Physician education and workforce: Physicians are trained primarily at public (but also private) universities, with their fees subsidized through the tax system. Annual tuition fees are approximately AUD 65,000 (USD 45,454), with the student contribution capped at AUD 10,754 (USD 7,520) per annum for Australian citizens.15
The federal government provides primary care doctors with financial incentives to practice in rural and remote areas. There is no cap on the number of physicians in Australia, and workforce shortages are addressed through internationally trained providers.
Primary care: In 2015, there were 34,367 GPs, 49,060 practitioners registered as both generalists and specialists, and 8,386 providers registered as specialists.16 GPs are typically self-employed, with about four physicians per practice on average.17 In 2013–2014, GPs earned an average of AUD 3,024 (USD 2,115) per week, around half (56%) of what specialists earned.18 The schedule of MBS service fees is set by the federal health minister. Registration with a GP is not required, and patients choose their primary care doctor. GPs operate as gatekeepers; a referral to a specialist is needed for a patient to receive the MBS subsidy for specialist services.
GPs are paid primarily on a fee-for-service basis through the MBS model, although they can also receive funding from a performance-based initiative called the Practice Incentives Program. The Practice Incentives Program accounts for 5.5 percent of federal expenditures on GPs.19
The federal government also encourages multidisciplinary care coordination by funding large multidisciplinary GP clinics, known as Super Clinics, and through the establishment of Primary Health Networks, which support more efficient, effective, and coordinated primary care.
In 2015, there were 11,040 nurses or midwives working in a general practice setting.20 Their role has been expanding with the addition of a practice nurse payment in the Practice Incentives Program. 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 public hospitals (3,745).21 Patients are able to choose which specialist they see but must be referred by their GP to receive MBS subsidies. Specialists are paid on a fee-for-service basis. They receive federal subsidies for 85 percent of the MBS 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 MBS 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. Because there is free access to emergency departments, some patients may use these facilities for after-hours primary care.
The government also provides funds to Primary Health Networks to support and coordinate after-hours services, and there is an after-hours advice and support line.
Hospitals: In 2016–2017, there were 695 public hospitals (673 acute, 22 psychiatric), with a total of nearly 60,300 beds. Hospital beds have increased by an annual average of 1.5 percent, maintaining a consistent supply of 2.5 beds per 10,000 population. In the same period, there were 630 private hospitals (341 day hospitals and 289 others) with 33,100 beds.22 Private hospitals are a mix of for-profit and nonprofit.
Public hospitals receive a majority of funding (92%) from the federal government and state governments, with the remainder coming from private patients and their insurers. Most of the public hospital funding (66% of total recurrent expenditures) goes toward the salaries of employed physicians.
Private hospitals receive most of their funding from private health insurers and patients (68%), with 32 percent coming from government.23
Public hospitals are organized into Local Hospital Networks, of which there were 136 in 2016–2017. 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 Local Hospital Networks 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 amount plus money for growth (for further details, see “How are costs contained?”).
Small rural hospitals are funded through block grants.24
Pharmaceuticals used in hospitals are subsidized by the federal government through the PBS.
Mental health care: Mental health services are a responsibility shared by the federal and state governments as articulated through a rolling series of five-year National Mental Health Plans, with the current plan running until 2022. In addition, federal and state health ministers agreed to the Fifth National Mental Health and Suicide Prevention Plan in August 2017.
Mental health care is provided in many settings, including GPs and specialist care, community-based care, hospitals (both inpatient and outpatient, public and private), and residential care. GPs provide general mental health care and may devise treatment plans of their own or refer patients to specialists. Specialist care and pharmaceuticals are subsidized through the MBS and 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.
In addition, nonprofit organizations, such as LifeLine, BeyondBlue, and HeadSpace, provide important services ranging from suicide prevention to primary preventive care for both adults and youth.
Australia spent AUD 9.0 billion on mental health–related services in 2015–2016. Most of this expenditure goes toward services delivered by state governments ($5.4 billion), with AUD 2.4 billion being for public hospital services and $2.0 billion for community health services. The Australian government subsidizes additional mental health services through the MBS (AUD 1.2 billion) and the PBS (AUD 511 million). Specialized mental health services in private hospitals cost AUD 493 million in 2015–2016.25
Long-term care and social supports: Three out of four people receiving long-term care receive residential aged care (nursing home care). Three-quarters of older Australians receive informal care and 60 percent receive formal care. In 2015, 11 percent of Australians were informal caregivers, and 32 percent of these caregivers were the primary caregiver, or carer.
In 2011–2012, the federal government provided AUD 3.18 billion (USD 2.22 billion) under the income-tested Carer Payment program for caregivers who are providing constant care and are unable to be otherwise employed. The government also contributes AUD 1.75 billion (USD 1.22 billion) to a separate caregiver program, called the Carer Allowance, that provides a supplement for daily care to primary carers, regardless of their income. In addition, the federal government provides an annual Carer Supplement of AUD 480 million (USD 336 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 AUD 1,000 (USD 699). There are also a number of respite programs providing further support for caregivers.26
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 and combines home and community care, respite care for caregivers, day therapy, and assistance with care and housing.27 The Western Australian government has its own initiative, the Home and Community Care Program, which is delivered with funding support from federal government.
Residential aged care be private nonprofit, for-profit, or run by state or local governments. Federally subsidized nursing home accommodations are available. The Australian government supports both permanent and respite residential care. Eligibility is determined through a needs assessment, and permanent care and accommodation costs are means-tested.28
Hospice care is provided by states through complementary programs funded by the Commonwealth.
In 2013, the federal government, in partnership with states, implemented the pilot phase of the National Disability Insurance Scheme. Full implementation is planned by 2020, at which point around 460,000 Australians are expected to receive support.29 The scheme provides more flexible funding support for long-term care (not means-tested), to allow greater tailoring of services. The main component of the NDIS is individualized packages of support to eligible people with disabilities.
Physician education and workforce: In 2018, Brazil had 451,777 registered physicians (2.18 physicians per 1,000 inhabitants). Of this number, about 63 percent were specialists and 37.5 percent were general practitioners.
The number of medical schools is growing exponentially, driven mainly by the opening of private institutions. In 2017, there were 289 medical schools, offering more than 29,000 training positions. Of these schools, 35 percent were in public universities and 65 percent are private medical schools.11 In 2019, about 80 percent were private institutions.12 Education and training at public medical schools are free. Tuition at private medical schools varies from USD 1,400 to USD 3,000 (BRL 6,000 to BRL 13,000) per month.13
The geographic distribution of doctors is highly skewed toward larger and wealthier cities. For instance, in 2018, there were one physician per 3,000 individuals in municipalities with fewer than 5,000 inhabitants. In comparison, there were one physician per 230 individuals for municipalities with more than 500,000 inhabitants. This disparity largely reflects the location of medical schools.
The Brazilian government has instituted several initiatives to address the shortage. Several national policies foster physician education, including specialty residencies. In addition, the federal government has begun efforts to ensure a greater supply of primary care physicians and to regulate the location of medical schools, establishing new rules and incentives to open schools in municipalities where health care needs are greatest.14
Primary care: The Family Health Strategy, implemented in 1994, is the national policy for the expansion of primary care in SUS. The model promotes the use of family health teams, made up of one doctor, one nurse, one nurse assistant, and up to 12 community health workers. The teams cover 2,000 to 4,000 individuals in households across a geographic area. Oral health teams of one dentist and one or two dental assistants may also be assigned to patient populations.
Further specialized services may be provided by support staff, including nutritionists, psychologists, social workers, psychiatrists, pharmacists, speech and hearing therapists, gynecologist/obstetricians, pediatricians, geriatricians, and others according to local needs.
To encourage the implementation of the team model, the federal government provides funding on a per-capita basis. On a monthly basis, up to BRL 10,695 (USD 2,493) per family health team is transferred to the municipalities, which are responsible for organizing and delivering primary care services. In 2019, 98 percent of the municipalities had adopted the Family Health Strategy model. There were more than 43,000 family health teams and at least 26,000 oral health teams providing care to more than 133 million people (64% of the population).15
Most municipalities hire family health team members and set their salaries, resulting in wide wage variations across the country.
The expansion of primary care has increased outpatient doctor visits, leading to a reduction in hospital admissions.16 In SUS, Brazilians have direct access to primary care and emergency services, but referrals are required for accessing outpatient specialties and hospitals.
The poor quality of services in primary care is a challenge. To address the problem, the federal government introduced a pay-for-performance program for family health teams in 2011.
In the private insurance sector, health plans have begun to offer access to family doctors with no copayment as an alternative to specialist visits — a policy fostered by the National Agency of Supplementary Health.
Outpatient specialist care: States or municipalities oversee the provision of specialty care, including service delivery and provider payment. Outpatient specialty care is usually organized in association with hospital care.
Facilities vary in scope and organization, ranging from stand-alone specialized ambulatory care facilities to polyclinics with several ambulatory specialities. Outpatient services can be delivered by public entities (municipal, state, or federal) or private facilities (nonprofit or for-profit). Most outpatient facilities are in the private sector.
SUS allows access to outpatient specialists after a hospital discharge. Otherwise, a referral from a primary care physician is required.
The federal government reimburses states or municipalities according to the volume of specialist services provided. States and municipalities pay for specialist services predominantly on a fee-for-service basis. The fees follow the national list of SUS procedures (tabela SUS), which are usually well below actual costs. For example, the fee schedule for a specialist consultation is less than BRL 10 (USD 2.33).
Specialists who work in the public sector have the freedom to undertake private work and see private patients.
Innovative initiatives are underway to change the outpatient specialist model of care and integrate specialist services into health networks.17 For instance, public–private partnerships are being considered.18 However, integration has been challenging, and access to specialist services is a major bottleneck in SUS. The unnecessary referral and retention of patients by specialists results in long queues for individuals in genuine need of specialized care. Unmet demand and delays in diagnosis are also common problems.
Specialist outpatient services are free of charge in SUS, but capacity shortages have constrained access to specialist services in the public sector and encouraged the growth of a substantial private market in outpatient specialist care.
Administrative mechanisms for direct patient payments to providers: Since primary and specialty outpatient care is free to Brazilians under SUS, patients do not have to make any direct payments to providers.
After-hours care: After-hours care is usually provided by hospitals, as well as by emergency care units. Created in 2008 to address the lack of hospital beds, these units are an important component of the emergency care network, with each unit providing 24/7 services to cover a population of 50,000 to 300,000 people.19
Although emergency care units are supposed to be integrated with primary care services, ambulance services, and hospital care in health regions, coordination between these services is weak. In 2019, there were 1,072 emergency units in 868 municipalities.20 Doctors or nurses in the emergency care units usually also work in hospitals or ambulances, and less commonly in primary care.
The Ministry of Health has created monetary incentives to ensure adequate emergency care. In addition to helping municipalities invest in new emergency care units, the government helps cover expenses for established units.
Hospitals: Although the federal government contributes to the financing and delivery of services by federal hospitals, the contracting and reimbursement of hospital services is the responsibility of either the state or the municipal government.
In 2015, there were 6,154 general and specialized hospitals in Brazil, with 443,257 beds, of which 71 percent were in SUS. Of the total number of hospitals, 38 percent were public and 62 percent private. Among the public hospitals, 4 percent were federal, 25 percent were owned by states, and 70 percent were owned by municipalities. Among private hospitals, 38 percent were nonprofit and 63 percent were for-profit.21
While the majority of hospitals (52%) are located in municipalities, most of these are small, with fewer than 50 beds, and have low levels of efficiency and effectiveness. Federal and state public hospitals are usually larger in size, have higher occupancy rates, and provide higher-complexity procedures.
Inpatient care is financed using two mechanisms. First, the federal government estimates the number and profile of hospital admissions for each municipality or state on the basis of population needs, available infrastructure, and historical trends. Predetermined payments are set for different diagnoses. For each diagnosis, there is a package of procedures and an expected length of hospitalization. Based on those estimates, the Ministry of Health transfers funds to the state or municipality, which in turn reimburses the hospitals on a fee-for-service basis.
There is also a second payment system for high-complexity procedures. Every establishment that delivers highly complex procedures, such as chemotherapy, and distributes high-cost drugs is reimbursed under this system. The Ministry of Health directly reimburses municipalities or states according to the volume of complex services delivered. The state or municipality then pays the facilities providing the services.
The fees under both payment systems follow the national list of SUS procedures, which is not updated regularly. As a result, relative prices are distorted. To compensate in part for this deficit, the Ministry of Health has implemented performance-based incentive payments for state- or municipality-owned hospitals to achieve specific goals, including the integration of hospitals with other health care providers.
In public hospitals, health professionals are typically contracted by the government and paid fixed monthly salaries. More recently, some states and municipalities have begun contracting with private organizations and/or entered into public–private partnerships to manage hospitals. In 2015, there were 51 organizations contracted to provide inpatient care.
Mental health care: In 2001, Brazil began shifting mental health care from hospitals and hospice-based inpatient settings to community- and home-based outpatient care.22 Psychosocial Care Centers form the core of these mental health services. The centers have multiprofessional teams that provide care for people with behavioral health issues, including substance use disorder. They offer clinical care and psychosocial rehabilitation, and aim to avoid hospitalization and emphasize social inclusion. In 2019, there were just over 3,000 centers in some 2,000 municipalities. The centers are being reorganized as part of mental health networks.23
Mental health networks also include:
- residential therapeutic services for patients who have previously received inpatient care and do not have any relatives who can take care of them
- host units, which are short-term residential services offering continuous care mainly for vulnerable populations
- mental health teams that are integrated with family health teams at primary care centers, emergency care units, and hospitals.
Brazil also provides subsidies to some individuals with mental disorders during their post-discharge rehabilitation period. Individuals who receive inpatient care for more than two years without interruption are eligible to receive a cash transfer of approximately BRL 412 (USD 96) per month for one year, which can be renewed if necessary.24
Long-term care and social supports: In 2015, 11,227 hospital beds (2.5% of total) were classified as beds for chronic patients. Of those, 9,439 (84%) were in SUS; the rest were in the private sector.18 Since 2012, the Ministry of Health has been financing long-stay beds, characterized as extended-care units, for clinically stable patients receiving rehabilitation.
SUS also offers home care services, according to a patient’s health needs. Less-complex patients can receive visits by the family health team. Cases of higher complexity, requiring more intensive health care, can be seen by multiprofessional home care teams.
In 2019, there were 831 home care teams in 241 municipalities across the country.18 Each team can cover 30 to 60 patients.
Physician education and workforce: Students who obtained a medical degree from one of Canada’s 17 public medical schools paid an average annual tuition of CAD 14,780 (USD 11,730) in 2018–2019.10 About 27 percent of Canada’s physicians received their degree outside Canada.11
In 2017, 92 percent of physicians practiced in urban locations.12 There are no national programs to ensure a supply of doctors in rural and remote locations. However, most provinces have rural practice initiatives. For example, Alberta’s Rural, Remote, Northern Program guarantees physicians an income greater than CAD 50,000 (USD 39,382).13
Primary care: In 2017, there were 2.3 practicing physicians per 1,000 population; about half (1.2 per 1,000 population) were family physicians, or general practitioners (GPs), and the rest specialists (1.15 per 1,000 population).14 GPs act largely as gatekeepers, and many provinces pay lower fees to specialists for non-referred consultations.
Most physicians are self-employed in private practices. In 2014, the last year of the National Physician Survey, about 46 percent of GPs worked in a group practice, 19 percent in an interprofessional practice, and 15 percent in a solo practice.15 In several provinces, networks of GPs work together and share resources, with variations across provinces in the composition and size of teams.16
In 2017, about 62 percent of regulated nurses (registered nurses, nurse practitioners, and licensed practical nurses) worked in hospitals and 15 percent in community health settings on salaries.17 In the three northern territories (Yukon, Northwest Territories, and Nunavut), primary care is often nurse-led.
In theory, patients have free choice of a GP; in practice, however, patients may not be accepted into a physician’s practice if the physician has a closed list. The requirements for patient registration vary considerably by province and territory, but no jurisdiction has implemented strict rostering.18 Quebec, through Family Medicine Groups, has used patient enrollment and added (human and financial) resources to improve access to care.
Fee-for-service is the primary form of physician payment, although there has been a movement toward alternative forms of payment, such as capitation. In 2016–2017, fee-for-service payments made up about 45 percent of GP payments in Ontario, 72 percent in Quebec, and 82 percent in British Columbia; capitation and, to a lesser extent, salaries made up remaining payments.19
In 2016–2017, the average clinical payment was CAD 276,761 (USD 219,651) for family medicine, CAD 357,264 (USD 283,543) for medical specialties, and CAD 477,406 (USD 378,894) for surgical specialties.20In most provinces, specialists have the same fee schedule as primary care physicians.
Provincial ministries of health negotiate physician fee schedules (for primary and specialist care) with medical associations. In some provinces, such as British Columbia and Ontario, payment incentives have been linked to performance.
Outpatient specialist care: Specialists are mostly self-employed. There are few formal multispecialty clinics.
The majority of specialist care is provided in hospitals, on both an inpatient and an outpatient basis, although there is a trend toward providing less-complex services in nonhospital diagnostic or surgical facilities.
Specialists are paid mostly on a fee-for-service basis, although there is variation across provinces. For example, in Quebec, alternative payment structures made up about 15 percent of total payments to specialists in 2016–2017, as compared to 22 percent in British Columbia and 33 percent in Saskatchewan.
Patients can choose to go directly to a specialist, but it is more common for GPs to refer patients to specialty care. Specialists who bill P/T public insurance plans are not permitted to receive payment from privately insured patients for services that would be covered under public insurance.
Administrative mechanisms for direct patient payments to providers: The majority of physicians and specialists bill P/T governments directly, although some are paid a salary by a hospital or facility. Patients may be required to pay out-of-pocket for services that are not covered by public insurance plans.
After-hours care: After-hours care is often provided in physician-led walk-in clinics and hospital emergency rooms. In most provinces and territories, a free telephone service allows citizens to get health advice from a registered nurse 24 hours a day.
Historically, GPs have not been required to provide after-hours care, although newer group-practice arrangements stipulate requirements or financial incentives for providing after-hours care to registered patients.21 In 2015, 48 percent of GPs in Canada (67% in Ontario) reported having arrangements for patients to see a doctor or nurse after hours.22 Yet, in 2016, only 34 percent of patients reported having access to after-hours care through their GP.23
Hospitals: Hospitals are a mix of public and private, predominantly not-for-profit, organizations. They are often managed by delegated health authorities or hospital boards representing the community. In most provinces and territories, many hospitals are publicly owned,24 whereas in Ontario they are predominantly private not-for-profit corporations.25
There are no specific data on the number of private for-profit clinics (primarily diagnostic and surgical). However, a 2017 survey identified 136 private for-profit clinics across Canada.26
Hospitals in Canada generally operate under annual global budgets, negotiated with the provincial ministry of health or delegated health authority. However, several provinces, including Ontario, Alberta, and British Columbia, have considered introducing activity-based funding for hospitals, paying a fixed amount for some services provided to patients.27
Hospital-based physicians generally are not hospital employees and are paid fee-for-service directly by the provincial ministries of health.
Mental health care: Physician-provided mental health care is covered under Canadian Medicare, in addition to a fragmented system of allied services. Hospital-based mental health care is provided in specialty psychiatric hospitals and in general hospitals with mental health beds. The P/T governments 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.28
Private psychologists are paid out-of-pocket or through private insurance. Psychologists who work in publicly funded organizations receive a salary.
Mental health has not been formally integrated into primary care. However, some organizations and provinces have launched efforts to coordinate or collocate mental health services with primary care. For instance, in Ontario, an intersectoral mental health strategy has been in place since 2011 and was expanded in 2014 to better integrate mental health and primary care.29
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 P/T governments fund such services through general taxation, but coverage varies across jurisdictions. All provinces provide some residential 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. Many jurisdictions require copayments.
Eligibility for home and residential long-term care services is generally determined via a needs assessment based on health status and functional impairment. Some jurisdictions also include means-testing. About half of P/T governments provide some home care without means-testing, but access may depend both on assessed priority and on the availability of services within capped budgets.30
The government funds personal and nursing care in residential long-term facilities. In addition, financial supplements based on ability to pay can help support room-and-board costs. Some provinces have established minimum residency periods as an eligibility condition for facility admission.
Spending on nonhospital institutions, most of which are residential long-term care facilities, was estimated to account for just over 11 percent of total health expenditures in 2017, with financing mostly from public sources (70%).31 A roughly equal mix of private for-profit, private nonprofit, and public facilities provide facility-based long-term care.
Public funding of home care is provided either through P/T government contracts with agencies that deliver services or through government stipends to patients to purchase their own services. For example, British Columbia’s Support for Independent Living program allows clients to purchase their own home-support services.32
Provinces and territories are responsible for delivering palliative and end-of-life care in hospitals (covered under Canadian Medicare), where the majority of such costs occur. But many provide some coverage for services outside those settings, such as physician and nursing services and drug coverage in hospices, in nursing facilities, and at home.
In June 2016, the federal government introduced legislation that amended the criminal code to allow eligible adults to request medical assistance in dying from a physician or nurse practitioner. Since that time, P/T governments and medical associations have set up processes and regulatory frameworks to allow for medical assistance in dying for individuals facing terminal or irreversible illnesses.
More than 8 million Canadians are estimated to have provided unpaid support to persons living with chronic health and social needs in 2012.33 Support for informal caregivers (estimated to provide 66% to 84% of care to the elderly) varies by province and territory.34 For example, Nova Scotia's Caregiver Benefit Program offers eligible caregivers and care recipients CAD 400 (USD 317) per month.35 There are also some federal programs, including the Canada Caregiver Credit and the Employment Insurance Compassionate Care Benefit.
Physician education and workforce: The number of physicians is not regulated at the national level, and the government is trying to encourage more people to complete medical school. All the medical schools are public. Tuition varies by region, ranging from CNY 5,000 (USD 1,408) to CNY 10,000 (USD 2,816) per year. Tuition is heavily subsidized by the government.
To ensure a supply of medical providers in rural or remote areas, China waives tuition and lowers entrance qualifications for some medical students. Medical students who attend these education programs must work in rural or remote areas for at least six years after graduation.
Primary care: Primary care is delivered primarily by:
- Village doctors and community health workers in rural clinics
- General practitioners (GPs) or family doctors in rural township and urban community hospitals
- Medical professionals (doctors and nurses) in secondary and tertiary hospitals.
In 2018, there were 506,003 public primary care facilities and 437,636 private village clinics. Village doctors, who are not licensed GPs, can work only in village clinics. In 2018, there were 907,098 village doctors and health workers. Village clinics in rural areas receive technical support from township hospitals.
Patients are encouraged to seek care in village clinics, township hospitals, or community hospitals because cost-sharing is lower at these care sites than at secondary or tertiary hospitals. However, residents can choose to see a GP in an upper-level hospital. Signing up with a GP in advance is not required, and referrals are generally not necessary to see outpatient specialists. There are few localities that use GPs as gatekeepers.
In 2018, China had 308,740 licensed and assistant GPs, representing 8.6 percent of all licensed physicians and assistant physicians.10 Unlike village doctors and health workers in the village clinics, GPs rarely work in solo or group practices; most are employed by hospitals and work with nurses and nonphysician clinicians, who are also hospital employees.
Nurses and nonphysician clinicians are sometimes employed as care managers or coordinators to assist GPs in treating patients with chronic illnesses or complex needs. Care coordination is generally not incentivized well, although it is always encouraged by health authorities.
Fee schedules for primary care in government-funded health institutions are regulated by local health authorities and the Bureaus of Commodity Prices. Primary care doctors in public hospitals and clinics cannot bill above the fee schedule. To encourage nongovernmental investment in health care, China began allowing nonpublic clinics and hospitals to charge above the fee schedule in 2014.11
Village doctors and health workers in village clinics earn income through reimbursements for clinical services and public health services like immunizations and chronic disease screening; government subsidies are also available. Incomes vary substantially by region. GPs at hospitals receive a base salary along with activity-based payments, such as patient registration fees. 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. No official income statistics are reported for doctors.
In 2018, 42 percent of outpatient expenses and 28 percent of inpatient expenses, on average, were for prescription drugs provided to patients in hospitals.12
Outpatient specialist care: Outpatient specialists are employed by and usually work in hospitals. Most specialists practice in only one hospital, although practicing in multiple settings is being introduced and encouraged in China. Specialists receive compensation in the form of a base salary plus activity-based payments, with fee schedules set by the local health authorities and Bureaus of Commodity Prices.
Patients have a choice of specialist through their hospital. Outpatient specialists are paid on a fee-for-service basis through the hospitals in which they work, and specialist doctors in the public hospitals cannot bill above the fee schedule.
Administrative mechanisms for direct patient payments to providers: Patients pay deductibles and copayments to hospitals for primary care and specialty physician office visits, and for hospital admissions at the point of service. Hospitals bill insurers directly for the remaining covered payment at the same time through electronic billing systems.
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. In addition, rural township hospitals and urban secondary and tertiary hospitals have emergency 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. 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. Patients can call 120 or 999 for emergency ambulance services at any time.
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, more like village clinics than actual hospitals.
In 2018, there were approximately 12,000 public hospitals and 21,000 private hospitals (excluding township hospitals and community hospitals), of which about 20,500 were nonprofit and 12,600 were for-profit.13
The National Health Commission directly owns some hospitals in Beijing, and national universities (directly administrated by the Ministry of Education) also own affiliated hospitals. Local government health agencies in each province may have a similar structure and often own provincial hospitals.
Hospitals are paid through a combination of out-of-pocket payments, health insurance compensation, and, in the case of public hospitals, government subsidies. These subsidies represented 8.5 percent of total revenue in 2018.14
Although fee-for-service is the dominant form of provider payment, diagnosis-related group (DRG) payments, capitation, and global budgets are becoming more popular for inpatient care in selected areas. Pay-for-performance is rare. Local health authorities set fee schedules, and doctors’ salaries and other payments are included in hospital reimbursements. There are no special allowances for the adoption of new technologies.
Mental health care: Diagnosis, treatment, and rehabilitation of mental health conditions is provided in special psychiatric hospitals and in the psychology departments of tertiary hospitals. Patients with mild illnesses are often treated at home or in the community clinics; only severely mentally ill patients are treated in psychiatric hospitals. Mental health care is not integrated with primary care.
Outpatient and inpatient mental health services are covered by both public health insurance programs (Urban Employee Basic Medical Insurance and Urban-Rural Resident Basic Medical Insurance). In 2018, there were 42 million mental health patient visits to special psychiatric hospitals; on average, one psychiatrist treated 4.7 patients per day.15
Long-term care and social supports: Long-term care and social supports are not part of China’s public health insurance.
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, although private providers (some of them international entities) are entering the market, with services aimed at middle-class and wealthy families. Family caregivers are not entitled to financial support or tax benefits, and long-term care insurance is virtually nonexistent; expenses for care in the few existing long-term care facilities are paid almost entirely out-of-pocket.
The government has designated 15 cities as pilot sites for long-term care insurance, with the aim of developing a formal national policy framework by 2020. 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 housekeeping, meals, and basic services like transportation, but very few health services. Some, however, may coordinate health care with local township or community hospitals.
Governments encourage the integration of long-term care with other health care services, particularly those funded by private investment. There were 3.8 million beds for aged and disabled people in 2016.16
Some hospice care is available, but it is normally not covered by health insurance.17
Physician education and workforce: The number of physicians is regulated at the national level through limitations on the number of medical education training positions and the number of practicing physicians per region who can receive public funding. There are four medical schools, all public, offering medical studies lasting six years. None of them charge tuition fees.
In recent years, there has been a shortage of medical providers willing to set up general practices in rural areas. This has led to legislative changes that allow the regions to invite bids for practices or to run the practices as regional units. The regions have also undertaken other initiatives to address the shortage, such as developing programs to attract foreign doctors, providing clinic buildings for free, and allowing doctors to own several clinics. The state has also increased uptake at medical schools.
Primary care: Approximately 22 percent of doctors work in general practice. Almost all 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 physician associations.
The average income for a GP was DKK 1.1 million (USD 149,500) in 2012, which is about the same as the average salary for senior hospital doctors (specialists).10
The practice structure is gradually shifting from solo to group practices, typically consisting of two-to-four GPs and two-to-three nurses.11 Nurses are paid by the clinics and typically assist in the management of patients with chronic illnesses or complex needs, as well as blood sampling and vaccinations. Multispecialty clinics — with GPs, physiotherapists, and office-based specialists operating out of the same facilities but under separate management — have also been increasing in recent years.
As explained earlier, Danes have a choice of two public health insurance options. Patients who choose Group 1 coverage are required to register with a GP; they have free choice of any available local GP.
GPs cannot charge above the fee schedule for publicly funded patients in Group 1.
Outpatient specialist care: Outpatient specialist care is delivered at hospital-based ambulatory clinics by doctors employed by the hospital or by self-employed specialists in privately owned facilities.
Private self-employed specialists may work full-time or part-time. Part-timers may also work in the hospital sector, subject to codes of conduct, with their activity level monitored and the earnings in their private outpatient clinics limited by the regions.
Self-employed private providers are paid by the regions on a fee-for-service basis for public patients. Fees to private providers are set through national negotiations between regional representatives and physician associations, based on regional priorities and resource assessments.
Private specialists and hospitals also receive out-of-pocket payments from patients and reimbursements by private voluntary insurers. Fees for private (and Group 2) patients are set by the specialists, and may be above the fee schedule. Private practitioners and private hospitals may also receive patients referred from public-sector providers; they are paid for these services through specific agreements with the regions.
Administrative mechanisms for direct patient payments to providers: There is no out-of-pocket payment for primary or specialty care consultations and treatments for patients in Group 1, while drugs prescribed in clinics outside hospitals do incur a copayment when below the annual limit of DKK 4,030 (USD 548). Primary care physicians 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 by regions.11
After-hours care: After-hours care is organized by the regions. The first line of contact is a regional after-hours telephone service with a GP (or a specialized nurse in the Copenhagen region) triaging to home visits or to an after-hours clinic, which is usually colocated with a hospital emergency department. Information on after-hours patient visits is routinely sent electronically to GPs.
GPs enter collective agreements with regions to provide after-hours care. The GPs are responsible for delivering after-hours care; however, individual GPs have flexibility in taking on more or less responsibility within this scheme, and they receive a higher fee-for-service payment for after-hours care than for normal care. Capitation does not apply to after-hours care.
There are also walk-in emergency units at larger hospitals.
Regions decide on budgeting mechanisms, generally using a combination of a fixed budget and activity-based funding based on diagnosis-related groups (DRGs). The fixed budget makes 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 expenditures. This strategy succeeded in increasing activity and productivity by an average of 2.4 percent annually from 2003 to 2015.12 Bundled payments are not yet used extensively, but experiments are being carried out in all five regions. Similarly, all five regions are experimenting with various types of value-based payment schemes for select hospitals and departments.
Hospital physicians are salaried and employed by regional hospitals. Physicians employed by public hospitals are not allowed to see private patients within the hospital. Patients can choose among public hospitals, and payment follows the patient to the receiving hospital if the facility is in another region.
Mental health care: Inpatient psychiatric care in public psychiatric hospitals and wards is fully covered by public health insurance without cost-sharing. Outpatient psychiatric care is provided in hospital clinics by salaried hospital staff or in private clinics by privately practicing specialists who receive most of their income through public fee-for-service funding.
Psychologists are employed in hospitals by municipalities, or operate in private practices. Community mental health services are provided by the municipalities, which can contract with a combination of private and public service providers; however, most providers are public and salaried.
Since 2014, Danes have had the right to a diagnostic psychiatric assessment within one month of referral. 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 and social supports: Responsibility for long-term and chronic care is shared between regional hospitals, GPs, and providers of municipal institutional and home-based services. Hospital-based ambulatory chronic care is financed in the same way as other hospital services and is provided to patients who have severe chronic care needs or require specialized rehabilitation services. GPs are responsible for ongoing medical follow-up for most people with chronic care needs, while the municipalities organize, fund, and deliver care and assisted living support at home or in municipal institutions, based on individual needs assessments.
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. Municipal assisted-living support with ongoing visits is relatively extensive. However, a recent study showed that 46 percent of relatives have provided voluntary assistance to older relatives one-to-two times a week, mostly for shopping, cleaning, cooking, and other practical activities.13 A minority (9%) of relatives also assist in personal care.
The proportion of citizens over age 75 who live in protected housing and nursing homes dropped from 15 percent to 13 percent between 2010 and 2015.14 Home nursing is funded with a medical referral, but temporary home care may be subject to cost-sharing.
Municipalities organize markets to ensure access to both public and private home care providers (personal and practical care, such as cleaning and shopping), and patients may choose between public and 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. Most providers are public or private not-for-profit, and a few are private for-profit.15
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 fully funded by regions and municipalities. GPs or hospitals can refer terminally ill patients to hospice when no further treatment is possible. There is free choice of hospice with a referral.
Physician education and workforce: There is a growing shortage of doctors, affecting primary care and certain specialties. In 2016, the government promised an additional 5,000 GPs by 2021, including new trainees, overseas recruits, and physicians returning to practice.15 Financial incentives have been made available to trainees and returnees to attract doctors to areas where there are shortages, including rural and urban areas.
The government regulates the number of university slots for undergraduate medical and dentist degrees: In 2018–2019, a total of 6,700 places were available for medical degrees across public universities in England.16 This is 500 more slots than were available in 2017–2018. Over time, the government has promised to expand the number of undergraduate training slots by 25 percent to address the workforce shortage.
Undergraduate degrees are financed through student fees and government subsidies. The remainder of medical training (four to six years) is funded by government.
Primary care: Primary care is delivered mainly through GPs, who act as gatekeepers for secondary care. 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.
In September 2017, there were approximately 34,000 GPs (full-time equivalents) in nearly 7,400 practices, with an average of about 8,000 patients per practice and 1,400 patients per GP.17 Eleven percent of practices were solo practices in 2017, while 46 percent had five or more GPs.
Most GPs (59.4 percent) are private contractors (self-employed). The proportion of GPs employed in practices or on a salaried basis as locums (standing in when other GPs are unavailable) is increasing and is currently around 22 percent.
Most (69%) of practices operate under General Medical Services contracts, negotiated between the British Medical Association (representing doctors) and government. Physician payment is about 60 percent capitation for essential services, about 15 percent fee-for-service payments for optional additional services (such as vaccines for at-risk populations), and about 10 percent performance-related payments.18 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.
General practice is undergoing a structural change, from single-handed corner shops to networked practices, including larger organizations using multidisciplinary teams of specialists, pharmacists, and social workers.19 The average income for GPs (contracted and salaried) in England was GBP 92,500 (USD 131,579) before tax in 2015–2016, with GPs earning 82 percent of what specialists earn.20
Most general practices employ other professionals on salaries, such as nurses, whose duties include managing patients with long-term conditions, and providing minor treatments. In December 2017, there were about 15,800 nurses working in general practice.21
Outpatient specialist care: Nearly all specialists are salaried employees of NHS hospitals. Salaries are agreed on as part of a national contract between the Department of Health and the British Medical Association.
As of the end of 2017, there were approximately 45,800 hospital specialists and 52,800 hospital doctors in training.22
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. In 2006, an estimated 55 percent of doctors performed private work, a proportion that is declining as the earnings gap between public and private practice narrows.23
Patients are able to choose which hospital to visit, and the government has introduced the right to choose a particular specialist within a hospital. Most outpatient specialist consultations are carried out in hospitals, although a small proportion of consultations take place in general practices.
Administrative mechanisms for direct patient payments to providers: U.K. residents do not pay for physician services, which are all free at the point of use. The bulk of general practices are reimbursed monthly by NHS England 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 NHS England.
After-hours care: Since 2004, GPs are no longer required to personally provide after-hours care to their patients; however, GPs must ensure that adequate arrangements for after-hours care are in place. In practice, this means that CCGs contract mainly with GP cooperatives and private companies for after-hours care, both of which usually pay GPs on a per-session basis.
Providers are expected to send electronic discharge summaries to the patient’s usual GP within 24 hours of using an emergency service.
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 (paid per session). These are generally NHS-run and can be free-standing or attached to a hospital.
Telephone advice is available on a 24-hour basis through NHS 111 for those with an urgent but not life-threatening condition. Callers are able to speak to a clinician, if appropriate, after triage.
Hospitals: Publicly owned hospitals are organized either as NHS trusts (currently 64) directly accountable to the Department of Health or as foundation trusts (currently 142) regulated by NHS Improvement.24 Foundation trusts have more freedom to borrow and invest and have local people and staff involved in governance.
All public hospitals contract with local CCGs to provide services. They are reimbursed mainly at nationally determined diagnosis-related group (DRG) rates, which include medical staff costs. DRG payments account for about 60 percent of hospital income, with the remainder coming from activities not covered by DRGs, such as mental health, education, and research and training funds.25 For some services, such as community services, payment is made for the overall service. Bundled payments (such as for the total annual cost of care per diabetic patient) are being developed at the local level but are not yet in widespread use. There is no cap on hospital incomes.
Responsibility for setting DRG rates is shared between NHS England and NHS Improvement. Some DRG rates are set to incentivize best practices, such as the use of day-case surgery (same-day surgery) when appropriate.
There are an estimated 515 private hospitals offering health care services in the U.K., a mixture of for-profit and nonprofit.
There are no comprehensive public data on the total number of patients treated in private hospitals, but of the 285 hospitals that submitted data in 2017, 735,522 patients received treatment. By comparison, more than 8.5 million nonurgent patients were treated by the NHS that year.26
Private hospitals 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.27 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 providers remains low: 7.6 percent of overall spending by CCGs on hospital services in 2015–2016.28
Mental health care: Mental health care is an integral part of the 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 specialist mental health trusts. Some of these services are provided by community-based practitioners. 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 expanding services for mild-to-moderate adult mental health problems, such as depression and anxiety, through the Increasing Access to Psychological Therapies program, which integrates mental health into primary care. In 2017–2018, 550,479 people referred to the program completed courses of therapy, lasting an average of six weeks.29
Long-term care and social supports: The NHS pays for long-term care (at home or in residential facilities) for people with care needs arising from illness, disability, or accident, including at the end of life. About 135,000 people were receiving this form of care at the end of 2018.30
All other long-term services and supports are paid either out of pocket or by local authorities. Local authorities are legally obliged to assess the needs of all people who request these services. Unlike NHS services, however, locally funded social care is not typically free at the point of use, except for certain services (such as time-limited rehabilitation services for people recovering from illnesses or injuries, the provision of some equipment, and home modifications).
To receive regular financial support for home care, nursing care, and residential care, individuals need to pass a needs and a means test. Full local authority support for residential care, for example, is available only to those with high care needs and less than GBP 14,250 (USD 20,270) in assets, with a sliding scale discount applied to assets up to GBP 23,250 (USD 33,072). There is a national framework for assessing need, but local authorities are free to set eligibility thresholds, which have become progressively more restricted over the past decade.31 Local authorities fund long-term care from local taxes and grants from central government. Central government funding for local authorities has fallen an estimated 49 percent in real terms between 2010–2011 and 2017–2018.32
Those who qualify for local authority funding are liable for copayments, with some people contributing almost all of their assessed income, including pensions. Funding can be managed by the local authority (paying providers directly), or people can receive direct payments to purchase their own care, with the supervision of the local authority. In 2016–2017, GBP 15.0 billion (USD 21.3 billion) was spent on locally funded long-term care in England, of which GBP 1.8 billion (USD 2.6 billion) was spend on direct payments. Nearly 870,000 people received services in a nursing home, in a residential home, or at home. Community-based services were the most common: 75 percent of people received services in their home.33
Some additional allowances paid to users and caregivers are exempt from means testing, such as an attendance allowance worth a maximum of GBP 82.30 (USD 117.00) a week. An estimated 8 percent of the U.K. population are informal carers (5.4 million people), 33 percent of whom are caring for a parent outside their own household.34
In 2017, the private sector (for-profit and nonprofit) provided 78 percent of residential care places for older people and the physically disabled in the U.K., and 86 percent of nursing home places.35
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.
Physician education and workforce: Once a year, the Ministry of Social Affairs, Health, and Women’s Rights determines the maximum number of students that can be admitted to medical, dental, midwifery, and pharmacy schools, which are all public by law. Tuition fees are approximately EUR 500 (USD 633) per year.
The number of medical professionals is controlled at the point of entry into medical education. In addition, 12 percent of the current medical workforce are foreign-trained medical professionals. To date, there are no limitations on the number of practicing physicians by region. However, since 2013, outpatient physicians can enter into contractual agreements that guarantee a monthly salary of EUR 6,900 (USD 8,734) if they practice in a region with insufficient physician supply and agree to limit extra billing. For physicians who work full-time in medical centers in underserved areas, the guaranteed salary is approximately EUR 50,000 (USD 63,290) per year.
Primary care: There are roughly 102,299 general practitioners (GPs) and 121,272 specialists in France (a ratio of 3.4 per 1,000 population). About 59 percent of physicians are self-employed on a full-time or part-time basis (67% of GPs, 51% of specialists).9
More than 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 also include nurses and a range of allied health professionals. The average patient panel size is about 900 patients for GPs.
There is a voluntary gatekeeping system for people aged 16 and older, with financial incentives offered to those who opt to register with a GP or specialist. About 95 percent of the population have chosen a GP as their gatekeeper, but specialists can also serve as gatekeepers.
Self-employed GPs are paid mostly on a fee-for-service basis, with fees determined by SHI funds and the Ministry of Social Affairs, Health, and Women’s Rights. In 2018, GP fees were EUR 25 (USD 32) per consultation. GPs can also receive a capitated per-person annual payment of EUR 40 (USD 51) to coordinate care for patients with chronic conditions. In addition, GPs receive an average of EUR 5,000 (USD 6,330) a year for achieving pay-for-performance targets.
In 2014, the average income of primary care doctors was EUR 86,000 (USD 108,860), 94 percent of which came from fees for consultations and the remainder from financial incentives and salary.10
GPs can bill above the national fee schedule, and 25 percent do. Specialists earn, on average, 1.3 times what GPs earn.
Experimental GP networks are being piloted that provide chronic-care coordination, psychological services, dietician services, and other care not covered by SHI. These networks are financed by earmarked funds from the Regional Health Agencies. In addition, more than 1,000 medical homes provide multi-professional services (usually with three-to-five physicians and roughly a dozen other health professionals) and after-hours care.
Outpatient specialist care: About 36 percent of outpatient specialists are exclusively self-employed, either in offices or private clinics, and are paid on a fee-for-service basis; the rest either are fully salaried hospital employees or have a mix of income sources.
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 earned fees to the hospital. A 2013 report estimated that 10 percent of the 46,000 hospital specialists in surgery, radiology, cardiology, and obstetrics had treated private patients.
Half of specialists are in group practices, and this percentage is increasing among specialties that require major investments in technology and equipment to serve patients, such as nuclear medicine, radiotherapy, pathology, and digestive surgery. The specialist fee set by SHI ranges from EUR 25 (USD 32) to EUR 69 (USD 88). Specialists can balance-bill, and nearly 43 percent do.
The average yearly income of self-employed specialists is EUR 140,610 (USD 177,800).11 All specialists who are self-employed can participate in pay-for-performance programs. 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 EUR 5,480 (USD 6,937) per physician, which constitutes less than 2 percent of total funding for outpatient services.
Patients with a referral can choose among specialists. Seeing a specialist without a referral from a gatekeeping physician results in reduced SHI coverage. However, some specialists can be directly accessed without a referral, including gynecologists, ophthalmologists, psychiatrists, and stomatologists.
Administrative mechanisms for direct patient payments to providers: Patients pay the full fee (reimbursable portion and balance billing, if any) at the end of a physician visit. After the insurance claim is filed, patients are reimbursed the full sum or less, depending on their coverage, minus the copayment.
After-hours care: After-hours care is organized by the Regional Health Agencies and delivered by contracted hospital emergency departments, self-employed physicians who work for emergency services, and medical homes financed by SHI and staffed by doctors and nurses on a voluntary basis. Primary care physicians are not mandated to provide after-hours care.
There is no systematic method to ensure that information from the patient visit is transferred to the patient’s GP.
There is currently no national or regional medical advice phone service, but teleconsultation became legal in September 2018 and can be used for after-hours care in certain localities.
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 make up the remainder.
All hospitals are reimbursed under SHI via the diagnosis-related group (DRG) system set by the Ministry of Social Affairs, Health, and Women’s Rights, which applies to all inpatient and outpatient admissions and covers all medical services and physicians’ salaries in public and not-for-profit hospitals. Neither bundled payment nor performance incentives exist.
Hospitals are reimbursed for certain expensive and innovative drugs and devices in addition to the DRG tariff. A list of covered drugs and devices is updated every year by the Ministry of Social Affairs, Health, and Women’s Rights, based on semitransparent criteria of innovativeness, price, and the share of the DRG population requiring the innovative drug or device.
Public hospitals are funded mainly by SHI (80%), with voluntary insurance and direct patient payments accounting for their remaining income. Public and private nonprofit hospitals also receive research and teaching grants (up to 13% of hospital budgets) and provisions for providing emergency services, organ harvesting, and organ transplantation (on average, 10%–11% of 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. Physician 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.
Mental health care: Services for people with mental illness 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.
SHI covers mental health care provided by GPs and psychiatrists in private practice, public mental health care clinics, and private psychiatric hospitals. Care provided by psychologists, psychotherapists, or psychoanalysts is fully paid by patients or covered by VHI. Copayments and the flat-rate fee for accommodation can also be fully covered by VHI. Copayments do not apply to persons with diagnosed long-term psychiatric disorders, including schizophrenia, bipolar disorder, severe anxiety, and depression.
Mental health care is not formally integrated with primary care, but a large number of disorders are treated on an outpatient basis by GPs or private psychiatrists or psychologists.
Long-term care and social supports: Health and social care for elderly and disabled people comes under the jurisdiction of the General Councils, which are the governing bodies at the local (departmental) level. The total number of frail elderly is estimated at about 1.25 million, or 2 percent of the population.12 Total expenditures for long-term care were estimated to be EUR 30 billion (USD 37.9 billion) in 2015, or 1.7 percent of GDP.13
Institutional long-term care is provided in retirement homes and long-term care units, totaling roughly 10,000 institutions with a total of 728,000 beds.10 Of these institutions, currently 54 percent are public, 28 percent private nonprofit, and 18 percent for-profit, although the percentage of for-profit institutions is increasing.
SHI covers the medical costs of long-term care in facilities, while families are responsible for the housing costs. These out-of-pocket costs average EUR 1,500 (USD 1,900) per month, some of which can be covered by VHI. End-of-life care in hospitals is fully covered.
Funding of home care and services for the elderly and disabled comes from the National Solidarity Fund for Autonomy, which is financed by SHI and the revenues from an unpaid working solidarity day. One day a year, employers pay the SHI their employees’ daily wages. Local authorities, the General Councils, and households also participate in financing these categories of care.14
Home care for the elderly is provided mainly by self-employed physicians and nurses and, to a lesser extent, by community nursing services. It is covered by SHI and VHI, based on medical need; there is no means testing.
In addition, temporary care for dependent patients and respite services for their caregivers are available without means testing from the states or regions.
Means-tested cash allowances are provided to the frail elderly to pay for in-kind nonmedical services. The allowances are adjusted in relation to the individual’s dependence level, living conditions, and needs, 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 but do not receive a cash allowance.
To address the loss of autonomy among the elderly, a law enacted at the end of 2015 established local conferences of stakeholders that meet yearly to define priorities, identify existing services, and create new programs as necessary.15
Physician education and workforce: About 35 public universities and five private ones offer degrees in medicine. Studying at public universities is free, while private institutions sometimes require tuition fees ranging from EUR 6,000 (USD 7,702) to EUR 11,500 (USD 14,763) per semester. The minimum qualifications for a medical degree are determined at the federal level by the Licensing Regulations for Physicians, state laws, and individual university requirements. Specialization requirements are regulated and enforced by the medical chambers within each state.
Primary and outpatient specialist care: General practitioners (GPs) and specialists in ambulatory care typically work in their own private practices—around 56 percent in solo practice and 33 percent in dual practices. In 2017, there were about 2,500 multispecialty clinics, where some 18,000 of Germany’s ambulatory care physicians (11%) work. Most physicians working in multispecialty clinics are salaried employees. Some specialized outpatient care is provided by hospital specialists, including treatment of rare, severe, or progressive diseases as well as highly specialized procedures.
The total number of ambulatory care physicians and psychotherapists is more than 170,000.9 In 2017, family physicians, including GPs, internists, and pediatricians, accounted for 45 percent of self-employed, SHI-contracted ambulatory care physicians (57,600 of roughly 129,000), while 55 percent (71,400) were specialists.
Most physicians employ medical assistants, while other nonphysicians (such as physiotherapists) have their own premises. Advanced practice nurses have not yet prevailed in primary care; however, there are an increasing number of medical assistants who complete further training as care managers.
Individuals have free choice among GPs and specialists. Registration with a family physician is not required, and GPs have no formal gatekeeping function. However, sickness funds are required to offer members the option of enrolling in a family physician care model, which has been shown to provide better services than traditional care approaches and often provides incentives for complying with gatekeeping rules.
Under SHI, GPs and specialists are generally reimbursed on a fee-for-service (FFS) basis according to a uniform fee schedule that is negotiated between sickness funds and regional associations of physicians. The law requires SHI-contracted ambulatory physicians to be members of these regional associations, which act as financial intermediaries between physicians and sickness funds and are responsible for coordinating care requirements within their region.
The associations receive monies from sickness funds in the form of annual capitations. The physicians then bill the associations according to the SHI fee schedule. However, physician payments are limited to a predefined quarterly maximum number of patients per practice and reimbursement points per patient, setting quarterly thresholds for the number of patients and of treatments per patient for which a physician can be reimbursed. If physicians exceed the quarterly thresholds, they are paid considerably less for any additional services provided. This can lead physicians to postpone nonurgent patient visits once they reach the thresholds, which means patients may have longer appointments wait times at the end of each quarter.
For private patients, GPs and specialists are also paid on a fee-for-service basis, but private tariffs are usually higher than the tariffs in the SHI fee schedule.
The average SHI reimbursement for a family physician is more than EUR 200,000 (USD 256,739) per year. This must cover the costs of operating a practice, including personnel, etc. Physicians may also earn income from privately insured patients.
The average SHI reimbursement for ambulatory care specialists is about the same as for GPs. But reimbursement varies widely across specialties, depending on the specialty, from EUR 77,000 (USD 98,845) for a psychotherapist to EUR 367,000 (USD 471,117) for a radiologist, not including private health insurance reimbursements and direct patient payments.10
Pay-for-performance has not yet been established. 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 USD154, in 2016) for patients enrolled in a disease management program, in which physicians provide patient training and document patient data. Bundled payments are not common in primary care. But a regional shared-savings initiative, called Healthy Kinzigtal (named for a valley in southwest Germany), offers primary care physicians and other providers financial incentives for integrating care across providers and services.
Administrative mechanisms for direct patient payments to providers: Copayments or payments for services not included in the SHI benefit package 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 to ensure access to ambulatory care around the clock. After-hours care assistance is available mainly through a nationwide telephone hotline. However, physicians are obliged to provide after-hours care in their practices, with differing regional regulations. In some areas, such as Berlin), after-hours care has been delegated to hospitals. The patient is given a report of the visit afterwards to hand to his or her GP.
There is also a tight network of emergency care providers (under the responsibility of the municipalities). Payment for ambulatory after-hours care is based on fee schedules, 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 accounting for about one-sixth of all beds). All hospitals are staffed principally by salaried physicians. Physicians in hospitals (similar to U.S. hospitalists) are typically not allowed to treat outpatients, but exceptions are made if necessary care cannot be provided by office-based specialists. Senior doctors can treat privately insured patients on an FFS basis. Hospitals can also provide certain highly specialized services on an outpatient basis.
Inpatient care is paid per admission through a system of DRGs, which are revised annually. Currently, there are around 1,300 DRG categories. DRGs cover all services and all physician costs. Highly specialized and expensive services like chemotherapy, as well as new technologies, can be reimbursed through supplementary fees. 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 provided largely by psychiatric wards in general (acute) hospitals. The number of hospitals providing care only for patients with psychiatric and/or neurological illnesses is low.
In the ambulatory care sector, there were about 38,000 office-based psychiatrists, neurologists, and psychotherapists in 2017.11 Qualified GPs can provide basic psychosomatic services. Ambulatory psychiatrists also coordinate a set of SHI-financed benefits called sociotherapeutic care (which requires referral by a GP), intended to encourage the chronically mentally ill to access needed care and to avoid unnecessary hospitalizations. To further promote outpatient care for psychiatric patients (particularly in rural areas with a low density of ambulatory psychiatrists), hospitals can be authorized to offer treatment in outpatient psychiatric departments.
Long-term care and social supports: Statutory LTCI is mandatory. People typically get statutory LTCI from the same insurers that provide SHI. Employees share the contribution rate of 3.05 percent of gross salary with their employers; people without children pay an additional 0.25 percent.
Everybody with a physical or mental illness or disability (who has contributed for at least two years) can apply for LTCI benefits, which are:
- Dependent on an evaluation of individual care needs by the SHI Medical Review Board, which leads either to a denial of benefits or to an assignment to one of five levels of care
- Limited to certain maximum amounts, depending on the level of care.
Beneficiaries can choose between free or discounted long-term care services and cash payments. Around a quarter of LTCI expenditures go toward cash payments. Both home 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. In 2016, around 3.4 million Germans with SHI and private health insurance also had supplementary private LTCI.
As a separate public benefit, family caregivers get financial support through continuing payment of up to 50 percent of care costs.
Of the approximately 2.9 million recipients of long-term care in 2015, 48 percent were cared for at home by relatives, 24 percent received home care supplied by ambulatory care service providers, and 27 percent were treated as inpatients in nursing homes.
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 2016.12
Physician education and workforce: Medical education is provided by both state-led institutions and private colleges. In some states, private medical colleges charge about 16 times the fees charged by government colleges.23 Private fees for a five-year course typically range from INR 3 million to INR 5 million (USD 42,000–70,000 for undergraduate education.24
The Medical Council of India establishes standards for undergraduate medical education, accredits undergraduate and postgraduate medical education programs, determines equivalencies for foreign medical graduates, and maintains a general directory for all certified physicians.25
Primary care: Under the Health and Wellness Centres program, 150,000 subcenters (the lowest tier of the health system) across the country are being upgraded to provide comprehensive primary health care services, free essential medicines, and free diagnostic services. Nutritional support will also be provided to all beneficiaries with tuberculosis at a rate of INR 500 (USD 7) per month during treatment. Other primary health care providers include primary health centers (PHCs) and community health centers. No patient registration is required.
The PHC is the first point of contact between a village community and a medical officer. These centers provide curative and preventive services to 20,000–30,000 people and serve as a referral unit for six subcenters with four to six beds each. The community health centers serve as a referral center for four PHCs and also provide facilities for obstetric care and specialist consultations.
The three facility types differ according to whether it is in a rural or urban setting, the size of the population served, and the resources and services available.
Under the Health and Wellness Centres program, the subcenter is the first point of contact for patients. It is 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 additional female health visitor supervise six subcenters.
All medical personnel, including primary and specialty physicians, working at public outpatient or inpatient facilities are paid fixed salaries, which vary based on area of work and level of specialization. Currently, there are no performance-based payment incentives. However, the prime minister announced recently that all accredited social health activists will be enrolled in one of the social security schemes and provided free insurance coverage.
Physicians are allowed to operate private clinics in some states in accordance with regulations determined by the state in which they live and practice. Doctors in states where this is disallowed receive an additional non-practicing allowance payment.26 Some government doctors violate service rules by resorting to private practice during office hours. There is also some evidence that patients have made informal payments to their physicians for services that are supposed to be provided for free, in a bid to improve the quality of their care.27
Outpatient specialist care: Community health centers also provide outpatient specialist care and are required to have four medical specialists (surgeon, general practitioner, gynecologist, and pediatrician) supported by paramedical and other staff. They must also have 30 beds, a laboratory, X-ray services, and other facilities. Each center covers 80,000 to 120,000 people. All outpatient specialized services not provided at community centers are referred to district hospitals.
Administrative mechanisms for direct patient payments to providers: Government or entitlement coverage schemes, such as the Central Government Health Scheme and National Health Protection Scheme, are cashless. Beneficiaries are able to obtain care at facilities enrolled in the schemes by using their smart cards.28
After-hours care: The India Public Health Standards determine which health care facilities are required to operate 24 hours a day, seven days a week. Depending on the facility type, specific services — like basic obstetrics — are made available at all times while others are daytime-only procedures.
After-hours care by telephone is not well established in India. However, officials are exploring the acceptability and feasibility of mobile phone consultations as a means of improving health care access in rural India and addressing workforce shortages and resource constraints.29
Private sector hospitals and clinics typically provide after-hours care with concomitant fees. Depending on the type of facility, some consultations and services can be provided via telephone or at home.30,31
Hospitals: Patients using the public health system can be referred to a district hospital, which is the terminal referral center. District hospitals offer services similar to community health centers, such as emergency care, maternity services, and newborn care, but serve larger urban centers.32 In total, there were 763 functioning district hospitals in 2015, located largely in the most populous states.33
The research hospitals and education centers funded by the central and state governments offer specialized care in a variety of disciplines, such as ophthalmology, cardiothoracic surgery, neurosciences, trauma, cancer, and drug dependence.34,35 Under the National Health Protection Scheme, some district hospitals will be upgraded to tertiary care facilities to improve access to specialized services and strengthen physician workforce capacity.36
Public hospitals account for only approximately 10 percent of the total number of hospitals throughout the country.37,38 The remainder are operated almost entirely by the private for-profit sector, and a small number by charitable organizations. There has been significant growth in the number of private sector hospitals as a result of perceived poor-quality care in public facilities and the rise of medical tourism.39
In most public hospitals, prices are set administratively. Public district and tertiary hospitals are paid through an annual budgetary mechanism funded by either the state or central government. All private hospitals operate on a fee-for-service basis, with no standardization of service price.40
Mental health care: National health initiatives have established psychiatric centers within specialized public hospitals. With the launch of the National Health Protection Scheme, comprehensive mental health care will also be available for beneficiaries at newly established Health and Wellness Centre programs.
Despite recent policy measures to strengthen mental health care, resources are extremely limited. Across India, there is only one trained psychiatrist for every 250,000 people and fewer than one mental health worker for every 100,000 people.41 In addition, few hospital beds are dedicated to inpatient psychiatric care.42
Most private insurance plans typically do not provide comprehensive coverage for such care.43 In the few that do, covered treatment options usually focus on short-term psychotherapy rather than on long-term management.44
Long-term care and social supports: The central government launched the National Programme for Health Care of the Elderly in 2011 with the aim of improving workforce capacity for long-term care and providing dedicated health care facilities and services to senior citizens (ages 65+) at all levels of the health care delivery system.45 Such services are meant to be provided for free for elderly people through state primary and secondary facilities.
However, as revealed by funds utilization, there has been slow progress on implementation, indicating a continuous unmet need for comprehensive elderly care.46 The recent launch of the National Health Protection Scheme aims to counter this trend by improving access to geriatric care at the primary level for beneficiaries.
In addition, the Ministry of Social Justice and Empowerment has launched a central scheme (Integrated Programme for Older Persons) to develop solutions to the health and emotional needs of the elderly. The scheme provides funding to state government, Panchayati Raj institutions, non-governmental organizations, and charities to establish food, shelter, and health care programs, intergenerational relationship–strengthening programs, active and productive aging programs, and institutional and non-institutional care facilities.
Some states have launched their own activities to increase access to palliative care. In Kerala, for example, the state was the first to establish a palliative-care policy, which subsequently resulted in a network of more than 60 facilities that provide low-cost and community-based hospice and palliative care.47 This implementation model has resulted in similar policies and projects that have been launched in Assam, Maharasthra, Punjab, Haryana, and Karnataka by state governments and nongovernmental organizations.48
Physician education and workforce: Israel has six medical schools, which are all part of public, nonprofit universities. The number of medical schools and students is regulated by the higher education council. As of 2015, more than half (58%) of Israeli physicians under age 65 had completed their medical studies abroad. Annual tuition, heavily subsidized by the government, is approximately NIS 11,100 (USD 3,000) for the first three years and NIS 14,800 (USD 4,000) for the next three years.
To address physician shortages in the entire country and in remote areas in particular, the government introduced two measures in 2011: it increased the number of physician positions in all hospitals throughout the country and introduced financial incentives (onetime bonuses and salary differentials) to encourage physician graduates to pursue their residencies in remote regions. The combination of these two programs has increased the number of residencies completed, especially in remote settings. Similar financial incentives encourage physicians to choose in-demand specialties, such as anesthesiology, geriatrics, and pediatric neurology.
Primary care: In 2018, 5,052 of the 38,523 licensed physicians (13%) were employed as general practitioners (GPs). The average number of GPs per capita in Israel is 0.6 GPs per 1,000 people (or 1 GP per 1,653 insured). However, this rate varies across regions and health plans (ranging from 0. 57 to 0.73).9
Most GPs contract with one of the four competing nonprofit NHI health plans. Only 5 percent have contracts with more than one health plan.10
The four NHI health plans (Clalit, Maccabi, Meuhedet, and Leumit) have different approaches to organizing care. Clalit, the largest health plan, provides most primary care in clinics that it owns and operates, and GPs are salaried employees. The typical clinic is multidisciplinary, with three-to-six GPs and several nurses, pharmacists, and other professionals. Clalit also contracts with independent physicians who tend to work in solo practices, with some access to administrative and nonphysician services at Clalit district clinics.
The other three health plans also use a mix of multidisciplinary clinics and independent primary care practices. 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.
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. Clalit is also the only plan that requires gatekeeping; referrals are required for secondary care, except for five common specialties (dermatology, otorhinolaryngology, ophthalmology, orthopedics, and gynecology). In Leumit, patients are registered with a clinic rather than with a GP, and in the other two plans there is no registration.
Approximately one-third of Israel’s nurses work in community settings, primarily as salaried employees of the four NHI health plans. Their roles have been expanding beyond traditional routine nursing care (see “What innovations and reforms have recently been introduced?”). In a 2015-2016 national survey, 38 percent of frontline nurses employed by health plans identified “caring for chronically ill patients” as their main area of activity in addition to routine care, and 30 percent noted “health promotion.”11
Doctors are paid entirely by the health plans; they cannot collect additional fees from their patients.
Salaries of Clalit clinic-based physicians are set via a collective bargaining agreement with the Israel Medical Association. Capitation rates for independent physicians in all health plans are set by the plans in consultation with physicians’ associations.
Clalit and Leumit use predominantly “passive capitation,” a quarterly, per-member payment made irrespective of whether the member visited the GP in the relevant quarter. Maccabi and Meuhedet use “active capitation,” whereby 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. Quality-related financial incentives are generally not used.
Outpatient specialty care: Outpatient specialty care is provided predominantly in community settings, either in health plan clinics or in physicians’ offices. The former tend to be integrated multispecialty clinics, while the latter tend to be single-specialty.
Patients can choose freely among community-based specialists who are contracted with their health plan. Services provided by out-of-network specialists are paid for out-of-pocket or covered by voluntary health insurance.
Most outpatient specialists are paid on an active capitation basis, plus fee-for-service for certain procedures, up to a quarterly ceiling. Rates are set by the health plans. Specialists may not “balance bill” for NHI-covered services. Nevertheless, specialists can receive patients from NHI health plans along with patients who have private voluntary health insurance, but not the same patient in both settings. For privately insured patients, specialists can set their payment rates at their discretion.
Administrative mechanisms for direct patient payments to providers: When copayments and coinsurance are owed, such as for specialist visits and pharmaceuticals, patients never pay providers directly. Instead they use their health plan membership cards to make copayments. The provider then receives the full fee from the health plans, which collect copayments electronically from enrollees’ bank accounts each month.
After-hours care: After-hours care is available via hospital emergency departments (EDs), freestanding walk-in urgent care centers (both nonprofit and for-profit), and physician home visits provided by for-profit companies. The Ministry of Health has overall responsibility for after-hours care, and it has promoted the establishment of urgent care in several localities that are far from hospital EDs.
Primary care physicians are not required to provide after-hours care. They receive reports on their patients from the after-hours providers and, increasingly, this information is conveyed electronically.
All health plans operate national telephone advice lines for their members, staffed by nurses with physician backup. All of Israel’s hospital EDs are connected to the national health information exchange; efforts are underway to link them with community-based urgent care centers as well.
Hospitals: Of the 45 acute care hospitals, 18 are government-owned, either by the Ministry of Health or by municipalities. These account for 57 percent of the national capacity. Another 40 percent of acute care beds are operated by 16 private nonprofit hospitals that are owned by health plans or nonprofit organizations. Eleven for-profit hospitals account for the remaining 3 percent of bed capacity. These tend to be smaller hospitals that specialize in elective procedures.12
Reimbursement of hospital care varies:
- Hospital emergency care is reimbursed on a fee-for-service basis.
- Inpatient medical care is reimbursed on a per-diem basis.
- Inpatient procedures are paid either per diem or through activity-based, procedure-related group (PRG) arrangements.13
- Outpatient care is reimbursed on either a fee-for-service or a procedure-related group basis.
Maximum payment rates are set by the government, but health plans negotiate discounts. The government also sets revenue parameters (minimum and maximum), which limit the extent to which each hospital’s total revenues can decrease or grow from year to year. Hospital payments cover all costs, including the cost of the physicians. Procedure-related group payments include all costs of a hospitalization episode, excluding rehabilitation. There are no extra payments for severity, outliers, expensive treatments, or the adoption of new technologies.
Government and nonprofit hospitals follow a national hospital fee schedule, but for-profit hospitals’ prices are unregulated. Fee-for-service is the predominant payment mode for private for-profit hospitals.
In government and nonprofit hospitals, physicians are predominantly salaried employees, with limited arrangements for supplemental fee-for-service payments for procedures performed outside regular hospital hours.
Until 2018, there was largely no choice of specialist in nonprofit hospitals. Patients wishing to choose a specialist or surgeon had to go to a for-profit hospital and pay out of pocket or use voluntary health insurance. Since 2018, some large public hospitals have started offering free choice of surgeon.
Mental health care: In 2015, responsibility for the provision of mental health care was transferred from the Ministry of Health to the NHI health plans, which provide care through a mix of salaried professionals, contracted independent professionals, and purchased services. The Ministry of Health continues to own and operate community-based mental health clinics, which are now under contract with the health plans.
NHI-mandated mental health coverage is broad and includes psychotherapy, medications, and inpatient and outpatient care. Integration of mental health and medical services is currently limited but is expected to improve because of the transfer of responsibility to the health plans. Psychologists are the main source of professional mental health care for half of patients, and psychiatrists and primary care physicians serve a quarter of patients.14
Since the health plans took over mental health care, the availability of community-based services has increased substantially. However, there are still significant waiting times, particularly for psychotherapy and child psychiatry. These delays are due in part to shortages of some types of mental health professionals and to the health plans’ difficulties in attracting and contracting with professionals, who can earn much more in the private sector.
Long-term care and social supports: Long-term care is not covered by NHI, but is covered separately. The government publicly funds long-term care services through general taxes.
In 2014, 86 percent of adults age 65 and older with disabilities received community-based long-term care, while the remaining 14 percent received institutional long-term care.15 Community-based services account for 52 percent of total long-term care expenditures, of which 67 percent was publicly funded.16
Approximately half of the adult population purchases private long-term care insurance.17
Institutional long-term care financing is subsidized by the Ministry of Health and is awarded based on needs and means tests. These subsidies are generally paid directly to providers, although families can receive cash subsidies to pay providers.
Community-based long-term care is funded by the National Insurance Institute, and eligibility is based on needs and means tests. It includes personal care and housekeeping services for community-dwelling seniors with disabilities.18 In addition, the National Insurance Institute covers an extensive network of daycare centers and a growing network of supportive neighborhoods. An emergency call service, physician home visits, and social activities are also covered. Additionally, in every community, a facilitator coordinates social supports and apartment repairs.
Until 2018, there was no financial support for informal or family caregivers; there are means-tested government subsidies for home aids.
NHI health plans are responsible for providing medical care, such as home nursing care, for 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.
About two-thirds of nursing home care and nearly all home aids are provided by private, for-profit companies, with the remainder being public.
Hospice care is a mandated NHI benefit. In practice, however, while some hospice care is available, particularly home hospice, there is considerable unmet need.
Physician education and workforce: Enrollment in university medical education programs (medicine, surgery, and dentistry) is based on a competitive assessment exam. There are also restrictions on advancement to postgraduate levels, where medical school graduates can specialize in fields such as cardiology, neurology, and general surgery. Medical schools are largely public, with yearly fees of approximately EUR 2,200 (USD 2,500). Postgraduate students pay the same fee but also receive a monthly stipend of EUR 1,800 (USD 2,000).
Primary care: Primary care is provided by contracted self-employed and independent GPs and pediatricians. They are paid a capitation fee based on the number of patients on their list.8 Local health units also can pay additional allowances for delivering care to specific patients, such as home care to chronically ill patients; for reaching targets related to quality or spending levels; or for delivering additional patient services.
Capitation is adjusted for patient age, and accounts for approximately 70 percent of a GP’s overall payment. On average, the gross income of a GP ranges between EUR 80,000 (USD 110,957) and EUR 120,000 (USD 166,436), depending on list size. All the costs — for medical tools, office rental, and personnel — are borne by the GP.
GPs and pediatricians willing to work in rural or remote areas receive an additional payment of approximately EUR 5 (USD 6) per patient.
In 2017, there were approximately 52,000 GPs and pediatricians (34% of all practitioners) working for the SSN. In comparison, there were 101,000 hospital clinicians, including specialists (66%).9
Patients are required to register with a gatekeeping GP. They 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.
The payment levels, duties, and responsibilities of GPs are determined in a collective agreement signed periodically after consultations between the central government and the GPs’ trade unions. In addition, regions and local health units can sign contracts covering additional services.
GPs are not allowed to bill patients for any procedure delivered, although they are allowed to deliver treatments in a private setting provided they do not dedicate more than five hours per week to private care. If GPs decide to deliver private care for more than five hours per week, they must accept a reduction in their maximum number of patients (48 patients per additional hour).
In recent years, group practices have become more widespread, particularly in the northern part of the country. GPs and pediatricians who participate in some type of group practice — and ideally share offices and patient health record systems — receive additional payments per patient. They also receive additional payments for employing a nurse or secretary. In 2017, nearly 71 percent of GPs and 65 percent of pediatricians were working in a team.9 Group practices typically include from three to eight GPs.
To further coordinate meeting all the health needs of their populations, some regions are asking GPs to work in multidisciplinary groups composed of specialists, nurses, and social workers. This arrangement is encouraged by additional payments to GPs per patient and by supplying teams with needed 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 can choose any public or private accredited hospital but are not given a choice of specialist. Payment rates for outpatient specialist care are determined by each region, with national averages serving as a reference.
Outpatient specialist visits are generally provided by self-employed specialists working under contract with the SSN. They are paid an hourly fee negotiated nationally between the government and the trade unions; the current rate is approximately EUR 32 (USD 44). Outpatient specialists seeing public patients cannot bill above the fee schedule, but can see private patients without any limitations. Specialists employed by local health units and public hospitals can see private patients in public hospitals by allotting a portion of their extra income to the hospital.
Multispecialty groups are more common in northern regions of the country.
Administrative mechanisms for direct patient payments to providers: Patient copayments are 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: After-hours emergency care is the responsibility of local health units, which provide emergency medical services (Guardia medica) staffed by continuous-care physicians. The hourly rate, negotiated between the GP trade unions and the government, is approximately EUR 25 (USD 35). After examining patients and providing any initial treatment, the doctors can prescribe medications, issue employees’ medical certificates, and recommend hospital admission. The service normally operates at night and on weekends.
Primary care doctors are not required to provide after-hours care, but many are open until 8 p.m. There is no national or regional medical telephone advice line.
Information on a patient’s after-hours visit is not routinely sent to the patient’s GP. To improve accessibility, government and GP associations are trying to promote a model in which GPs, specialists, and nurses coordinate to ensure 24-hour access and avoid unnecessary use of hospital emergency departments. Implementation is uneven across regions.
Hospitals: Public funds are allocated by local health units to public and accredited private hospitals (for-profit and nonprofit). In 2017, there were approximately 165,000 beds in public hospitals and 44,000 in private accredited hospitals.9 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. (However, hospitals run directly by local health units typically have global budgets.) Rates include all hospital expenses, including physician salaries, and costs for expensive technologies and medicines. Teaching hospitals receive additional payments — typically 8 percent to 10 percent 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 all regions, a portion of funding is administered outside the prospective payment system, such as funding of specific functions like emergency departments and teaching programs.
Hospital-based physicians are salaried employees with an average gross income of EUR 106,000 (USD 147,018). 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.
In April 2015, the Ministry of Health approved a decree for the reorganization of hospital care. The decree classified public hospitals into three groups, based on population size, service intensity, and scope: base, first-level, and second-level.
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 2017, there were about 2,000 residential facilities and 870 semiresidential facilities.9
The promotion and coordination of mental health care are the responsibility of mental health departments in local health units. Multidisciplinary teams include psychiatrists, psychologists, nurses, social workers, educators, occupational therapists, people with training in psycho-social 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 responsibility for low-complexity cases (mild depression) to GPs.10
Long-term care and social supports: In Italy, home care, residential care, and semiresidential long-term care are covered by the SSN, with delivery of care organized by local health units. All patients are eligible; admission is based on clinical criteria only.
There has been a significant shift of long-term care from institutions to the communities and an emphasis on home care. Patients with long-term care needs receive predominantly home care (approximately 1 million cases in 2017), with fewer patients receiving care in residential facilities (approximately 278,000 beds in 2017) or semiresidential facilities (16,000 beds).9
Residential and semiresidential facilities provide nurses, physicians, specialist care, rehabilitation services, medical therapies, and devices. Patients must be referred in order to receive residential care. Cost-sharing for residential services varies widely by region but is generally determined by patients’ income. Residential facilities are managed by a mixture of public and private, for-profit and nonprofit organizations.
Community home care is not designed to provide physical or mental health care services but to provide additional assistance during a treatment or therapy. Community home care networks use integrated care teams of nurses, GPs, and specialist physicians to ensure that patient needs are met and families are involved. Community home care is funded publicly.
In spite of government provisions for residential and home care services, long-term care in Italy has traditionally been characterized by a lower degree of public financing and provision than what is found in other European countries. Patients do not receive individual budgets. In addition, no financial support is provided for caregivers, although Italian legislation allows caregivers three days off work per month to look after relatives in need.
Financial assistance for long-term care patients and for their caregivers 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 EUR 500 (USD 693) per month. It can be used to buy any type of service.
- Care vouchers: Awarded by municipalities on the basis of income, need, and clinical severity. Only some municipalities currently offer these vouchers. The amount ranges between EUR 300 and EUR 600 (USD 416 and USD 832) 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 hospital-based palliative care units. In 2017, there were some 270 hospices, with approximately 3,100 beds. However, regional disparities persist: northern regions care, on average, for 95 patients per 100,000 residents at the end of life, while in central and southern regions the rate is 50 per 100,000.9
Physician education and workforce: The number of people enrolling in medical school and the number of basic medical residency positions are regulated nationally. The number of residency positions in each region is also regulated.
Approximately two-thirds of medical students study at public medical schools, while the remaining one-third are enrolled at private schools. Total tuition fees for a public six-year medical education program are around JPY 3.5 million (USD 35,000). Total private school tuition is JPY 20 million–45 million (USD 200,000–450,000).16
Since the mid-1950s, the government has been working to increase health care access in remote areas. Recent measures include subsidies for local governments in those areas to establish and maintain health facilities and develop student-loan forgiveness programs for medical professionals who work in their jurisprudence. Most of these measures are implemented by prefectures.17
Primary care: Historically, there has been no institutional or financial distinction between primary care and specialty care in Japan. The idea of “general practice” has only recently developed.
Primary care is provided mainly at clinics, with some provided in hospital outpatient departments. Most clinics (83% in 2015) are privately owned and managed by physicians or by medical corporations (health care management entities usually controlled by physicians). A smaller proportion are owned by local governments, public agencies, and not-for-profit organizations.
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.18 Nurses and other staff are usually salaried employees. In some places, nurses serve as case managers and coordinate care for complex patients, but duties vary by setting.
Clinics can dispense medication, which doctors can provide directly to patients. Use of pharmacists, however, has been growing; 73 percent of prescriptions were filled at pharmacies in 2017.19
Patients are not required to register with a practice, and there is no strict gatekeeping. However, the government encourages patients to choose their preferred doctors, and there are also patient disincentives for self-referral, including extra charges for initial consultations at large hospitals.
Payments for primary care are based on a complex national fee-for-service schedule, which includes financial incentives for coordinating the care of patients with chronic diseases (known as Continuous Care Fees) and for team-based ambulatory and home care. The schedule, set by the government, 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. In some cases, providers can choose to be paid on a per-case basis or on a monthly basis. Bundled payments are not used. Providers are usually prohibited from balance billing, but can charge for some services (see “Cost-sharing and out-of-pocket spending” above).
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 (see above).
At hospitals, specialists are usually salaried, with additional payments for extra assignments, like night-duty allowances. Those working at public hospitals can work at other health care institutions and privately with the approval of their employers; however, even in such cases, they usually provide services covered by the SHIS.
The employment status of specialists at clinics is similar to that of primary care physicians. Physicians working at medium-sized and large hospitals, in both inpatient and outpatient settings, earned on average JPY 1,514,000 (USD 15,140) a month in 2017.20
Administrative mechanisms for direct patient payments to providers: Clinics and hospitals send insurance claims, mostly online, to financing bodies (intermediaries) in the SHIS, which pay a major part of the fees directly to the providers. Patients pay cost-sharing at the point of service.
After-hours care: After-hours care is provided by hospital outpatient departments, where on-call physicians are available, and by some medical clinics and after-hours care clinics owned by local governments and staffed by physicians and nurses.
The national government gives subsidies to local governments for these clinics. Hospitals and clinics are paid additional fees for after-hours care, including fees for telephone consultations.
Patients can walk in at most hospitals and clinics for after-hours care. 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. In some regions and metropolitan areas, fire and emergency departments organize telephone emergency consultation with nurses and trained staff, supported by physicians.21
Hospitals: As of 2016, 15 percent of hospitals are owned by national or local governments or closely related agencies. The rest are private and nonprofit, some of which receive subsidies because they’ve been designated public interest medical institutions.22,23 The private sector has not been allowed to manage hospitals, except in the case of hospitals established by for-profit companies for their own employees
Acute-care hospitals, both public and private, choose whether to be paid strictly under traditional fee-for-service or under a diagnosis-procedure combination (DPC) payment approach, which is a case-mix classification similar to diagnosis-related groups.24 The DPC payment consists of a per-diem payment for basic hospital services and less-expensive treatments and a fee-for-service payment for specified expensive services, such as surgical procedures or radiation therapy.25 Most acute-care hospitals choose the DPC approach. 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, reduced to 10 percent for individuals with chronic mental health conditions. Covered services include psychological tests and therapies, pharmaceuticals, and rehabilitative activities. Specialized mental health 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 under the guidance of the national government, covers those age 65 and older, and people ages 40 to 64 who have select disabilities. LTCI covers:
- home care
- respite care
- services at long-term care facilities
- disability equipment
- assistive devices
- home modification.
End-of-life care is covered by the SHIS and LTCI. The SHIS covers hospice care (both at home and in facilities), palliative care in hospitals, and home medical services for patients at the end of life. Either the SHIS or LTCI covers home nursing services, depending on patients’ needs. Home help services are covered by LTCI.
Taxes provide roughly half of LTCI funding, with national taxes providing one-fourth of this funding and taxes in prefectures and municipalities providing another one-fourth.
The remaining LTCI funding comes from individual mandatory contributions set by municipalities; these are based on income (including pensions) as well as estimated long-term care expenditures in the resident’s local jurisdiction. Citizens age 40 and over pay income-related contributions in addition to SHIS contributions. Employers and employees split their contributions evenly.
A 20 percent coinsurance rate applies to all covered LTCI 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 low-income individuals. All costs for beneficiaries of the Public Social Assistance Program are paid from local and national tax revenue.26
The majority of LTCI home care providers are private. In 2016, 66 percent of home help providers, 47 percent of home nursing providers, and 47 percent of elderly day care service providers were for-profit, while most of the rest were nonprofit.27 Meanwhile, most LTCI nursing homes, whose services are nearly fully covered, are managed by nonprofit social welfare corporations.
Family care leave benefits (part of employment insurance) are paid for up to 93 days when employees take leave to care for family members with long-term care needs. A portion of long-term care expenses can be deducted from taxable income.
Physician education and workforce: The number of medical doctors is regulated through caps on the number of medical students, at both a national and a university level. Medical schools are located in private, nonprofit university medical centers. Medical students pay a yearly tuition fee of approximately EUR 2,100 (USD 2,691). The Capacity Body (Capaciteitsorgaan) advises the Ministry of Health on all specialized postgraduate training programs for medical specialists to ensure that supply matches demand.
There are no national initiatives to ensure an adequate supply of medical providers in rural or remote areas. In rural areas, GPs may assume the role of pharmacists.11
Primary care: In 2017, there were 13,364 registered primary care doctors (GPs) and 23,236 medical specialists.12,13 Eighty-two percent of these physicians worked in small practices of two to seven physicians in 2016; 18 percent worked in solo practices.14
Most GPs work independently or in a self-employed partnership; one-third are employed by or have a short-term contract with a practice owned by another GP.15
The GP is the central figure in Dutch primary care. The typical practice size is approximately 2,200 patients per full-time working GP. Although registration with a GP is not formally required, most citizens (over 95%) are registered with one they have chosen, and patients can switch GPs as often as they like. GPs have a gatekeeping function; referrals are required for both hospital and specialist care.16
Many GP practices employ salaried nurses and primary care psychologists. Reimbursement for primary nursing care is received by the GP, so any productivity gains that result from substituting a nurse for a doctor accrue to the GP.
Chronic care management is coordinated through care groups, which are mostly GP networks. Care groups are legal entities that assume clinical and financial responsibility for enrolled chronic disease patients. 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 model17 comprising three segments:
- Segment 1 (approximately 75% of GP spending) funds core primary care services and consists of a capitation fee per registered patient, consultation fees for GPs (including phone consultations), 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 (approximately 15% of GP 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 (approximately 10% of GP spending) provides GPs and insurers with the opportunity to negotiate additional contracts that encourage innovation and tie payment to performance.
Primary care providers are not allowed to bill patients above the fee schedule.
In 2018, self-employed GPs earned an average gross annual income of EUR 135,000 (USD 173,004), excluding after-hours care. In comparison, in 2016, maximum gross annual incomes of specialists were estimated at EUR 160,000 (USD 205,042) for salaried specialists, and EUR 211,000 (USD 270,399) for independent specialists.18 The ratio of specialists to GPs was 1.7:1 in 2017.19,20
Outpatient specialist care: Nearly all specialists are hospital-based and either are part of a group practice (39%) or are on salary, mostly in university clinics (49%). The remaining 12 percent worked both on salary and independently in 2015.21
As of 2015, specialist fees are freely negotiable between independent specialist associations and hospitals. This so-called integral funding dramatically changed the relationship between medical specialists and hospitals. Hospitals now have to allocate their financial resources among their specialists.
After patients receive a referral for specialist treatment (in any hospital), they are free to choose their provider, but insurers may set different conditions, like cost-sharing, for choosing certain specialists.22
In 2016, there were 229 independent private and nonprofit outpatient treatment centers whose services were limited to same-day admissions for nonacute, elective care (such as orthopedic surgery) covered by statutory insurance.23
Administrative mechanisms for direct patient payments to providers: Regular GP visits are free of charge, being exempt from the deductible. Patients generally do not pay specialists directly. Instead, the annual deductible is paid to the insurer. The insured has the option of paying the deductible before or after receiving health care and may choose to pay all of the deductible at once or in installments. Copayments, such as those for drugs or transportation, 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 walk-in centers, typically run by a nearby hospital, that provide primary care between 5:00 p.m. and 8 a.m. Nearly all GPs work for a GP Post. They must provide at least 50 hours of after-hours care annually to maintain their registration as GPs.
Specially trained medical assistants answer the phone and perform triage; GPs decide whether patients need to be referred to a hospital. Doctors are compensated separately at hourly rates for after-hours care and house calls (on top of their regular income).
The GP Post sends information regarding a patient’s visit electronically to the patient’s regular GP. Since after-hours care is typically provided at hospitals, there is no national medical telephone hotline advising patients on their nearest after-hours locations.
Hospitals: In 2018, there were 71 hospital organizations, including eight university medical centers.24 All hospitals are private entities, but profits may not be distributed to shareholders, making the hospital market virtually 100 percent nonprofit.
Hospital payment rates are determined mostly through negotiations between insurers and hospitals over prices, quality, and volumes. The great majority of payments take place through the case-based, diagnosis-treatment combination (DBC) system, which is similar to a diagnosis-related group approach. In 2012, the number of DBCs was reduced from 30,000 to 4,400 to reduce administrative complexity.
The rates for approximately 70 percent of DBCs can be negotiated by providers and insurers. The remaining 30 percent are set nationally by the Dutch Health Care Authority.
Since 2015, independent medical specialist groups have negotiated physician payments with hospitals. Diagnosis–treatment combinations cover both outpatient and inpatient care, as well as specialist costs, strengthening the integration of specialist care within the hospital organization.
A small part of hospital care is reimbursed through so-called add-ons. Add-ons are separate payments that have been developed for the reimbursement of expensive drugs and intensive care unit admissions. In addition, university medical centers receive special allowances for the adoption of new technologies.
Mental health care: Mental health care for mild-to-moderate mental disorders is provided by specially trained psychologists, nurses, and social caregivers in basic ambulatory care settings, such as GP offices. In cases of complicated and severe mental disorders, GPs will often refer patients for specialized mental health care.
Outpatient mental health care is generally covered as part of the basic statutory benefit package. In contrast, inpatient mental health care is covered as part of the Long-Term Care Act of 2015 (see next section). Hospitals provide acute mental health care.
E-health applications are used widely in mental health care. The government stimulates the use of e-health through various programs, including a EUR 90 million (USD 115 million) investment fund in 2019.25
Long-term care and social supports: In the Netherlands, long-term care and social support programs are separate from but complementary to the curative health system. Long-term care is financed through the Long-Term Care Act (Wet langdurige zorg) of 2015, a statutory social insurance scheme for long-term care and otherwise uninsurable medical risks and costs that cannot be reasonably borne by individuals. To fund long-term care insurance, taxpayers contributed 9.65 percent of their taxable income up to EUR 33,791 (USD 43,304) in 2017.26
Long-term care encompasses residential care, personal care, supervision, medical care, and nursing care, as well as medical aids and transport services. Patients in need of permanent supervision or who need assistance 24 hours a day to prevent escalation or serious harm are eligible for long-term care benefits. The Center for Needs Assessment (Centrum Indicatiestelling Zorg), a governmental agency, determines eligibility based on clinical need alone (no means-testing). In 2016, 314,220 people used long-term care.27
A total of EUR 20 billion (USD 26 billion) was spent on long-term care in 2017, making the Netherlands one of the highest long-term care spenders among countries in the Organisation for Economic Co-operation and Development.28 To reduce spending, some long-term care responsibilities have been transferred to municipalities, with the goal of shifting care from institutional settings to community-based care.
Municipalities receive block grants from the government to cover long-term care expenses. Municipalities have very limited tax-raising abilities.
Municipalities are responsible for ensuring the provision of household services, medical aids, home modifications, services for informal caregivers, preventive mental health care, transport facilities, and other assistance. Municipalities have a great deal of freedom in how they organize long-term care services and in how they support caregivers. In 2017, 1,042,790 people used social support services funded by municipalities.29
Cost-sharing depends on annual income and wealth, age, and household size. For long-term care, an income- and wealth-related copayment up to a maximum of EUR 2,332 (USD 2,988) per month is required.30 For municipal home care and social services, most municipalities require a small income-related copayment.
Long-term care is provided by private, nonprofit organizations. For home care, profits are allowed by law. Home care is provided increasingly by self-organizing nursing units, following the innovative business model of Buurtzorg, a 2007 startup that has increasingly penetrated the Netherlands’ home care market.31
Most palliative care, including hospice care, is integrated into the health system and can be delivered by GPs, home care providers, nursing homes, specialists, and volunteers. Palliative care is financed through a number of sources, but mostly through the Long-Term Care Act.
Personal budgets are provided for patients to buy and organize their own long-term care. In 2016, about 14,200 personal budget holders received on average of almost EUR 20,000 (USD 25,630) annually.32 Personal budgets can be spent on various care and welfare functions, including family caregivers and informal caregivers, although regulations have been tightened.
Physician education and workforce: Practicing physicians must be registered with the Medical Council of New Zealand. There is no limit to the number of registered physicians. However, the two medical schools, Otago and Auckland, both public, have a limited student intake, and specialist colleges also limit training places. Medical school limits are determined largely by the government, which is the primary funder of medical education.
Students pay a portion of costs, presently around NZD 15,000 (USD 10,100) per year, for the six-year medical degree. Students from rural areas are eligible for fee subsidies and reimbursements if they return to practice rurally. Rural practice remains on the New Zealand immigration department’s list of high-priority professions, meaning foreign doctors who opt to practice in rural areas of New Zealand are given preference when lodging immigration applications.
Primary care: GPs are usually independent and self-employed. Most belong to one of about 30 primary health organizations (PHOs), which are networks of providers.
About half of a GP’s income comes from capitated, government-determined national subsidies, paid through the primary health organizations. The capitation rate is periodically adjusted in negotiations with GPs and primary health organizations.
Patient copayments, set by individual GPs, and payments from the Accident Compensation Corporation account for a GP’s remaining compensation. In general, copayments are not regulated by any fee schedule; however, the government caps copayments for New Zealanders residing in low-income areas. A higher annual per-patient capitation rate is paid to GPs for these low-income patients. Primary health organizations receive additional per-capita funding to improve access (especially for low-income and vulnerable populations) 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.
Primary health organizations also receive an incentive-type payment, up to 3 percent in additional funding, that can be shared with GPs who reach recommended targets for disease screening and follow-up, as well as for vaccinations.
GPs have an average income of NZD 180,000–200,000 (USD 122,000–135,000) per year. GPs who own their own clinics earn more.
The ratio of GPs to specialists is about 2:3. GPs act as gatekeepers to specialist care.
Patient registration is not mandatory, but GPs and primary health organizations 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.
An average of 3.48 GPs work together in each practice, assisted by practice nurses. Nurses are paid a salary by GPs and have a significant role in the management of long-term conditions like diabetes, incentivized by government funding for chronic care management.
Outpatient specialist care: Most specialists are employed by district health boards and receive a salary for working in a public hospital. The average public hospital specialist salary is around NZD 230,000 (USD 155,000).5 Thereby, specialists in public hospitals make about 1.1 to 1.3 times the income of GPs.
Specialists 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.6
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. Insurers pay private specialists only up to a maximum set amount, meaning that patients pay any difference.
In public hospitals, patients generally have limited choice of a specialist.
Administrative mechanisms for direct patient payments to providers: As noted above, GPs’ income is derived from government subsidies, payments from the Accident Compensation Corporation, and copayments from patients.
Some patients enrolled in private insurance may be eligible to file a claim to cover copayments.
Patients pay the full cost of private specialist visits up front, unless the service is funded by the Accident Compensation Corporation 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 a higher per-patient rate 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 (except for most children under age 13, who can get free after-hours GP services). Consequently, some patients will visit a hospital emergency department instead of after-hours clinics or avoid after-hours services 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. The “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 district health boards, 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 public hospital, the budget tends to be allocated to the various inpatient services using a case-mix funding system, although some services are funded regardless of case mix.
A proportion of district health board funding for elective surgery is held by the Ministry of Health, and payments are made on delivery of surgery.
Following a pay-for-performance-type scheme, payments can be withheld if a district health board does not meet elective targets.
Certain areas of funding, such as mental health, are “ring-fenced”; the district health board 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 community-based primary mental health services, often through their GP, who will then coordinate any referred services. However, there are also school-based health services and community services provided by nongovernmental agencies, which are all publicly funded.
District health boards deliver a range of mental health services (including secondary services), such as forensic, acute inpatient, and community-based services. They also provide support to primary care providers and fund nongovernment providers of community-based services. Private provision is limited.
Long-term care and social supports: District health board funding for long-term care is based on a patient needs assessment, age, and means-testing. Services are funded 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).
Eligible individuals receive comprehensive services, including medical care and home care. Respite care is available for informal or family-member caregivers and, in some circumstances, ongoing financial support is provided. Residential facilities, mostly private, provide long-term care. District health boards also provide hospital- and community-based palliative care. Around 33 percent of people over age 65 who receive support live in some form of aged residential care, with the remainder receiving home-based services.
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. District health boards 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. District health funds 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. Some district health boards have experimented with providing personal budgets to home support recipients to spend on selected approved services, but mostly home care services are directly funded by district health funds.
Physician education and workforce: Medical education programs are offered at four public universities. The yearly educational capacity is set at 600 students, and the tuition fees are about NOK 1,200 (USD 118).
In 2015, 38 percent of physicians were trained outside Norway; however, nearly 50 percent of foreign-trained doctors are Norwegian-born. Many Norwegian students choose to study in EU countries and return to Norway to practice medicine.
Statistics Norway and the Directorate of Health have a shared responsibility for monitoring the health care workforce in Norway. Municipalities are primarily responsible for ensuring GP supply, but may apply to the Directorate of Health for extra funding to ensure an adequate supply of physicians. Funding may support the establishment of new practices and facilitate continuing medical education or other skill-building.
Primary care: The municipalities are responsible for providing primary care to their populations. Registered residents have the right to go to a GP of their choosing, assuming the physician has capacity to take on additional patients. The average patient panel size for a GP was 1,120 in 2016.6
Municipalities contract with individual GPs, who are mostly self-employed; only 6 percent are salaried municipal employees. Average annual earnings are NOK 804,000 (USD 78,824).7 GP practices typically comprise one to six physicians and employ nurses, lab technicians, and secretaries. GP networks that enable sharing of resources are not common.
GPs function as gatekeepers. A GP referral is required for coverage of specialist treatment.
GPs receive 35 percent of their income from the municipalities, 35 percent on a fee-for-service basis from the central government through Helfo, and 30 percent from out-of-pocket payments from patients. GP financing is determined nationally through negotiations between the Norwegian Medical Association and the central government (represented by the Ministry of Health and Care Services, Ministry of Finance, and Directorate of Health), as well as representatives from the RHAs and the Association of Municipalities. The fee-for-service scheme also includes specific, relatively small fees available for: medication reconciliation, care coordination, and the development of care plans for patients with complex needs.
Outpatient specialist care: Public hospitals and self-employed specialists provide specialty care. There are 2.8 specialists in hospitals or ambulatory care for every practicing primary care physician.8
Hospital-based specialists are salaried; the average salary for hospital specialists is an estimated NOK 1,032,000 (USD 101,176). Private-practice specialists may or may not contract with an RHA to be reimbursed under the NIS. RHA-contracted specialists are paid annual lump sums, based on the type of practice and number of patients, which account for 35 percent of their reimbursement. These specialists also receive fee-for-service payments (35% of payment) and copayments (30% of payment).
The annual lump sum and the out-of-pocket fees are set by the central government, and the fee-for-service payment scheme is negotiated between the government and the Norwegian Medical Association. The Ministry of Health and Care Services sets the RHAs’ budgets and issues an annual document instructing the RHAs on health care goals and priorities. Specialists with an RHA contract can charge patients only the nationally set out-of-pocket fee.
GPs and specialists who do not receive public financing are neither regulated nor subject to the out-of-pocket expenditure caps.
In principle, patients can choose their own specialists; in practice, however, specialist availability varies by geographic location. In densely populated areas, private multidisciplinary physician clinics have emerged in 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.
Administrative mechanisms for direct patient payments to providers: Patients make copayments directly to care providers during their visits. The process is fully electronic and automated, alerting the patient and provider if the annual safety net ceiling has been reached.
After-hours care: The municipalities are responsible for arranging after-hours emergency primary care. Contracts with GPs include a requirement to provide after-hours emergency services on rotation. The municipalities pay the GPs a fee and provide offices, equipment, and assistance. Additional payments are provided through the national fee-for-service system and out-of-pocket payments from patients.
Some cities have walk-in centers where nurses triage patients and answer calls, with several physicians seeing patients throughout 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 either at home or at the center. In larger cities, there are a few private after-hours clinics where patients pay in full. A national medical helpline guides patients on where to seek assistance.
Information about after-hours visits is not consistently shared with patients’ regular GPs.
Hospitals: Acute-care hospital services are the responsibility of the RHAs. Most hospital care is provided through Norway’s 20 public hospital trusts, which are state-owned and -governed as publicly owned corporations. In 2017, the public hospital trusts had 11,000 beds and accounted for 94 percent of all hospital stays, with 760,000 overnight stays.
Not-for-profit private hospitals, which can have tender agreements with RHAs, accounted for 5 percent of overnight hospital stays in 2017. The for-profit hospital sector, which is small, covered 6.5 percent of daytime stays, mostly outpatient surgeries.9 For-profit hospitals do not offer acute care or a full range of services. Some services in private hospitals may receive public funding, but the proportion varies, from almost none to 85 percent. Public funding of hospital care averages 85 percent.
Patients need a referral to acute-care services from a GP. However, in specific cases (e.g., accidents, suspected heart attack), patients can be taken directly to the hospital via ambulance. Patients are free to choose a hospital for elective services, but not for emergency care. All municipalities must provide intermediate-care units for patients who need pre- or post-hospital services for a limited time (<72 hours).
The RHAs are free to decide how hospitals are paid, and all four have chosen a diagnosis-related group (DRG) funding mechanism. Most services, including hospital administration, are included in DRG payments. One exception is somatic services, which are financed in part (50%) by block grants. Financing of hospital-initiated pharmaceutical care is the responsibility of the RHAs.
All hospital personnel are salaried, including doctors.
Mental health care: Mental health care is provided in municipalities by GPs, psychologists, psychiatric nurses, and social care workers. Many municipalities have multidisciplinary mental health outreach teams.
Psychological care for children under the age of 18 is fully covered. Preventive services for mental health are directed toward children and adolescents through the school system.
For specialized care, GPs may refer patients either to private psychologists and psychiatrists or to community mental health centers, which provide acute-care services (inpatient, outpatient, and day care) and rehabilitation services while also supervising and supporting primary care. These centers are dispersed throughout the country and often include psychiatric outreach teams.
More advanced specialized services are provided in the inpatient psychiatric wards of general hospitals or in mental health hospitals. Hospital inpatient treatment is provided free of charge, and outpatient services are subject to the same cost-sharing as other ambulatory visits. Psychiatric services in hospitals and community mental health centers are funded in full (100%) by block grants through the 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 the RHAs. The role of private treatment centers for addiction (mainly to drugs and alcohol) is prominent and funded mostly through contracts with RHAs. In general, treatment for drug dependence is delivered by specialized treatment units, while GPs are involved in opioid substitution treatment.10
The majority of long-term care recipients (70%) receive care at home, while 10 percent live in sheltered or assisted housing facilities, which are independent housing arrangements in between home and institutional care. About 20 percent of recipients live in an institution or a home with personnel available 24 hours a day.11 Twenty-five percent of patients with extensive needs for assistance live in their own home.
Most nursing homes are owned and funded by municipalities; only 10 percent of all long-term care beds are in private nursing homes.12 Very few patients pay individually for full-time private nursing home care.
Service eligibility is needs-based, determined by municipal criteria in cooperation with GPs. Home-based and institutional care for older or disabled people requires means-testing; cost-sharing is high, up to 85 percent of personal income.
End-of-life care for terminal patients is often provided in specific wards within dedicated nursing homes. There are few designated hospice facilities.
There is a system in place for informal caregivers to apply for financial support from the municipalities. In 2017, 10,099 caregivers were granted such support,13 averaging around 10 hours per week. In addition, caregivers may be entitled to pension credits.
Physician education and workforce: Singapore has three medical schools, all of which are part of public universities. Clinical teaching is carried out almost exclusively in public health care institutions. The government regulates the number of doctors by varying the number of admissions to medical schools according to projected needs. The pipeline of doctors is supplemented by foreign-trained doctors. The government regulates the entry of these doctors by adjusting a list of approved overseas medical schools.28
Between 2012 and 2018, the total annual admissions of medical students to the three local universities increased by about 40 percent. Tuition fees are heavily subsidized: net annual fees for Singapore nationals are about SGD 29,000 to 33,000 (USD 21,000 to 24,000) for five-year undergraduate medical programs, or SGD 47,000 (USD 34,000) for four-year graduate programs.29 Upon graduation, all medical students are required to work in the public health care system for four to five years.30
As of 2018, Singapore had 13,766 registered medical practitioners, with nearly two-thirds in the public sector. This translates to about 2.4 doctors per 1,000 people, a significant increase from 1.9 in 2012. Around 41 percent of doctors are specialists.31
Primary care: Primary care is provided through public polyclinics and private GPs. There are currently 20 polyclinics and more than 2,200 GP clinics.32 Polyclinics usually have more than 10 doctors and some also provide dental, psychiatric, and allied health services. Polyclinics provide 20 percent of primary care, with a strong focus on chronic-disease management.33
The majority of GP clinics operate as solo practices (including those run by clinic chains), and primarily operate on a fee-for-service payment model; the clinics have flexibility to set their own fees. Patients can choose a primary care doctor at a polyclinic or at a GP clinic, and they can usually walk in and be seen the same day without needing a prior appointment. Patients are free to change providers or to be seen by two or more providers over a given period.
The Ministry of Health has launched several initiatives over the years to tap into the capability and capacity of GPs, including the Chronic Disease Management Program, which covers 20 chronic diseases. Another initiative, the Primary Care Networks (PCN) scheme, aims to anchor effective chronic-disease management in primary care through the organization of like-minded GPs in a network. As of 2019, there are 10 primary care networks and more than 350 participating GP clinics. The ministry provides resources to these PCNs for managing patients with complex needs, including nurse counsellors and care coordinators, chronic-disease registries, and administrative support. In return, GPs in PCNs are expected to adhere to stipulated clinical quality requirements.34
In terms of manpower, 59 percent of registered doctors are nonspecialists, including primary care doctors and those still undergoing specialist training in public institutions. The gross median monthly income for GPs is SGD 13,707 (USD 10,006), while the gross median monthly income for specialists is SGD 20,078–23,705 (USD 14,657–17,305).35
Outpatient specialist care: Specialist outpatient services are provided by both the public and the private sector on a fee-for-service basis. Public-sector specialists are salaried and see both private and subsidized patients in the specialist outpatient clinics of public hospitals and national specialty care centers.36 Fees for private and subsidized patients at these clinics are determined by and paid to the hospital.
Polyclinic referrals are considered subsidized patients at specialist outpatient clinics, while referrals from GPs are treated as private patients unless they are referred by clinics accredited by the Community Health Assist Scheme. Patients who refer themselves to specialist outpatient clinics are considered private patients. Private patients can choose their specialist, while subsidized patients have a specialist assigned to them.
Private specialist clinics receive referrals from GPs as well as self-referrals, and have flexibility to set their fees.
Administrative mechanisms for direct patient payments to providers: Singaporeans prepay for care through MediSave (via payroll deductions) and MediShield Life (mandatory premiums).
After-hours care: Polyclinics are not open at night or on Sundays and public holidays. However, a significant number of GP clinics are open at night and on weekends and public holidays. Thirty GP clinics are open 24 hours, as are emergency departments in public hospitals and some emergency clinics in private hospitals. There are also telehealth providers that are available any time of day.
Hospitals: As of 2017, Singapore had 18 acute care hospitals: nine public hospitals, eight for-profit hospitals, and one not-for-profit Catholic hospital.
In total, Singapore has 2.4 beds per 1,000 population.37 The majority of public-hospital patients are admitted through emergency departments, making up more than 70 percent of admissions. Admissions to private hospitals tend to be elective.
Legally speaking, public hospitals are corporatized companies wholly owned by the government.38 As owner, the government can shape hospitals’ behavior without having to resort to onerous regulations or purchase negotiations.39 This has enabled the Ministry of Health to reorganize the public health care system to ensure better-coordinated and seamless care (for example, by creating integrated clusters of public hospitals and polyclinics).
The government funds public hospitals on the basis of diagnosis-related groups (DRGs) for inpatient and day surgery services and per piece rates for outpatient visits subject to an overall block.40 Public hospitals are required to meet expenses from government payments and patient fees. Public hospitals are allowed to keep surpluses but need to meet shortfalls from their reserves, unless there are exceptional circumstances.
The government introduced community hospitals to provide rehabilitation and subacute care, including to patients who have dementia or need palliative care. Community hospitals also provide outpatient services, such as day rehabilitation. There were seven community hospitals in 2018, with nearly 1,700 beds.41 The Ministry of Health pays community hospitals on a per-diem basis. Patients admitted to community hospitals may be eligible for subsidized care, ranging from 20 percent to 75 percent based on their per-capita household income and residency status.
Mental health care: The Institute of Mental Health, a public hospital, is Singapore’s only psychiatric hospital, and provides acute tertiary psychiatric, rehabilitative, and counselling services for children, adolescents, adults, and the elderly. It has both inpatient wards, with more than 2,000 beds, and Specialist Outpatient Clinics at various community locations. The Community Mental Health Team, which comprises doctors, community psychiatric nurses, and allied health professionals, provides community-based treatment and psychosocial rehabilitation for patients after discharge so they may continue to live in the community while working toward recovery.
Other public and private hospitals also have psychological medicine departments or specialists that offer psychiatric services.
The Ministry of Health is working with health care institutions and professionals to implement the Community Mental Health Plan, which was launched in 2017. By early 2019, mental health or dementia services were available at 12 polyclinics.
The ministry has also expanded the Mental Health General Practitioner (GP) Partnership program to encourage patients with emotional health issues to seek early treatment. GPs in the program can prescribe psychiatric drugs at a lower cost and have a liaison coordinator to facilitate referrals between services. Patients can also get subsidies for mental health conditions.
The number of GPs trained to diagnose and support persons with mental health conditions grew from 70 in 2012 to 190 by the end of 2018. These GPs are supported by 20 community intervention teams led by allied health professionals.42
Long-term care and social supports: There are three main groups of long-term care services.
Center-based services. These cater to seniors who require care services during the day on a regular basis while their family members are at work. As of 2017, there were 102 day care centers, dementia day care centers, day rehabilitation centers, and senior care centers.
Home-based services. As of 2017, there were 21 home medical and home nursing providers, and nine home palliative care providers.43 In addition, three inpatient hospices are run by charitable organizations.
Long-term residential facilities. Nursing homes provide a range of services, including medical care, nursing care, and rehabilitative services to residents who are unable to be cared for at home. Respite care is also available at some of the nursing homes. As of 2017, there were 73 nursing homes, including private, nonprofit, and public facilities, contributing a total of approximately 14,900 beds.44 The Ministry of Health contributes to the growth and development of eldercare services in Singapore, as well as the development of nursing homes, under its Build Own Lease framework.
MediSave cannot currently be used for nursing home services or home-/center-based services, but residents can use ElderShield, a basic long-term care insurance scheme designed to cover severe disability, especially during old age, on top of government subsidies of up to 80 percent for various services.45 Coverage is automatically extended to all citizens and permanent residents with a MediSave account when they reach age 40. Residents can opt out, and the opt-out rate is 5 percent in recent years.46
ElderShield is a prefunded insurance scheme within which premiums are collected during policyholders’ working years and risk-pooled within each generation. Premiums do not rise with age, and policyholders are covered for life. The scheme provides monthly cash payouts of $400 for 72 months or $300 for 60 months, depending on the plan.47 Policyholders can also purchase supplements that provide higher coverage — for example, higher payouts or a longer duration of payouts — and pay for premiums using their MediSave coverage (up to a limit).
Physician education and workforce: Medical schools are public, and there is no tuition fee for medical education; however, the number of students accepted each year is limited.
Primary care: Primary care accounts for about 17 percent of all health expenditures,8 and about 16 percent of all physicians work in this setting.9
There are about 1,200 primary care practices; 60 percent are owned by regions and the remainder are privately owned. Regions control the establishment of new private practices by regulating clinic hours, clinical competencies, and other organizational aspects and by regulating financial conditions for accreditation and payment. The right to establish a practice and be publicly reimbursed applies to all public and private providers fulfilling the conditions for accreditation.
Team-based primary care, comprising GPs, nurses, midwives, physiotherapists, and psychologists, is the main form of practice. There are an average of four to five GPs in a primary care practice.
District nurses, employed by municipalities, coordinate care for patients with chronic illness or complex needs, especially the elderly; they have limited prescribing authority. These nurses also participate in home care and regularly make home visits.
All provider fees at all levels of care are set by regions. Providers cannot bill above the fee schedule.
Primary care centers (public and private) are paid through a combination of payments:
- Fixed capitation for registered individuals (accounting for 60%–95% of total payment)
- Fee-for-service (accounting for 5%–38% of payment)
- Performance-related bonuses (0%–3% of payments) for achieving quality targets related to patient satisfaction, care coordination, compliance with evidence-based guidelines, and other metrics.
Public and private physicians (including GPs and hospital specialists), nurses, and other categories of health care staff at all levels of care are predominantly salaried employees. Primary care physicians in the centers are paid a salary, determined at the regional level or by private providers. There is a general shortage of physicians in primary care, especially in more remote locations. This leads to higher salaries in such areas to attract physicians.
While there is no formal gatekeeping function, general practitioners (GPs) or district nurses are usually the first point of contact for patients. People can choose to register with any public or private provider accredited by the local region; most individuals register with a practice instead of with a physician. Registration is not required to visit a practice. In primary care, there is competition among providers (public and private) to register patients, although providers cannot compete through pricing because the regions set fees.
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.
Outpatient specialist care: Outpatient specialist care is provided at university and regional hospitals and in private clinics. In both cases, specialists are salaried employees (of hospitals and clinics). Patients are free to choose a specialist.
Public and private specialists are paid through a combination of global budgets and per-case payments based on diagnosis-related groups (DRGs), which are determined at the regional level. Price or volume ceilings and quality-related bonuses may also apply.
The average monthly salary for a physician specialist (including general medicine specialists working in primary care) was SEK 77,900 (USD 8,532) in 2018.10 Regions set fee schedules, while salaries are determined by the regions and by private clinics in their role as employers.
Administrative mechanisms for direct patient payments to providers: Patients normally pay out-of-pocket fees up front for primary care and other outpatient visits, including specialty physician 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. Often, three to five primary care practices located close to each other collaborate to provide after-hours arrangements. Through their websites and phone services, providers advise registered patients where to go for care. Regions and regional bodies also provide information on how and where to seek care through their websites and a national phone line, with medical staff available all day to give treatment advice.
Staff providing primary care services after hours normally include GPs and nurses. The same patient copayments apply as during regular hours.
In addition, to reduce emergency care use at hospitals, urgent care centers in some areas are typically open 8 a.m. to 10 p.m.
Hospitals: There are seven university hospitals, all public, and about 70 public community hospitals owned by the regions. There are also six private hospitals, of which three are not-for-profit. Private hospitals include emergency, orthopedic, and surgery centers. All hospital staff are salaried employees.
Acute-care hospitals (seven university hospitals and two-thirds of the 70 region hospitals) provide full emergency services. Swedish counties are each grouped into six health care regions to facilitate cooperation among providers 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 ensure high quality and greater efficiency and to create opportunities for development and research.
A mix of global budgets, DRGs, and/or performance-based methods is used to reimburse hospitals. The use of global budgets, set by regions, is most common. When DRGs are used, they constitute less than half of total payments. Performance-based payments related to meeting quality targets constitute less than 5 percent of total payments. 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. Specialized inpatient and outpatient psychiatric care, including that related to substance use disorders, is available to adults, children, and adolescents.
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.
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 (financed through taxation). However, the regions are responsible for patients’ routine health care. Older adults and disabled people incur a separate maximum copayment for services commissioned by the municipalities, which was SEK 1,772 (USD 194) 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, such as home care aids, home care, and meal deliveries. Eligibility for services and assistance is based on need, which is determined by care managers from the municipality together with the client and often a relative. Means-testing does not play a role.
End-of-life care is also included, 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 regions and the municipalities manage palliative care. The organization and quality of palliative care vary widely both between and within regions. 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 24 percent of all nursing home and 18 percent of all home care was privately provided in 2017,11 although the percentage varies significantly among municipalities. Payment to private providers is usually contract-based, following a public tendering process.
In general, Sweden aims to have individuals stay in ordinary housing rather than in nursing homes. 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). Among adults with long-term care needs in 2017, 72 percent had their needs met through home care and 28 percent in institutions.12
Physician education and workforce: Medical training takes place in public universities in a six-year program. After receiving the federal medical diploma, graduates enter the specialist training phase. The title of “specialist” is one of the conditions for practicing medicine in an independent medical practice.
Although increasing the national capacity for the training of health workers is a high priority of the Health2020 strategy,10 entry restrictions may apply at certain universities. Training requirements are determined at the federal level. Tuition fees vary by the university chosen and range between CHF 1,000 (USD 826) and CHF 1,700 (USD 1,405) for Swiss students. Some cantons offer scholarships to help cover tuition fees.
The responsibility for ensuring an adequate supply of medical providers lies with the cantons.
Primary care: Registering with a GP is not required, and most people generally have free choice among self-employed, private GPs, except those enrolled in managed-care plans. In 2017, 42.9 percent of doctors in the outpatient sector were classified as GPs (including pediatricians). While 53.7 percent of physicians (GPs and specialists) were in solo practice, the remainder were in practices with an average of 4.2 physicians.11 The median number of patients per GP practice was 1,779 in 2015.12
Primary (and specialist) care tends to be physician-centered, with nurses and other health professionals playing a relatively small role. Regional medical networks with shared resources and coordination between all stakeholders are becoming more common.
There are no specific financial incentives for GPs to take care of chronically ill patients, and no concrete reform efforts are under way to engage GPs in bundled payments for patients with a chronic illness, such as diabetes. Apart from some managed-care plans in which physician groups are paid through capitation, most GPs are paid according to a national fee-for-service scale, called TARMED, which was introduced in 2004. TARMED fees are negotiated annually between the health insurers’ associations and cantonal provider associations or may be set by cantonal government if the parties cannot agree. Billing above the fee schedule is not permitted.
The median income of primary care doctors was CHF 236,885 (USD 195,772) for independent physicians and CHF 155,752 (USD 128,721) for employed physicians in 2014; these were lower than the average median income of all specialists.13
Outpatient specialist care: In the outpatient sector, 57.1 percent of doctors in private practices were classified as specialists in 2017; they are mostly self-employed.14 Residents have free access (without referral) to specialists unless enrolled in a managed-care plan with gatekeeping.
Like GPs, specialists are paid fee for service in accordance with TARMED and cannot bill above the fee schedule. There are also no incentive payments for specialists.
Specialist practices tend to be concentrated in urban areas and within proximity of acute-care hospitals. The Swiss system allows specialists to see patients with private insurance as well as mandatory insurance.
Administrative mechanisms for direct patient payments to providers: Mandatory health insurance allows different methods of payment: Providers can invoice the patient, who makes the initial payment and claims reimbursement from the insurer retrospectively. Alternatively, providers can bill the insurer directly for the entire sum. The insurer then bills the patient for any coinsurance or copayments owed.
After-hours care: The cantons are responsible for after-hours care. They delegate the services (with fees set by TARMED) to cantonal doctors’ associations, which organize urgent-care networks in collaboration with their affiliated doctors. Swiss physicians are not statutorily required to provide after-hours care through these networks.
The networks can include ambulance and rescue services, hospital emergency services, walk-in clinics (hospital-based or stand-alone), and telephone advice lines that are run or contracted by insurers. These services are mostly available 24/7. Staffing patterns and the use of nurse triage in these networks vary between localities.
There are no formal processes for the exchange of information between these services and GPs’ offices, as people are not required to register.
Hospitals: In 2016, there were 283 hospitals (102 general and 181 specialty hospitals), with a total of 38,058 beds.15 Hospitals are publicly or privately owned. Hospital care represented one-third (35.3%) of total health expenditures in 2016.
Hospitals receive at least 55 percent of their funding from cantons.16,17 The rest is covered by mandatory health insurance and by coinsurance and copayments from patients. Services covered by mandatory health insurance are billed through the national diagnosis-related group (DRG) payment system. There are no pay-for-performance initiatives.
The cantons are responsible for hospital planning and are legally bound to coordinate plans with other cantons. Since 2012, patients have been free to obtain care in any canton. Remuneration mechanisms depend on insurance contracts; consequently, fee-for-service for inpatient services not covered under mandatory health insurance 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: Care for mental illnesses is covered by mandatory health insurance if provided by certified physicians, including psychiatrists. The services of nonphysician professionals, such as psychotherapy provided by psychologists, are covered only if prescribed by a qualified medical doctor and provided in his or her practice.
Psychiatric hospitals normally provide a full range of services, such as psychiatric diagnostics and treatment, psychotherapy, pharmaceutical treatment, and forensic services. Clinics are most commonly specialized in specific conditions.
There is also a wide range of socio-psychiatric facilities and day care institutions that are run and funded mainly by the cantons. Often, the socio-psychiatric facilities and day care institutions offer the same services as the clinics, but normally treat patients with less-acute symptoms.
Psychiatric care is not systematically integrated into primary care. Some GPs provide mental health services.
Long-term care and social supports: Some long-term care services are covered under mandatory health insurance. Inpatient care is provided in nursing homes and institutions for disabled and chronically ill persons. Patients receive outpatient home care through specialized organizations.
Coverage for palliative care provided in hospitals, in nursing homes, in hospices, or at home is similar to coverage for acute services in these provider settings. Hospice care is covered as long as there is an underlying disease.
There is no provision of individual or personal budgets for patients to organize their own services, nor is there financial support at the national level for informal hired help or family caregivers.
For services in nursing homes and institutions for disabled and chronically ill persons, mandatory health insurance pays a contribution to cover care-related, medically necessary costs; the patient pays at most 20 percent of care-related costs, and the remaining care-related costs are financed by the canton or the municipality.
Long-term inpatient care costs represented 16.1 percent of total health expenditures in 2016. Thirty-six percent of these costs were paid by private households, 24 percent by government subsidies, 22 percent by old-age and disability benefits, and 18 percent by mandatory health insurance and other social insurances.
Of the 1,570 nursing homes in operation in 2016, 27.5 percent were state-operated and state-funded, 27.5 percent were privately operated with public subsidies, and 45 percent were exclusively private.18 In 2016, 56 of every 1,000 people over age 65 were in nursing homes.
Home care providers (Spitex) represented 1.7 percent of total health expenditures in 2016. More than half (57.8%) of these costs are financed by mandatory health insurance and the other social insurances. The insurers limit their contributions to medically necessary health care at home. Government subsidies made up roughly one-third of total Spitex spending (29.4%). The rest (12.8%), devoted mainly to support and household services, was typically paid out-of-pocket or covered by old-age and disability benefits, by voluntary health insurance, or by other private funds.19 In 2016, 31 percent of Spitex providers were subsidized nonprofit organizations, 20 percent were nonsubsidized for-profit companies, and 49 percent were individual health care workers.20
Physician education and workforce: Taiwan's government limits medical school admissions to 1,300 per year. There are both public and private medical schools. In 2018, tuition and fees at public medical schools were approximately TWD 36,170 (USD 1,194) per semester. Private tuition and fees were TWD 72,269 (USD 2,385) per semester.17
Two types of government-sponsored medical education programs help ensure a supply of medical providers in traditionally underserved areas. In the first type, the government may specify what residency-training specialties graduates need to pursue, as well as the location or hospital they need to practice in for two to four years. In the second type, high school graduates from Taiwan's aboriginal communities and offshore islands are admitted, through preferential affirmative action, into either public or private medical schools where they can choose their residency-training specialty but must return to their tribes or offshore islands to practice for six to seven years after graduation.
Physician care: Approximately 40 percent of Taiwan’s physicians practice in their own private clinics. The rest work in hospitals as employees. Eighty percent to 90 percent of clinics are solo practices; the remainder are group practices, which may include multiple specialties.18 In recent years, there has been a trend toward multispecialty group practices.
There is no gatekeeping system in Taiwan. Patients can choose to see any doctor at any time (family medicine or specialist), with no requirement to register with a primary care physician.
When doctors deem it necessary or expedient to refer patients to a higher level of care or another provider (usually a regional hospital or medical center), the patient will pay a lower copayment for that visit. This referral policy is intended to encourage patients with minor illnesses to seek care at local clinics, reducing waste and overcrowding at large hospitals and medical centers and ensuring that patients who truly need tertiary services can access them.
Physicians in Taiwan fall into six specialties: internal medicine, surgery, pediatrics, obstetrics/gynecology, emergency medicine, and “other.” All physicians who practice in clinics are considered primary care doctors in Taiwan. However, only about 5 percent of all clinic doctors have received formal training in primary care.19
Nearly all private clinics (98%) contract with the NHIA to deliver services. Physicians are paid predominantly on a fee-for-service basis, according to national uniform fee schedules set by the NHIA with input from industry stakeholders. A primary care global budget is divided among and managed by the six NHIA regional offices. To maximize revenue, the clinics within each region compete fiercely for patients.
To date, clinic physicians’ financial incentives to change their behavior are relatively limited.On average, less than 1 percent of physician income is derived from capitation or pay-for-performance programs.20 (See “What are the major strategies to ensure quality of care?” below for more on pay-for-performance.)
Other sources of physician income are patient registration fees, services and goods not covered by NHI, and copayments and coinsurance. Physicians, including both family doctors and specialists in private practice, receive the same fees. Fees for psychiatry and emergency medicine are higher.21
Billing above the fee schedule is not permitted, except for a limited number of medical devices. In 2018, these devices included drug-eluting and bioactive coronary stents, ceramic hip joints, and intraocular lens implants.
Hospital-based physicians in all specialties, in both private and public facilities, also see patients on an outpatient basis. As hospital employees, they are paid a salary and bonuses pegged to productivity, such as volume of services delivered or papers published.
There is no specific fee schedule for ancillary medical professionals; most are paid a monthly salary plus a seasonal or annual bonus.22
Administrative mechanisms for direct patient payments to providers: Patients pay copayments at the point of service for physician visits, and pay coinsurance upon hospital discharge. In addition to copayments and coinsurance, clinics and hospitals charge nominal patient registration fees.
After-hours care: There are no formal after-hours care provisions. Although the hospital association and the NHIA have an agreement to provide telephone consultations after hours, the future of the arrangement is uncertain, as physician associations mandate that doctors must rest on weekends.23
Lack of widespread after-hours care is not viewed as a serious problem in Taiwan. Many physician clinics are open until 9:00 p.m. during the week and on Saturdays. Outside these hours, patients may visit one of Taiwan’s more than 400 hospital emergency departments, where access is generally considered convenient and affordable.24 In recent years, however, emergency departments have experienced increasing traffic.
Between 10:00 p.m. and 6:00 a.m., fees for emergency room visits are 50 percent higher than fees charged during the daytime; fees for weekend and holiday visits are 20 percent higher.25
Hospitals: Taiwan has both public and private hospitals. By law, private hospitals are nonprofit. As of 2016, 67 percent of all beds are private.26
Hospitals in Taiwan derive revenues from a global hospital budget set by the NHIA; this system differs from those of many other countries, in which hospitals receive hospital-specific budgets. The global hospital budget is divided into six regional budgets, each administered by one of six NHIA regional offices. Under this arrangement, competition for revenues is intense among hospitals within each region. Hospital business strategies include mergers, to expand market share, and direct-to-consumer advertising.
Hospitals are paid fee-for-service according to uniform national fee schedules and diagnosis-related groups (DRGs) set by the NHIA with input from stakeholders. As of 2016, there were 401 DRGs, accounting for 22 percent of all hospital payments. Uptake of DRGs has been slow, owing to provider resistance.
Hospitals also derive revenues from direct payments for non-NHI-covered services and goods, copayments for outpatient services and coinsurance for inpatient services, and registration fees collected at the time of service.
Mental health care: NHI covers mental health services on an outpatient basis (including day care), and on an inpatient basis for both acute and chronic mental health problems. Over the past 15 years, Taiwan has been increasing its mental health bed capacity to alleviate a shortage in the supply of such beds.
All copayments associated with chronic mental health care are waived.27
Long-term care and social supports: As of 2017, 14 percent of Taiwan's population was aged 65 or older. In response to Taiwan's rapidly growing elderly population, the government has implemented a long-term care policy that seeks to integrate medical care, long-term care, prevention, and health maintenance to facilitate aging in place, healthy aging, and active aging.
In October 2016, the government began a trial implementation of its 10-Year Long Term Care Plan 2.0. A new service delivery system is being developed to provide services through a three-tiered, community-based network:
- Level A agencies, or community-based service centers, are responsible for preparing care plans for individuals with cognitive impairments.
- Level B agencies are connected to Level A agencies and are responsible for delivering long-term care services.
- Level C agencies, or neighborhood long-term care stations, are connected to Level B agencies and are responsible for providing preventive and disability delay services.
Communities may elect to implement either an A-B-C network model or a B-C network model of delivery.
Both public and private hospitals and medical centers participate in the three-tier long-term care service delivery.
Services covered include home care, day care, transportation, meals, purchase and rental of equipment, home accident-proofing, home nursing care, home and community rehabilitation services, respite care, caregiver support services, and training to prevent or delay the onset of disabilities (e.g., swallowing and muscle strength training).
Enrollment in long-term care coverage is mandatory starting at birth. Financing currently relies on three sources: government, employers, and out-of-pocket payments by users of services. For low-income families, the government subsidizes 100 percent of long-term care costs.
As of June 2019, long-term care remains a work in progress in Taiwan.
Physician education and workforce: Most medical schools (59%) are public. Median tuition fees in 2019 were $39,153 in public medical schools and $62,529 in private schools. Most students (73%) graduate with medical debt averaging $200,000 (2019), an amount that includes pre-medical education.21 Several federal debt-reduction, loan-forgiveness, and scholarship programs are offered; many target trainees for placement in underserved regions. Providers practicing in designated Health Professional Shortage Areas are eligible for a Medicare physician bonus payment.
Primary care: Roughly one-third of all professionally active doctors are primary care physicians, a category that encompasses specialists in family medicine, general practice, internal medicine, pediatrics, and, according to some, geriatrics. Approximately half of primary care doctors were in physician-owned practices in 2018; more commonly, these are general internists rather than family practitioners.22
Primary care physicians are paid through a combination of methods, including negotiated fees (private insurance), capitation (private insurance and some public insurance), and administratively set fees (public insurance). The majority (66%) of primary care practice revenues come from fee-for-service payments.23 Since 2012, Medicare has been experimenting with alternative payment models for primary care and specialist providers.
Outpatient specialist care: Specialists can work both in private practices and in hospitals. Specialist practices are increasingly integrating with hospital systems, as well as consolidating with each other. The majority of specialists are in group practices, most often in single-specialty group practices.24
Outpatient specialists are free to choose which form of insurance they will accept. For example, not all specialists accept publicly insured patients, because of the relatively lower reimbursement rates set by Medicaid and Medicare. Access to specialists for beneficiaries of these programs—not to mention for people without any insurance—can therefore be particularly limited.
Administrative mechanisms for direct patient payments to providers: Copayments for doctor visits are typically paid at the time of service or 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. There are thousands of codes, making this process time-consuming; providers typically hire coding and billing staff.
Because of administrative hurdles, a small number of providers do not accept any insurance. Instead, they accept only cash payments or require annual or monthly retainer payments to the providers for “concierge medicine,” which offers enhanced access to services.
After-hours care: Primary care physicians are not required to provide or plan for after-hours access for their registered patients. However, in 2019, 45 percent of primary care doctors had after-hours arrangements: 38 percent of these provide care in the evenings and 41 percent on the weekends.25
After-hours care is increasingly provided through walk-in appointments at private urgent-care centers or retail clinics that typically serve younger, healthier individuals who require episodic care and may not have a primary care provider.26
Hospitals: In 2018, 57 percent of the 5,198 short-term acute care hospitals in the U.S. were nonprofit; 25 percent were for-profit; and 19 percent were public (state or local government–owned).27 In addition, there were 209 federal government hospitals.
Hospitals are free to choose which insurance they accept; most accept Medicare and Medicaid. Hospitals are paid through a combination of methods.
Medicare pays hospitals through prospective diagnosis-related group (DRG) rates, which do not include physician payments.
Medicaid pays hospitals on a DRG, per diem, or cost-reimbursement basis,28 and states have considerable discretion in setting hospital payment rates.
Private insurers pay hospitals usually on a per diem basis, typically negotiated between each hospital and its insurers on an annual basis.
Mental health care: Services are provided by both generalists and specialists—including primary care physicians, psychiatrists, psychologists, social workers, and nurses—with the majority delivered in an outpatient setting. Providers are mostly private (nonprofit and for-profit), with some public providers, including public mental health hospitals, Veterans Affairs providers, and federally qualified health centers.
The federal Substance Abuse and Mental Health Services Administration provides states with grants, including Mental Health Block Grants, that fund community mental health services. State and local governments provide additional funding.
The ACA mandated that marketplace insurers provide coverage of mental health and substance use conditions as an essential health benefit. The law also requires all private insurers, including employer-sponsored plans, to provide the same level of benefits for mental and physical health conditions.
Some individuals with serious, long-term mental illnesses qualify for Medicare before age 65. Otherwise, Medicaid is the single largest source of funding for mental health services in the country.29 Many employer-sponsored plans and some state Medicaid programs provide benefits through carve-out contracts with managed behavioral health care organizations.30
Long-term care and social supports: There is no universal coverage for long-term care services. Public spending represents approximately 70 percent of total spending on long-term care services, with Medicaid accounting for the majority.31 Medicare and most employer-sponsored plans cover only post–acute care services following hospitalization, including hospice, short-term nursing services, and short-term nursing home stays (up to 100 days following acute hospitalization).
Private long-term care insurance is available but rarely purchased; private insurance represented only 7.5 percent of total long-term care spending in 2016.
The ACA originally included the Community Living Assistance Services and Supports Act, which would have created a universal, voluntary, public long-term care insurance option for employed persons. However, the program was deemed unworkable and was repealed in 2013.