INTERNATIONAL PROFILES OF HEALTH CARE SYSTEMS, 2013 AUSTRALIA, CANADA, DENMARK, ENGLAND, FRANCE, GERMANY, ITALY, JAPAN, THE NETHERLANDS, NEW ZEALAND, NORWAY, SWEDEN, SWITZERLAND, AND THE UNITED STATES EDITED BY SARAH THOMSON, LONDON SchOOL OF ECONOMIcs AND POLITICAL SCIENCE, ROBIN OSBORN, THE COMMONWEALTH FUND, DAVID SQUIRES, THE COMMONWEALTH FUND, AND MIRAYA JUN, LONDON SchOOL OF ECONOMIcs AND POLITICAL SCIENCE NOVEMBER 2013 THE COMMONWEALTH FUND is a private foundation that promotes a high performance health care system providing better access, improved quality, and greater efficiency. The Fund’s work focuses particularly on society’s most vulnerable, including low- income people, the uninsured, minority Americans, young children, and elderly adults. The Fund carries out this mandate by supporting independent research on health care issues and making grants to improve health care practice and policy. An international program in health policy is designed to stimulate innovative policies and practices in the United States and other industrialized countries. INTERNATIONAL PROFILES OF HEALTH CARE SYSTEMS, 2013 AUSTRALIA, CANADA, DENMARK, ENGLAND, FRANCE, GERMANY, ITALY, JAPAN, THE NETHERLANDS, NEW ZEALAND, NORWAY, SWEDEN, SWITZERLAND, AND THE UNITED STATES EDITED BY SARAH THOMSON, LONDON SchOOL OF ECONOMIcs AND POLITICAL SCIENCE, ROBIN OSBORN, THE COMMONWEALTH FUND, DAVID SQUIRES, THE COMMONWEALTH FUND, AND MIRAYA JUN, LONDON SchOOL OF ECONOMIcs AND POLITICAL SCIENCE NOVEMBER 2013 Abstract: This publication presents overviews of the health care systems of Australia, Canada, Denmark, England, France, Germany, Japan, Italy, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United States. Each overview covers health insur- ance, public and private financing, health system organization and governance, health care quality and coordination, disparities, efficiency and integration, use of information technology and evidence-based practice, cost containment, and recent reforms and inno- vations. In addition, summary tables provide data on a number of key health system char- acteristics and performance indicators, including overall health care spending, hospital spending and utilization, health care access, patient safety, care coordination, chronic care management, disease prevention, capacity for quality improvement, and public views. To learn more about new publications when they become available, visit the Fund’s website and register to receive email alerts. Commonwealth Fund pub. no. 1717. CONTENTS Table 1. Health Care System Financing and Coverage in Fourteen Countries 6 Table 2. Selected Health Care System Indicators for Fourteen Countries 7 Table 3. Selected Health Care System Performance Indicators for Eleven Countries 8 Table 4. Provider Organization and Payment in Twelve Countries 9 The Australian Health Care System, 2013 11 The Canadian Health Care System, 2013 19 The Danish Health Care System, 2013 28 The English Health Care System, 2013 37 The French Health Care System, 2013 45 The German Health Care System, 2013 57 The Italian Health Care System, 2013 66 The Japanese Health Care System, 2013 76 The Dutch Health Care System, 2013 85 The New Zealand Health Care System, 2013 95 The Norwegian Health Care System, 2013 104 The Swedish Health Care System, 2013 113 The Swiss Health Care System, 2013 120 The U.S. Health Care System, 2013 129 Table 1. Health Care System Financing and Coverage in Fourteen Countries HEALTH SYSTEM AND PUBLIC/PRIVATE INSURANCE ROLE BENEFIT DESIGN Private Insurance Role (Core Benefits; Cost-Sharing; Noncovered Benefits; Private Facilities or Amenities; Government Role Public System Financing Substitute for Public Insurance) Caps on Cost-Sharing Exemptions and Low-Income Protection Australia Regionally administered, joint (national & General tax revenue; earmarked income tax ~50% buy coverage for private hospital costs No. Safety nets include 80% OOP rebate Low-income and older people: Lower cost- state) public hospital funding; universal pub- & noncovered benefits if physician costs exceed AUS$1,222 sharing; lower OOP maximum before 80% lic medical insurance program (Medicare) [US$1,160] subsidy Canada Regionally administered universal public Provincial/federal tax revenue ~67% buy coverage for noncovered benefits No No cost-sharing for Medicare services. Some insurance program (Medicare) cost-sharing exemptions for non-Medicare services, e.g., drugs outside hospital; varies by province Denmark National health service Earmarked income tax ~55% buy coverage for cost-sharing, No. Decreasing copayments with higher Drug OOP cap for chronically ill (DKK 3,410 noncovered benefits, or access to private drug OOP spending [US$617]); financial assistance for low- facilities income and terminally ill people England National health service General tax revenue (includes employment- ~11% buy for private facilities mainly for No general cap for OOP. Prepayment certifi- Drug cost-sharing exemption for low- related insurance contributions) elective surgery and consultations with cate with £2 [US$3.20] per week ceiling for income, older people, children, pregnant specialists those needing a large number of prescrip- women and new mothers, and some dis- tion drugs. abled/chronically ill. Financial assistance with transport costs available to people on low incomes. France Statutory health insurance system, with all Employer/employee earmarked income and ~90% buy or receive government vouchers No. €50 [US$67] cap on deductibles for con- Exemption for low-income, chronically ill and SHI insurers incorporated into single national payroll tax; general tax revenue, earmarked for cost-sharing; some noncovered benefits sultations and services disabled, and children exchange taxes Germany Statutory health insurance system, with 134 Employer/employee earmarked payroll tax; Cost-sharing + amenities (~20%); Substitute: Yes. 2% income; 1% income for chronically ill Children exempt competing SHI insurers (“sickness funds” in a general tax revenue 10% opt-out of SHI system for private cover- + low-income people national exchange); high income can opt out age only for private coverage Italy National health service National earmarked corporate and value- ~15% buy coverage for access to private No. €46.15 [$59 USD] copayment on outpa- Exemptions for low-income older people/ added taxes; general tax revenue and facilities and amenities tient care; limited copayment (regional rates) children, pregnant women, chronic condi- regional tax revenue on drugs tions/disabilities, rare diseases Japan Statutory health insurance system, with General tax revenue; insurance contributions Majority buy coverage for cash benefits/ No. Coinsurance reduced to 1% after 80,100 Low-income monthly OOP ceiling: 35,400 approx. 3,500 noncompeting public, quasi- cost-sharing yen [$999 USD] monthly cap yen [$441 USD]; reduced cost-sharing for public, and employer-based insurers young children and older people Netherlands Statutory health insurance system, with Earmarked payroll tax; community-rated Private plans provide universal core benefits; No. But annual deductible of €350 [US$472] Children exempt from cost-sharing; premium universally mandated private insurance insurance premiums; general tax revenue 90% buy for noncovered benefits covers most cost-sharing subsidies for low-income (national exchange) New Zealand National health service General tax revenue ~33% buy for cost-sharing, access to special- No. Subsidies after 12 doctor visits/20 pre- Lower cost-sharing for low-income, some ists, and elective surgery in private hospitals scriptions in past year chronic conditions, Maori and Pacific Island- ers; young children mostly exempt Norway National health service General tax revenue <10% holds VHI, mainly bought by employ- Yes. Main cost sharing ceiling is NOK 2,040 Exemptions for children <16 years somatic, ers for providing employees quicker access [US$342] <18 years psychiatric, pregnant women, and for some communicable diseases (STDs) Sweden National health service General tax revenue <5% buy for private facilities Yes. SEK 1100 [US$169] for health services & Exemption for children and pregnant women SEK 2200 [US$337] for drugs Switzerland Statutory health insurance system, with Community-rated insurance premiums; Private plans provide universal core benefits; Yes. 700 CHF [US$768] max after deductible Income-related premium assistance (30% re- universally mandated private insurance general tax revenue majority buy private plans for noncovered ceive); some assistance for low-income; some (regional exchanges) benefits and amenities exemptions for children, pregnant women United Medicare: age 65+, some disabled; Medicaid: Medicare: payroll tax, premiums, federal tax Primary private insurance covers 56% of No Low-income: Medicaid; older people and States* some low-income (most under age 65 cov- revenue; Medicaid: federal, state tax revenue population (employer-based and individual); some disabled on Medicare ered by private insurance; 16% of population supplementary for Medicare uninsured) * Prior to January 1, 2014. 6 THE COMMONWEALTH FUND Table 2. Selected Health Care System Indicators for Fourteen Countries New United United Australia Canada Denmark France Germany Italy Japan Netherlands Zealand Norway Sweden Switzerland Kingdom States Population, 2011 Total Population (1,000,000s of people) 22.323 34.484 5.571 65.161 81.373 60.724 127.799 16.718 4.404 4.952 9.447 7.912 61.760 311.588 Percentage of Population Over Age 65 13.7% 14.7%