridge model, which is based on taxation and has many public providers. The second is the Bismarck 'mixed' model, funded by a premium- Introduction financed social insurance system and with a mixture of public and private providers. Finally, the 'Private This report provides a short description of the various Insurance model' is only in existence in the US. The European healthcare systems, focusing on the present report explores the impact of these healthcare healthcare economics and reforms and their influence models on the access to, quality and cost of healthcare on healthcare provision and outcome in general. in selected European countries. Access is nearly 100% in Differences in the following key areas are discussed: countries with a public provider system, while in most access or equity efficacy of healthcare or quality out- of the 'mixed' countries, the difference from 100% is comes and, finally, cost efficiency to achieve these made up by supplementary private insurance. No outcomes. However, a short analysis of some future differences are seen between public and mixed provider trends, based on the effects of demographic changes systems in terms of quality of care, despite the fact and possible health policy reforms, are also provided. that the countries with the former model spend, in Possible factors with an important impact on the general, less of their Gross National Product on structure and quality of healthcare in a given country, healthcare. The Private Insurance/private provider such as culture and traditions, the way of living and model of the US produces the highest costs, but is legislative aspects, are not considered, although they Beveridge Model Private Insurance Bismarck Model UK, Italy, Spain USA France, Germany Sweden, Denmark, Austria Switzerland Norway Finland, Belgium, Holland, Canada Japan predominantly private taxation funding premium-funded National Health Service Medicare/aid + Managed Mandatory Insurance Care predominantly public providers predominantly private private/public providers providers public private mixed Fig. 1. An overview of the three main healthcare models in Europe, the US and Japan. Correspondence and offprint requests to: N. Lameire, Renal Division, Department of Internal Medicine, University Hospital, 185, De Pintelaan, B-9000 Gent, Belgium. © 1999 European Renal Association-European Dialysis and Transplant Association  N. Lameire el al. Canada 100 UK 100 Denmark 100 Finland 100 Public Norway 100 Sweden 100 Italy 100 Switzerland 90 Germany 92 France I 99 Holland Mixed I 69 Belgium I 99 Austria I 99 Downloaded from https://academic.oup.com/ndt/article/14/suppl_6/3/1829904 by guest on 05 September 2024 Japan I 100 USA Private 20 40 60 80 100 Fig. 2. The access to healthcare, expressed as the percentage of the population covered through solidarity systems, in the three groups of countries. 3977 4060 4362 4186 Public Private 1000 2000 3000 4000 5000 6000 Fig. 3. Quality of outcomes in the different healthcare systems, based on premature mortality. The number of potential life years lost is calculated for the year 1989. may be inherent to a given system. However, only capacity. Healthcare systems are therefore different all non-medical factors related to healthcare systems are over the world and are strongly influenced by each considered. This will serve as background for an ana- nation's unique history, traditions and political system. lysis of the differences in provision of the several This has led to different institutions and a large vari- treatment modalities of end-stage renal disease (ESRD) ation in the type of social contracts between the citizens in some of the European countries, presented in other and their respective governments. reports in this issue. In some societies, healthcare is viewed as a predomi- nantly social or collective good, from which all citizens belonging to that society should benefit, irrespective of The healthcare systems in Europe whatever individual curative or preventive care is needed. Related to this view is the principle of solidar- According to the World Health Organization (WHO), ity, where the cost of care is cross-subsidized intention- the healthcare systems present in different countries ally from the young to the old, from the rich to the are strongly influenced by the underlying norms and poor and from the healthy to the diseased. values prevailing in the respective societies. Like other Other societies, more influenced by the market- human service systems, healthcare services often reflect oriented thinking of the 1980s, increasingly perceive deeply rooted social and cultural expectations of the healthcare as a commodity that should be bought and citizenry. Although these fundamental values are gen- sold on the open market. These marketing incentives erated outside the formal structure of the healthcare possibly allow a more dynamic and greater efficiency system, they often define its overall character and of healthcare services and a better control of growth Healthcare systems: an international review Public Downloaded from https://academic.oup.com/ndt/article/14/suppl_6/3/1829904 by guest on 05 September 2024 Private 2.0 4.0 6.0 8.0 10.0 Fig. 4. Quality of outcomes in the different healthcare systems, based on the number of stillbirths. The number of stillbirths per 1000 newborns is given for the year 1994. 81.2 Public S£tss*i8%m^ 70 75 80 85 Fig. 5. Quality of outcomes in the different healthcare systems, based on the life expectancy at birth. The life expectancy is given in years for men (hatched bars) and women (open bars) at birth in the year 1994. in healthcare expenditure. At present, this concept The three models of healthcare where health services are perceived as a market com- modity does not prevail in Europe. Today, three main models of healthcare, based on the Data discussed herein have been published by the source of their funding, can be distinguished: the Organization for Economic Co-operation (OECD) and Beveridge model, the Bismarck model and the Private the WHO. Insurance model (Figure 1). The following countries have been selected for this In the Beveridge 'public' model, funding is based review: the UK, France, Germany, Sweden, Norway, mainly on taxation and is characterized by a centrally Finland, Denmark, Belgium, The Netherlands, organized National Health Service where the services Switzerland, Austria, Italy and Spain. Data from the are provided by mainly public health providers (hos- US, Canada and Japan have been included for comparat- pitals, community doctors, etc.). In this model, ive purposes. healthcare budgets compete with other spending priorit-  N. Lameire et al. 9.8 Public Downloaded from https://academic.oup.com/ndt/article/14/suppl_6/3/1829904 by guest on 05 September 2024 Private 10 12 14 16 Fig. 6. Percentage of the Gross National Product (GNP) spent on healthcare in the three healthcare systems for the year 1994. 2010 Public Mixed Private 1484 500 1000 1500 2000 2500 3000 3500 Fig. 7. Calculation of the expenditures for healthcare expressed as 'Purchasing Power Parities' in US dollars per capita for the year 1994. ies. The countries using this model are the UK, Italy, 'private', respectively, to indicate the different provider Spain, Sweden, Denmark, Norway, Finland and systems. Canada. All healthcare systems are aiming at 'perfection', i.e. The Bismarck 'mixed' model is funded mainly by a they try to achieve an optimal mixture of access to premium-financed social/mandatory insurance and is healthcare, quality of care and cost efficiency. found in countries such as Germany, France, Austria, Switzerland and Benelux. Also, Japan has a premium- based mandatory insurance funds system. This model Access to or equity of the healthcare systems results in a mix of private and public providers, and allows more flexible spending on healthcare. Figure 2 summarizes the access to healthcare, expressed In the 'private' insurance model, funding of the system as the percentage of the population covered through is based on premiums, paid into private insurance com- solidarity systems, such as mandatory Social Security panies, and in its pure form actually exists only in the or National Health Service systems, in the three groups US. In this system, the funding is predominantly private, of countries. It is clear that countries in the 'public' with the exception of social care through Medicare and system show practically a 100% coverage—at least Medicaid. The great majority of the providers in this officially. 'Mixed' countries also come very close to model belong to the private sector. this requirement, with the exception of The In this report, the countries as mentioned above will Netherlands. In most of the 'mixed' countries, the be referred to under the terms 'public', 'mixed' and difference to 100% is made up through additional Healthcare systems: an international review 15.8 Downloaded from https://academic.oup.com/ndt/article/14/suppl_6/3/1829904 by guest on 05 September 2024 5.0 10.0 15.0 20.0 Fig. 8. The percentage of the population older than 65 years in the different categories of countries in the years 1960 (hatched bars) and 1994 (open bars). private insurance, and this part of the population is in per 1000 newborns was not different between the general wealthy enough to bear this additional burden. 'public' and the 'mixed' group of countries, and ranged In contrast, in the 'private' system, represented by between 4.4 and 7.6 and between 4.2 and 8.0 per 1000 the US, Medicare and Medicaid cover only 44% of the births, respectively. The lowest figure is achieved in population. Another 40% are insured by private insur- Japan. The highest number of 'stillbirths' is observed ance, but ~ 37 million Americans (15% of the popula- in the US (8.5 per 1000 births). tion) are not covered. Life expectancy at birth Quality or efficacy of the healthcare systems Figure 5 depicts the life expectancy in years for men For the measurement of the quality or efficacy of a and women at birth in 1994. No significant difference given healthcare system, indicators from the OECD between the various country groups for this parameter database commonly are used, such as the number of could be established. The shorter life expectancy in life years lost, defined as either premature death or men is a general finding in every country. unnecessary death within a population before the age of 65 years, perinatal mortality or number of stillbirths per 1000 newborns, and life expectancy in years at Costs or efficiency of the healthcare systems birth. The efficiency of a given healthcare system for the Premature mortality provision of access to and quality of care can be to measured as the cost of the system, calculated either Figure 3 provides data on quality outcome reflected by as a percentage of the Gross National Product (GNP) premature mortality as measured in the year 1989 in spent on healthcare, or as expenditure for healthcare the three groups of countries. No significant differences in 'Purchasing Power Parities', defined as the equiva- can be found between the 'public' and 'mixed' groups. lent amount of US dollars spent per head of population The number of potential life years lost ranges between per year. Figure 6 compares the cost of the system, 3375 and 4368 years, and between only 2890 and 4654 calculated as a percentage of the GNP spent on years in the 'public' and in the 'mixed' countries, healthcare in the various countries. respectively. In contrast, a higher number of life years There is a clear difference between the 'public' and is lost in the US, at least if the important segment of the 'mixed' countries and a strong difference with the population without social security or with insuffi- regard to the 'private' US system. 'Public' countries in cient coverage is included in this analysis. general spend less of their GNP (between 6.7 and 8.5%, Canada with 9.8% being an exception) on healthcare than 'mixed' countries (between 7.3 and Number of stillbirths 9.9%). In contrast, the US spends 14.2% of its GNP on healthcare, which is more than double the amount Figure 4 provides data on the number of stillbirths per spent in Denmark (6.7%). 1000 births in the year 1994. The number of stillbirths Figure 7 shows the calculations of the expenditures  N. Lameire et al. Canada 10.7 Public UK 7.3 Sweden 10.9 Italy 9.1 Spain 10.6 Germany 10.4 Mixed France 10.6 Holland 10.2 Japan 8 Downloaded from https://academic.oup.com/ndt/article/14/suppl_6/3/1829904 by guest on 05 September 2024 Private US* I 15.1 1 1 i 1 0 5 10 15 20 Fig. 9. Prediction of the cost of healthcare in selected countries in the year 2000, expressed as a percentage of the GNP spent on healthcare. for healthcare in 'Purchasing Power Parities', in the Taken together with the high life expectancy in three groups of countries for the year 1994. Between virtually all countries, some realistic calculations on US$971 and US$2010 per head is spent on healthcare the growth of the costs of healthcare can be made. in 'public' countries, which is much lower than in the The National European Research Associates (NERA) 'mixed' countries. The latter spend from US$1484 to had already in 1993 made such calculations for a US$2294 per year per capita. Despite the lowest access selected number of countries (Figure 9). Most of these to healthcare (with only 85% of the population covered countries, regardless to which group they belong, will by either Medicare and Medicaid or by private insur- reach a level of healthcare cost of 10-11% of their ance) and the lowest quality performance, at least GNP, and the US will reach > 15% in the year 2000. based on the number of life years lost or on the number It is interesting to note that healthcare expenses have of stillbirths, the US spend US$3498 per year on grown over the past 50 years because of and/or in healthcare, which is a factor of 3.5 times higher than spite of several healthcare reforms. After World War Spain, for example. II, a first major wave of reforms focused on equity, Consequently, the amount of money spent on creating access to healthcare for everybody. Hospital healthcare in a given system is in itself not an indicator care was seen as the main provider. The second wave of its quality, but is related more to differences in of reforms in the 1970s tried to improve quality by provider structures in the systems. 'Public' countries emphasizing prevention and primary care. An increase tend in general to spend less money on healthcare in the quality of ambulatory care was emphasized in compared with 'mixed' and 'private' countries, but this an effort to contain growing hospital expenses. lower spending does not seem to be associated with Today, further reforms are necessary because of differences in quality outcomes. uncontrolled increases in cost. The increasing need for care for a growing elderly population, the development of new technologies and the improvement of care in Future prospects general in the presence of a growing economic con- straint create a number of dilemmas for all govern- Two important questions can be raised: first, will the ments. It is thus not surprising that all current reform increase in quality requirements be stimulated by the efforts are centred around cost and cost control. development of new health technologies, or will the The principle of solidarity and the assurance of growing quantitative needs due to the increasing age quality in healthcare, more specifically in the fast of the populations lead to a further growing cost in growing segment of chronic diseases, such as ESRD, the future? Second, how will the governments in the may be questioned in the future. The impact of these various countries respond to these new challenges? considerations on the different treatment modalities of Figure 8 depicts the evolution between 1960 and ESRD is the subject of other papers in this supplement. 1994 of the percentage of the population older than 65 years in the different countries. This share of the elderly population has already considerably increased Data sources in all countries included in this review. The differences European Healthcare Reforms, Analysis of Current Strategies. WHO between the country groups are remarkably small, with Copenhagen, 1996 a share of the older population of