Comparative Analysis Of Healthcare Structure In America And Denmark
The U.S is one of the most powerful and technologically advanced countries in the world and yet their healthcare system is often criticized in the media. The healthcare system in the U.S is a pluralist one which means consumers can gain access to health insurance from both public and private institutions. Hospitals charge their patients on a fee-for-service system where people that access the hospital are billed for every single service they use from laboratory tests to oral medications, imaging etc. Physicians operate in a similar way but most of them see their patients in their private clinics where they also bill on a fee-for-service system. The hospitals and physicians are then paid for their services by insurance companies that can be either private or public which cover most of the services and the patient.
Most Americans have health insurance coverage provided by their place of employment. Individuals who carry employment-based insurance have to pay for these services through different fees that are deducted from their paycheck. Individuals who do not qualify for insurance coverage from their employers and people who are self-employed need to purchase private insurance. The other portion of the population who cannot afford the cost of private insurance or is not employed can potentially benefit from public government health insurance from Medicaid or Medicare. Beneficiaries of Medicaid need to meet certain economic standards that place them at a certain level below the poverty line in order for them to qualify. Medicare is government-based insurance that covers Americans 65 and older but also includes disabled people and their dependents.
Denmark benefits from a decentralized universal healthcare which is fundamental to their “government’s obligation to promote population health and prevent illness”. The majority of the hospitals (around 97%) are publicly owned and the get paid by regional funding established by a mixed method consisting of a fixed budget and activity-based funding based on DRGs (diagnosis-related groups). The fixed budgeting makes up the majority of the funding while DRGs are calculated by “the Ministry of Healthy based on average costs. Almost all Danish physicians (around 78%) are self-employed and they work in their own private practices. They get paid by the regions where they work by capitation (30%) and fee-for-service basis (70%). The doctor rates are established by national agreements with doctor’s associations. All Danish registered citizens are automatically covered by their free public health care. Other individuals such as undocumented immigrants and visitors who do not fall under this category are covered by a privately funded initiative funded by Danish doctors. Individuals who purchase voluntary private insurance do so in order to benefit from complimentary services that are not covered by the public insurance. Around 3.7 million Danes hold private insurance and they do so to gain expanded access to private providers too. Most private policies are purchased through employers or seven-for-profit insurance companies.
Coverage
The American citizens who did not have health insurance before 2010 were able to be covered under the Affordable Care Act that was enacted under President Barack Obama. The ACA or Obamacare makes it mandatory for almost every American to be covered by some form of health insurance by providing different options for people. Minor exceptions included Native Americans, people with extreme hardships and religious objectors. Recent data suggests that about 11.3 % of Americans are uninsured. According to the Center for Disease Control, about 51% of Americans saw their primary doctor in 2015. The numbers of annual physician visits are affected by rising cost because many people are simply cannot afford to go see their doctor. People who reside in rural and urban communities are also very underserved by healthcare services. These people often have to travel long distances in order to have access to see a physician and a specialist. This occurs because physicians often prefer to practice in big urban places vs rural areas. Rural areas are often lacking physicians, pediatricians but are served by nurse practitioners.
In Denmark, all citizens are automatically covered by their public insurance. Citizens also have the option to supplement their insurance by purchasing private insurance that is offered by for-profit companies or from their employers. Data from Denmark suggests that people are not afraid to access health care services and in 2014 a citizen saw their doctor about 8 times. Waiting times in Denmark are increasingly shortening from 90 days for a scheduled surgery in 2001 to 48 days in 2015. Denmark’s health care system is based on their 7 principles enacted by their parliament that recognize geographic equality as one of their main ethical principles. Different regions and municipalities have established mandatory health agreements to reach patients in underserved areas. They also have established “health houses” with specialized nurses and GPs who develop an overview of the patient’s needs.
Comprehensiveness of benefits
After Congress passed the ACA in 2010, many people lost their health insurance policies because they did not cover basic benefits. The ACA delineated minimum services that needed to be covered by all health insurance plans such as outpatient visits, emergency room visits, hospitalization, maternity, and newborn care, mental health and substance use services, prescription drugs, rehabilitation services, laboratory tests, preventive and chronic disease care, and pediatric services. People with pre-existing conditions could now no longer be denied healthcare coverage. Some exclusions are still in existence as some Americans still have trouble getting coverage for their specialists or elective procedures and treatments. Patients often have some degree of choice when choosing their primary care even though most often than not they fall under a network of doctors who take their insurance.
While most insurance plans cover outpatient visits to your provider, patients often require a referral to see a specialist. Denmark’s public coverage includes visits to your GP (general practitioner), home nursing, medical equipment’s and appliances needed for home health are also free, rehabilitation services, mental health services, childhood immunizations, 100% free prescriptions for the terminally ill. Some services such as dentists, physiotherapists, and psychologists are covered by requiring a co-pay. Citizens have the right of free medical care from their GP when he is registered for the public health system. They also can benefit from free medical assistance to a private practice specialist when referred by their GP. There are some exceptions with ophthalmologists, otologists, and dentists who do not require a referral to see patients. Most patients in Denmark have their first contact with their GP who is considered the gate-keeper for specialist care.
Affordability
Increasing healthcare cost in the U.S has made access to health care more difficult for people of lower and middle class. Upper-class citizens are the ones who are able to pay for all the healthcare services they need and more often than not also the ones they want. Middle-class citizens who are employed full-time can benefit from employer-based healthcare coverage. Lower class citizens can apply for government-based insurance like Medicaid and/or Medicare, but they need to meet certain standards. While the ACA has brought some benefits to U.S citizens it also brought some negative aspects such as rising cost, higher taxes, and deductibles. About 80% of ACA beneficiaries received federal subsidies to help pay for their insurance but the other 20% had to pay for everything out of pocket. Insurance deductibles of $3000 or more were too expensive for poor people belonging to the lower class. It is no surprise that a considerable portion of the U.S is considered underinsured. Underinsured individuals are able to pay their insurance fee but cannot meet their deductibles, so they are unable to access healthcare services. Most employment-based insurance premiums have a 70/30 coverage which still makes it too expensive for some citizens. People that have HMOs are entitled to little to no-cost prescription medicines because HMOs see reduced hospital stays due to their preventative care philosophy. This does not include surgical procedures and treatments with recent findings suggesting that up to 20% of them being unnecessary. Recently prescription drugs have seen an incredible cost of almost 100% and even more with Martin Shkreli attempting to inflate the drug Daraprim by almost 4000%.
Citizens of Denmark do not worry about the affordability of cost due to its universal all-inclusive nature. The government has enacted health care law based on principles of equality and for all citizens. They are offered high-quality services that are paid for by general taxes. Most of their hospitals are public so their hospitalizations are covered by their public free healthcare. People who are chronically ill and dying can benefit from a 100% reimbursement of their prescription drugs. People with very low incomes can also benefit from government assistance and this assistance can be increased for expensive medications. In Denmark, there is an even coverage for health insurance for different social classes.
The degree of Consumer Choice
U.S citizens who have access to health care are limited when it comes to choosing their physicians, clinics, and hospitals. These limitations derive from their insurance providers that allow patients to pick doctors who are in a network at a lower cost compared to out-of-network doctors. Most patients in the U.S have managed care in the form of HMO (Health maintenance organization) or PPO (Preferred Provider Organizations). While the latter is mostly used by employers who purchase group health insurance the former is increasingly becoming a favorite because of cost control. HMOs are prepaid group services in which people pay monthly premiums for comprehensive services that include lab tests, physician services, X-rays and low to no cost prescription drugs. These types of managed care organizations focus on prevention and achieve cost containment by having lower hospitalization overall lower medical costs. One of the downfalls of an HMO is that patients may sometimes see the doctor is who is working “on call” rather than their own physician. PPOs, on the other hand, boasts an increased volume of patients and more freedom of choice. Medicaid beneficiaries often struggle to find a physician as only 69% of them accept Medicaid patients.
The citizens of Denmark may freely choose any doctor and hospital from the public or private sector. If the hospital that they have chosen cannot initiate care within 30 days, citizens have the right to choose a private hospital in Denmark or abroad to take over their care. The level of care includes both physical and mental illnesses. The region where the patient resides makes sure that the patient is seen by the new hospital within 30 days of referral and that he/she receives a detailed plan of their care. Most citizens are often seen by their GP who is often in charge of the majority of their care without other referrals needed.
Financial efficiency
The U.S spends around 17.9% of its annual GDP or $3.3 trillion on health care and 31% it goes towards the administrative cost. The very fragmented, nature of healthcare delivery has contributed to high overhead, increased inefficiency, and ineffectiveness. Patients with enormous medical bills are forced to declare medical bankruptcy. In order to contain cost, public and private buyers have switched their attention towards value-based purchasing models that reward effective and efficient healthcare delivery.
Public health insurance in Denmark is mainly funded by an 8% centrally collected health contribution tax. The central government distributes funding to five regions and ninety-eight municipalities. The Denmark government reports in 2015 that public expenditures accounted for 84.2% of total health spending that represent 10.6% of their GDP. The Danes are very organized when it comes to healthcare with the increased sharing of data and IT utilization. Data suggests that 98% of their GPs exchange data electronically with digital workflows being fully integrated. Regional patient advisers who work independently of the region and hospital are provided free of charge for patients who wish to complain about waiting times, diagnosis, treatment abroad and receiving compensation. Denmark prefers a centralized method of providing care with only 10% of patients going to a specialized hospital. They are also constantly margining smaller specialized hospitals into larger organizations in order to serve more patients in better and improved ways. The Danish Health authority is constantly researching ways to contain cost with new treatments that focus on chronic disease prevention and follow-up interventions. This organization monitors indicators such as the speed the patient diagnosed and treated while developing guidelines for hospitals.
Health Outcomes
The center for disease control has predicted that life expectancy in the U.S in 2015 was 78.8 years old. According to this data, the average American born in 2015 is not expected to make it past 80 years old. These numbers testify to an increasingly aging population in the U.S compared to only 100 years ago where life expectancy numbers were much lower. According to data from the World Health Organization, the crude death rate in the U.S (the number of deaths from all causes) in 2013 was 8.4 per 1000 people. While Americans are expected to reach their 70s and almost 80s, their infant mortality rates are pretty high in comparison with the CDC placing them at 5.9 per 1000 live births. The most commonly reported causes of death in the U.S are heart disease, cancer, accidents, chronic lower respiratory diseases, strokes, Alzheimer, diabetes, diabetes, self-harm etc.
Denmark’s life expectancy has risen from 77.9 years in 2005 to 80.6 years in 2015. Danish women tend to have longer life expectancies (82.5 years ) and men’s life expectancy is 78.6 years. Their crude death rate in 2013 was reported to be 9.6 per 1000 people WHO,2013) but has been slowly decreasing by 1% each year. Infant mortality rates were 3.7 in 2017 according to the world bank organization and have been declining since the 1960s. Their most common causes of death are ischemic heart disease, cerebrovascular disease and Alzheimer's disease.
