WWS 597 Reinhardt THE HEALTH CARE SYSTEMS OF GERMANY AND SWITZERLAND Merely slouching towards “Regulated Competition” SOCIAL INSURANCE WITH PRIVATE PURCHASING THE FINANCING OF HEALTH CARE SOCIAL PRIVATE NO HEALTH INSURANCE INSURANCE OWNERSHIP INSURANCE OF PROVIDERS (Ability-to-Pay Financing) (Actuarially fair premiums) Single Multiple Non- For- Out-of- Payer Carriers Profit Profit pocket Government A D G J M Private, but non-profit B E H K N Private, and commercial C F I L O First, some comparative statistics International Comparison of Spending on Health, 1980–2007 Average spending on health per capita ($US PPP) 8000 7000 U.S. Switzerland 6000 Netherlands 5000 Germany 4000 3000 2000 1000 0 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Source: OECD Health Data 2009 (June 2009) cited in http://www.commonwealthfund.org/Content/Publications/Chartbooks/2009/Multinational-Comparisons-of-Health-Systems- Data-2009.aspx International Comparison of Spending on Health, 1980–2007 Total expenditures on health as percent of GDP 16 15 U.S. 14 Switzerland 13 Germany 12 Netherlands 11 10 9 8 7 6 5 005 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2 2006 2007 Source: OECD Health Data 2009 (June 2009) cited in http://www.commonwealthfund.org/Content/Publications/Chartbooks/2009/Multinational-Comparisons-of-Health-Systems- Data-2009.aspx Percentage of Population over Age 65 Percent with Influenza Immunization, 2007 80 77.5 77.0 73.5 69.0 70 66.7 64.9 64.3 63.7 58.9 60 56.0 56.0 50 40 30 20 10 0 a AUS* NETH UK FR US ITA CAN NZ OECD GER SWITZ Median * 2006 Source: OECD Health Data 2009 (June 2009). Obesity (BMI>30) Prevalence Among Adult Percent Population, 2007 34.3 35 30 26.5 25 24.0 20 15.4 15 13.6 11.2 10.5 10.2 9.9 9.0 10 8.1 5 0 US* NZ UK CAN GER** NETH FR* SWE ITA NOR SWITZ * 2006 ** 2005 Note: BMI = body mass index. For most countries, BMI estimates are based on national health interview surveys (self-reported data). However, the estimates for the US, UK, and New Zealand are based on actual measurements of weight and height, and estimates based on actual measurements are usually significantly higher than those based on self-report. Source: OECD Health Data 2009 (June 2009). Potential Years of Life Lost Because of Diabetes per 100,000 Population, 2007 99 100 80 64 60 40 37 36 36 35 33 31 29 25 19 20 0 US** NZ** NOR* SWE* OECD GER* NETH ITA* FR* UK SWITZ* Median * 2006 ** 2005 Source: OECD Health Data 2009 (June 2009). Health Care Expenditure per Capita by Source of Funding, 2008 Dollars In Purchasing‐Power Parity Dollars (PPP $s) 8,000 $7,538 Out-of-pocket spending 7,000 912 Private spending Public spending 6,000 $5,003 5,000 3,119 $4,627 756 $4,029 35 $3,796 $3,737 4,000 1,424 600 273 $3,472 $3,362 487 $3,319 648 543 616 382 605 3,000 467 88 347 197 494 2,000 4,213 3,507 2,863 2,875 2,869 2,736 2,841 2,585 1,000 2,263 0 US NOR SWITZ CAN FR GER SWE AUS* UK * 2007 SOURCE: OECD DATA BASE 2010, cited in Anderson and Markovich, “Multinational Comparisons of Health Systems Data, 2010, Commonwealth Fund International Symposium, 2010. Out‐of‐Pocket Health Care Spending per Capita, 2008 In Purchasing‐Power Parity Dollars (PPP $s) Dollars $1,600 $1,500 $1,424 $1,400 $1,300 $1,200 $1,100 $1,000 $912 $900 $756 $800 $700 $600 $605 $543 $492 $600 $487 $500 $372 $347 $400 $273 $300 $232 $200 $100 $0 SWITZ US NOR CAN AUS SWE OECD GER NZ UK FR NETH 2006 Median SOURCE: OECD DATA BASE 2010, cited in Anderson and Markovich, “Multinational Comparisons of Health Systems Data, 2010, Commonwealth Fund International Symposium, 2010. Hospital Discharges per 1,000 Population, 2007 300 274 250 227 200 172 166 165 163 162 150 139 135 126 126 109 100 84 50 0 FR GER NOR SWITZ SWE OECD AUS* ITA* NZ US* UK NETH CAN* Median * 2006 Source: OECD Health Data 2009 (June 2009). Number of Practicing Physicians per 1,000 Population, 2007 4 3.9 3.9 3.9 3.7 3.6 3.5 3.4 3.2 3 2.8 2.5 2.4 2.3 2.2 2 1 0 NETH NOR SWITZ ITA SWE* GER FR OECD AUS* UK US NZ CAN Median * 2006 Source: OECD Health Data 2009 (June 2009). Pharmaceutical Spending per Capita, 2007 Dollars Adjusted for Differences in Cost of Living 900 $878 800 $691 700 $588 600 $542 $518 500 $454 $446 $446 $431 $422 $381 400 300 $241 200 100 0 US CAN FR GER ITA SWITZ SWE OECD AU S* N ET H N O R N Z Median * 2006 Source: OECD Health Data 2009 (June 2009). Drug Prices for 30 Most Commonly Prescribed Drugs, 2006–07 1.00 US is set at 1.0 1.0 0.8 0.77 0.76 0.63 0.6 0.51 0.49 0.45 0.44 0.4 0.34 0.2 0.0 US CAN GER SWITZ UK AUS NETH FR NZ Source: IMS Health. Drug Prices: Lipitor (atorvastatin), 2006–07 Dollars Price for one dose $3 $2.82 $2 $1.83 $1.52 $1.46 $1.45 $1.45 $1.35 $1.01 $1 $0.71 $0 US CAN SWITZ AUS UK NETH GER FR NZ Source: IMS Health. Drug Prices: Nexium (esomeprazole), 2006–07 Dollars Price for one dose $3.91 $4 $3 $2.15 $1.97 $2 $1.32 $1.28 $1.22 $1.02 $1 $0.88 $0 US SWITZ CAN UK NETH FR AUS GER Source: IMS Health. Magnetic Resonance Imaging (MRI) Machines per Million Population, 2007 30 25.9 20 18.6 14.4 10 8.8 8.5 8.2 8.2 6.7 6.6 5.7 5.1 0 US ITA SWITZ NZ OECD G ER U K C AN N ET H * * FR AU S Median ** 2005 Source: OECD Health Data 2009 (June 2009). MRI Scan and Imaging Fees, 2009 Dollars 1,400 1,200 1,200 1,000 839 824 800 567 600 436 400 179 200 0 US GER CAN NETH FR UK Source: International Federation of Health Plans, 2009 Comparative Price Report. Coronary Bypass Procedures per 100,000 Population, 150 2007 132 125 100 85 81 77 76 73 73 75 59 58 56 50 45 32 31 25 0 GER US* NOR* NZ AUS* ITA* CAN* OECD NETH SWE UK FR SWITZ Median * 2006 Source: OECD Health Data 2009 (June 2009). A closer look at German health care THE HEALTH INSURANCE SYSTEM OF GERMANY A health‐are system with the following features 1. Mandated, universal health insurance (about 90% in the non‐ profit, private, Statutory Health Insurance (SHI) system (initiated by Chancellor Otto von Bismarck in the late 1880s), and about 10% with highly regulated for‐profit private insurers. 2. A mixed public‐private delivery system with a heavy for‐profit component, even among hospitals. 3. Overall pervasive and tight government regulation at both the state and federal levels. 4. By American standards, relatively low cost. THE STATUTORY HEALTH INSURANCE SYSTEM OF GERMANY The system grew out of the self‐help “friendly societies” established by workers during the industrialized revolution of the 1880s. Became a federal system in 1998 with Bismarck’s RVO –the Reichs‐versicherungsverordnung (Imperial Insurance Decree) which survives, after a myriad amendments over time to this day. Originally composed of over 1,000 quasi‐private, non‐profit sickness funds with what is called “self‐regulation”, but only within the very narrow limits allowed by the RVO. THE STATUTORY HEALTH INSURANCE SYSTEM OF GERMANY Up to an income threshold that has changed over time (currently $62,500), all employed Germans were mandated to be insured under the SHI. Above the threshold people were free to choose private insurance or remain in the SHI or go without insurance. Until very recently (starting in 1992 and fully since 2004) people in the SHI did not have a choice of sickness plans, but instead were assigned to it on the basis of either craft, employer or location. Until 2004, the payroll contributions to the SHI (shared 50:40 by employers and employees) varied enormously among funds, which brought on the reforms of 2004. THE STATUTORY HEALTH INSURANCE SYSTEM OF GERMANY Since 2004, Germans can choose among any of the 200 or so surviving sickness funds, at a uniform payroll tax, which covers the employee and dependent non‐working spouse, but not children, whose premiums are paid by the federal government. Unlike in the US, where patients often are confined to networks of providers, Germans have long enjiyed completely free choice of providers. Premiums paid by the insured now flow through the system as follows: Premiums Central health for Fund Children Federal (Risk Equalization Fund Government Uniform payroll contribution of Risk adjusted capitation about 15% (and growing) of gross to sickness fund chosen wages shared by employer and by the insured employee ~ 160 non-profit Adult Insured Sickness Funds (Insurers) C o For unemployed people -P DGRs for hospitals; capital from state ays the Unemployment FFS for ambulatory physicians Insurance fund pays the premiums.