NUR 5290 Module 4 Global Health System Comparison Example

Same Visit, Three Countries: How the United States, Germany and Canada Finance and Ration an Outpatient Follow-Up

Student Name

Master of Science in Nursing (MSN), Thomas Edison State University

NUR-5290: U.S. Health Policy and Global Health

Mentor Name

Month Day, Year

Same Visit, Three Countries: How the United States, Germany and Canada Finance and Ration an Outpatient Follow-Up

Global comparisons in health policy courses often turn into rankings: which country has the best system. This paper avoids that by holding one thing constant, a routine follow-up visit for blood pressure in an older adult, and asking how three countries pay for it and how each limits its use. The United States, Germany and Canada were chosen because they represent three different financing models: a mixed public and private system, a statutory social insurance system and a single-payer system administered by provinces. Every health system rations care in some way; the useful question is how.

The Spending Context

Papanicolas et al. (2018) set American spending beside that of ten other wealthy nations for 2016: close to eighteen cents of every dollar of national income went to health care in the United States, against roughly ten to twelve cents elsewhere. Use of most services, including physician visits and hospital stays, was not higher in the United States; prices for labor, drugs and administration were. That finding matters for this comparison. The difference between countries in the cost of a follow-up visit lies less in how often visits happen than in what each visit costs and in how many separate payments it generates.

The United States: Prices That Depend on the Building

In the United States, the visit's price depends on who pays and where it happens. For a traditional Medicare patient at an independent office, Medicare pays the physician fee schedule rate and the patient owes coinsurance. At a hospital-owned clinic, as earlier modules showed, the same visit generates a professional fee and a facility fee, both with coinsurance and no annual out-of-pocket ceiling. For a commercially insured patient, prices are negotiated separately by each insurer with each provider and are usually much higher than Medicare's. Rationing in this system works mainly through price: deductibles, coinsurance and facility fees discourage some visits, and uninsured patients may skip care altogether. Waiting is generally short for those who can pay.

Germany: One Fee Schedule, Many Insurers

Germany finances care through statutory health insurance, which covers most of the population through competing nonprofit sickness funds financed by income-related contributions shared between employers and employees. Busse et al. (2017) describe a system shaped by solidarity, self-governance and regulated competition, in which the federal joint committee of payers and providers sets benefits and a uniform fee schedule governs payment for ambulatory physicians. A follow-up visit with an office-based physician is paid under that schedule regardless of which fund the patient belongs to, and the strict separation of ambulatory and hospital sectors historically meant that routine outpatient visits occurred in physician offices rather than hospital departments.

Rationing in Germany works mainly through budgets and the structure of supply. Regional budgets for ambulatory care limit total payments to physicians, and the planning of physician locations controls where practices can open. Cost sharing for physician visits is minimal. Patients have broad choice of physician and relatively short waits by international standards, but the separation of sectors creates coordination problems of its own.

The American approach also produces administrative work that the other two systems largely avoid. Because each payer has its own prices, rules and forms, clinics employ staff to verify coverage, code visits for multiple payers and pursue unpaid balances. Our clinic's billing office grew after the acquisition, partly to manage the separate facility claims. In Germany and Canada, a single fee schedule per region and far simpler billing reduce that work, which is part of why administrative spending is lower there.

Canada: Free at the Point of Care, Paid For by Waiting

Canada's provinces and territories run single-payer insurance plans financed mainly through general taxation, with federal transfers conditioned on the principles of the Canada Health Act. Martin et al. (2018) describe a system in which medically necessary physician and hospital services are covered without user charges, physicians are paid largely through provincial fee schedules negotiated with medical associations, and there are no facility fees for insured physician services. The follow-up visit costs the patient nothing.

Rationing in Canada works mainly through supply and waiting. Provinces control budgets for hospitals and negotiate physician fees, and the authors identify long waits for specialist and elective care as a persistent weakness. A follow-up with a family physician is usually available, but a referral to a specialist may take months. The system limits care by time rather than by price, which protects patients from financial harm but imposes a different burden, especially on those whose condition worsens while they wait.

German policy has recently begun to loosen the boundary between sectors, allowing hospitals to provide some outpatient services, which brings new questions about how to price them. That debate, in a country that has long paid one price for an office visit, shows that the question of site-based payment is not unique to the United States.

What the Comparison Teaches

Laid side by side, the three systems show three answers to the same problem. The United States pays different prices for the same visit depending on the payer and the building, and rations largely through what patients pay. Germany pays one price under a uniform schedule and rations through budgets and planning. Canada makes the visit free and rations through waiting. None avoids rationing; each chooses who bears its cost.

For the facility fee debate at home, the comparison is clarifying. Neither Germany nor Canada pays more for the same outpatient visit because a hospital owns the office. That does not prove the American approach is wrong, since hospitals argue that facility fees support standby capacity and services that offices do not provide. It does show that paying the same price for the same service is a workable principle in other wealthy countries, which is the starting point for the advocacy argument in the next module.

Lessons from abroad therefore come with a caution. Other countries pay one price for the same visit within systems that also cap total budgets or control supply, and importing only the price rule without those structures would produce different results here.

References

Busse, R., Blümel, M., Knieps, F., & Bärnighausen, T. (2017). Statutory health insurance in Germany: A health system shaped by 135 years of solidarity, self-governance, and competition. The Lancet, 390(10097), 882-897. https://doi.org/10.1016/S0140-6736(17)31280-1

Martin, D., Miller, A. P., Quesnel-Vallée, A., Caron, N. R., Vissandjée, B., & Marchildon, G. P. (2018). Canada's universal health-care system: Achieving its potential. The Lancet, 391(10131), 1718-1735. https://doi.org/10.1016/S0140-6736(18)30181-8

Papanicolas, I., Woskie, L. R., & Jha, A. K. (2018). Health care spending in the United States and other high-income countries. JAMA, 319(10), 1024-1039. https://doi.org/10.1001/jama.2018.1150