CMA AFFILIATES NEWS
American Group Practice Association hears Canadian, British, Australian views on health system MILAN KORCOK No matter where they turn for their national health insurance models, American physicians continue to hear variations on the same theme: Politics and medicine make uneasy bedfellows. As discussants from Australia, Britain, and Canada told the annual meeting of the American Group Practice Association: it doesn't matter whether the system is National Health Service, or Medibank, or Medicare, governments' inconsistencies and the public's seemingly insatiable demand for free care often leave the physician feeling like a pawn in some game beyond his control. Dr. Robert G. Wilson, CMA secietary general, told the meeting: "Provincial governments are insinuating themselves between the doctor and his patient, and while physicians strive for quality of care, politicians are striving for control of the cost of care. "As a result of this difference in attitude, the physician finds himself in the position of feeling harassed because the provincial government questions not only his treatment, but his motives and the return from his work." It was a message physicians at the conference found disconcerting even more so when they heard from Dr. George D. Repin, secretary general of the Australian Medical Association; and Robin Anson-Owen, administrator of the Buckinghamshire Health Authority in England. "Changes in health insurance arrangements, and shifting the burden
of cost back and forth between government and the public and private health insurance funds, have been made with such frequency in Australia throughout the 1 970s as to leave the public confused and bewildered," said Dr. Repin. "The effect . . . on the medical profession has been considerable." (See following article for detailed report on Dr. Repin's presentation.) Said Anson-Owen: "There is much to be applauded in Britain's health system (but) I am not advocating it, because I think it is overindulgent and I think the welfare state has been overplayed. The traditional stoicism of the Christian Victorian era was perhaps too extreme, but the growing self-indulgence of the 1 970s is educating the population to expect unrealistic levels of wellbeing without paying for it." Different systems It was clear throughout the discussions that the various health systems in the three nations were vastly different, yet there were common problems, and most converged about one issue - costs. In Canada, as noted by Dr. Wilson, health-care spending as a percentage of the gross national product (GNP) is less than in the United States, Sweden and West Germany. But federal and provincial governments continue to keep on the pressure for further reductions. Much of this pressure is aimed at physicians, said Wilson, even though the percentage of GNP spent on physicians' services has declined over
the past decade and even though the major cost spirals are attributable primarily to the spending of hospitals. In 1974, said Dr. Wilson, Canada had a 6.6 bed-per-thousand ratio, of which 5.5 were in general hospitals. In the United States there is now a 4.7 total bed-per-thousand ratio, of which 4.4 are in community hospitals. He noted the strong move across the country to expand chronic and long-term care facilities and to develop more ambulatory-care units and home-care services. This could certainly offer economic benefits, he said. But at the same time the average Canadian citizen still seems to consider anything short of the acute-care hospital bed as second-class care. As was also emphasized by speakers from other countries, there is an inherent problem in any health-insurance program if its beneficiaries perceive it as free. This has been well demonstrated in Canada, as it has been in Australia and Britain. "Patients tend to lose sight of the cost of care and look upon it as a free service," said Wilson. Yet if anyone suggests patient participation in the costs of care "it is considered politically unsalable and... a tax upon the poor." The result, said Dr. Wilson, "is that utilization tends to creep up reP-ardless of how one educates one's
patients." As at least a partial response to this phenomenon, Dr. Wilson urged physicians in the medical-school sys-
CMA JOURNAL/DECEMBER 23, 1978/VOL. 119 1453
tem to stress the economics of health care among students - "Medical schools may have been delinquent in their lack of instruction of economic reality. "All of us have witnessed the problems related to the new graduate who wildly over-investigates his patient, because of legal pressures and the defensive and academic pressure
of teaching hospitals." Added Wilson pointedly: "Doctors do ignore the cost-effectiveness of what they do and when their judgement is questioned they defend themselves very ably." Relatively good funding Wilson's comments indicated that despite federal and provincial governments' claims that health care costs in Canada were exorbitant, this country has been doing relatively well in comparison to many other nations who would be quite satisfied with Canada's 7% of GNP that goes to health care. Ironically, the British spend even less than Canada, ap-
proximately 5.7% of GNP on health care, yet that system, according to Dr. Wilson, "appears to be strangulating because of the inability to introduce new money into the system." Anson-Owen, who admits that the British health service often gives signs of staggering and continues to be plagued by internal conflict, contends that it will be maintained: "Because the man in the street thinks highly of it" and despite its imperfections, "it is manifestly superior to what went on before." But the service is under strain, he adds. It needs more money each year simply to provide the same service for the ageing. In 1951 there were just over 41/2 million people 65 and over in Britain, now there are more than 6½/2 million. "There is widespread feeling in Britain that more funds would improve services, and there is no doubt that this is true, but where is the end of the seemingly inexorable rise in health spending?" In outlining Britain's growing cost-
squeeze, Anson-Owen reflected perfectly the dilemma of most other nations caught in a spiral of technological advance. "In Britain, as elsewhere, there is no sign that health needs, and the resources available for them, will ever come into balance. Needs rise with the average age of the population; demands increase as a result of those needs, medical advances and higher expectations of the public." Warning Anson-Owen warned his audience that whatever health insurance system is adopted in the US, demand will never be contained. "Rationing is inevitable," said Anson-Owen. "If it is not by price, it will have to be by some less-satisfactory method such as the rules, technical devices, forced medical judgements and political decisions we endure in Britain. "Would it not be prudent for you to make some changes, to give a little, before government takes all?"
Australian health insurance an off-and*on system So long as Australians keep changing governments, they are bound to remain mystified about what kind of health insurance system they really have. That was the message in a speech delivered to the American Group Practice Association by Dr. George D. Repin, secretary general of the Australian Medical Associa-
tioni. Repin told the audience the public has been left confused and bewildered by the relentless shifting of fiscal responlsibility back and forth between government and the public and private insurance funds. Adding to that confusion is the additional change of scheme effective Nov. 1. But to clarify where Australians stand now it is necessary to find out where they stood some months, even years ago. Dr. Repin explained that in 1975 the Labour government instituted its Medibank system covering the entire population without individual contributions. It was financed directly
from taxation. Under that scheme Medibank paid
medical benefits at 85 % of the scheduled fee, with the patient responsible for up to $5 payment per service to the doctor. If the doctor charged more than the scheduled fee, the patient's payment was that much more than $5. (These figures are in Australian dollars.) Medibank also offered entirely free hospital accommodation and treatment in a standard ward. Physicians were paid by the hospital on a salaried, sessional or modified-fee basis. Under the free hospital program patients could not choose which doctor would treat them in hospital. There were, however, private insurance optiolns over and above to allow for intermediate or private-ward accommodation and doctor selection. New government's changes
Soon after the introduction of this program, the Labour government was ousted by the Liberal Country Party (conservative) and further changes were made to Medibank, the major
1454 CMA JOURNAL/DECEMBER 23, 1978/VOL. 119
one being a health insurance levy of 2.5% of taxable income to help pay for Medibank. People were allowed to opt out of the levy if they could prove they were covered by an adequate alternative health insurance plan. More than half the population chose to opt out, said Dr. Repin. And at present, nearly 66% of Australians are covered for preferred hospital accommodation providing choice of doctor. But now, smarting under increased financial pressures, the government has decided to let the Treasury Department manipulate insurance rather than leave it to the Department of Health, and as of Nov. 1, this is what the new system looks like. The Medibank levy has been abolished - Medibank itself is being largely dismantled - and government will once again start paying out of general revenues. But coverage has
been sharply altered: * Free accommodation in hospital and treatment in a standard ward to anyone who wants it but without choice of doctor.
American Group Practice Association hears Canadian, British, Australian views on health system MILAN KORCOK No matter where they turn for their national health insurance models, American physicians continue to hear variations on the same theme: Politics and medicine make uneasy bedfellows. As discussants from Australia, Britain, and Canada told the annual meeting of the American Group Practice Association: it doesn't matter whether the system is National Health Service, or Medibank, or Medicare, governments' inconsistencies and the public's seemingly insatiable demand for free care often leave the physician feeling like a pawn in some game beyond his control. Dr. Robert G. Wilson, CMA secietary general, told the meeting: "Provincial governments are insinuating themselves between the doctor and his patient, and while physicians strive for quality of care, politicians are striving for control of the cost of care. "As a result of this difference in attitude, the physician finds himself in the position of feeling harassed because the provincial government questions not only his treatment, but his motives and the return from his work." It was a message physicians at the conference found disconcerting even more so when they heard from Dr. George D. Repin, secretary general of the Australian Medical Association; and Robin Anson-Owen, administrator of the Buckinghamshire Health Authority in England. "Changes in health insurance arrangements, and shifting the burden
of cost back and forth between government and the public and private health insurance funds, have been made with such frequency in Australia throughout the 1 970s as to leave the public confused and bewildered," said Dr. Repin. "The effect . . . on the medical profession has been considerable." (See following article for detailed report on Dr. Repin's presentation.) Said Anson-Owen: "There is much to be applauded in Britain's health system (but) I am not advocating it, because I think it is overindulgent and I think the welfare state has been overplayed. The traditional stoicism of the Christian Victorian era was perhaps too extreme, but the growing self-indulgence of the 1 970s is educating the population to expect unrealistic levels of wellbeing without paying for it." Different systems It was clear throughout the discussions that the various health systems in the three nations were vastly different, yet there were common problems, and most converged about one issue - costs. In Canada, as noted by Dr. Wilson, health-care spending as a percentage of the gross national product (GNP) is less than in the United States, Sweden and West Germany. But federal and provincial governments continue to keep on the pressure for further reductions. Much of this pressure is aimed at physicians, said Wilson, even though the percentage of GNP spent on physicians' services has declined over
the past decade and even though the major cost spirals are attributable primarily to the spending of hospitals. In 1974, said Dr. Wilson, Canada had a 6.6 bed-per-thousand ratio, of which 5.5 were in general hospitals. In the United States there is now a 4.7 total bed-per-thousand ratio, of which 4.4 are in community hospitals. He noted the strong move across the country to expand chronic and long-term care facilities and to develop more ambulatory-care units and home-care services. This could certainly offer economic benefits, he said. But at the same time the average Canadian citizen still seems to consider anything short of the acute-care hospital bed as second-class care. As was also emphasized by speakers from other countries, there is an inherent problem in any health-insurance program if its beneficiaries perceive it as free. This has been well demonstrated in Canada, as it has been in Australia and Britain. "Patients tend to lose sight of the cost of care and look upon it as a free service," said Wilson. Yet if anyone suggests patient participation in the costs of care "it is considered politically unsalable and... a tax upon the poor." The result, said Dr. Wilson, "is that utilization tends to creep up reP-ardless of how one educates one's
patients." As at least a partial response to this phenomenon, Dr. Wilson urged physicians in the medical-school sys-
CMA JOURNAL/DECEMBER 23, 1978/VOL. 119 1453
tem to stress the economics of health care among students - "Medical schools may have been delinquent in their lack of instruction of economic reality. "All of us have witnessed the problems related to the new graduate who wildly over-investigates his patient, because of legal pressures and the defensive and academic pressure
of teaching hospitals." Added Wilson pointedly: "Doctors do ignore the cost-effectiveness of what they do and when their judgement is questioned they defend themselves very ably." Relatively good funding Wilson's comments indicated that despite federal and provincial governments' claims that health care costs in Canada were exorbitant, this country has been doing relatively well in comparison to many other nations who would be quite satisfied with Canada's 7% of GNP that goes to health care. Ironically, the British spend even less than Canada, ap-
proximately 5.7% of GNP on health care, yet that system, according to Dr. Wilson, "appears to be strangulating because of the inability to introduce new money into the system." Anson-Owen, who admits that the British health service often gives signs of staggering and continues to be plagued by internal conflict, contends that it will be maintained: "Because the man in the street thinks highly of it" and despite its imperfections, "it is manifestly superior to what went on before." But the service is under strain, he adds. It needs more money each year simply to provide the same service for the ageing. In 1951 there were just over 41/2 million people 65 and over in Britain, now there are more than 6½/2 million. "There is widespread feeling in Britain that more funds would improve services, and there is no doubt that this is true, but where is the end of the seemingly inexorable rise in health spending?" In outlining Britain's growing cost-
squeeze, Anson-Owen reflected perfectly the dilemma of most other nations caught in a spiral of technological advance. "In Britain, as elsewhere, there is no sign that health needs, and the resources available for them, will ever come into balance. Needs rise with the average age of the population; demands increase as a result of those needs, medical advances and higher expectations of the public." Warning Anson-Owen warned his audience that whatever health insurance system is adopted in the US, demand will never be contained. "Rationing is inevitable," said Anson-Owen. "If it is not by price, it will have to be by some less-satisfactory method such as the rules, technical devices, forced medical judgements and political decisions we endure in Britain. "Would it not be prudent for you to make some changes, to give a little, before government takes all?"
Australian health insurance an off-and*on system So long as Australians keep changing governments, they are bound to remain mystified about what kind of health insurance system they really have. That was the message in a speech delivered to the American Group Practice Association by Dr. George D. Repin, secretary general of the Australian Medical Associa-
tioni. Repin told the audience the public has been left confused and bewildered by the relentless shifting of fiscal responlsibility back and forth between government and the public and private insurance funds. Adding to that confusion is the additional change of scheme effective Nov. 1. But to clarify where Australians stand now it is necessary to find out where they stood some months, even years ago. Dr. Repin explained that in 1975 the Labour government instituted its Medibank system covering the entire population without individual contributions. It was financed directly
from taxation. Under that scheme Medibank paid
medical benefits at 85 % of the scheduled fee, with the patient responsible for up to $5 payment per service to the doctor. If the doctor charged more than the scheduled fee, the patient's payment was that much more than $5. (These figures are in Australian dollars.) Medibank also offered entirely free hospital accommodation and treatment in a standard ward. Physicians were paid by the hospital on a salaried, sessional or modified-fee basis. Under the free hospital program patients could not choose which doctor would treat them in hospital. There were, however, private insurance optiolns over and above to allow for intermediate or private-ward accommodation and doctor selection. New government's changes
Soon after the introduction of this program, the Labour government was ousted by the Liberal Country Party (conservative) and further changes were made to Medibank, the major
1454 CMA JOURNAL/DECEMBER 23, 1978/VOL. 119
one being a health insurance levy of 2.5% of taxable income to help pay for Medibank. People were allowed to opt out of the levy if they could prove they were covered by an adequate alternative health insurance plan. More than half the population chose to opt out, said Dr. Repin. And at present, nearly 66% of Australians are covered for preferred hospital accommodation providing choice of doctor. But now, smarting under increased financial pressures, the government has decided to let the Treasury Department manipulate insurance rather than leave it to the Department of Health, and as of Nov. 1, this is what the new system looks like. The Medibank levy has been abolished - Medibank itself is being largely dismantled - and government will once again start paying out of general revenues. But coverage has
been sharply altered: * Free accommodation in hospital and treatment in a standard ward to anyone who wants it but without choice of doctor.
