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How is the delivery system organized and financed?

  • Australia

    Primary care: In 2015, there were 34,367 general practitioners (GPs), 49,060 practitioners registered as generalists and specialists, and 8,386 specialists. GPs are typically self-employed, with about four per practice on average. In 2012, those in nonmanagerial positions earned an average of AUD2,862 (USD1,858) per week. The schedule of service fees is set by the federal health minister through the MBS.

    Registration with a GP is not required, and patients choose their primary care doctor. GPs operate as gatekeepers, in that a referral to a specialist is needed for a patient to receive the MBS subsidy for specialist services. The fee-for-service MBS model accounts for the majority of federal expenditures on GPs, while the Practice Incentives Program (PIP) accounts for 5.5 percent.

    State community health centers usually employ a multidisciplinary provider team. The federal government provides financial incentives for the accreditation of GPs, for multidisciplinary care approaches, and for care coordination through PIP and through funding of GP “Super Clinics” and Primary Health Networks (PHNs). PHNs (which have replaced Medicare Locals) are being implemented in 2015–2016 to support more efficient, effective, and coordinated primary care.

    In 2015, there were 11,040 nurses or midwives working in a general practice setting. Their role has been expanding with the support of the PIP practice nurse payment. Nurses are also funded through practice earnings. Nurses in general practice settings provide chronic-disease management and care coordination; preventive health education; and oversight of patient follow-up and reminder systems.

    Outpatient specialist care: Specialists deliver outpatient care in private practice (8,001 specialists in 2015) or in a public hospital (3,745). Patients are able to choose which specialist they see, but must be referred by their GP to receive Medicare Benefits Scheme (MBS) subsidies. Specialists are paid on a fee-for-service basis. They receive a subsidy through the MBS of 85 percent of the schedule fee and set their patients’ out-of-pocket fees independently. Many specialists split their time between private and public practice.

    Administrative mechanisms for direct patient payments to providers: Many practices have the technology to process claims electronically so that reimbursements from public and private payers are instantaneous, and patients pay only their copayment (if the provider charges above the Medicare Benefits Scheme fee). If the technology is not in place, patients pay the full fee and seek reimbursement from Medicare and/or their private insurer.

    After-hours care: GPs are required to ensure that after-hours care is available to patients but are not required to provide care directly. They must demonstrate that processes are in place for patients to obtain information about after-hours care and that patients can contact them in an emergency. After-hours walk-in services are available and may be provided in a primary care setting or within hospitals. As there is free access to emergency departments, these also may be utilized for after-hours primary care.

    The federal government provides varying levels of practice incentives for after-hours care, depending on whether access is direct or provided indirectly through arrangements with other practitioners in the area. Government also funds Primary Health Networks’ support for and coordination of after-hours services, and there is an after-hours advice and support line.

    Hospitals: In 2014–2015, there were 698 public hospitals (678 acute, 20 psychiatric), with a total of nearly 60,300 beds, an increase of 1,700 beds over the previous year, despite there being 20 fewer hospitals. In the same period, there were 624 private hospitals (342 day hospitals and 282 others) with 32,000 beds. Private hospitals are a mix of for-profit and nonprofit.

    Public hospitals receive a majority of funding (91%) from the federal government and state governments, with the remainder coming from private patients and their insurers. Most of the funding (62% of the total recurrent expenditure) is for public-physician salaries. Private physicians providing public services are paid on a per-session or fee-for-service basis. Private hospitals receive most of their funding from insurers (47%), federal government’s rebate on health insurance premiums (21%), and private patients (12%).

    Public hospitals are organized into Local Hospital Networks (LHNs), of which there were 147 in 2016. These vary in size, depending on the population they serve and the extent to which linking services and specialties on a regional basis is beneficial. In major urban areas, a number of LHNs comprise just one hospital.

    State governments fund their public hospitals largely on an activity basis, using diagnosis-related groups. Federal funding for public hospitals includes a base level of funding, with funding for growth set at 45 percent of the “efficient price of services,” determined by the Independent Hospital Pricing Authority. From July 2017, the Commonwealth will fund 45 percent of the efficient growth in these services, capped at 6.5 percent of total growth. States are required to cover the remaining cost of services, providing an incentive to keep costs at the efficient price or lower. Small rural hospitals are funded through block grants.

    Mental health care: Mental health services are provided in many ways, including by general practitioners (GPs) and specialists, in community-based care, in hospitals (both in- and outpatient, public and private), and in residential care. GPs provide general care and may devise treatment plans of their own or refer patients to specialists. Specialist care and pharmaceuticals are subsidized through the Medicare Benefits Scheme (MBS) and Pharmaceutical Benefits Scheme (PBS). State governments fund and deliver acute mental health and psychiatric care in hospitals, community-based services, and specialized residential care. Public hospital–based care is free to public patients.

    As part of the federal government’s response to a recent review by the National Mental Health Commission, funding through Primary Health Networks will be redirected to commission mental health services that meet local needs. The focus will be on suicide prevention and coordinated care.

    Long-term care and social supports: The majority of people living in their own homes with severe or profound limitations in core activities receive informal care (92%). Thirty-eight percent receive only informal assistance, and 54 percent receive a combination of informal and formal assistance. In 2009, 12 percent of Australians were informal caregivers, and around 30 percent of those were the primary caregiver (carer). In 2011–2012, federal government provided AUD3.18 billion (USD2.07 billion) under the income-tested Carer Payment program, and AUD1.75 billion (USD1.14 billion) through the Carer Allowance (not income-tested and offered as a supplement for daily care). Federal government also provides an annual Carer Supplement of AUD480 million (USD312 million) to help with the cost of caring. Recipients of the Carer Allowance who care for a child under the age of 16 receive an annual Child Disability Assistance Payment of AUD1,000 (USD649). There are also a number of respite programs providing further support for caregivers.

    Home care for the elderly is provided through the Commonwealth Home Support Program in all states except Western Australia. Subsidies are income-tested and may require copayments from recipients. Services can include assistance with housework, basic care, physical activity, and nursing, among others. The program began in July 2015 as a consolidation of home and community care, planned respite for caregivers, day therapy, and assistance with care and housing. The Western Australian government administers and delivers its Home and Community Care Program with funding support from federal government.

    Aged-care, or nursing, homes may be private nonprofit or for-profit, or run by state or local governments. Federally subsidized residential aged-care positions are available to those who are approved by an Aged Care Assessment Team. Hospice care is provided by states through complementary programs funded by the Commonwealth. The Australian government supports both permanent and respite residential aged care. Eligibility is determined through a needs assessment, and permanent care is means-tested.

    In 2013, the federal government, in partnership with states, implemented the pilot phase of the National Disability Insurance Scheme, with full implementation planned for 2019–2020. The scheme provides more-flexible funding support (not means-tested), allowing greater tailoring of services.

  • Canada

    Primary care: In 2015, there were 2.28 practicing physicians per 1,000 population, about half of whom were general practitioners, or GPs (1.15 per 1,000 population), and the rest specialists (1.13 per 1,000 population). Primary care physicians act largely as gatekeepers, and many provinces pay lower fees to specialists for non-referred consultations. Most physicians are self-employed in private practices and paid fee-for-service, although there has been a movement toward group practice and alternative forms of payment, such as capitation. In 2014–2015, fee-for-service payments made up 45 percent of payments to GPs in Ontario, compared with 68 percent in Quebec and 84 percent in British Columbia. In 2014, 46 percent of GPs reported to work in a group practice, 19 percent in an interprofessional practice, and 15 percent in a solo practice.

    Patients have free choice of primary care doctor. The requirement for patient registration varies. Clinical fee-for-service payments to primary care physicians in Canada averaged CAD271,417 (USD217,134) in 2014–2015. In several provinces, networks of GPs work together and share resources, with variations across provinces in the composition and size of teams.

    Provincial and territorial ministries of health negotiate physician fee schedules (for primary and specialist care) with provincial and territorial medical associations. In some provinces, such as British Columbia and Ontario, payment incentives have been linked to performance.

    Outpatient specialist care: The majority of specialist care is provided in hospitals, although there is a trend toward providing services in private nonhospital facilities. Specialists are mostly self-employed and paid fee-for-service, although there is variation across provinces. Specialists in Canada received an average of CAD370,091 (USD296,073) annually in clinical fee-for-service payments in 2014–2015. In most provinces, specialists have the same fee schedule as primary care physicians. In 2014, 65 percent of specialists reported to work in a hospital, compared with 24 percent in a private office or clinic. Patients can choose, and have direct access to, a specialist, but it is common for GPs to refer patients to specialty care. Specialists who work in the public system are not permitted to receive payment from private patients for publicly insured services. There are few formal multispecialty clinics.

    Administrative mechanisms for paying primary care doctors and specialists: The majority of physicians and specialists bill provincial governments directly, although some are paid a salary by a hospital or facility. There are no direct payments from patients to physicians; there is no cost-sharing, although patients may be required to pay for services that are not medically necessary.

    After-hours care: After-hours care is provided generally by physician-led (and mainly privately owned) walk-in clinics and by hospital emergency rooms. In most provinces and regions, a free telephone service (“telehealth”) is available 24 hours a day for health advice from a registered nurse. Traditionally, primary care physicians were not required to provide after-hours care, although many of the government-enabled group practice arrangements have requirements or financial incentives for providing after-hours care to registered patients. In 2015, 48 percent of primary care physicians in Canada (67% in Ontario) reported having arrangements for patients to see a doctor or nurse after hours.

    Hospitals: Hospitals are a mix of public and private, predominantly not-for-profit, organizations, often managed locally by regional authorities or hospital boards representing the community. In provinces with regional health authorities, many hospitals are publicly owned, whereas in other provinces, such as Ontario, they are predominantly private nonprofit corporations. There are no data on the number of private for-profit clinics (which are mostly diagnostic and surgical).

    Hospitals in Canada generally operate under annual global budgets, negotiated with the provincial or territorial ministry of health or regional health authority. However, several provinces, including Ontario, Alberta, and British Columbia, have considered introducing activity-based funding for hospitals. Hospital-based physicians generally are not hospital employees and are paid fee-for-service directly.

    Mental health care: There is universal coverage for physician-provided mental health care, along with a fragmented system of allied services. Hospital mental health care is provided in specialty psychiatric hospitals and in general hospitals with mental health beds. The provinces and territories all provide a range of community mental health and addiction services including case management, help for families and caregivers, community-based crisis services, and supportive housing. Psychologists may work privately and are paid out-of-pocket or through private insurance, or under salary in publicly funded organizations. Mental health has not been formally integrated into primary care; any coordination or colocation of mental health services with primary care is unique to its particular practice. In Ontario, an inter-sectoral mental health strategy has been in place since 2011 and was expanded in 2014 to better integrate mental health care into primary care.

    Long-term care and social supports: Long-term care and end-of-life care provided in nonhospital facilities and in the community are not considered insured services under the Canada Health Act. All provinces and territories fund services, but coverage varies among and within them. All provinces provide some nursing home care and some combination of case management and nursing care for home care clients, but there is considerable variation when it comes to other services, including medical equipment, supplies, and home support, and many jurisdictions require client contributions. About half of the provinces and territories provide some home care without means-testing, but access may depend both on assessed priority and on availability within capped budgets.

    Eligibility criteria for home and institutional long-term care services generally include a needs assessment based on health status and functional impairment. Some provinces have established minimum residency periods as an eligibility condition for facility admission. Spending on nonhospital institutions, of which the majority are long-term care facilities, accounted for just under 11 percent of total health expenditure in 2015, with financing mostly from public sources (70%).

    A mix of private for-profit (44%), private not-for-profit (30%), and public facilities (27%) provide facility-based long-term care. Public funding of home care is provided either through provincial or territorial government contracts with agencies that deliver services or through government stipends to patients to purchase their own services.

    Provinces and territories are responsible for delivering palliative and end-of-life care in hospitals, where the majority of such costs occur. But many provide some coverage for services outside those settings, such as doctors, nurses, and drug coverage in hospices, in nursing facilities, and at home.

    Support for informal caregivers (estimated to provide 66% to 84% of care to the elderly) varies by province and territory. In Ontario, for example, the Family Caregiver Leave Bill offers job protection to caregivers. There are also some federal programs, including the Family Caregiver Tax Credit and the Employment Insurance Compassionate Care Benefit.

  • Switzerland

    Primary care: As registering with a general practitioner (GP) is not required, people not enrolled in managed care plans generally have free choice among self-employed GPs. In 2015, 38.2 percent of doctors in the outpatient sector were classified as GPs. There are no specific financial incentives for GPs to take care of chronically ill patients, and no concrete reforming efforts are under way to engage GPs in “bundled payments” for chronic patients (e.g., diabetics). Primary (and specialist) care tends to be physician-centered, with nurses and other health professionals playing a relatively small role. In 2015, 56.1 percent of physicians were in solo practice.

    Apart from some managed care plans in which physician groups are paid through capitation, ambulatory physicians (including GPs and specialists) are paid according to a national fee-for-service scale (TARMED). Billing above the fee schedule is not permitted. The introduction of TARMED in 2004 aimed to improve reimbursement for GP services by giving greater weight to nontechnical services than to technical services and by incentivizing less resource-intensive forms of care. These incentives, however, are criticized by GPs as insufficient to render desirable services like home visits, after-hours care, and coordination and communication with chronically ill patients. In response, the Swiss Federal Council (SFC) decided to slightly increase remuneration for consultations in primary care as of October 2014, while remuneration for some more technical services (such as computer tomography) has been slightly reduced. The median income of primary care doctors was CHF190,150 (USD149,109) in 2009.

    Outpatient specialist care: In the outpatient sector, 61.8 percent of doctors were classified as specialists in 2015. Residents have free access (without referral) to specialists unless enrolled in a gatekeeping managed care plan. Specialist practices tend to be concentrated in urban areas and within proximity of acute-care hospitals. The public health system allows specialists to see mandatory health insurance (MHI) patients as well as private patients.

    Administrative mechanisms for direct patient payments to providers: MHI allows different methods of payment among insurers, patients, and providers. Providers can invoice the patient, who pays up front and claims reimbursement from the insurer, or the patient can forward the invoice to the insurer for payment. Alternatively, providers can directly bill the insurer, who makes payment and bills any balance to the patient.

    After-hours care: The cantons are responsible for after-hours care. They delegate those services (with fees set by TARMED) to cantonal doctors’ associations, which organize urgent-care networks in collaboration with their affiliated doctors. The networks can include ambulance and rescue services, hospital emergency services, walk-in clinics, and telephone advice lines run or contracted by insurers. There is no institutionalized exchange of information between these services and GPs’ offices, as people are not required to register.

    Hospitals: In 2014, there were 289 hospitals (108 general and 181 specialized hospitals), with a total of 37,540 beds. Hospital care represented one-third (36.4%) of total health expenditures in 2014. For services covered by MHI and billed through a national diagnosis-related group (DRG) payment system, hospitals receive around half (45%–55%) of their funding from insurers. The other half is covered by cantons and municipalities, or, in case of additional services, by private health insurance.

    The cantons are responsible for hospital planning and funding and are legally bound to coordinate plans with other cantons. In 2012, in parallel to the introduction of the DRG system, free movement of patients between cantons was allowed, reducing cantonal fragmentation. Remuneration mechanisms depend on insurance contracts; consequently, fee-for-service for inpatient services not covered under MHI is still possible. Hospital-based physicians are normally paid a salary, and public-hospital physicians can receive extra payments for seeing privately insured patients.

    Mental health care: Psychiatric practices are generally private, and psychiatric clinics and hospital departments are a mix of public, private with state subsidies, and fully private. There is also a wide range of socio-psychiatric facilities and daycare institutions that are mainly state-run and state-funded.

    Psychiatric hospitals or clinics normally provide a full range of medical services such as psychiatric diagnostics and treatment, psychotherapy, pharmaceutical treatment, and forensic services. Often, the socio-psychiatric facilities and daycare institutions offer the same medical services as the clinics, but normally treat patients with less acute illnesses or symptoms. The main field of activity of mental health practices is psychotherapy; psychiatrists are allowed to prescribe medication. The provision of psychiatric care is not systematically integrated into primary care. Prices for outpatient psychiatric services are calculated using TARMED, while psychiatric inpatient care prices are usually calculated as a daily rate.

    Long-term care and social supports: Services are provided for inpatient care in nursing homes and institutions for disabled and chronically ill persons and for outpatient care through Spitex. In some cases, admission is possible only through a hospital or by approval from an admission authority. Palliative care provided in hospitals, in nursing homes, in hospices, or at home is not regulated separately in MHI, so coverage of services is similar to acute services in the respective provider setting. There is no provision of individual or personal budgets for patients to organize their own services.

    Inpatient long-term somatic and mental services are covered by MHI but are highly subsidized by the cantons. For services in nursing homes and institutions for disabled and chronically ill persons, MHI pays a fixed contribution to cover care-related inpatient long-term care costs; the patient pays at most 20 percent of care-related costs that are not covered, and the remaining care-related costs are financed by the canton or the municipality. Long-term inpatient care costs totaled CHF12.3 billion (USD9.7 billion) in 2014, representing 17.3 percent of total health expenditures. Around one-third of these costs (31.3%) were paid by private households, one-quarter (24.1%) by old age and disability benefits, one-fifth (19.1%) by MHI and other social insurances, and the rest by government subsidies (25.4%). Of the 1,575 nursing homes in operation in 2014, 29.2 percent were state-operated and state-funded, 30.5 percent were privately operated with public subsidies, and 40.3 percent were exclusively private.

    Almost half (47.1%) of the total Spitex expenditure of CHF2.0 billion (USD1.6 billion), as of 2014, is financed by government subsidies. MHI and the other social insurances covering the cost of medically necessary health care at home made up roughly one-third (34.9%). The rest (18.0%), devoted mainly to support and household services, was paid out-of-pocket, by old age and disability benefits, by voluntary health insurance (VHI), or by other private funds. In 2014, one-third of Spitex organizations were subsidized nonprofit organizations (36.6%), 13.6 percent were nonsubsidized for-profit companies, and almost half (49.8%) of Spitex organizations were individual health care workers. At the national level, there is no legal basis for financial support for informal help or family caregivers.

  • China

    Primary care: Primary care is delivered mainly through village doctors and health workers in rural clinics, general practitioners (GPs) in rural township and urban community hospitals, and medical professionals in secondary and tertiary hospitals. Village doctors, who are not licensed GPs, can work only in village clinics. In 2014, there were 1.06 million village doctors and health workers. Although rural patients are encouraged to seek care in village clinics or township hospitals and urban patients in community hospitals—as such providers are associated with lower cost-sharing rates—residents can also see any GP in upper-level hospitals directly.

    Registration with a GP is not required and, except for the very few areas that use GPs as gatekeepers, referrals are generally not necessary to see outpatient specialists. In 2014, China had some 173,000 licensed and assistant GPs, representing 6.0 percent of all licensed physicians and assistant physicians. Unlike village doctors and health workers in the village clinics, GPs rarely practice solo or through partnership but instead work in a hospital with nurses and nonphysician clinicians. Village clinics in rural areas receive technical support from township hospitals.

    Fee schedules for primary care in government-funded health institutions are regulated by local health authorities and the Bureaus of Commodity Prices. Village doctors and health workers in the village clinics receive income through reimbursement of public health services (e.g., immunizations and chronic disease screening) and clinical services, as well as through markups on prescription drugs and government subsidies. Incomes vary substantially by region.

    GPs at hospitals receive a base salary along with activity-based payments (e.g., patient registration fees, surgeries performed). With fee-for-service still the dominant payment mechanism for hospitals (see below), hospital-based physicians have strong financial incentives to induce demand. It is estimated that wages constitute only one-quarter of physician incomes; the rest is thought to be derived from practice activities.

    In 2014, 47 percent of outpatient revenues and 38 percent of inpatient revenues were from prescription drugs provided to patients in tertiary hospitals. Care coordination is generally not incentivized, although it is always encouraged by health authorities.

    Outpatient specialist care: Outpatient specialists are employed by and usually work in hospitals, through which they obtain their practice licenses. Although practicing in multiple settings is being introduced and encouraged in China, most specialists practice in one hospital only. They receive compensation in the form of a base salary plus activity-based payments. Patients can usually see outpatient specialists without GP referral and have a choice of specialist through their hospital.

    Administrative mechanisms for direct patient payments to providers: Patients pay deductibles and copayments to hospitals at the point of service. Hospitals directly bill insurers for the covered payment at the same time if the payment mechanism is fee-for-service or a diagnosis-related group (DRG) system. Hospitals receive annual lump-sum payments under global budgets or capitation.

    After-hours care: Because village doctors and health workers often live in the same community as patients, they voluntarily provide some after-hours care when needed. Rural township hospitals and urban secondary and tertiary hospitals have emergency rooms or departments (EDs) where both primary care doctors and specialists are available, minimizing the need for walk-in after-hours care centers. In EDs, nurse triage is not required and there are few other restrictions, so people can simply walk in and register for care at any time. (Urban community hospitals often do not provide after-hours care, given the availability of secondary and tertiary hospitals.) ED use is not substantially more expensive than usual care for patients. Information on patients’ emergency visits is not routinely sent to their primary care doctors.

    Hospitals: Hospitals can be public or private, nonprofit or for-profit. Most township hospitals and community hospitals are public, but both public and private secondary and tertiary hospitals exist in urban areas. Rural township hospitals and urban community hospitals are often regarded as primary care facilities—closer to village clinics than “true” hospitals. In 2014, there were 13,314 public hospitals and 12,546 private hospitals (excluding township hospitals and community hospitals), of which 17,705 were nonprofit and 8,155 were for-profit. In 2014, there were 491,885 public primary care facilities and 425,450 private village clinics.

    Hospitals are paid through a combination of out-of-pocket payments, health insurance compensation, and, in the case of public hospitals, government subsidies—the last of these representing 13.2 percent of total revenue in 2014. A significant number of patients pay 100 percent out-of-pocket, because they receive out-of-network services. Although fee-for-service is dominant, diagnosis-related group, capitation, and global budgets are becoming more popular in selected areas. Local health authorities set fee schedules, and doctors’ salaries and other payments are included in hospital reimbursement.

    Mental health care: Mental health care, including disease diagnosis, treatment, and rehabilitation services, is provided in special psychiatric hospitals and in the psychology departments of tertiary hospitals. Patients with mild illness are often treated at home or in the community; only severely mentally ill patients are treated in psychiatric hospitals. Both outpatient and inpatient mental health services are covered by insurance, with benefits subject to lower copayment rates. In 2014, there were 34 million mental health patient visits to special psychiatric hospitals, and on average one psychiatrist treated 4.8 patients per day. Mental health care is not integrated with primary care.

    Long-term care and social supports: In accordance with Chinese tradition, long-term care is provided mainly by family members at home. There are very few formal long-term care providers. Family caregivers are not entitled to financial support or tax benefits, and long-term care insurance is virtually nonexistent; expenses for care in long-term care facilities are paid almost entirely out-of-pocket. Local governments often provide some subsidies to long-term care facilities.

    On average, conditions in long-term care facilities are poor, and there are long waiting lists for enrollment in high-end facilities. Formal long-term care facilities usually provide only housekeeping, meals, and basic services such as transportation, with very few health care services. Some, however, may coordinate health care with local township or community hospitals. Governments encourage integration of long-term care and health care services, particularly those funded by private investment. There were 3.9 million beds for aged and disabled people in 2014. Some hospice care is available, but it is normally not covered by health insurance.

  • Denmark

    Primary care: Around 22 percent of all doctors work in general practice. Almost all general practitioners (GPs) are self-employed and are paid by the regions via capitation (about 30% of income) and fee-for-service (70% of income). Rates are set through national agreements with doctors’ associations. Service-based fees are used as financial incentives to prioritize services. National fees are paid per consultation, whether for office visits, e-consults, or home visits. The average income for a GP was DKK1.1 million (USD146,000) in 2011. The average salary for senior hospital doctors was DKK1 million (USD133,000).

    The practice structure is gradually shifting from solo to group practices, typically consisting of two to four GPs and two to three nurses. The number of nurses employed has increased in the past decade; they are paid by the practice and have gradually assumed responsibility for such tasks as blood sampling and vaccination. Colocation of various clinicians is also on the rise, with GPs, physiotherapists, and office-based specialists operating out of the same facilities but under separate management.

    Anyone who chooses the “group 1” coverage option (98% of the population), under which GPs act as gatekeepers for secondary care, is required to register with a GP. People can register with any available local GP. “Group 2” coverage provides free choice of GP and access to practicing specialists without referral, though a copayment is required. Under both groups, access to hospitals requires referral.

    Outpatient specialist care: Outpatient specialist care is delivered through hospital-based ambulatory clinics (fully integrated and funded, as are other public hospital services) or by self-employed specialists in privately owned facilities. Private self-employed specialists can be full-time or part-time; full-timers may not have other full-time jobs. Part-timers may also work in the hospital sector, subject to codes of conduct, with their activity level monitored and their incomes limited by the regions. Practices may be colocated but normally do not operate in formal multispecialty groups.

    Services from self-employed private providers are paid by the regions on a fee-for-service basis for referred public patients. Fees are set through negotiations with the regions and are based on regional priorities and resource assessments. Private specialists and hospitals also receive patients paying out-of-pocket or covered by voluntary insurance. Fees for patients without referral are set by the specialists. As a result of legislation introduced in 2013 guaranteeing patients the right to diagnostic assessment within 30 days of referral, private practitioners and hospitals may also receive patients referred from public-sector providers; they are paid for these services through specific agreements with the regions.

    Patients have a choice of private outpatient specialists upon referral (group 1) or without referral (group 2).

    Administrative mechanisms for direct patient payments to providers: There is no out-of-pocket payment for medical services for patients in group 1. Primary care doctors and specialists are paid directly by the regions when registering provision of services electronically. Group 2 patients make a copayment to supplement the automatic payment.

    After-hours care: After-hours care is organized by the regions, mainly by collective agreement with GPs. The Copenhagen region employs staff including specialized nurses, who do the initial screening of calls. GPs can volunteer to take on more or less responsibility within this scheme and receive a higher rate of payment for after-hours than for normal care. Capitation does not apply to after-hours care. The first line of contact is a regional telephone service, with a GP (or a nurse, in the Copenhagen region) deciding whether to refer the patient for a home visit or to an after-hours clinic, which is usually colocated with a hospital emergency department. Information on patient visits is sent routinely to GPs. There are walk-in emergency units in larger hospitals.

    Hospitals: Approximately 97 percent of hospital beds are publicly owned. Regions decide on budgeting mechanisms, generally using a combination of fixed-budget and activity-based funding based on diagnosis-related groups (DRGs), with the fixed budget making up the bulk of the funding (although significant fluctuations occur among specialties and hospitals). DRG rates are calculated by the Ministry of Health at the national level, based on average costs. Activity-based funding is usually combined with target levels of activity and declining rates of payment to control expenditure. This strategy succeeded in increasing activity and productivity by an average of 5 percent annually from 2009 to 2011 and by 1.4 percent from 2011 to 2012. Bundled payments are not yet used extensively, but experiments are being carried out in all five regions. Hospital physicians are salaried and employed by regional hospitals, which bear the attendant costs, as are other health care professionals in hospitals and in most municipal health services. Patients can choose among public hospitals upon referral, and payment follows the patient to the receiving hospital if it is located in another region. Physicians at public hospitals are not allowed to see private patients within the hospital.

    Mental health care: There is no cost-sharing for inpatient psychiatric care, but there is some cost-sharing (which may be covered by voluntary health insurance) for psychologists in private practice. Some GPs offer specific therapeutic consultations, but their main role is early detection and referral.

    Social psychiatry and care are a responsibility of the municipalities, which can choose to contract with a combination of private and public service providers, but most providers are public and salaried. A right to diagnostic assessment for psychiatry within one month of referral was introduced in 2014. Treatment must be commenced within two months for less serious conditions and one month for more serious conditions. There are walk-in units for acute psychiatric care in all regions.

    Long-term care: Responsibility for chronic care is shared between regional hospitals, general practitioners, and providers of municipal institutional and home-based services. Hospital-based ambulatory chronic care is financed in the same way as other hospital services. Long-term care outside of hospitals is needs-based and is organized and funded by municipalities. Most municipal long-term care is provided at home, in line with a policy initiative to enable people to remain at home as long as possible. Home nursing is fully funded after medical referral. Permanent home care is free of charge, while temporary home care can be subject to cost-sharing if the recipient’s income is above DKK143,300 (USD18,890) for single individuals and DKK215,300 (USD28,380) for couples. Municipalities are obliged to organize markets with open access for both public and private providers of home care (personal and practical care such as cleaning and shopping), and patients may choose between public or private providers. While this system functions relatively well in most municipalities, it has been difficult to attract private providers to remote areas. A considerable number of the elderly choose private providers. Some municipalities also have contracted with private institutions for institutional care of older people, but more than 90 percent of residential care institutions (nursing homes) remain public.

    Providers are paid directly by the municipalities, and no cash benefits are paid to patients. Public providers are employed by the municipalities. For staying in residential care institutions, patients pay according to the facility’s costs, the size of the dwelling, and their income and savings; patients also are responsible for heating and electricity charges.

    Relatives of seriously ill individuals are allowed to take paid leaves of absence from their jobs for up to nine months. These can be incremental and may be divided among several relatives. A similar scheme exists for relatives of terminally ill patients who no longer receive treatment.

    Hospices, which may be public or private, are organized by the regions and are funded by regions and municipalities. There is free choice of hospice upon referral.

  • Germany

    Physicians: General practitioners (GPs) and specialists in ambulatory care who get reimbursed by statutory health insurance (SHI) are by law mandatory members of regional associations that negotiate contracts with sickness funds. Regional associations of SHI-accredited physicians are responsible for coordinating care requirements within their region and act as financial intermediaries between the sickness funds and the physicians in ambulatory care. However, ambulatory physicians typically work in their own private practices—around 60 percent in solo practice and 25 percent in dual practices. Most physicians employ doctors’ assistants, while other nonphysicians (e.g., physiotherapists) have their own premises. In 2015, of the roughly 108,500 self-employed SHI-accredited physicians in ambulatory care, 51,900 (48%) were practicing as family physicians (including GPs, internists, and pediatricians) and 56,600 (52%) as specialists. There were about 2,000 multispecialty clinics, with more than 13,000 physicians (10% of ambulatory care physicians), in 2015. Around 11,000 physicians working in multispecialty clinics are salaried employees, while 12,000 are employed in practices of self-employed physicians. The total number of ambulatory-care physicians and psychotherapists is more than 140,000. Some specialized outpatient care is provided by hospital specialists, including treatment of rare diseases and of severe progressive forms of disease, as well as highly specialized procedures.

    Individuals have free choice among GPs, specialists, and, if referred to inpatient care, hospitals. Registration with a family physician is not required, and GPs have no formal gatekeeping function. However, sickness funds are required to offer their members the option to enroll in a “family physician care model,” which has been shown to provide better services and also often provides incentives for complying with gatekeeping rules.

    SHI-accredited physicians in ambulatory care (GPs and specialists) are generally reimbursed on a fee-for-service (FFS) basis according to a uniform fee schedule negotiated between sickness funds and physicians. Payments are limited to covering a predefined maximum number of patients per practice and reimbursement points per patient, setting thresholds on the number of patients and of treatments per patient for which a physician can be reimbursed. For the treatment of private patients, GPs and specialists also get an FFS, but the private tariffs are usually higher than the tariffs in the SHI uniform fee schedule. Pay-for-performance has not been established yet. The average reimbursement of a family physician is above EUR200,000 (USD254,452) per year, covering costs for personnel, etc., but excluding income from private patients, which varies substantially.

    Financial incentives for care coordination can be part of integrated care contracts, but are not routinely implemented. The only regular financial incentive that GPs receive is a fixed annual bonus (EUR120, or USD153, in 2016) for patients enrolled in a Disease Management Program (DMP), in which physicians provide patient training and document patient data. Bundled payments are not common in primary care, but a regional initiative, “Healthy Kinzigtal” (Kinzigtal is a valley in southeast Germany), provides an example of a shared savings model offering primary care doctors and other providers financial incentives for integrating care across providers and services.

    Administrative mechanisms for direct patient payments to providers: Statutory health insurance (SHI) physicians in ambulatory care bill their regional associations according to a uniform fee schedule; the associations receive the money from the sickness funds in the form of annual capitations. Copayments or payments for services not included in the benefit catalogue are paid directly to the provider. In cases of private health insurance, patients pay up front and submit claims to the insurance company for reimbursement.

    After-hours care: After-hours care is organized by the regional associations of statutory health insurance (SHI)-accredited physicians to ensure access to ambulatory care around the clock. Physicians are obliged to provide after-hours care in their practices, with differing regional regulations. In some areas (e.g., Berlin), after-hours care has been delegated to hospitals. The patient is given a report of the visit afterward to hand to his or her GP. There is also a tight network of emergency care providers (the responsibility of the municipalities). After-hours care assistance is also available via a nationwide telephone hotline (116 117-´┐Żrztlicher Bereitschaftsdienst). Payment for ambulatory after-hours care is based on the above-mentioned fee schedules, again with differences in the amount of reimbursement by SHI and private health insurance.

    Hospitals: Public hospitals make up about half of all beds, while private not-for-profits account for about a third. The number of private, for-profit hospitals has been growing in recent years (now around one-sixth of all beds). All hospitals are staffed principally by salaried doctors. Doctors in hospitals are typically not allowed to treat outpatients (similar to hospitalists in the U.S.), but exceptions are made if necessary care cannot be provided by office-based specialists. Senior doctors can treat privately insured patients on a fee-for-service basis. Hospitals can also provide certain highly specialized services on an outpatient basis.

    The 16 state governments determine hospital capacity, while ambulatory care capacity is subject to rules set by the Federal Joint Committee. Inpatient care is paid per admission through a system of diagnosis-related groups (DRGs) revised annually, currently based on around 1,200 DRG categories. DRGs also cover all physician costs. Other payment systems like pay-for-performance or bundled payments have yet to be implemented in hospitals.

    Mental health care: Acute psychiatric inpatient care is largely provided by psychiatric wards in general (acute) hospitals, while the number of hospitals providing care only for patients with psychiatric and/or neurological illness is low. In 2015, there were a total of 35,368 office-based psychiatrists, neurologists, and psychotherapists working in the ambulatory care sector (paid fee-for-service). Qualified GPs can provide basic psychosomatic services. Ambulatory psychiatrists are also coordinators of a set of statutory health insurance (SHI)-financed benefits called “sociotherapeutic care” (which requires referral by a GP), intended to encourage the chronically mentally ill to use necessary care and to avoid unnecessary hospitalizations. To further promote outpatient care for psychiatric patients (particularly in rural areas with a low density of psychiatrists in ambulatory care), hospitals can be authorized to offer treatment in outpatient psychiatric departments.

    Long-term care and social supports: Long-term care insurance (LTCI) is mandatory and is usually provided by the same insurer as health insurance and therefore comprises a similar public–private insurance mix. The contribution rate of 2.35 percent of gross salary is shared between employers and employees; people without children pay an additional 0.25 percent. The contribution rate will increase by 0.2 percent in early 2017. Everybody with a physical or mental illness or disability (who has contributed for at least two years) can apply for benefits, which are: 1) dependent on an evaluation of individual care needs by the statutory health insurance (SHI) Medical Review Board (leading either to a denial or to a grouping into currently one of three levels of care); and 2) limited to certain maximum amounts, depending on the level of care. Beneficiaries can choose between in-kind benefits and cash payments (around a quarter of LTCI expenditure goes to these cash payments). Both home care and institutional care are provided almost exclusively by private not-for-profit and for-profit providers. As benefits usually cover approximately only 50 percent of institutional care costs, people are advised to buy supplementary private LTCI. Family caregivers get financial support through continuing payment of up to 50 percent of care costs.

    Hospice care is partly covered by LTCI if the SHI Medical Review Board has determined a care level. Medical services or palliative care in a hospice are covered by SHI. The number of inpatient facilities in hospice care has grown significantly over the past 15 years, to 235 hospices and 304 palliative care wards nationwide in spring 2016. The Act to Improve Hospice and Palliative Care passed in 2015, with the aim of guaranteeing care in underserved rural areas and linking long-term care facilities more strongly to ambulatory palliative and hospice care.

  • France

    Collective agreements between representatives of the health professions and statutory health insurance (SHI), signed at the national level, apply to all but those professionals who expressly opt out. These agreements set the fee schedule as well as coordination and quality incentives.

    Primary care: There are roughly 221,000 general practitioners (GPs) and 119,000 specialists in France (a ratio of 3.4 per 1,000 population). About 59 percent of physicians are fully or partly self-employed (67% of GPs, 51% of specialists). Over 50 percent of GPs, predominantly younger doctors, are in group practices. An average practice is made up of two to three physicians. Seventy-five percent of practices are made up exclusively of physicians; the remaining practices comprise a range of allied health professionals, typically paid fee-for-service.

    There is a voluntary gatekeeping system for adults age 16 and older, with financial incentives offered for registering with a GP or specialist.

    Self-employed GPs are paid mostly fee-for-service (currently EUR23, or USD28, to be increased to EUR25, or USD30, in 2017) and can receive a yearly capitated per-person payment of EUR40 (USD48) to coordinate care for patients with a chronic condition. In addition, up to EUR5,000 (USD6,024) annually is provided for achieving targets related to the use of computerized medical charts, electronic claims transmission, delivery of preventive services such as immunization, compliance with guidelines for diabetic and hypertensive patients, generic prescribing, and limited use of psychoactive drugs for elderly patients.

    Since 2013, GPs also can enter into a contractual agreement under which they are guaranteed a monthly income of EUR6,900 (USD8,313) if they set up their practice in a region with insufficient physician supply. For those who elect to work full-time in medical centers, the guaranteed salary is around EUR50,000 (USD60,240).

    The average income of primary care doctors in 2011 was EUR82,020 (USD98,820), 94 percent of which came from fees and the remainder from financial incentives and salary. Fees, set by the health ministry and SHI, have been frozen since 2011, but revenues from other sources have increased.

    Experimental GP networks providing chronic care coordination, psychological services, dietician services, and other care not covered by statutory health insurance (SHI) are financed by earmarked funds from the Regional Health Agencies. In addition, over 1,000 medical homes, providing multiprofessional services (usually with three to five physicians and roughly a dozen other health professionals) and after-hours care, will be in operation by the end of 2016.

    Outpatient specialist care: About 36 percent of outpatient specialist care providers are exclusively self-employed and paid on a fee-for-service basis; the rest are either fully salaried by hospitals or have a mix of income. In October 2014, participation in pay-for-performance programs was extended to all self-employed physicians, including specialists; specialists must meet disease-specific quality targets in addition to those targets that apply to GPs. The average annual income derived from pay-for-performance is EUR5,480 (USD6,602) per physician; such income constitutes less than 2 percent of total funding for outpatient services.

    Patients can choose among specialists upon referral by a GP, with the exception of gynecologists, ophthalmologists, psychiatrists, and stomatologists. Bypassing referral results in reduced statutory health insurance (SHI) coverage.

    The specialist fee set by SHI is EUR28 (USD34), but specialists can balance-bill. The average yearly income of self-employed specialists is EUR133,460 (USD160,795). Half of specialists are in group practices, which are increasing among specialties that require major investments, such as nuclear medicine, radiotherapy, pathology, and digestive surgery.

    Specialists working in public hospitals may see private-pay patients on either an outpatient or an inpatient basis, but they must pay a percentage of their fees to the hospital. A 2013 report to the health ministry estimated that 10 percent of the 46,000 hospital specialists in surgery, radiology, cardiology, and obstetrics had treated private patients. The mounting discontent over excessive balance billing revealed in the press, together with claims by private clinics of unfair competition, has prompted several public inquiries—the latest of which resulted in recommendations to increase public control over this activity.

    Administrative mechanisms for direct patient payments to providers: Patients pay the full fee (reimbursable portion and balance billing, if any) and claim reimbursement covering the full sum or less, depending on coverage, minus EUR1.00 (USD1.20), capped at a maximum of EUR50.00 (USD60.00) per patient per year. A very controversial article in the 2015 Touraine law was the third-party payment management system (Système du tiers-payant) as a safety net for the poorest populations. Third-party payment makes physicians’ consultations totally free at the point of care: practitioners will be paid directly by social security and supplementary health insurance.

    After-hours care: After-hours care is delivered by the emergency departments of public hospitals, private hospitals that have signed an agreement with their Regional Health Agency, self-employed physicians who work for emergency services, and medical homes financed by statutory health insurance (SHI) and staffed by health professionals on a voluntary basis. Primary care physicians are not mandated to provide after-hours care.

    Emergency services can be accessed via the national emergency phone number, which is staffed by trained professionals who determine the type of response needed. The feasibility of telephone or telemedicine advice is undergoing experimentation; it would include sharing information from the patient’s electronic medical record with the patient’s primary care doctor. Publicly funded multidisciplinary health centers with self-employed health professionals (physicians and nonphysicians) allow better after-hours access to care in addition to more comprehensive care; fee-for-service payment is the rule for these centers.

    Hospitals: Public institutions account for about 65 percent of hospital capacity and activity, private for-profit facilities account for another 25 percent, and private nonprofit facilities, the main providers of cancer treatment, make up the remainder. As of 2008, all hospitals and clinics are reimbursed via the diagnosis-related group (DRG) system, which applies to all inpatient and outpatient admissions and covers physicians’ salaries in public and not-for-profit hospitals. Bundled payment by episode of care does not exist.

    Public hospitals are funded mainly by statutory health insurance (80%), with voluntary insurance and direct patient payment accounting for their remaining income. Public and private nonprofit hospitals also benefit from grants that compensate research and teaching (up to an additional 13% of the budget) and from the provision of emergency services, organ harvesting, and organ transplantation (on average, an additional 10%–11% of a hospital’s budget). Private, for-profit clinics owned either by individuals or, increasingly, by large corporations have the same funding mechanism as public hospitals, but the share of respective payers differs. Doctors’ fees are billed in addition to the DRG in private clinics, and DRG payment rates are lower there than they are in public or nonprofit hospitals. This disparity is justified by differences in the size of facilities, the DRG mix, and the patients’ characteristics (age, comorbid conditions, and socioeconomic status). Rehabilitative hospitals also have a prospective payment system based on length of stay and care intensity.

    Mental health care: Services for mentally ill people are provided by both the public and the private health care sector, with an emphasis on community-based provision. Public care is provided within geographically determined areas and includes a wide range of preventive, diagnostic, and therapeutic inpatient and outpatient services. Ambulatory centers provide primary ambulatory mental health care, including home visits.

    Mental health care is not formally integrated with primary care, but a large number of disorders are also treated on an outpatient basis by GPs or private psychiatrists or psychologists, some of them practicing psychotherapy and, occasionally, psychoanalysis.

    Statutory health insurance covers care provided by GPs and psychiatrists in private practice, public mental health care dispensaries, and private psychiatric hospitals. Copayments do not apply to persons with a diagnosed long-term mental illness. Care provided by psychotherapists or psychoanalysts is fully financed by patients or covered by voluntary health insurance (VHI). Copayments and the flat-rate fee for accommodation can also be fully covered by VHI.

    Long-term care and social supports: Total expenditure for long-term care in 2013 was estimated to be EUR39 billion (USD47 billion), or 17 percent of total health expenditures. Statutory health insurance covers the medical costs of long-term care, while families are responsible for the housing costs in hospices and other long-term facilities—on average, EUR1,500 (USD1,809) per month. End-of-life care in hospitals is fully covered. Some funding of care for the elderly and disabled comes from the National Solidarity Fund for Autonomy, which is in turn financed by SHI and the revenues from an unpaid working “solidarity” day. Local authorities, the general councils, and households also participate in financing these categories of care.

    Home care for the elderly is provided mainly by self-employed physicians and nurses and, to a lesser extent, by community nursing services. Long-term care in institutions is provided in retirement homes and long-term care units, totaling roughly 10,000 institutions with a total of 720,000 beds. Of these institutions, 54 percent are public, 28 percent private nonprofit, and 18 percent for-profit, although the percentage of for-profit institutions is increasing.

    In addition, temporary care for dependent patients and respite services for their caregivers are available without restrictions from the states or regions.

    Means-tested monetary allowances are provided for the frail elderly. The allowances are adjusted in relation to the individual’s dependence level, living conditions, and needs, as assessed by a joint health and social care team, and may be used for any chosen service and provider. About 1.1 percent of the total population is estimated to be eligible. Informal caregivers also benefit from tax deductions.

    To address loss of autonomy among the elderly, a law enacted at the end of 2015 established local conferences to define priorities, identify existing services, and create new programs as necessary.

  • England

    Primary care: Primary care is delivered mainly through general practitioners (GPs), who act as gatekeepers for secondary care. In 2015, there were 34,592 general practitioners (full-time equivalents) in 7,674 practices, with an average of 7,450 patients per practice and 1,530 patients per GP. There were 43,632 hospital specialists and a further 51,460 hospital doctors in training. The number of solo practices was 843 in 2014, while there were 3,589 practices with five or more GPs. General practices are normally patients’ first point of contact, and people are required to register with a local practice of their choice; however, choice is effectively limited because many practices are full and do not accept new patients. In some areas, walk-in centers offer primary care services, for which registration is not required.

    Most GPs (66%) are private contractors, and approximately 56 percent of practices operate under the national General Medical Services contracts, negotiated between the British Medical Association (representing doctors) and government. These provide payment using a mixture of capitation to cover essential services (representing about 60% of income), optional fee-for-service payments for additional services (e.g., vaccines for at-risk populations, about 15%), and an optional performance-related scheme (about 10%). Capitation is adjusted for age and gender, local levels of morbidity and mortality, the number of patients in nursing and residential homes, patient list turnover, and a market-forces factor for staff costs as compared with those of other practices. Performance bonuses are given mainly on evidence-based clinical interventions and care coordination for chronic illnesses. The proportion of income from these bonuses will fall when the new 2014–2015 contract is fully implemented, as the number of bonus-related services is reduced and funding rerouted into capitation.

    The proportion of GPs employed in practices or on a salaried basis as locums (e.g., standing in when other GPs are unavailable) is increasing (currently around 20%). Most general practices employ other professionals such as nurses, whose duties include monitoring patients for blood pressure and providing minor treatments. General practice is undergoing a structural change, from single-handed “corner shops” to networked practices, including larger multipractice organizations using multidisciplinary teams of specialists, pharmacists, and social workers. The average income for combined GPs (contracted and salaried) in England was GBP91,000 (USD131,503) before tax in 2014–2015.

    Outpatient specialist care: Nearly all specialists are salaried employees of National Health Service (NHS) hospitals, and Clinical Commissioning Groups (CCGs) pay hospitals for outpatient consultations at nationally determined rates. Specialists are free to engage in private practice within specially designated wards in NHS or private hospitals; the most recent estimates (in 2006) were that 55 percent of doctors performed private work, a proportion that is declining as the earnings gap between public and private practice narrows. Patients are able to choose which hospital to visit, and the government has introduced the right to choose a particular specialist within a hospital (not yet fully implemented). Most outpatient specialist consultations are carried out in hospitals, although consultation may take place in general practices. Some GPs “with specialist interests” also offer specialist consultations, paid on a per-session or fee-for-service basis.

    Administrative mechanisms for paying primary care doctors and specialists: The bulk of general practices are reimbursed monthly for the services they deliver on the basis of data extracted automatically from practices’ electronic records. Some payments may require practices to enter data manually on the number of patients screened or treated for “enhanced services” that qualify for additional payments, such as diagnosis and support for patients with dementia. These data are collated and validated by National Health Service (NHS) England.

    After-hours care: GPs are no longer required personally to provide after-hours care to their patients (a small minority still do), but must ensure that adequate arrangements for its provision are in place. In practice, this means that Clinical Commissioning Groups (CCGs) contract mainly with GP cooperatives and private companies, both of which usually pay GPs on a per-session basis.

    Serious emergencies are handled by hospital emergency departments. In some areas, less-serious cases are seen in urgent care centers or minor-injury units, which are staffed in a variety of ways and include both nurse-led and GP-led centers. Telephone advice is available on a 24-hour basis through National Health Service (NHS) 111 for those with an urgent but not life-threatening condition.

    Hospitals: Publicly owned hospitals are organized either as National Health Service (NHS) trusts (currently 72) directly accountable to the Department of Health or as foundation trusts (currently 150) regulated by NHS Improvement, whose functions include the economic regulation of public and private providers.

    Both NHS trust and foundation trust hospitals contract with local Clinical Commissioning Groups (CCGs) to provide services. They are reimbursed mainly at nationally determined diagnosis-related group (DRG) rates, which include medical staff costs and account for about 60 percent of income, with the remainder coming from activities not covered by DRGs, such as mental health, education, and research and training funds. Responsibility for setting those rates is shared between NHS England and NHS Improvement. In some areas, rates are not applied and payments are made for an overall service, such as emergency care. Also at the local level, fees for “years of care”—for example, for the total cost of the care a diabetic patient receives over 12 months—are being developed but as yet are not in widespread use. There is no cap on hospital incomes.

    An estimated 548 private hospitals and between 500 and 600 private clinics in the U.K. offer a range of services, including treatments either unavailable in the NHS or subject to long waiting times, such as bariatric surgery and fertility treatment, but generally do not have emergency, trauma, or intensive-care facilities. Private providers must be registered with the Care Quality Commission and with NHS Improvement, but their charges to private patients are not regulated, and there are no public subsidies. Although the volume of care purchased from private providers by the NHS has increased recently in areas outside of mental health, NHS use of private hospitals remains low—3.6 percent of overall spending by commissioners on hospital services in 2012–2013.

    Mental health care: Mental health care is an integral part of the National Health Service (NHS) and covers a full range of services. Less-serious illnesses—mild depressive and anxiety disorders, for example—are usually treated by GPs. Those requiring more advanced treatment, including inpatient care, are treated by mental health or hospital trusts. Some of these services are provided by community-based staff. About a quarter of NHS-funded, hospital-based mental health services are provided by the private sector.

    Over the past decade, policy has focused on increasing access to psychological therapies for mild-to-moderate mental health problems, although there can still be long waiting times. Policies to improve the care of more severe conditions in the community have focused on outreach and early intervention, and there is an overarching aim to ensure “parity of esteem” between mental health and other kinds of health services. A review conducted in 2012 suggested that treatment of mental health, by comparison with that of physical illnesses, has been underfunded.

    Long-term care and social supports: The National Health Service (NHS) pays for some long-term care, such as care for people with continuing medical or skilled-nursing needs, but payments in recent years have been substantially reduced. Most long-term care is provided by local authorities and the private sector. Local authorities are legally obliged to assess the needs of all people who request it, but, unlike NHS services, state-funded social care is not universal. With the exception of time-limited “reablement” services, some equipment and home modifications (in some areas), and information services, residential and home care are needs- and means-tested. Full state support for residential care, for example, is available only to those with less than GBP14,250 (USD20,592) in assets who are also assessed as having high levels of need, with a sliding scale applied up to GBP23,250 (USD33,600). There is a national framework for assessing need, but local authorities are free to set eligibility thresholds for access to funds, which has become progressively more restricted. Plans to impose a cap on total out-of-pocket spending on long-term care have been postponed until 2020.

    Those eligible are liable for copayments, with some people contributing almost all of their “assessed income,” including pensions. Beneficiaries can receive personal budgets to purchase their own care or can opt to have the local authority arrange it. Some additional allowances paid to users and carers are exempt from means testing, such as “attendance allowance,” worth a maximum of GBP82.30 (USD119.00) a week.

    In 2009, the private sector provided 78 percent of residential care places for older people and the physically disabled in the U.K. The NHS provides end-of-life palliative care at patients’ homes, in hospices (usually run by charitable organizations), in care homes, or in hospitals. Separate government funding is available for working-age people with disabilities.

  • India

    Health care services are delivered by a complex network of public and private providers, ranging from single doctors to specialty and multispecialty tertiary care hospitals.

    Public sector: The government health care system is designed as a three-tier structure comprising primary, secondary, and tertiary facilities. In rural areas, primary health care services are provided through a network of subcenters, primary health centers, and community health centers. The subcenter is the first point of contact between the primary health care system and the community, designed to handle maternal and child health, disease control, and health counseling for a population of 3,000 to 5,000. At least one auxiliary nurse midwife or female health worker, one male health worker, and one female “health visitor” supervise six subcenters.

    The primary health center is the first point of contact between a village community and a medical officer and provides curative and preventive services to 20,000 to 30,000 people. It serves as a referral unit for six subcenters and has four to six beds for patients.

    Community health centers are managed and maintained by state governments and are required to have four medical specialists supported by 21 paramedical and other staff, with 30 beds, laboratory, X-ray, and other facilities. It covers 80,000 to 120,000 people.

    Finally, an existing facility like a district or subdivisional hospital or a community health center is named as a fully operational first referral unit if it is equipped to provide round-the-clock emergency obstetric care and blood storage. District hospitals function as the secondary tier of public providers for the rural population. Of a total of 628,708 government beds, 196,182 are in rural areas. Government hospitals operate within a yearly budget allocation.

    Despite this elaborate infrastructure, severe shortages of staff and supplies in public-sector health facilities remain. India has a doctor-to-population ratio of 1:1,674, compared with the World Health Organization norm of 1:1,000, a situation that results in acute shortages and uneven distribution of doctors. India’s urban poor are especially vulnerable, given that primary care facilities in the cities are generally less organized and fewer in number than in rural communities. Lack of access to care appears to take a toll: nearly 60 percent of urban poor children have not received all recommended immunizations before age 1. Life in slums also exposes people to a variety of diseases.

    Private sector: India’s private health care sector is not well regulated. Private health care providers deliver an array of outpatient services in solo practices ranging from those not registered with the relevant medical council to trained medical practitioners to small nursing homes and multispecialty clinics. An estimated 40 percent of private care is provided by unqualified providers.

    The private hospital sector has expanded rapidly, and government-sponsored health schemes also rely on private hospitals as a part of public–private partnerships. From 2002 to 2010, the private sector created more than 70 percent of new beds, contributing 63 percent of total hospital beds. Private hospitals currently provide about 80 percent of outpatient care and 60 percent of inpatient care. Until the 1980s, private-sector hospitals were mainly nonprofits run by charitable trusts. With India’s economic liberalization, growing middle class, and the rise in medical tourism, the number of private, for-profit hospitals has grown substantially.

    Public sector: Physicians working in government facilities earn salaries and are not permitted to work in private practice in most states. Other staff members such as nurses and technicians also earn fixed salaries.

    Private sector: Physician payment in the private sector varies depending on local market conditions. Overall, private-sector physicians are better paid than their government counterparts. However, nurse salaries in the private sector have historically been low; India’s Supreme Court is looking into the issue.

  • Israel

    Primary care: Nearly all Israeli primary care physicians provide care through only one of the four competing nonprofit health plans, which vary markedly in how they organize care. (In this profile, we refer to primary care physicians as general practitioners, or GPs, although they also include board-certified family physicians.)

    In Clalit, the largest health plan, most primary care is provided in clinics owned and operated by the plan, and GPs are salaried employees. The typical clinic has three to six GPs and several nurses, pharmacists, and other professionals. Clalit also contracts with independent physicians; although these doctors tend to work in solo practices with limited on-site support from non-physicians, they have access to various administrative and nursing services at Clalit district clinics.

    The other three health plans also use a mix of clinics and independent primary care practices, with the mix varying across plans. In Maccabi (the second-largest plan) and Meuhedet, almost all of the primary care is provided by independent physicians, while in Leumit the clinic model predominates (though not to the same extent as in Clalit).

    Members of all plans can generally choose their GP from among those on the plan’s list and can switch freely. In practice, nearly all patients remain with the same GP for extended periods.

    In Clalit, each patient is registered with a GP who has responsibility for coordinating care and who acts as a gatekeeper to secondary care, with the exception of five common specialties. In Leumit, patients are registered with a clinic rather than with a GP, and in the other two plans there is no registration. However, in all plans there is a movement under way to associate each member with a physician for purposes of quality assurance and accountability. Clalit is the only plan that requires referral to secondary care.

    Independent physicians in all plans are paid on a capitation basis, with Clalit and Leumit using “passive capitation” (a quarterly, per-member payment made irrespective of whether the member visited the GP in the relevant quarter) and Maccabi and Meuhedet using “active capitation” (where the payment is made only for members who visited their GP at least once during the quarter). Independent physicians also receive limited fee-for-service payments for certain procedures.

    Plans monitor the care provided by their GPs and work closely with them to improve quality. However, quality-related financial incentives are generally not used.

    The salaries of Clalit clinic physicians are set via a collective bargaining agreement with the Israel Medical Association. The capitation rates of independent physicians, in all the health plans, are set by the plans in consultation with their physicians’ associations.

    In 2012–2014, Israel had an average of approximately 27,700 employed physicians. As of 2011, approximately 7,000 of them worked with or for the health plans as GPs.

    Outpatient specialty care: Outpatient specialty care is provided predominantly in community settings, either in health plan clinics (the dominant mode in Clalit) or in physicians’ offices (the predominant mode in the other health plans). The former tend to be integrated multispecialty clinics, while the latter tend to be single-specialty. Most specialists are paid on an active capitation basis, plus fee-for-service for certain procedures. Rates are set by the health plans and, within the national health insurance (NHI) system, specialists may not balance-bill; patients pay the quarterly copayment only. Patients can choose from a list of specialists provided by their health plans. Specialists who work for the plans may also see private patients.

    Administrative mechanisms for direct patient payments to providers: As noted above, the only direct payments to national health insurance (NHI) providers are copayments. Patients can usually use their health plan membership cards instead of making cash payments; the provider receives the full fee from the health plans, which then collect the copayments from enrollees.

    After-hours care: After-hours care is available via hospital emergency departments (EDs), freestanding walk-in “emergi-centers,” and companies that provide physician home visits. Physicians providing care in EDs and emergi-centers come from a range of disciplines, including primary care, internal medicine, general surgery, orthopedics, and, increasingly, emergency medicine. Nurses play a significant role in triage. They are typically salaried, while physicians working for home-visit companies are typically paid per visit.

    Primary care physicians are not required to provide after-hours care. They receive reports from the after-hours providers, and increasingly this information is conveyed electronically.

    All the health plans operate national telephone advice lines for their members, staffed by nurses with physician backup.

    Hospitals: Acute-care bed capacity is divided approximately as follows: government, 50 percent; Clalit, 30 percent; other nonprofits, 15 percent; for-profits, 5 percent. However, the for-profits account for a much larger share of admissions and an even larger share of surgical operations.

    Hospital outpatient care is reimbursed on a fee-for-service basis, and inpatient care is reimbursed using a mix of per-diem and activity-based diagnosis-related group (DRG) arrangements, with approximately two-thirds of revenue coming from per-diem payments. Maximum rates are set by government, but health plans negotiate discounts. There are also revenue caps set by government, which limit the extent to which each hospital’s total revenues can grow from year to year. Generally speaking, hospital payments include the cost of the physicians working for the hospitals.

    In government and nonprofit hospitals, physicians are predominantly salaried employees, with limited arrangements for supplemental fee-for-service in some hospitals. Fee-for-service is the predominant payment mode in private hospitals.

    Mental health care: Responsibility for the provision of mental health care was transferred in mid-2015 from the Ministry of Health to the health plans, which provide care through a mix of salaried professionals, contracted independent professionals, and services purchased from organizations (including the ministry’s mental health clinics). The benefit package is broad and includes psychotherapy, medications, and inpatient and outpatient care. Integration with primary care is currently limited but is expected to improve because of the transfer of responsibility to the health plans.

    Long-term care and social supports: The financing of institutional long-term care is considered a responsibility of patients and their families, to the extent that they can afford it. An extensive range of needs-based, graduated subsidies is available from the Ministry of Health. These are generally paid directly to providers, although recently a change was made to the law to make it easier for families to receive cash subsides to be used in paying providers.

    The health plans are responsible for medical care of the disabled elderly living in the community. In recent years, they have increased access to clinicians (particularly for the homebound elderly) via home care teams and telemedicine.

    The National Insurance Institute finances personal care and housekeeping services for the community-dwelling seniors with disabilities. Additional supports include an extensive network of daycare centers and a growing network of supportive neighborhoods. An emergency call service, physician home visits, and social activities are offered. Additionally, in every community a facilitator coordinates social supports and apartment repairs.

    For nursing homes, home medical care, and home aids, eligibility is based on the degree of inability to carry out activities of daily living. In addition, there are means tests for government assistance for nursing home and home aids, but not for medical home care provided by the health plans or for any services provided through private insurance.

    Private, for-profit providers deliver about two-thirds of nursing home care, virtually no medical home care (which is delivered by the private, nonprofit health plans), and nearly all home aids.

    Although the government maintains that hospice care is included in the NHI benefit package that the health plans are supposed to provide, the plans dispute this. Some hospice care is available (particularly home hospice), though much less than is needed. Approximately half of the adult population has private long-term care insurance. There is no direct financial support for informal or family caregivers.

  • Italy

    Primary care: Primary care is provided by self-employed and independent physicians, general practitioners, and pediatricians, under contract and paid a capitation fee based on the number of people on their list. Local health units also can pay additional allowances for the delivery of planned care to specific patients (e.g., home care to chronically ill patients), for reaching performance targets (e.g., to reward effective cost containment for prescribed pharmaceuticals, laboratory tests, and therapeutic treatments), or for delivering additional treatments (e.g., medications, flu vaccinations). Capitation is adjusted for age and accounts for approximately 70 percent of overall payment. The variable portion comprises fee-for-service payment for specific treatments, including minor surgery, home care, preventive activities, and care of chronically ill patients. On average, the gross income of a GP ranges between EUR80,000 (USD107,000) and EUR120,000 (USD160,000), depending on list size.

    The payment levels, duties, and responsibilities of GPs are determined in a collective agreement signed every three years by consultation between central government and the GPs’ trade unions. In addition, regions and local health units can sign contracts covering additional services.

    In 2012, there were approximately 53,000 GPs and pediatricians (33.6% of all practitioners working for the NHS) and 104,600 hospital clinicians (66.4%). Patients are required to register with a gatekeeping GP, who has incentives to prescribe and refer only as appropriate: in most cases, incentives are awarded only to those GPs and pediatricians who fall below a predetermined spending maximum or consumption target. People may choose any physician whose list has not reached the maximum number of patients allowed (1,500 for GPs and 800 for pediatricians) and may switch at any time.

    In recent years, the solo practice model has been progressively modified toward group practice, particularly in the northern part of the country. Legislation encourages GPs and pediatricians to work in three ways: base group practice, in which GPs from different offices share clinical experiences, develop guidelines, and participate in workshops that assess performance; network group practice, which functions like base group practice but allows GPs and pediatricians to access the same patient electronic health record system; and advanced group practice, in which GPs and pediatricians share the same office and patient health record system and are able to provide care to patients beyond individual catchment areas. In 2012, approximately 70.3 percent of GPs and 61.2 percent of pediatricians were working in a team. Group practices typically range from three to eight GPs.

    General practitioners working in base group practices receive an additional EUR2.58 (USD3.70) for each patient registered in their list, while GPs in a network practice receive EUR4.70 (USD6.30) (the payment for pediatricians is EUR8.00, or USD11.00). Lastly, GPs working in a group practice receive EUR7.00 (USD10.00) and pediatricians EUR9.00 (USD12.00). General practitioners or pediatricians receive an additional payment of EUR4.00 (USD6.70) for employing a nurse and EUR3.50 (USD4.70) for a secretary.

    Some regions are promoting care coordination by asking their GPs to work in groups comprising specialists, nurses, and social workers. The aim is for each group to be in charge of all the health needs of its assigned population. This arrangement is encouraged by additional payments to GPs per patient and by supplying teams with personnel.

    Outpatient specialist care: Outpatient specialist care is generally provided by local health units or by public and private accredited hospitals under contract with them. Once referred, patients are given a choice of any public or private accredited hospital but are not given a choice of specialist. Outpatient specialist visits are generally provided by self-employed specialists working under contract with the National Health Service. They are paid an hourly fee contracted nationally between the government and the trade unions; the current rate is approximately EUR32 (USD43). Outpatient specialists can see private patients without any limitations, whereas specialists employed by local health units and public hospitals cannot. Multispecialty groups are more common in northern regions of the country.

    Administrative mechanisms for paying primary care doctors and specialists: Patient copayment is limited to outpatient specialist visits and diagnostic testing, while primary care visits are provided free of charge. Copayments are usually paid by the patient before the visit or test.

    After-hours care: In the case of after-hours emergency care, or when a consultation with a GP is not possible, service is provided by the emergency medical service (guardia medica), staffed by “continuous-care physicians” (medici di continuità assistenziale). The hourly rate, negotiated between the GP trade unions and the government, is approximately EUR25 (USD33). Following examination and initial treatment, the doctor can prescribe medications, issue employees’ medical certificates, and recommend hospital admission. The service normally operates at night and on weekends.

    Information on a patient’s visit is not routinely sent to the patient’s GP. To improve accessibility, government and GP associations are trying to promote a model whereby GPs, specialists, and nurses coordinate to ensure 24-hour access and avoid unnecessary use of hospital emergency departments. Implementation is uneven across regions.

    Hospitals: Depending on the region, public funds are allocated by local health units to public and accredited private hospitals. In 2012, there were approximately 187,000 beds in public hospitals and 45,500 in private accredited hospitals. Public hospitals either are managed directly by the local health units or operate as semi-independent public enterprises. A diagnosis-related group–based prospective payment system operates across the country and accounts for most hospital revenue but is generally not applied to hospitals run directly by local health units, where global budgets are common. Rates include all hospital costs, including those of physicians. Teaching hospitals receive additional payments (typically 8% to 10% of overall revenue) to cover extra costs related to teaching. There are considerable interregional variations in the prospective payment system, such as how fees are set, which services are excluded, and what tools are employed to influence patterns of care. However, all regions have mechanisms for cutting fees once a spending threshold is reached, in order to contain costs and as an incentive to increase admissions.

    In all regions, a portion of funding is administered outside the prospective payment system (e.g., funding of specific functions such as emergency departments and teaching programs).

    Hospital-based physicians are salaried employees. Public-hospital physicians are prohibited from treating patients in private hospitals; all public physicians who see private patients in public hospitals pay a portion of their extra income to the hospital.

    Mental health care: Mental health care is provided by the National Health Service in a variety of community-based, publicly funded settings, including community mental health centers, community psychiatric diagnostic centers, general hospital inpatient wards, and residential and semiresidential facilities. In 2012, there were 1,938 residential facilities and 819 semiresidential facilities, providing care to approximately 69,000 patients. The promotion and coordination of mental illness prevention, care, and rehabilitation are the responsibility of specific mental health departments in local health units. These are based on a multidisciplinary team, including psychiatrists, psychologists, nurses, social workers, educators, occupational therapists, people with training in psychosocial rehabilitation, and secretarial staff. In most cases, primary care does not play a role in the provision of mental health care; a few regions have experimented with assigning the responsibility of low-complexity cases (mild depression) to general practitioners.

    Long-term care and social supports: Patients are generally treated in residential (approximately 180,000 beds in 2012) or semiresidential (14,000 beds) facilities or in home care (approximately 634,000 cases). Residential and semiresidential services provide nurses, physicians, specialist care, rehabilitation services, medical therapies, and devices. Patients must be referred to receive residential care. Cost-sharing for residential services varies widely according to region but is generally determined by patients’ income.

    Community home care is funded publicly, whereas residential facilities are managed by a mixture of public and private, for-profit and nonprofit organizations. Community home care is designed not to provide physical or mental care services but to provide additional assistance during a treatment or therapy. In spite of government provision of residential and home care services, long-term care in Italy has traditionally been characterized by a low degree of public financing and provision as compared with other European countries.

    Financial assistance for patients can take two forms:

    • Accompanying allowance: Awarded by the National Pension Institute to all Italian citizens who need continuous assistance. The allowance, which is related to need but not to income or age, amounts to approximately EUR500 (USD714) per month.
    • Care vouchers: Awarded by municipalities on the basis of income, need, and clinical severity only to residents of those municipalities offering the service. The amount ranges between EUR300 and EUR600 (USD426 to USD857) per month.

    Voluntary organizations still play a crucial role in the delivery of palliative care. A national policy on palliative care has been in place since the late 1990s and has contributed to an increase in services such as hospices, day care centers, and palliative care units within hospitals. In 2012, there were 176 hospices, with approximately 1,800 beds. But much still needs to be done to ensure the diffusion of palliative care services because disparities persist: northern regions cared, on average, for 54 patients per 100,000 residents, while in central and southern regions the rate fell to 27 patients.

  • Japan

    Primary care: Primary care is provided at most clinics and some hospital outpatient departments. Approximately one-third of physicians are salaried employees of clinics, and nearly all others are self-employed. Clinics are often owned by physicians or by medical corporations (special legal entities for health care management, usually controlled by physicians, that own medical institutions), but sometimes by local governments or public agencies.

    Primary care practices typically include teams with a physician and a few employed nurses. In 2014, the average clinic had 6.8 full-time-equivalent workers, including 1.3 physicians, 2.0 nurses, and 1.8 clerks. Clinics can dispense medication (which doctors can provide directly to patients). Use of pharmacists, however, has been growing; 67 percent of prescriptions were filled at pharmacies in 2013. Patients are not required to register with a practice, and there is no strict gatekeeping, although government encourages patients to choose their preferred doctors, and there are patient disincentives for self-referral including extra charges for initial consultations at large hospitals with many specialties. Patients can choose and drop in at any clinic, except those requiring reservations. An entity managing many clinics can share their resources. A scheme for cross-entity resource sharing will start in 2017 as described below.

    Payments for primary care are based principally on a complex national fee-for-service schedule, which includes financial incentives for coordinating the care of patients with chronic diseases, and for team ambulatory and home care. The schedule, set by the government (described below), includes both primary and specialist services, which have common prices for defined services such as consultations, examinations, laboratory tests, imaging tests, and defined chronic disease management. Per-case payments can be chosen by providers in select cases, such as daily payments for pediatrics care and monthly payments for treating patients with diabetes. Bundled payments are not used. Providers can charge for designated services as exceptions to the rule of prohibiting balance billing.

    Outpatient specialist care: Most outpatient specialist care is provided in hospital outpatient departments, but some is also available at clinics, where patients can visit without referral. Fees are determined by the same schedule that applies to primary care, as they do not usually vary by provider type, although some services must be provided by specialists in order to be covered by the Statutory Health Insurance System (SHIS). There are no collective regulations on payments for specialists. At hospitals, specialists are usually salaried, with additional payments such as night duty allowance. Those working at public hospitals can work at other health care institutions and privately with the approval of their employers, but in such cases they usually provide services covered by the public system. The employment status of specialists at clinics varies similarly to that of primary care physicians.

    Administrative mechanisms for paying primary care doctors and specialists: Legal entities managing clinics and hospitals send insurance claims, mostly online, to financing bodies in the Statutory Health Insurance System (SHIS), which pay a major part of the fees directly to providers; patients pay liable copayments at the point of service. Using the payments they receive for services, self-employed, clinic-based primary care physicians and specialists pay for employees and other inputs, allocate funds for investments, and retain surpluses. There are no direct payments from the SHIS financing bodies to salaried physicians.

    After-hours care: After-hours care is provided by hospital outpatient departments, where on-call physicians are available, and by some regular clinics and after-hours care clinics owned by local governments and staffed by physicians and nurses that local medical societies provide. Hospitals and clinics are paid “top-up” fees for after-hours care, including fees for telephone consultations. There is no strict formal requirement for clinics to provide such services, although physicians have a general obligation to consult with patients when requested. Patients can walk in at most hospitals and clinics. The national government gives subsidies to local governments for these clinics. Patient information from after-hours clinics is provided to family physicians if necessary (such information is often handed to patients to show to family physicians). There is a national pediatric medical advice telephone line available after hours.

    Hospitals: As of 2014, 15 percent of hospitals are owned by national or local governments or closely related agencies; most of the rest are private and nonprofit, some of which receive subsidies because they are designated as having partly public roles. More than 20 percent of all beds are in government hospitals; the rest are mostly in nonprofit hospitals. Some of them are designated as public-interest medical institutions. The private sector has not been allowed to manage a hospital, except in the case of existing hospitals established by for-profit companies for their own employees (e.g., Toyota). Payments to hospitals from the Statutory Health Insurance System (SHIS) include costs for physicians’ salaries.

    Consultation fees for large hospitals and academic medical centers are lower than those for small hospitals and clinics. More than half of all acute-care hospital beds are paid for using the Diagnosis Procedure Combination (DPC) system, a case-mix classification similar to diagnosis-related groups. The rest are paid for solely on a fee-for-service basis. Hospitals choose whether to receive the DPC payments or to remain under traditional fee-for-service. The DPC payment consists of a fee-for-service and a DPC component in the form of a per diem payment determined by the DPC grouping, which includes basic hospital services and less expensive treatments; the fee-for-service component includes surgical procedures, rehabilitative services, and other specified expensive services. Episode-based payments involving both inpatient and outpatient care are not used.

    Mental health care: Mental health care is provided in outpatient, inpatient, and home care settings, with patients charged the standard 30 percent coinsurance (although there is reduced cost-sharing and other financial protections for patients in the community). Covered services include psychological tests and therapies, pharmaceuticals, and rehabilitative activities. Specialized mental clinics and hospitals exist, but services for depression, dementia, and other common conditions are also provided by primary care. Most psychiatric beds are in private hospitals owned by medical corporations.

    Long-term care and social supports: National compulsory long-term care insurance (LTCI), administered by municipalities, covers those age 65 and older and some disabled people ages 40 to 64. It covers home care, respite care, domiciliary care, disability equipment, assistive devices, and home modification. Palliative care and hospice care in hospitals and medical services provided in home palliative care are covered by the Statutory Health Insurance System (SHIS), while nursing services and home help services are covered by the LTCI. Long-term home care services can be considered a part of home hospice services as dying patients become eligible.

    Roughly half of long-term care financing comes through taxation and half through premiums. Citizens age 40 and over pay income-related premiums along with SHIS premiums. Employers and employees each contribute 50 percent of the premium. Premiums for those age 65 and older are also income-based (including pensions) and set by municipalities based on estimated expenditures; they are paid only by the beneficiaries. A 20 percent coinsurance rate applies to all covered services, up to an income-related ceiling. For low-income people age 65 and older, the coinsurance rate is reduced to 10 percent. There is an additional copayment for bed and board in institutional care, but it is waived or reduced for those with low income (all costs for those with means-tested social assistance are paid from local and national tax revenue).

    Eligible people are entitled to use long-term services up to needs-based ceilings (called “care levels”) set by local LTCI boards, according to assessment of physical and mental conditions. People are not allowed to buy unlisted services with the budget provided, but they can purchase such services with their own money. Care management—covered by the LTCI and offered by public, nonprofit, and for-profit providers—is available to help people arrange long-term care services.

    The majority of LTCI home care providers are private. In 2014, 64 percent of home help providers, 40 percent of home nursing providers, and 58 percent of elderly day care service providers were for-profit, while most of the rest were nonprofit. Meanwhile, LTCI nursing homes, whose services are nearly fully covered, are either public or nonprofit. Costs for long-term care services in non-LTCI private nursing homes and group homes are partly covered by LTCI.

    Family care leave benefits (part of employment insurance) are paid for up to three months when employees take leave to care for their families. Additionally, more than half of the municipalities have established marginal financial supports, mostly limited to those with lower incomes, with their own financial capacities and legislations.

  • Netherlands

    Primary care: There were more than 11,600 practicing primary care doctors (GPs) in 2015, and more than 22,585 specialists in 2013. Thirty-nine percent of practicing GPs worked in group practices of three to seven, 40 percent worked in two-person practices, and 22 percent worked solo (2015). Most GPs work independently or in a self-employed partnership; only 16 percent are employed in a practice owned by another GP.

    The GP is the central figure in Dutch primary care. Although registration with a GP is not formally required, most citizens are registered with one they have chosen, and patients can switch GPs without formal restriction. Referrals from a GP are required for hospital and specialist care.

    Many GPs employ nurses and primary care psychologists on salary. Reimbursement for the nurse is received by the GP, so any productivity gains that result from substituting a nurse for a doctor accrue to the GP. Care groups are legal entities (mostly GP networks) that assume clinical and financial responsibility for the chronic disease patients who are enrolled; the groups purchase services from multiple providers. To incentivize care coordination, bundled payments are provided for certain chronic diseases, such as diabetes, cardiovascular conditions, and chronic obstructive pulmonary disease (COPD).

    In 2015, the government introduced a new GP funding model comprising three segments. Segment 1 (representing ?75% of spending) funds core primary care services and consists of a capitation fee per registered patient, a consultation fee for GPs (including phone consultation), and consultation fees for ambulatory mental health care at the GP practice. The Dutch Health Care Authority (Nederlandse Zorgautoriteit) determines national provider fees for this segment. Segment 2 (~15% of spending) consists of funding for programmatic multidisciplinary care for diabetes, asthma, and COPD, as well as for cardiovascular risk management; prices are negotiated with insurers. Segment 3 (?10% of spending) provides GPs and insurers with the opportunity to negotiate additional contracts—including prices and volumes—for pay-for-performance and innovation. Self-employed GPs earned average gross annual income of €97,500 (USD117,900) in 2012, while salaried GPs earned €80,000 (USD97,000).

    Outpatient specialist care: Nearly all specialists are hospital-based and either in group practice (in 2015, 54% of full-time-equivalent specialists, paid under fee-for-service) or on salary (46%, mostly in university clinics). As of 2015, specialist fees are freely negotiable as a part of hospital payment. This so-called “integral funding” dramatically changed the relationship between medical specialists and hospitals. Hospitals now have the responsibility of allocating their financial resources among their specialists.

    There is a nascent trend toward working outside of hospitals—for example, in growing numbers of (mostly multidisciplinary) ambulatory centers—but this shift is marginal, and most ambulatory centers remain tied to hospitals. Specialists in ambulatory centers tend to work most of the time in academic or general hospitals. Only a small minority of doctors working in hospitals choose to work part-time in ambulatory centers. Ambulatory care center specialists are paid fee-for-service, and the fee schedule is negotiated with insurers. Medical specialists are not allowed to charge above the fee schedule. Patients are free to choose their provider (following referral), but insurers may set different conditions (e.g., cost-sharing) for different choices within their policies.

    Administrative mechanisms for paying primary care doctors and specialists: The annual deductible (see above) is paid to the insurer. The insured have the option of paying the deductible before or after receiving health care and may choose to pay all at once or in installments. Other copayments—those for drugs or transportation, for example—have to be paid directly to the provider.

    After-hours care: After-hours care is organized at the municipal level in GP “posts,” which are centers, typically run by a nearby hospital, that provide primary care between 5 p.m. and 8 a.m. Nearly all GPs work for a GP post. Specially trained assistants answer the phone and perform triage; GPs decide whether patients need to be referred to a hospital. Doctors are compensated at hourly rates for after-hours care and must provide at least 50 hours of after-hours care annually to maintain their registration as general practitioner. The GP post sends the information regarding a patient’s visit to the patient’s regular GP. There is no national medical telephone hotline.

    Hospitals: In 2015, there were 89 hospital organizations, including eight university medical centers. Practically all organizations were private and nonprofit. In 2015, there were 231 independent private and nonprofit treatment centers whose services were limited to same-day admissions for nonacute, elective care (e.g., eye clinics, orthopedic surgery centers) covered by statutory insurance.

    Hospital payment rates, through which doctors are paid, are determined through negotiations between each insurer and each hospital over price, quality, and volume. The great majority of payments take place through the case-based diagnosis treatment combination system, and the rates for approximately 70 percent of hospital services are freely negotiable; the remaining 30 percent are set nationally. The number of diagnosis treatment combinations was reduced from 30,000 to 4,400 in 2012. Diagnosis treatment combinations cover both outpatient and inpatient as well as specialist costs, strengthening the integration of specialist care within the hospital organization.

    Mental health care: Mental health care is provided in basic ambulatory care settings, such as GP offices, for mild-to-moderate mental disorders. In cases of complicated and severe mental disorders, GPs will often refer patients to basic mental health care (e.g., a psychologist or an independent psychotherapist) or to a specialized mental health care institution. The delivery of preventive mental health care is the responsibility of municipalities and is governed by the Social Support Act.

    A policy of further integration of general practice and mental health was agreed on in 2012, with the goals of ensuring that patients receive timely care from the right source and reducing the need for specialized care. For several years, policymakers have been aiming to substitute outpatient care for inpatient care, as reflected in the steady increase in the number of GPs who employ primary care psychologists.

    Long-term care and social supports: A substantial proportion of long-term care is financed through the Long-Term Care Act (Wet langdurige zorg), a statutory social insurance scheme for long-term care and uninsurable medical risks and cost that cannot be reasonably borne by individuals. It operates nationally, and taxpayers pay a contribution based on taxable income. The remainder of services are financed through the Social Support Act. Long-term care encompasses residential care; personal care, supervision, and nursing; medical aids; medical treatment; and transport services. Cost-sharing depends on size of household, annual income, indication, assets, age, and duration of care. In 2015, copayments covered 8.7 percent of total spending in the compulsory long-term care scheme.

    With funding provided through a block grant from the national government, municipalities are responsible for household services, medical aids, home modifications, services for informal caregivers, preventive mental health care, transport facilities, and other assistance, in accordance with the Social Support Act (Wet maatschappelijke ondersteuning). Municipalities have a great deal of freedom in how they organize services, including needs assessments, and in how they support caregivers (e.g., through the provision of respite care or a small allowance).

    Long-term care is mostly provided by private, nonprofit organizations, including home care organizations, residential homes, and nursing homes. Most palliative care is integrated into the health system and delivered by general practitioners, home care providers, nursing homes, specialists, and volunteer workers.

    Under the Health Insurance Act, the Social Support Act and the Long-Term Care Act, personal budgets are provided for patients to buy and organize their own (long-term) care. Under the Health Insurance Act and the Social Support Act, health insurers and municipalities are free to set “sufficient” budget rates (typically about 70% of in-kind rates), whereas under the Long-Term Care Act, budget rates are set nationally. Municipalities have a great deal of freedom in how to support caregivers, for example, through respite care or a small allowance.

  • Norway

    Primary care: The municipalities provide primary care in accordance with current legislation, government directives, and quality requirements set by the Directorate for Health.

    The “regular GP scheme,” whereby people register with one general practitioner, covers 99.6 percent of the population. There was an average of 1,127 patients per GP in 2015. Patients may change their GP twice a year. GPs function as gatekeepers, as referral by a GP is required for coverage of specialist treatment.

    There are 2.4 specialists in hospitals or ambulatory care for every practicing primary care physician. Financial incentives encourage physicians to certify as a specialized GP and to see many patients per day.

    Municipalities contract with individual GPs, who receive a combination of capitation from the municipalities (35% of income), fee-for-service from the Norwegian Health Economics Administration (Helfo) (35%), and out-of-pocket payments from patients (30%). GP financing is determined nationally by negotiation between the Ministry of Health and the Norwegian Medical Association. In the fee-for-service scheme, there are fees provided for medication reconciliation, for taking part in coordination of care, and for coordinating the creation and follow-up of individual plans for patients with complex needs, but these are relatively low. Most GPs are self-employed; only 5 percent are salaried municipal employees. The average salary is estimated to be NOK750,000 (USD76,530), but can be substantially higher for full-time practitioners. GP practices typically comprise one to six physicians and employ nurses, lab technicians, and secretaries, but networks for shared resources are not common. Many municipalities have multidisciplinary mental health outreach teams.

    Specialist care: The four regional health care authorities (RHAs), which are state-owned corporations that report to the Ministry of Health, are responsible for supervising specialist inpatient somatic and psychiatric care, as well as treatment for alcohol and substance abuse. The ministry provides the RHAs’ budgets and issues an annual document instructing the RHAs as to aims and priorities.

    Outpatient specialist care is provided both by hospitals and by self-employed specialists. Hospital-based specialists are salaried. Privately practicing specialists contracted by an RHA are paid a combination of annual lump sums, based on the type of practice and number of patients on the list (35%); fee-for-service payments (35%); and patients’ copayments (30%). The annual lump sum and the out-of-pocket fees are set by government, and the fee-for-service payment scheme is negotiated between government and the Norwegian Medical Association. Specialists with an RHA contract can charge patients only the specified out-of-pocket fee. Those who do not receive public financing are neither regulated nor subject to the out-of-pocket expenditure caps.

    In principle, patients have a choice of specialist, although in practice specialist availability varies by geographic location. In the more densely populated areas, clinics with multidisciplinary specialists have emerged during the last few years and seem to be increasing in number. Hospital-employed specialists cannot see private patients at the hospital, but may practice privately after hours, on their own time.

    Patient out-of-pocket payments: Patients pay their out-of-pocket fee directly to the provider. If they reach the first safety net ceiling, it is automatically registered and copayments are made directly to the provider by Helfo. For the second ceiling, patients need to submit an application with proof of payment of the out-of-pocket costs.

    After-hours care: After-hours emergency primary care services are the responsibility of the municipalities, whose contracts with GPs include after-hours emergency services on rotation. The municipalities provide offices, equipment, and assistance and pay the GPs a small fee. Other payments are provided by the national fee-for-service system and out-of-pocket payments from patients. The more densely populated municipalities have walk-in centers where nurses triage patients and answer calls, with several doctors seeing patients all through the day and night. In smaller municipalities, patients call an after-hours phone number and speak with a nurse, who calls the GP if the patient needs to be seen. There is a common national phone number for primary care after-hours services (legevakt), through which calls are directed to the caller’s local service. In larger cities, there are also a few privately owned and run after-hours clinics where patients pay in full.

    There is variation as to whether information from emergency visits is shared with patients’ regular GPs. There is an emergency phone number that patients can call for urgent ambulance services, but no national medical advice line. Patient out-of-pocket fees are higher for after-hours emergency services (about NOK100 [USD10] higher per consultation).

    Acute-care hospital services are the responsibility of RHAs. Patients need an acute-care referral to these services by a primary care physician or, in specific cases (accidents, suspected heart attack, stroke, etc.), can access them directly via ambulance.

    Hospitals: Public hospital trusts are state-owned, formally registered legal entities with an executive board and are governed as publicly owned corporations. A few hospitals are privately owned, and those owned by nonprofit humanitarian organizations provide publicly funded services as part of RHAs’ plans for providing acute care. The for-profit hospital sector is small, providing less than 0.2 percent of somatic hospital stays and 7 percent of daytime stays, mostly outpatient surgery. For-profit hospitals do not provide a full range of services and do not offer acute care. Some of their services may be publicly funded, but the proportion varies, from almost none to 85 percent.

    Patients are free to choose a hospital for elective services, but not for emergency care. Public hospitals are financed through RHAs. While mental health is funded 100 percent by block grants to the RHAs, somatic services are financed only 50 percent by block grants, with the rest activity-based (based on diagnosis-related groups, or DRGs). The RHAs are free to decide how the hospitals are paid, but all four have chosen the same funding mechanism for somatic services: 50 percent as block grant and 50 percent based on DRGs. All health personnel are salaried, including doctors, and all payments, public and private, include all services.

    Mental health: Mental health care is provided by GPs and by other providers (psychologists, psychiatric nurses, social care workers) in municipalities. For specialized care, GPs refer patients to private psychologists or psychiatrists, or to a low-threshold hospital (district psychiatric center). These hospitals are dispersed throughout the country and often include psychiatric outreach teams. More advanced specialized services are organized in the inpatient psychiatric wards of general hospitals or in mental health hospitals. Hospital treatment is provided free of charge, and outpatient services are subject to the same cost-sharing as described above. Psychiatric services in the larger hospitals as well as in the district psychiatric centers are funded by government block grants through RHAs. Private mental hospitals account for about 12 percent of mental health care, including services for eating disorders, nursing home care for older psychiatric patients, and some psychiatrist and psychologist outpatient practices, mostly contracted by RHAs. The role of private treatment centers for addiction (mainly drugs and alcohol) is more prominent (38%) and funded mostly through contracts with RHAs.

    Long-term care: The municipalities are responsible for providing long-term care and contract also to some extent with private providers. Cost-sharing for institutionalized care is income-based and set at 75 percent to 85 percent of patients’ income. The levels of care at home or in a nursing home are determined by the municipality. Only about 3 percent of nursing homes are private, and for home nursing care the proportion is even lower. Patients may purchase home nursing care and other services from private providers as a supplement to services by public home care. In some densely populated areas, patients themselves have a choice of home care provider or nursing home. People under 67 with permanently reduced functioning who live at home have a right to a personal assistant who will aid them according to their preferences. Very few patients pay individually for full-time private nursing home care. End-of-life care for terminal patients is often provided in specific wards within dedicated nursing homes. There is a system in place for informal caregivers to apply for financial support from the municipalities.

  • New Zealand

    Primary care: The ratio of general practitioners (GPs) to specialists is about 2:3. GPs, who act as gatekeepers to specialist care, are usually independent and self-employed. Accounting for about half their income is a capitated government-determined subsidy, paid through primary health organizations (PHOs); patient copayments, set by individual GPs, account for their remaining compensation. An average of 3.48 GPs work together in each practice, assisted by practice nurses. Nurses are salaried and paid by GPs and have a significant role in the management of long-term conditions (e.g., diabetes), incentivized by specific government funding for chronic care management. Patient registration is not mandatory, but GPs and PHOs must have a formally registered patient list to be eligible for government subsidies. Patients enroll with a GP of their choice; in smaller communities, choice is often limited.

    PHOs receive additional per-capita funding to improve access, especially for those who can least afford primary care, and to aid in promoting health, coordinating care, and providing additional services for people with chronic conditions. In some cases, this support has led to the development of multidisciplinary care teams that may include specialists, such as nutritionists or podiatrists. PHOs also receive up to 3 percent additional funding, which is handed on to GPs who reach targets for cancer, diabetes, and cardiovascular disease screening and follow-up, as well as for vaccinations. Most GPs belong to an organized network that provides management and other clinical support services. The larger networks represent several hundred GPs each.

    Outpatient specialist care: Most specialists are employed by district health boards (DHBs) and salaried for working in a public hospital. However, they are also able to work privately in their own clinics or treat patients in private hospitals, where they are paid on a fee-for-service basis. The impact of this “dual practice” on the public sector remains under-researched. Many specialists are based in multispecialty clinics but work independently, renting their office from the clinic. Private specialists are concentrated in larger urban centers and set their own fees, which vary considerably; insurance companies have little, if any, control over those fees, although insurers will pay only up to a maximum amount, meaning that patients pay any difference. In public hospitals, patients generally have limited choice of a specialist.

    Administrative mechanisms for paying primary care doctors and specialists: As noted above, GPs’ income is derived from government subsidies, which include payments from the Accident Compensation Corporation (ACC) and copayments from patients. Some patients subscribing to private insurance may be eligible to claim for a copayment. Patients pay the full cost of private specialist visits up front, unless the service is funded by ACC or by private insurance. In the latter case, patients may seek reimbursement from their insurer, or there may be no direct patient charge if a specialist or private hospital holds a contract with the insurer.

    After-hours care: GPs are required in their funding contracts to provide after-hours care or to arrange for its provision, and they receive a separate government subsidy for doing so, which is higher per patient than the general capitation rate. In rural areas and small towns, GPs work on call; in some of these areas, a nurse practitioner with prescribing rights may provide first-contact care. In cities, GPs tend to provide after-hours service on a roster at purpose-built, privately owned clinics in which they are shareholders. These facilities employ their own support staff, such as nurses, but patients usually see a GP in the first instance. Patient charges at these clinics are higher than those for services during the day (although 95% of children under age 13 can have access to free after-hours GP services; the remainder are charged for services). Consequently, some patients will visit a hospital emergency department instead or avoid after-hours service altogether. A patient’s usual GP routinely receives information on after-hours encounters. The public also has access to the 24-hour, seven-day-a-week phone-based “Healthline,” staffed by nurses who provide advice in response to general health questions. “Plunketline” provides a similar service for child and parenting problems.

    Hospitals: New Zealand has a mix of public and private hospitals, but public hospitals constitute the majority, providing all emergency and intensive care. Public hospitals receive a budget from their owners, the DHBs, based on historic utilization patterns, population needs projections, and government goals in areas such as elective surgery. The budget includes the costs of health professionals and other staff, all of whom are salaried. Within a DHB hospital, the budget tends to be allocated to the various inpatient services using a case-mix funding system. A proportion of DHB funding for elective surgery is held by the Ministry of Health, and payments are made upon delivery of surgery. Certain areas of funding, such as mental health, are “ring-fenced”—the DHB must spend the money on a specified range of services.

    Private-hospital patients with complications are often admitted to public hospitals, in which case the costs are absorbed by the public sector. Public-hospital services are provided largely by consultant specialists, specialist registrars, and house surgeons.

    Mental health care: Most people get access to mental health care through primary mental health services in the community, often through their GP, who will then coordinate any referred services, but also through school-based health services and community services provided by nongovernmental agencies, which are all publicly funded. DHBs deliver a range of mental health services (including secondary services), such as forensic, acute inpatient, and community-based services, and provide support to primary care providers; they also fund nongovernment providers of community-based services. Private provision is limited.

    Long-term care and social supports: DHBs fund long-term care for patients based on needs assessment, age, and means-testing. They fund services for those over age 65 and those “close in age and interest” (e.g., people with early-onset dementia or a severe age-related physical disability). Those eligible receive comprehensive services including medical care; many older or disabled people receive home care. Respite care is available for informal or family caregivers, and in some circumstances ongoing financial support is provided. Residential facilities, mostly private, provide long-term care. DHBs also provide hospital- and community-based palliative care.

    Disability support services for those under age 65 are purchased directly by the Ministry of Health. Some disabled people opt for individualized funding, which enables disabled people to directly manage their disability supports.

    End-of-life care in New Zealand is provided in a range of settings, including hospitals, a network of hospices, aged residential care, and the individual’s home. DHBs either fully fund or contribute to these settings, according to population needs. Hospices also rely on fundraising for support.

    Long-term care subsidies for older people are means-tested. Individuals with assets over a given national threshold pay the cost of their care up to a maximum contribution. Those with assets under the allowable threshold contribute all their income, except for a small personal allowance. DHBs cover the difference between a person’s payments and the contract price for residential care. For people in their own homes, household management (e.g., cleaning), which accounts for less than one-third of home support funding, is income-tested. Personal care (e.g., showering) is provided free of charge. Home care services are all provided by nongovernment agencies.

  • Singapore

    Primary care: Primary care is administered mostly by private providers, with 1,400 private clinics offering primary care.6 Eighteen public polyclinics (multidoctor primary care clinics) provide subsidized outpatient care, immunizations, health screenings, pharmacy services, and sometimes dental care. Although accessible to all Singaporeans, these clinics generally serve the lower-income population; the bulk of primary care is delivered by private general practitioner (GP) clinics.

    Patients can choose their primary care doctor, with registration not required. Private primary care doctors make referrals but generally do not function as gatekeepers. They are usually paid on a fee-for-service basis.

    The Singaporean health care system is strengthening its ties to private GP networks. The Community Health Assist Scheme, introduced in 2012, provides portable subsidies to Singaporeans from lower- to middle-income households. The scheme subsidizes visits to participating private clinics for acute conditions, specified chronic illnesses, specified dental procedures, and recommended health screening. There are about 720 participating medical clinics and about 460 dental clinics.

    Outpatient specialist care: There are numerous specialty care centers, including ones focused on cancer, oral care, cardiovascular disease, diseases of the nervous system, and skin diseases. The National Heart Centre, for example, offers a full range of treatment, from prevention to rehabilitation; it is the national and regional referral center for any cardiovascular complications. Research, teaching, and training are also conducted there. Specialists who work in the public system are salaried and also may see nonsubsidized patients.

    Administrative mechanisms for paying primary care doctors and specialists: The government pays subsidies directly to provider institutions, reimbursing them for a portion of treatment costs. Patients receive subsidy benefits for outpatient care provided in public clinics and public hospitals; for emergency care at public hospitals; for intermediate- and long-term care at facilities managed by voluntary welfare organizations; and, through means-testing, for care in private nursing homes. Eligible lower- and middle-income patients may receive subsidies for outpatient treatment from private primary care providers for chronic or acute conditions, as well as certain dental procedures.

    After-hours care: Numerous public and private hospitals offer round-the-clock emergency care, and approximately 30 clinics throughout the country provide 24-hour care. Many other clinics have late-night hours, with lists of these posted online. A 24-hour emergency hotline can be used for contacting ambulances operated by the Singapore Civil Defence Force. A mobile 24-hour house call medical service is available as well. Information on patient visits is not routinely sent to primary care doctors.

    Hospitals: General care is delivered at regional hospitals. In 2010, there were more than 11,000 beds (public and private sector) in 30 hospitals (15 public and 15 private, including specialty centers, community hospitals, and chronic care hospitals). In 2010, there were 4 million public hospital outpatient visits, two-thirds of them subsidized.7

    Public hospitals are funded from a block budget. Part of the budget is based on the Casemix system, which classifies medical conditions using diagnosis-related groups. Hospitals can reallocate budget savings to other aspects of public health care services. The block budgets are reviewed every three to five years to ensure that subvention models keep up with changes in models of care and hospital operations. Additional government funds are available for personnel training and research.

    Wards in Singapore’s public hospitals are tiered in four main classes according to level of amenities. A-class wards comprise one or two-bedded rooms and have the highest level of amenities. Patients there are seen by doctors assigned by the hospital; because they are treated as private patients, their bills are not subsidized. Patients in the other wards receive means-tested subsidies that vary according to choice of ward.

    The private sector provides about 20 percent of the secondary and tertiary levels of care. Private hospitals generally offer faster service and more amenities and are more involved in medical tourism than are public facilities.

    Mental health care: The Institute of Mental Health is Singapore’s acute tertiary psychiatric hospital. It provides psychiatric, rehabilitative, and counseling services for children, adolescents, adults, and the elderly, as well as long-term care and forensic services. Patients with addictions can be treated in the institute’s National Addictions Management Services unit. Many public hospitals also offer general and specialized services for eating and sleep disorders, addiction, and geriatric psychiatric conditions.

    Health care and social agencies involved in mental health are guided by the National Mental Health Blueprint of 2007. They provide integrated services such as education and prevention, early detection, and treatment for at-risk individuals and those facing emotional difficulties. The blueprint has laid the groundwork for a network of care and support systems intended to eventually enable integrated community living. To improve accessibility of services, the government is establishing multidisciplinary shared-care teams that provide treatment and care to the mentally ill through service networks in the community. It is also providing support for caregivers, building community safety networks for people with dementia and depression, and providing training and support to GPs in managing and caring for people with mental illness in their communities. There are targeted community-based mental health programs for youth, adults, and the elderly as well.

    The Institute of Mental Health and voluntary welfare organizations handle most cases requiring residential care or a transition period with close supervision.

    Long-term care and social supports: Voluntary welfare organizations and private operators manage long-term care services for the elderly. Services are financed in several ways, including direct payment by individuals and families; direct government subsidy to patients through providers; and capital and recurrent funding for intermediate and long-term care providers to provide means-tested subsidized care. ElderShield, a long-term care insurance program regulated by the government and run through designated private insurers, provides monthly direct cash payouts for those who can no longer take care of themselves. Depending on which type of care and setting best suits their needs, seniors and their families can choose nursing facilities or home-based health care providers, including hospice care.

    Financial support is available for informal and family caregivers. The Caregivers Training Grant, administered by the Agency for Integrated Care, provides an annual SGD200 (USD235) subsidy for caregivers to attend approved training courses in taking care of the elderly or persons with disabilities. The Foreign Domestic Worker Grant provides SGD120 (USD141) monthly for hiring a foreign domestic worker to care for the frail elderly or for an individual with at least moderate disability.

  • Sweden

    The health system is highly integrated. An important policy initiative driving structural changes since the 1990s has been the shifting of inpatient care to outpatient and primary care and the concentration of highly specialized care in academic medical centers. All provider fees are set by county councils, leading to variation across the country. Public and private physicians (including hospital specialists), nurses, and other categories of health care staff at all levels of care are predominantly salaried employees. The average monthly salary for a physician with a specialist degree (including specialists in general medicine) was SEK63,000 (USD6,900) in 2015. There is no regulation prohibiting physicians (including specialists) and other staff who work in public hospitals or primary care practices from also seeing private patients outside the public hospital or primary care practice. Employers of health care professionals, however, may establish such rules for their employees.

    Primary care: Primary care accounts for about 20 percent of all expenditures on health, and about 16 percent of all physicians work in this setting. There is no formal gatekeeping function. Team-based primary care, comprising general practitioners (GPs), nurses, midwives, physiotherapists, psychologists, and gynecologists, is the main form of practice. There are, on average, four GPs in a primary care practice. GPs or district nurses are usually the first point of contact for patients. District nurses employed by municipalities also participate in home care and regularly make home visits, especially to the elderly; they have limited prescribing authority.

    People may register with any public or private provider accredited by the local county council; most individuals register with a practice instead of with a physician. Registration is not required to visit a practice. There are about 1,200 primary care practices, of which 40 percent are privately owned. Providers (public and private) are paid a combination of fixed capitation for their registered individuals (80%–95% of total payment), fee-for-service (5%–18%), and often performance-related payment (0%–3%) for achieving quality targets in such areas as patient satisfaction, care coordination, continuity, enrollment in national registers, and compliance with evidence-based guidelines.

    Outpatient specialist care: Outpatient specialist care is provided at university and county council hospitals and in private clinics. Patients have a choice of specialist. Public and private providers are paid through the same fixed, prospective, per-case payments (based on diagnosis-related groups [DRGs]), complemented by price or volume ceilings and quality components.

    Administrative mechanisms for direct patient payments to providers: Patients normally pay the provider fee up front for primary care and other outpatient visits. In most cases, it is also possible for patients to pay later.

    After-hours care: Primary care providers are required to provide after-hours care. Practices in proximity to each other (normally three to five practices) collaborate on after-hours arrangements. Through their websites and phone services, providers advise their registered patients where to go for care. Staff providing after-hours primary care services normally include GPs and nurses. There is no special arrangement for provider payment, and the same copayments apply as those during regular hours. Information regarding after-hours patient visits is routinely sent to the practice where the patient is registered. In addition, seven university hospitals and about 50 county council hospitals provide full emergency services 24 hours a day.

    All county councils and regional bodies provide information on how and where to seek care through their websites and a national phone line (1177), with medical staff available all day to give treatment advice. Moreover, all county councils and their regional counterparts collaborate to provide information online (at about pharmaceuticals, medical conditions, and pathways for seeking care.

    Hospitals: There are seven university hospitals and about 70 hospitals at the county council level. Six of them are private, and three of those are not-for-profit. The rest are public. Counties are grouped into six health care regions to facilitate cooperation and to maintain a high level of advanced medical care. Highly specialized care, often requiring the most advanced technical equipment, is concentrated in university hospitals to achieve higher quality and greater efficiency and to create opportunities for development and research. Acute-care hospitals (seven university hospitals and two-thirds of the 70 county council hospitals) provide full emergency services. Global budgets or a mix of global budgets, DRGs, and performance-based methods are used to reimburse hospitals. Two-thirds or more of total payment is usually in the form of budgets, and about 30 percent is based on DRGs. Performance-based payment related to attainment of quality targets constitutes less than 5 percent of total payment. Payments are traditionally based on historical (full) costs.

    Mental health care: Mental health care is an integrated part of the health care system and is subject to the same legislation and user fees as other health care services. People with minor mental health problems are usually attended to in primary care settings, either by a GP or by a psychologist or psychotherapist; patients with severe mental health problems are referred to specialized psychiatric care in hospitals. Specialized inpatient and outpatient psychiatric care, including that related to substance use disorders, is available to adults, children, and adolescents.

    Long-term care and social supports: Responsibility for the financing and organization of long-term care for the elderly and for the support of people with disabilities lies with the municipalities, but the county councils are responsible for those patients’ routine health care. Older adults and disabled people incur a separate maximum copayment for services commissioned by the municipalities (SEK1,772 [USD194] per month in 2016). The Social Services Act specifies that adults at all later stages of life have the right to receive public services and assistance, e.g., home care aids, home help, and meal deliveries. Also included is end-of-life care, either in the individual’s home or in a nursing home or hospice. The Health and Medical Services Act and the Social Services Act regulate how the county councils and the municipalities manage palliative care. The organization and quality of palliative care vary widely both between and within county councils. Palliative care units are located in hospitals and hospices. An alternative to palliative care in a hospital or hospice is advanced palliative home care.

    There are both public and private nursing homes and home care providers. About 30 percent of all nursing home and home care was privately provided in 2014, although the percentage varies significantly among municipalities. Payment to private providers is usually contract-based, following a public tendering process. Eligibility for nursing home care is based on need, which is determined collaboratively by the client and staff from the municipality; often a relative participates as well. National policy promotes home assistance and home care over institutionalized care, with older people entitled to live in their homes for as long as possible. Municipalities can also reimburse informal caregivers, either directly (“relative-care benefits”) or by employing the informal caregiver (“relative-care employment”).

  • Taiwan

    Primary care: Approximately 40 percent of Taiwan’s physicians practice in their own private clinics. From 80 percent to 90 percent of clinics are solo practices; the remainder are group practices. Nearly all private clinics (98%) contract with the National Health Insurance Administration (NHIA) to deliver services.

    Only about 5 percent of all clinic doctors have received formal training in family medicine. The rest are specialists. In recent years, there has been a trend toward multispecialty group practices.

    There is no requirement to register with a primary care physician, making care coordination difficult. Utilization of physician services has been high: the average number of office visits per person per year was 12.6 in 2012, significantly higher than the median for Organisation for Economic Co-operation and Development (OECD) countries (6.3), though lower than Korea (14.3) and Japan (12.9).

    Physicians are paid predominantly on a fee-for-service basis, according to national uniform fee schedules set by the NHIA, with stakeholder inputs, under the primary care global budget. To maximize their revenue, physicians compete fiercely for patients, although not on price. Pay-for-performance and capitation-based payment are currently being tried on a pilot basis.

    Other sources of physician income are patient registration fees paid at the time of visit, services and goods not covered by the NHI, and copayments.

    For most of the National Health Insurance program’s (NHI) history, no balance billing was permitted for either physician or hospital services. In recent years, however, the NHIA has made exceptions for six medical devices (intraocular lens implants, drug-eluting and bioactive stents, artificial ceramic knee joints, metal-on-metal artificial hip joints, bioprosthetic heart valves, and programmable ventriculoperitonneal shunts); patients opting for these devices pay the difference between the NHI fees and the actual price charged.

    Outpatient specialist care: Patients in Taiwan also have free choice of hospital-based specialists on an outpatient basis, with or without referrals. This has led to overcrowding in hospital outpatient departments, especially at large hospitals and major medical centers. To discourage people from doctor- and hospital-shopping or from accessing tertiary care without referral, the NHIA in recent years established graduated patient registration fee and copayment schedules, whereby patients without referrals pay higher fees and copays.

    Hospital-based physicians, including outpatient specialists, are salaried employees. They are eligible for bonuses pegged to productivity—volume of services delivered, papers published, and public lectures given, among other activities.

    After-hours care: There are no formal after-hours care provisions. Although the hospital association and the NHIA have an agreement to provide telephone consultation after hours, the future of the arrangement is uncertain, as physician associations mandate that doctors must “rest” on weekends. Telephone consultation is, however, available 24 hours for the 2.5 million people (10.6% of the population) who are enrolled in the Family Physicians Integrated Care Plan.

    That said, lack of after-hours care is not viewed as a serious problem. Many physician clinics are open until 9:00 p.m. and on Saturdays. Outside these hours, patients visit one of Taiwan’s more than 400 hospital emergency departments, where access is generally considered convenient and affordable. In recent years, however, emergency departments have experienced increasing traffic.

    Hospitals: As of 2014, of the 486 hospitals for Western medicine in Taiwan, 454 are accredited (93.4%), including 78 of 80 public hospitals and 376 of 406 private hospitals. All accredited hospitals contract with the NHIA to deliver services, with contracts renewed on three-year intervals upon passing evaluation. By law, hospitals are nonprofit. Hospitals in Taiwan have a closed-staff structure: once patients are admitted, on-staff physicians assume responsibility for their care. Hospital-based physicians see patients in the hospital on both an inpatient and outpatient basis.

    Hospitals in Taiwan provide both inpatient and outpatient services and derive revenues from a nationwide global hospital budget set by the NHIA (unlike in many other countries, where hospitals receive individual global budgets for operations). That overall national budget is divided into six regional budgets administered by the NHIA’s six regional offices. Under this arrangement, competition for revenues is intense among the hospitals in each region.

    Hospitals are paid based on diagnosis-related groups (DRGs) as well as on uniform national fee schedules set by the NHIA with input from stakeholders. As of 2016, there were 401 DRGs, which accounted for 22 percent of all hospital payments. When fully implemented, the battery of 1,062 DRGs will account for 60 percent of total hospital expenditures.

    Hospitals also derive revenues from non-NHI-covered services and goods, copayments for outpatient visits and coinsurance for inpatient services, and registration fees collected at the time of service.

    Access to care has been generally convenient: 85 percent of patients reach a hospital or clinic in less than 30 minutes, and 83 percent of patients wait 30 minutes or less before being seen by a doctor. There are essentially no waiting lines.

    Mental health care: Mental health services are a covered benefit. As of 2014, Taiwan had 32 acute mental health beds and 59 chronic mental health beds per 100,000 population, respectively. These represent a 21 percent increase in mental health beds between 2003, when there was an acute shortage, and 2013.

    NHI also covers mental health services on an ambulatory basis, at either private clinics or hospital outpatient mental health departments, as well as day care for patients with mental illness.

    Long-term care and social supports: Taiwan did not yet have a formal long-term care (LTC) program as of 2016 but needs one urgently to meet the growing needs of a rapidly aging population. As of 2016, 13.2 percent of Taiwan’s population was age 65 or over, a percentage expected to increase to 24.1 percent by 2030 and 36.9 percent by 2050. Moreover, the number of people with disabilities reached 3.45 percent of the population in 2016 and continues to grow.

    The previous government had hoped to implement an LTC system by 2016, but this did not happen. With the change in government in May 2016, there are unresolved issues related to LTC financing, benefits, eligibility, staffing, and workforce. For example, the current government abandoned the previous administration’s decision to finance LTC via premiums, instead opting for tax-based system of financing. In September 2016, the premier’s office passed the “Long-Term Care Ten-Year Plan 2.0” to promote capacity building and widespread distribution of LTC resources, with the principle objective of establishing an integrated, comprehensive community-based LTC system. As of the end of 2016, LTC in Taiwan remains a work in progress. Lack of LTC workforce, inadequate facilities, service fragmentation, and quality control remain major challenges.

    Meanwhile, through its new integrated home care program, the NHI provides home care for the elderly and disabled, including visits by physicians and nurses, community services, and end-of-life care. In the Economist Intelligence Unit’s 2015 “quality of death” rankings of 80 countries, Taiwan came in sixth, and first in Asia. (The top 10 countries in 2015 were: the United Kingdom, Australia, New Zealand, Ireland, Belgium, Taiwan, Germany, the Netherlands, the United States, and France.)

  • United States

    Publicly financed health care: In 2014, public spending accounted for about 49 percent of total health care spending. Medicare is financed through a combination of payroll taxes, premiums, and federal general revenues. Medicaid is tax-funded and administered by the states, which operate the program within broad federal guidelines. States receive matching funds from the federal government for Medicaid at rates that vary based on their per capita income—in fiscal year 2016, federal matching ranged from 50 percent to 74 percent of states’ Medicaid expenditures. The expansion of Medicaid under the Affordable Care Act (ACA) is currently fully funded by the federal government through 2017, after which the government’s funding share will be phased down to 90 percent by 2020 (subject to change under the new administration and Congress). Federal premium subsidies on the exchanges are offered in the form of tax credits.

    Privately financed health care: In 2014, private health insurance spending accounted for about 39 percent of total health care spending. Private insurers, which can be for-profit or nonprofit, are answerable to state insurance commissioners and subject to varying state (and federal) regulations. Private health insurance can be purchased by individuals but is usually funded by voluntary, tax-exempt premiums, the cost of which is shared by employers and workers on an employer-specific basis, sometimes varying by type of employee. The employer tax exemption is the government’s third-largest health care expenditure (after Medicare and Medicaid), reducing tax revenues by USD260 billion per year.

    Some individuals are covered by both public and private health insurance. For example, many Medicare beneficiaries purchase private supplemental Medigap policies to cover additional services and cost-sharing. Private insurers, in general, pay providers at rates higher than those paid by public programs, particularly Medicaid. This disparity leads to wide variations in provider payment rates and revenues, which depend to a large extent on payer mix and market power.

    Medicare’s payment rates are typically determined according to a fee schedule, with various adjustments based on cost of living and other local and provider characteristics. Medicaid rates vary by state. Private health insurers typically negotiate payment rates with providers.

    Primary care: Primary care physicians account for roughly one-third of all U.S. doctors. The majority operate in small self- or group-owned practices with fewer than five full-time-equivalent physicians, although larger practices are becoming increasingly common. Practices—particularly large ones—often include nurses and other clinical staff, who are usually paid a salary by the practice. Patients generally have free choice of doctor, at least among in-network providers, and are usually not required to register with a primary care practice, depending on their insurance plan. Primary care doctors have no formal gatekeeping function, except within some managed-care plans.

    Physicians are paid through a combination of methods, including negotiated fees (private insurance), capitation (private insurance), and administratively set fees (public insurance). Physicians can also be given financial incentives, made available by some private insurers and public programs like Medicare, based on various quality and cost performance criteria. Insured patients are generally directly responsible for some portion of physician payment, and uninsured patients are nominally responsible for all or part of physicians’ charges, although those charges can be reduced or waived.

    Outpatient specialist care: Specialists can work in both private practice and hospitals. Some insurance plans (such as health maintenance organizations, or HMOs) require a referral by a primary care doctor to see a specialist and limit patients’ choice of specialist, while other plans (such as preferred provider organizations, or PPOs) allow patients broader and direct access. Access to specialists can be particularly difficult for Medicaid beneficiaries and the uninsured, because some specialists refuse to accept Medicaid patients owing to low reimbursement rates, and safety-net programs for specialist care are limited. Like primary care physicians, specialists are paid through negotiated fees, capitation, and administratively set fees and are typically not allowed to bill above the fee schedule for services offered in-network. Multispecialty and single-specialty groups are increasingly common. Specialists can see patients with either public or private insurance.

    Administrative mechanisms for paying primary care doctors and specialists: Copayments for doctor visits are typically paid at the time of service or are billed to the patient afterward. Some insurance plans and products (including health savings accounts) require patients to submit claims to receive reimbursement. Providers bill insurers by coding the services rendered; this process can be very time-consuming, as there are thousands of codes.

    After-hours care: After-hours access to primary care is limited (39% of primary care doctors in 2015 reported having after-hours care arrangements), with such care often being provided by emergency rooms. As of 2007, there were between 12,000 and 20,000 urgent-care centers in the United States providing walk-in after-hours care. Most urgent-care centers are independently owned by physicians, while about 25 percent are owned by hospitals. Some insurance companies make after-hours telephone advice lines available.

    Hospitals: Hospitals can be nonprofit (approximately 70% of beds nationally), for-profit (15% of beds), or public (15% of beds). Public hospitals can serve private patients. Hospitals are paid through a combination of methods, including per-service or per-diem charges, per-case payments, and bundled payments, in which case the hospital may be financially accountable for readmissions and services rendered by other providers following discharge. Some hospital-based physicians are salaried hospital employees, but most are paid on some form of fee-for-service basis—physician payment is not included in Medicare’s diagnosis-related group (DRG) payments. Hospitalists are increasingly common and are now present in a majority of hospitals.

    Mental health care: Mental health care is provided by a mix of for-profit and nonprofit providers and professionals—including primary care physicians, psychiatrists, psychologists, social workers, and nurses—and paid for through a range of methods that vary by provider type and payer. Most insurance plans cover inpatient hospitalization, outpatient treatment, emergency care, and prescription drugs; other benefits may include case management and peer support services.

    The Affordable Care Act (ACA) aimed to improve access to mental health and substance abuse care by establishing it as an essential health benefit (see above), applying federal parity rules to ensure that coverage is comparable, and increasing access to health insurance more generally. As a result of the law, most health plans now cover preventive services and cannot deny coverage because of mental illness. Several ACA mechanisms, such as accountable care organizations and bundled payment (see below), promote the integration of behavioral and primary care.

    Long-term care and social supports: Long-term care is provided by a mix of for-profit and nonprofit providers and paid for through methods that vary by provider type and payer. Medicaid, but not Medicare, offers the most extensive coverage of long-term care, although it varies from state to state (within federal eligibility and coverage requirements). Since Medicaid is a means-tested program, patients must often “spend down” their assets to qualify for long-term care assistance. However, hospice care is included as a Medicare benefit, as are skilled short-term nursing services and nursing home stays of up to 100 days. Long-term care insurance that offers comprehensive care is available but rarely purchased. Most certified nursing facilities are for-profit (69%), while 24 percent are nonprofit and 6 percent are government-owned. Caregiver support programs and personal health budgets—such as cash and counseling programs in Medicaid—are available in some states to support caregivers and recipients of home-based care. Some of these programs allow recipients to employ family members. However, most informal and family caregivers do not receive payment or benefits for their work.