US and Scandinavian Healthcare System: A Comparison

The article puts it in very simple terms that Scandinavian countries’ healthcare system is for social good, and that of US is like a business (Bradley & Taylor, 2013).  Both the authors are quite accomplished.  Elizabeth Bradley is is a professor of public health at Yale University and the director of the Yale Global Health Leadership Institute.  Lauren Taylor is a Presidential Scholar at Harvard Divinity School where she teaches Health Ethics.  Together they have co-authored The American Healthcare Paradox, on which this essay is based. 

It is a know fact that United States spends most per capital on healthcare.  Against this backdrop, the authors have tried to analyze the reasons why it resists switching to publicly funded/delivered healthcare system.  It is something that has increased efficiency and coverage in other countries. 

It states that the United States in its belief to be different from other countries has consistently ignored their outcomes.  There is clear evidence that the “Scandinavian model”, when compared to US’s, outperforms in delivering better outcomes at reduced costs.  These countries spend a little more that half of what US spends on healthcare, cover 100% of their citizen, and have more physicians and acute care beds the latter.  This bring into front what we can learn from their model.  That is not to discount that they too must be having problems of their own.  Their research involving in-depth interviews and surveys with policy makers and practitioners found that both countries shared a common values, which is personal freedom.  To be more specific people of both countries value their personal freedom and their ability to control theirs as something paramount.  Also, one needs to take into account that the need for freedom and love for competition does not mean that quality and efficient care cannot be provided to the population.  Also, it does not hold true that the need for scientific innovation cannot find common ground with the belief in having humanistic approach to healthcare. 

The big question then is why is the there so much resistance to change? This is where the differences start.  Americans are less amenable to taxing the rich so as to cross-subsidize services to the poor.  This has to do with their psyche that social assistance in any form is likely to weaken the resolve of the people to exert and excel.  In contrast, the Scandinavians consider dependence on government as an assurance against their own insecurities.  These differences are prominently reflected across their respective healthcare system. 

The take away form this article is that its not the narrow comparison between the system of both the countries, but a broader view how these system evolved in the first place that is the key.  Further, it needs to be determined what is to be done in light of how the Americans view their system.  Up till now the debate on healthcare has always been restricted to ways to cut costs, increase access and improve outcomes.  And most would agree that the reforms so far have not been sufficient enough to curtail long-term costs or attain universal access.  In light of the prevailing view in US regarding government’s involvement in their daily life, a boarder debate on this required before any substantial progress can be made on healthcare.  It is only then that any comparison with Scandinavian model can have meaningful impact. 

The article is well structured, as sets the tone with usual WHO/OECD data.  Then builds upon a bit by describing the Scandinavian model.  It then tries to find a common ground between the US and Scandinavian values.  Then it moves on to more of analytical side by describing its survey and interview, which tries to go deeper into the problem.  Against this background, it tries to evaluate the reasons behind the difference in the system.  It concludes logically by bringing to front the psyche of people of respective countries, especially how they perceive the role of government in their daily lives.  Finally, how that reflects in their respective healthcare system.

After going through this article, I believe, before any further debate on healthcare, it is essential of have a broader debate about the role of government in the lives of average Americans.  It will be even tougher debate, and individual steps would be even harder to push.  Without broadening too much, they should limit the debate to health and social issues.  They should bring into forefront the need to take care of have-nots.  They should also consider promoting institutions, such as those that are typically people focused. 

Bradley, E. & Taylor, L. (2013). US Health Care Reform Is Only Getting Started. [online] Retrieved from: [Accessed: 11 Dec 2013].


Drummond’s Draft

Just going through an article on Toronto Star on Drummond’s report, and especially his recommendations on Healthcare.  And these would be my thoughts as I go through the article. 

The broad recommendations include amalgamating hospitals.  The reasons could be: to bring in economies of scale and scope; cut down on executives and hence their compensation and so forth.  He hasn’t recommended horizontal or vertical integration, so I would presume he is talking of horizontal only.  I think we should also think of vertical integration.  Something along those lines is already happening in terms of hospitals opening their own family health teams (FHTs).  Who know in future, hospitals transfer their ophthalmic and orthopaedic surgeries to these FHTs whenever they are mandated to.  Also, if you merge hospitals, you also remove the number of senior executives.  These measures only reduce cost, but have no impact on the level of care.  It needs to be seen if resources freed up here are to be used effectively elsewhere.

He recommends a 20yrs plan to drive down his 105 recommendations.  It makes sense to have such a long term plan, as it always better to tweak a plan than the current policy.  As he himself states

“To avoid short-term pain caused by quickly made policy decisions, Drummond feels the 20-year prescription needs to be followed.”

I haven’t had a chance to glace through the 105 recommendation, but shall do it over a time.  Meanwhile he is against further increase in physician compensation.   Fine!  But what has to be noted is that the biggest cost is not physician compensation, but costs due to doctors.  The multiplicity of tests and visits, are the ones that need to be curtailed.  Not blaming the physicians, but system should be such that duplications is avoided (hinting at system wide EPR).  

Good he is keeping the LHINs, as some sort or region focused approach is required.  What needs to be looked into is why they failed to live up to their expectations.   Strengthening them the right way would be the way to go.  Also, he is kind of hinting at often discussed model where hospitals serve as node and develop some sort of working arrangement with community agencies.  And, I’d like to thank him for solving the downtown headache by suggesting that Sickkids, Pricess Margaret Hospital and CAMH be kept aside due to their specialized role. 

He is against further increase in physician compensation.   Well! Nobody expected in such hard times, but thanks for making things clear and setting right expectations.  And also clarifying the point that doctors need not be consulted about what is included in OHIP and not.  It is purely for the government to decide what it wants to pay for, and what it doesn’t. 

Has endorsed what was stated in Bill 46 that executive compensation should be linked to patient safety and not number of procedures.

Good to align public health agencies with LHIN.  There is no great need to reduce their number to match that of LHINs.  Basically, these agencies shouldn’t straddle across LHIN boundaries.  If need be there can be more than one public health agency in a LHIN, but they should not cross the boundary. 

Good to see stress being given to preventive health measures.  These, and these alone can help cut down drug cost.  You just cannot/should not prevent physicians from prescribing newer expensive drugs.  Same holds true for diagnostic tests.  The only way out of the situation is preventing from falling sick. 

Yes Minister!

Just read: How Ontario plans to ‘transform’ health care on how Hon. Minister Deb Matthews plans to reform Ontario’s healthcare system.  Here would be my points are I read through the article.

The four key changes

  1. Surgery clinics:  High time there was some private participation in healthcare.  When it can happen in social and community sector, then why not in healthcare.  As is being hinted, cataract surgery would be one to go to community sector.  Other in line could possibly be basic surgery, orthopaedic surgery etc.
  2. A doctor when you need: The article says it is hard to fathom how they’ll make it possible.  But I feel they can certainly improve the situation through better scheduling.  I’d suggest there should be something along the lines of “best buddy” among the doctors.  Say doctors who work alternate days can have some sort of arrangement where they can see each other’s patients. 
  3. Funding the patient, not hospital:  Just a few days back was wondering how to generate competition amongst hospital, and voila!  Minister has a plan already.  And it is brilliant to say the least.  So, if your hospital provides the best service and attracts patients, you get the money.  Patient satisfaction surveys and all that crap can go to trash. 
  4. Less hospital, more home care:  As expected!  

Regarding delisting of C-section when they’re not medically necessary, I’d go for the cautious approach.  First of all it is physician’s call whether it is medically necessary in a particular care or not.  Say if it is identified that it is not medically necessary in a particular case, then why go for it in the first place.  What will happen is physicians will classify all the cases as medically necessary to avoid scrutiny.  Also, not going for C-section can have potential negative outcomes on mother and child in quite a few cases.  Physicians would be less inclined to classify a case as medically unnecessary, as there is a strong possibility of litigation in case something goes wrong.

Are we slipping towards private healthcare system

Was reading the following article: Walkom: Why Ontario’s bid to cut health-care costs could backfire

The article is good and there is nothing new for the initiated, but tells a lot to an average reader.  It talks about the possibility of having greater private participation in delivery of healthcare in Ontario.  Something along the lines of Medicare in US, where government reimburses private institutions for care delivered to those above 65.  

Privately delivered publicly funded healthcare system won’t work as the models are entirely different. Private organizations would want to maximize the profit, whereas government would want more for less. Just as in Medicare, you’ll see examples of overbilling caused by unnecessary appointments and tests. And where is the guarantee that the care will be better? Or closer home, it will be very similar to OHIP.

In general there are two modes of payment: capitation and those based on disease coding. In capitation system they have incentive to keep patient healthy. The flip side is that it encourages organizations to avoid chronically/terminally ill patients.

My main concern here is that there doesn’t seem to be any plan anywhere.  Whether private or public, there has to be a plan in place, and above all in public domain.  I wouldn’t want any step forward untill and unless there is thorough public debate on repercussions of every subtle step.  Lets not forget out current system is far easier to fix than that of US.  So, lets tread carefully as there are no winter tires for healthcare.