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Heart Care in U.S., Britain, Canada, and Germany    added 3/10/01

pages 251-257 of Health Care Policy, by David Calkins of Harvard Medical School and many contributors 1995

In this section, we shift to the micromanagement level and follow John Smith through the health care systems of the U.S., Britain, Canada, and Germany to see what each system is like from the perspective of the patient. We have given Mr. Smith heart disease because it is prevalent in all four countries.

The U.S. health care system is a pluralistic system with wide variations in coverage depending on your ability to pay for insurance or your membership in a group, such as the elderly, poor, or veterans. Due to the wide variation in coverage, we have chosen two scenarios for Mr. Smith. Mr. Smith is a middle-income person with insurance provided by his employer.

Mr. Smith is a 55 year-old man who is covered by insurance provided by his employer. Mr. Smith has both hospital coverage and physician coverage. When Mr. Smith consumes health services, the providers submit documentation to his insurer For reimbursement.

Mr. Smith has a one-year history of exertional angina, which has been followed by his primary care physician and his cardiologist. Mr. Smith chose his physician and cardiologist. Mr. Smith pays a $50 deductible and 10% of the fee amount to see his internist or cardiologist. In the U.S., the deductible and the percentage of the fee that the patient is responsible for varies from plan to plan, depending on its comprehensiveness. The internist, in conjunction with the cardiologist, prescribed a beta-blocker b.i.d. and sublingual trinitroglycerine p.r.n. for episodes of chest pain. Mr. Smith does have pharmaceutical coverage included in his insurance; therefore, he does not bear the brunt of the high cost of his drugs each month.

When unstable angina developed, a coronary angiogram was performed without delay. Unlike other countries, he did not have to be put on a waiting list. Pending the results of the coronary angiogram, Mr. Smith, if needed, would be scheduled for a coronary artery bypass graft (CABG) operation. Mr. Smith would not have to be put on a list for a CABG. The majority of the cost for both these procedures would be paid for by his insurer, although Mr. Smith would have to I pay a $500 deductible for the first 60 days of care in the hospital. Mr. Smith's cardiologist and cardiac surgeon would be paid by the insurer based on the negotiated fee-for-service schedule the insurer has with the physician. Mr. Smith's hospital care would be paid for by his insurer through a prospective payment. If services to Mr. Smith cost more than the prospective payment the hospital has received for his care, the hospital loses money.

Mr. Smith is a 55 year-old man who is cared for by the NHS. Mr. Smith does not pay for anything other than his private insurance for use of a private or semiprivate bed in an NHS hospital.

Mr. Smith has a one-year history of exertional angina, which has followed by his GP and a cardiologist that his GP chose and referred him to. Mr. Smith freely chose his GP, and he has had the same GP for 20 years. Mr. Smith does not pay a fee, a copayment, or a deductible to see his GP, who receives a capitated fee from the district FPC with which the GP has contracted. Mr. Smith does not pay a fee, a copayment, or a deductible to see his cardiologist, who is salaried by the hospital where he practices. The GP prescribed a beta-blocker b.i.d. and sublingual trinitroglycerine p.r.n. for episodes of chest pain. Mr. Smith pays a small amount for his medication because they are heavily subsidized by the government.

Mr. Smith has been on a list for a coronary angiogram for approximately nine months. According to NHS rules, Mr. Smith is not eligible for a CABG operation because of his age, and Mr. Smith is a retired laborer who does not have enough money to pay for it himself. It is hoped that a balloon angioplasty will be able to ameliorate his angina, but once he has his coronary artery angiogram, he will need to go on another list for balloon angioplasty. While he is waiting, there is a substantial risk that he could have a fatal or a further debilitating heart attack.

Mr. Smith is a 55 year-old man who is covered by his provincial Medicare plan. To receive care, all Mr. Smith has to do is show his provincial card; he pays for nothing other than a small annual premium to the province.

Mr. Smith has a one-year history of exertional angina, which has been followed by his primary care physician and his cardiologist. Mr. Smith chose his physician and his cardiologist. Mr. Smith does not pay a fee, a copayment, or a deductible to see his internist or cardiologist. His internist and cardiologist receive a capitated fee from the province, which is the sole insurer in the province. The internist, in conjunction with the cardiologist, prescribed a beta-blocker b.i.d. and sublingual trinitroglycerine p.r.n. for episodes of chest pain. Mr. Smith pays a small amount for his medication because they are heavily subsidized by the government.

When unstable angina develops, Mr. Smith is put on a list for a coronary angiogram for approximately one week. Pending the results of the coronary angiogram, Mr. Smith might then go on either a list for balloon angioplasty or a list for a CABG operation, both of which could be as long as one month, depending on the province. An important difference between Mr. Smith's experience in Canada relative to the U.S. is that Canadian physicians practice more conservative medicine; for moderate heart disease, they would be less likely to do a coronary angiogram, balloon angioplasty, or CABG. Both procedures would be paid in full by the province. Mr. Smith's cardiologist and cardiac surgeon would be paid by the province according to the rigid fee schedule negotiated by the provincial medical association and the province.

Mr. Smith is a 55 year-old man who is covered by his local sickness fund. Both Mr. Smith and his employer each pay 6.5% of his annual salary to Mr. Smith's sickness fund (total, 13% of Mr. Smith's annual income). Mr. Smith joined his sickness fund because his profession has traditionally been a member of that particular fund and most of his fellow workers belong to the fund.

Mr. Smith has a one-year history of exertional angina, which has been followed by his primary care physician and his cardiologist, who is hospital-based. Mr. Smith chose his physician and his cardiologist. If Mr. Smith needed hospitalization, his internist would not follow him in the hospital because the division between ambulatory physicians and hospital-based physicians is distinct. Mr. Smith does not pay a fee, a copayment, or a deductible to see his internist or cardiologist. When Mr. Smith receives care, he fills out a form for the ambulatory physician or hospital that they submit to the sickness fund for payment. The hospital-based cardiologist is an employee of the hospital and is paid a flat salary. The fee that Mr. Smith's internist receives from the local sickness fund has been negotiated by the region's physicians medical association and the region's association of sickness funds. The hospital is paid by the sickness fund on a per diem basis. This per diem amount was negotiated by the region's hospital association and the region's sickness fund association.

The internist prescribed a beta-blocker b.i.d. and sublingual trinitroglycerine p.r.n. for episodes of chest pain. Mr. Smith pays a small amount for his medication because they are heavily subsidized by the government.

When unstable angina develops, Mr. Smith has a coronary angiogram performed without delay. Pending the results of the coronary angiogram, Mr. Smith might then be scheduled for a balloon angioplasty or a CABG operation. He would not be placed on a list for either procedure. Both procedures would be paid in full by Mr. Smith's sickness fund. The hospital at which Mr. Smith's cardiologist and cardiac surgeon did the procedure would be paid by the sickness fund according to the rigid per diem fee schedule negotiated by the region's hospital association and the region's association of sickness funds.