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Healthcare in Other Developed
Countries—What’s the Difference
Aaron Liberman, Ph.D., LHRM
Professor
Department of Health Management &
Informatics
University of Central Florida
1
Conventional Wisdom RE Healthcare in
Other Developed Countries

CW#1-It’s Socialized Medicine out there &
U.S. is Capitalist Society-won’t work here
– Reality -Most developed countries use private
sector to address large portion of health needs
– Beveridge Model - prevalent in UK, Cuba, Spain,
Italy-Gov’t pays the bills-closest to Socialism
– NHI Model - Canada & Taiwan use private sector
for services-but Government pays bills
– Bismark Model - France, Germany, Netherlands,
Switzerland, Japan use private sector
– Self-Pay Model – Prevalent in less developed
countries & the U.S. (for uninsured)
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Conventional Wisdom (continued)
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CW#2-Care Rationed-Waiting Lists &
Limited Choices
– Reality of Choices-some countries allow
choice of insurance plans (Germany 200)
& others providers (France & Canada)
– Reality of Waiting Lists-Germany,
France, Sweden, Switzerland outperform
U.S. on Wait time for Specialists and Wait
time for elective procedures
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Conventional Wisdom (continued)

CW#3-Wasteful Systems with
Bloated Bureaucracies
– Reality-U.S. has highest administrative
costs for private insurance. 20% for
marketing, administration, & other
overhead (commissions)-a for-profit model
– Average Overhead in other countries
ranges between less than 2% (Taiwan) to
6% (Canada)-a not for profit model
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Conventional Wisdom (continued)

CW#4-Insurance Companies Must be
Rigid & Strict (Mean)
– Reality-France, Germany, Japan,
Switzerland insurance companies must
accept ALL applicants & pay ALL claims
– Reality- In all models, government
exercises oversight—including the U.S.
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Conventional Wisdom (continued)

CW#5-Those Systems are too foreign
to work in U.S.
– We believe foreign systems all the same
– Reality, countless varieties of systems
– Some require co-pay (F); others no copay (U.K.)
– Some governments set insurance
premiums (Germany, France); others
allow companies to set premiums (Swiss)
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Principal Challenge in America
Two Fold
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U.S. System Analogous to Binary
Numeral System
0 or 1-you have it (#1) or you don’t (#0)
America’s Healthcare System = 250
million people with health insurance (#1)
Up to 60 million people without health
insurance (#0)
Those without must fend for themselves
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Time for a Reality Check
Sampling of health care in
developed countries to see
how systems are structured
& what occurs when a
person seeks healthcare
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Health System of France
Every Resident of France is Covered
More Docs per capita & More Hospital
Beds per capita than America
Near the top worldwide in (WHO data):
– Disability Adjusted Life Expectancy (DALE)
– Infant Mortality
– Overall Life Expectancy
Source: Unraveling U.S. Healthcare—a Personal Guide
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Health System of France
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Citizens purchase insurance from
government health plan & from private
carriers to cover the costs
Insurance carriers (funds) are not-for-profit
entities focused on paying claims, not making
a profit
Delays in reimbursement are illegal
No limits on patient choice
No ‘in-network’ or ‘out-of network’ madness
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Health System of France
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Multi-Payer System with 14 carriers
(funds) to select from & a cluster of
supplemental plans
Functions like a single payer system
because Health Ministry dictates what
carriers can & cannot do
Universal carte d’assurance maladie or
Carte Vitale
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Health System of Germany
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Home of Bismarck System began in
1883 by Otto von Bismarck, founder of
modern German Republic
Sickness Insurance Law guarantees
medical care to 82 million citizens
Choice of doctor + hospital & the
krankenkassen must pay the bill
Choice of 200 krankenkassen plans
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Health System of Germany
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Physicians are private practitioners
in private clinics
Charges by Krankenkassen fixed by
government
Vigorous competition for participants
based on quality of service
Krankenkassen negotiates rates with
medical clinics, hospitals+DME &
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Pharma imports
Health System of Germany
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Freedoms and benefits cost $-German
system is most expensive among
European countries costing 11% GDP
All Germans must belong to a Sickness
Fund
No one can be turned down due to preexisting condition
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Health System of United
Kingdom
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Beveridge System-universal coverage,
no bills
NHS-Lord William Beveridge in 1942
Overarching proposition=no one should
be forced to pay a medical bill
System allows private supplemental
plans for 1% who want them
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Health System of United
Kingdom
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NHS has more than 1 million FTEs
Largest employer in Europe
Has $10 co-pay for drugs, but 85% of all
prescription costs are waived
First line of defense in cost control is network
of GPs. GPs are independent practitioners
as are pharmacists & dentists
Queue is also tool of cost control
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Health System of United
Kingdom
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NHS controls budget by range of funded
medications, tests, procedures
America does the same through
insurance company decisions re
reimbursements for procedures
Typical physician pays $4,200 /year for
malpractice insurance—1/12 the cost
for American counterpart
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Health System of United
Kingdom
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Medical School tuition in UK =$4,000
per year
Medical School tuition in America
approximately ten times that amount
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Japanese System of Healthcare
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Private sector Bismarck system with
private doctors and private hospitals
System has a rigid cost control
mechanism that favors the patient
Typical Japanese citizen visits doctor 15
times per year (U.S. average = 5 times
per year
Small co-pays charged—no wait lists
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Japanese System of Healthcare
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Japanese system = 8% of GDP
Monthly limit on patient co-pays of $650
Health plans must accept all who apply and
pay every bill submitted by providers
3,500 health plans to choose from
Types: (a) large employer plans; (b) small
employer plans; (c) Citizens Health Insurance
Plan for retirees & self employed
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Japanese System of Healthcare
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Financing of healthcare plans involves
cost sharing between government,
employers, & employees
All citizens must participate
If a citizen refuses to participate not
arrested. On becoming ill, no one
pays costs until citizen pays at least
one year of owed back premiums
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Japanese System of Healthcare
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Reimbursement system restrictions
have increased cost control efforts of
providers
MRI example-providers insisted on
lower cost equipment. Result=cost for
MRI Scanner in Japan=$150k=1/10th
the cost in America
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Japanese System of Healthcare
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Mission Statement Japanese Hospital
– We welcome each patient with a smiling
face, warm sympathy, soft language
– We offer a sense of assurance re your
health
– We will protect your privacy & dignity
– Preserving your life & health is the reason
we exist
TR Reid, The Healing of America, Penguin Books, 2010
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Canadian System of Healthcare
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Story of Tommy Douglas of Falkirk, Scotland
Emigrated to Canada in 1911. Elected
Governor of Saskatchewan in 1944
Turned healthcare system into single payer
system covering 1 million residents(Medicare)
Popularity resulted in Canada’s provinces
converting to this system in toto in 1961
South Korea & Taiwan followed Canadian
model as did America with Medicare 1966
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Canadian System of Healthcare
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System Guarantees healthcare to all who
need it
Cost is 50% of U.S. System
Result is due to much more efficient payment
system + clout of government negotiating
contracts for drugs, DME, & healthcare
services
Wait periods vary - (f) of location & diagnosis
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Canadian System of Healthcare
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In 2004, Canadian Broadcasting Corp.
poll to select ‘Greatest Canadian of all
Time.’ Tommy Douglas won in a
landslide beating out likes of Alexander
Graham Bell and Wayne Gretzky
Canadians pay 0 for Doctors visits, 0 for
hospital services, 0 for pharma, 0 for
dental surgery in a hospital
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Canadian System of Healthcare
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Binding Principles of Canadian System
– Administration-each Province’s system
operated on not-for-profit basis
– Comprehensive-pays for all needed svcs
Universal-equality of benefits for all
– Access-all citizens pay same fees (age or
illness does not differentiate)
– Portability-pays for treatment anywhere in
Canada & in some foreign countries
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Canadian System of Healthcare
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Principal disadvantage of the System =
long queues for specialty services
Persistent complaining by health
practitioners and hospital executives
Overall, opinion of vast majority of
Canadian citizens suggests they
treasure their system of healthcare
(upwards of 90% satisfaction)
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Advantages of a Unified System
of Healthcare
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Single set of rules, Equal access
Inherently Fair
Easy to Administer-1 set of forms, 1 set of
benefits, 1 set of rules, 1 price list
Powerful cost control force-1 buyer for all
–
–
–
–
Medical Supplies
Drugs
Hospital Fees
Physician Services
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Advantages of a Unified System
of Healthcare (continued)
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Easy use of digital records & smart cards
(Carte Vitale en France & Gesundheitskarte
auf Deutschland)
Eliminates Gamesmanship (egs Big Pharma)
Eliminates Cost Shifting as a strategy
Creates Incentives for Preventive Healthcare
Cost Control means gov’ts negotiate single
price of pharma & DME
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Advantages of a Unified System
of Healthcare (continued)
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Basis of system is being financed as a
not-for-profit endeavor
– System exists to pay bills, not to make a profit
– U.S. is only system that uses the ‘profit motive’ in
healthcare reimbursements
– 1966 House W&M predicted total Medicare
spending by 1990=$12B. It was $110B. This year
will be $600B)
– U.S. system likely will bankrupt America if not
changed (Steven Brill, “Bitter Pill,” Time Magazine March 4, 2013)
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Problems With U.S. System

Summary of Challenges
– Cost
– Coverage
– Quality
– Access (The American Way)
– Rampant Dishonesty
– Which one do we fix first? The trillion
dollar question
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Fixing the Problems
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Coverage-PPACA has made start; now need to
extend coverage to the other 23 million who were left
behind
Rampant dishonesty-HEAT Task Force is making
inroads in that area; needs to expand to Big Pharma
& provider dishonesty
Cost, Quality, & Access can be fixed once with
unified system & single overarching mission-COST
EFFECTIVE, QUALITY, & ACCESSIBLE CARE FOR
AMERICANS, ONE & ALL!!
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Let’s Consider Hospitals &
Doctors Next
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On-Line Dashboards report rates of
infection, readmission (bounce backs),
surgical complications, and errors (egs
surgical sponge left in a patient)
– An interesting corollary-60% of New
Yorkers look up a restaurant’s performance
rating before going out for a meal
– Do the same for hospitals and doctors
Source: WSJ, 9/22-23/2012, pp C1-2, “How to Stop Hospitals
from Killing Us,” by Marty Makary, M.D., slides 37-41.
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Let’s Consider Starting With
Hospitals & Doctors
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Safety Culture Scores – egs of prep
to remove fluid from a patient’s right
lung. Nurse interrupts and says ‘left’ or
‘right’ chest? Written orders said left.
However, intern prepped wrong side of
patient.
– Staff must be empowered to speak up
– No more doctor deference (silence)
– Teamwork is a key element
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Let’s Consider Starting With
Hospitals & Doctors

Cameras-review tapes of surgical
procedures and equate to quality control
and errors
– Doug Rex, MD, at IU College of Medicine
used videotapes of colonoscopies to check
thoroughness of procedures & resulted in
average length of procedure > by 50%
– Quality scores > by 30%. Docs performed
better knowing they were watched
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Let’s Consider Starting With
Hospitals & Doctors
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Open Notes-clinicians prepare
progress notes in front of patient so
patient has opportunity to correct
erroneous assumption(s)
– Cardiologist-provides copy of notes made
during each annual visit while in the office.
This enhances trust in his technique and
his judgment
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Let’s Consider Starting With
Hospitals & Doctors

Eliminate Gagging-today patients are
sometimes asked to sign a gag order
agreeing not to say anything negative re
their physician
– Lawyers make conditional a settlement offer
based on willingness of patient not to speak
publicly re injury sustained
– Gag orders need to be banned by law
– Transparency needed to restore public trust
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LASTLY!
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Civil discourse re our Disagreements
We need to use persuasion to change
people’s minds-not demagoguery
Persuasion facilitated by understanding
both sides of an argument
– Show respect
– Work honestly with opposition’s ideas
– Leave anger & hatred & invectives at home
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Epilogue
What are we waiting
for?
Thank you!
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