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This article describes policy-related systems. For the article on hospital networks, which are sometimes referred to as health care systems, see hospital network.

A health care system is an arrangement in which health care is delivered. There are many variations of health care systems around the world.

Goals

The goals for health systems, according to the World Health Report 2000 - Health systems: improving performance (WHO, 2000), are good health, responsiveness to the expectations of the population, and fair financial contribution. Duckett (2004) proposed a two dimensional approach to evaluation of health care systems: quality, efficiency and acceptability on one dimension and equity on another.

Financing

There are generally five primary methods of funding health care systems:

1. direct or out-of-pocket payments,
2. general taxation,
3. social health insurance,
4. voluntary or private health insurance, and
5. donations or community health insurance.

Defined narrowly, consumer driven health care (CDHC) refers to health insurance plans that allow members to use personal Health Savings Accounts (HSAs), Health Reimbursement Arrangements (HRAs), or similar medical payment products to pay routine health care expenses directly, while a high-deductible health insurance policy protects them from catastrophic medical expenses. High-deductible policies cost less, but the user pays routine medical claims using a pre-funded spending account, often with a special debit card provided by a bank or insurance plan. If the balance on this account runs out, the user then pays claims just like under a regular deductible. Users keep any unused balance or "rollover" at the end of the year to increase future balances, or to invest for future expenses.

This system of health care is referred to as "consumer driven health care" because routine claims are paid using a consumer-controlled account versus a fixed health insurance benefit. That gives patients greater control over their own health budgets. According to economist John C. Goodman, "In the consumer-driven model, consumers occupy the primary decision-making role regarding the health care they receive." Goodman points to a McKinsey study which found that CDHC patients were twice as likely as patients in traditional plans to ask about cost and three times as likely to choose a less expensive treatment option, and chronic patients were 20 percent more likely to follow treatment regimes carefully.

Insurance

The term health insurance is generally used to describe a form of insurance that pays for medical expenses. It is sometimes used more broadly to include insurance covering disability or long-term nursing or custodial care needs. It may be provided through a government-sponsored social insurance program, or from private insurance companies. It may be purchased on a group basis (e.g., by a firm to cover its employees) or purchased by individual consumers. In each case, the covered groups or individuals pay premiums or taxes to help protect themselves from high or unexpected healthcare expenses. Similar benefits paying for medical expenses may also be provided through social welfare programs funded by the government.

By estimating the overall risk of healthcare expenses, a routine finance structure (such as a monthly premium or annual tax) can be developed, ensuring that money is available to pay for the healthcare benefits specified in the insurance agreement. The benefit is administered by a central organization, most often either a government agency or a private or not-for-profit entity operating a health plan.

Payment models

Primary care

There are three ways to pay general practitioners. There has been growing interest in blending elements of these systems.

Fee-for-service

Fee-for-service arrangements pay general practitioners based on the service. They are even more widely used for specialists working in ambulatory care.

There are two ways to set fee levels:

• By individual practitioners.
• Central negotiations (as in Japan, Germany, Canada and in France) or hybrid model (such as in Australia, France's sector 2, and New Zealand) where GPs can charge extra fees on top of standardized patient reimbursement rates.

Other

In capitation payment systems, GPs are paid for each patient on their "list", usually with adjustments for factors such as age and gender. According to OECD, "these systems are used in Italy (with some fees), the United Kingdom (with some fees and allowances for specific services), Austria (with fees for specific services), Denmark (one third of income with remainder fee for service), Ireland (since 1989), the Netherlands (fee-for-service for privately insured patients and public employees) and Sweden (from 1994). Capitation payments have become more frequent in “managed care” environments in the United States."

According to OECD, "Capitation systems allow funders to control the overall level of primary health expenditures, and the allocation of funding among GPs is determined by patient registrations. However, under this approach, of GPs may register too many patients and under-serve them, select the better risks and refer on patients who could have been treated by the GP directly. Freedom of consumer choice over doctors, coupled with the principle of "money following the patient" may moderate some of these risks. Aside from selection, these problems are likely to be less marked than under salary-type arrangements."

In several OECD countries, general practitioners (GPs) are employed on salaries for the government. According to OECD, "Salary arrangements allow funders to control primary care costs directly; however, they may lead to under-provision of services (to ease workloads), excessive referrals to secondary providers and lack of attention to the preferences of patients." There has been movement away from this system.

Comparison

Comparison of five East Asian countries: (SocIns=Social Insurance)

Delivery system

Health informatics or medical informatics is the intersection of information science, medicine and health care. It deals with the resources, devices and methods required to optimize the acquisition, storage, retrieval and use of information in health and biomedicine. Health informatics tools include not only computers but also clinical guidelines, formal medical terminologies, and information and communication systems.

Special health care systems

• Occupational safety and health
• School health services

Health care by country

Template:Topic by country

See also

• Health economics
• Globalization and health
• Health services research
• Public health

References

1. Johns Hopkins University President William Brody (2008) proposed another set of criteria for evaluating the US health systems: Cost, Coverage, Consistency, Complexity and Chronic Illness.
2. Eldis.com. "Social Health Insurance." Retrieved August 18, 2006.
3. "Regional Overview of Social Health Insurance in South-East Asia, World Health Organization. And Overview of Health Care Financing". Retrieved August 18, 2006.
4. Goodman, John (2006), "Consumer Driven Health Care", Networks Financial Institute Policy Brief, Indiana State University
5. How Private Insurance Works: A Primer by Gary Claxton, Institution for Health Care Research and Policy, Georgetown University, on behalf of the Henry J. Kaiser Family Foundation
6. ^ Elizabeth Docteur and Howard Oxley (2003). "Health-Care Systems: Lessons from the Reform Experience" (PDF). OECD. {{cite journal}}: Cite journal requires |journal= (help)
7. Adam Wagstaff (25 Oct 2006). "Health systems in East Asia: what can developing countries learn from Japan and the Asian Tigers?". Health Economics.

Books

• Robin Means, Sally Richards and Randall Smith (2008) Community Care: Policy and Practice, Palgrave MacMillan. ISBN 0230006744

External links

• HRC/Eldis Health Systems Resource Guide provides access to free online research and other resources on health systems in developing countries
• Health Care Systems: An International Comparison, Strategic Policy and Research, Intergovernmental Affairs, May 2001
• Health policies, a list of latest publications by OECD.

• Healthcare
• Types of organization
• Medical and health organizations
• Social systems
• Public policy research
• Policy
• Health economics