You are a program officer for a major health care foundation that wants to revitalize primary care in the United States. You have been asked to look at the experiences of other countries to see whether the methods and ideas they have used to promote primary care might have application in this country. Here is some of the information you have found about Spain and Switzerland:
Spain’s 1978 Constitution declared health protection and health care to be the right of every citizen and required creation of a “universal, general, and free national health system that guaranteed equal access to preventive, curative, and rehabilitative services.” (Borkan, Eaton, Novillo-Ortiz, Corte, & Jadad, 2010, p. 1433)
Compared to the United States, by 2006, Spain had widened the gap in terms of greater life expectancy and lower infant mortality rates, and it had achieved or maintained lower rates of premature death for most major diseases, at an annual cost of less than $2,700 per person, compared to the U.S. per-capita rate of almost $7,300.
Spain’s rapid accomplishment relied on eight key principles: (a) greatly strengthened primary care; (b) giving citizens a voice in decisions; (c) adopting electronic health records; (d) creating an accessible network of community pharmacies (with medications free to people older than 65 years of age and some other groups); (e) regional and local flexibility in implementing national policy; (f) wide adoption of best practices; (g) a system wide approach that “transcend(s) traditional geographic, sector, and institutional boundaries”; and (h) a sustained, bipartisan commitment to achieving the goals of access and quality. (Borkan, Eaton, Novillo-Ortiz, Corte, & Jadad, 2010, p. 1438)
The system is funded through tax dollars. To ensure that every citizen has services nearby, the country’s 17 autonomous regions and communities are further broken down into health areas, which manage facilities, health services, and benefits for people in a prescribed geographic area, and even further, into “basic health zones” typically organized around a single primary care team and covering 5,000–25,000 residents.
In 1996, Switzerland restructured its health system in order “to turn the existing system of private voluntary health insurance into . . . a mandatory private social health insurance system.” (Cheng, 2010, p. 1442) Today, 84 highly regulated private health insurers, which offer basic benefits packages and supplemental coverage, compete for enrollees. Swiss citizens are required to have the basic package, and those who cannot afford it may receive a premium subsidy from the government, but the government itself does not offer an insurance plan. Private insurers are not allowed to earn profits on the basic packages they offer, only on supplemental coverage.
Health care providers receive the same reimbursement for basic benefits, regardless of the income level of their patients or whether they are subsidized. Basic benefits cover (a) what a doctor prescribes, (b) pharmaceuticals included in the national formulary, and (c) controversial procedures included on a “positive list” by the national health authority. “Negative lists” contain items excluded from basic benefits.
In the future, Switzerland wants to abandon its fee-for-service system for ambulatory care and move to “integrated care,” probably paid for on a capitated basis. Another step needed is to overcome the shortage of primary care physicians, who have long working hours and lower pay than specialists. Still, system leaders have managed to convince the citizenry that health promotion and disease prevention—pillars of primary care—are important parts of a complete health care system. However, says Thomas Zeltner, Switzerland’s former health minister, health reform is “a never-ending task.” (Cheng, 2010, p. 1450)
Using the aforementioned brief country descriptions and the other material about inter-national experiences in this chapter:
1. What are alternative ways to use system wide incentives to encourage delivery of high-quality, prevention-oriented primary care?
2. How might Americans be reoriented to using primary care, rather than costlier specialty services?
3. How does the design of the payment system affect individuals’ choice of provider?
4. What appear to be the best ideas from other nations’ experiences that could be tested in the United States as ways to increase primary care?
5. If Thomas Zeltner is correct that health reform efforts are never-ending, which of these promising ideas should be the top priority, or tried first?
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