Health care systems : models and today's challenges


​​​​​​​​​​​​​​Gemalto is providing electronic health care solutions to several countries around the world and contributes to more efficient national healthcare systems for the benefit of patients, health insurances and health professionals.

Socialized medicine and healthcare systems [2017 - study]:​​​​

  • Overview of insurance systems around the world
  • Origins of healthcare and health insurance systems​
  • The 3 main shared challenges facing organizations when providing health care
  • ​​​Smart card technology assessment​ and contribution.

Universal health care 

​4 basic models​ and mixed schemes

The healthcare sector is an important part of our societies, due to the resources which are allocated to it, the role played in healthcare by the state or regional authorities, and because of the large number of stakeholders which it links, either directly or more indirectly. And the idea of universal health care - providing health care and financial protection to all – is not new.

Indeed, government programs for healthcare, retirement benefits and family allocations, and in particular health insurance, are the legacies of national traditions. They have developed according to four different models.

#1 The Bismarck model

This model of universal health care was created in Germany by Bismarck, who enacted social legislation between 1881 and 1889. Health insurance and access to health care are therefore linked to the notion of employment in this system. It is financed through social contributions, rather than taxes.

This model relies on health insurance funded through social contributions (by employers and employees), managed by the representatives of companies and employees. The state must decide on the scope of intervention of health insurance funds, and take the appropriate measures if a financial imbalance arises.

The German example was used as a blueprint in Austria and Belgium,  in France with the decrees of October 1945, in Luxemburg and the Netherlands.

In all countries that have adopted the Bismarck model, protection has been extended to include population categories that were not protected initially (students, independent workers, etc.), and "risks" not taken into account to begin with.

Socialized Medicine 

#2 The Beveridge model​​​

Implemented in 1942 in the United Kingdom following Lord Beveridge's report, this social protection system is based on the principle of universal access to health care, nondependent on employment. This access to healthcare is not considered as contingent on employment, but rather as an intrinsic part of citizenship. Public authorities fund this system through taxes, rather than through social contributions.

A centralized system is in place in the United Kingdom and Ireland (NHS​ for National health System), while a decentralized system has been adopted by Mediterranean countries (Greece, Spain and Portugal).

#3 The Semashko ​model

This model, which was developed during the 1920s in the Soviet Union, then spread to the USSR's satellite states after 1945. It is named after Nicolai Semashko, the USSR's health minister from 1918 to 1930. This socialized medecine is, of course, the product of a specific political ideology.

Healthcare services belonged to the state, and healthcare professionals were paid by the state. Services were usually free, but patients had to pay out-of-pocket fees for medication, for example. 

The system provided universal access to health care. It was broadly a benefits in kind system. Coverage levels and the amounts set aside for healthcare spending (share of GDP) were defined centrally. Health care and health insurance systems from this era are currently undergoing radical change in the Central and Eastern European countries.

Access to health care 

#4 The out-of-pocket model

The fundamental principle of the American healthcare system is that health is a matter of individual responsibility and private insurance. 

So what's the story here?

In practice then, there is no compulsory national system, and a preponderance of private organizations (two-thirds of Americans under the age of 65 are covered by employment-related insurance). Public healthcare is only provided for the elderly (Medicare) and disadvantage (Medicaid), not unlike the Beveridge model. 

These two programs were established in 1965 under the administration of Democrat L.B. Johnson.

  • Medicare is a federally funded and managed healthcare system for citizens over 65
  • Medicaid is a jointly funded system between the federal and state governments for families with low incomes and resources.​

Both Medicare and Medicaid are the responsibility of the federal agency, Centers for Medicare & Medicaid Services (CMS). CMS directly manages Medicare and oversees Medicaid. The states manage their individual Medicaid programs for their citizens.

#5 European mixed-model plans

Mixed-model plans aimed at ensuring healthcare for all


The Bismarck and Beveridge models have had a lasting influence on most European countries. 

So what has been done?

During the second half of the 20th century, all European countries progressively extended universal health care to cover nearly all citizens.​

Since the implementation of the CMU (universal health care coverage), the French system for example has ensured that everyone has access to healthcare. Employment no longer determines access to healthcare, as is theoretically the case. 

But funding methods have not been called into question.

In all countries influenced by the English model, funding mainly comes from taxes, while in other countries it is mainly drawn from social contributions. 

In countries influenced by the Bismarck model, such as France or the Netherlands, social protection is mainly funded through contributions. 

These differences in funding are linked to how the system is organized: in general, 

  • ​funding through taxes corresponds to a state-run organization
  • while funding through social contributions usually means that trade unions and employers' organizations are involved

 

But is there an European health care system per se ? 

Social protection does not fall under the jurisdiction of the European Commission, but is an example of the principle of subsidiarity, and therefore under the jurisdiction of national governments.That being said, Europe-wide cooperation does exist on the matter, in particular concerning the cross-border mobility of patients (with measures such as the E111 form).

Cooperation also facilitates the exchange of knowledge and best practices.   

More than €1,400 billion is spent in the European Union (including UK) on healthcare.

Faced with the sharp rise in healthcare costs, all European countries have tried to rein in spending, while improving the efficiency of universal health care systems in place. 


Annual spending on health care represents a significant part of a nation's Gross Domestic Product

The healthcare system management 

Let's see now the 3 major challenges when considering healthcare system management.

3 chief challenges to providing health care 

Providing long-term healthcare

Long-term healthcare while ensuring a steady source of funding

The first challenge is of course to maintain or improve the health of citizens by providing healthcare that meets the legitimate expectations (medical or otherwise) of the general public. Issues surrounding the funding of the system, continuity and proper management are, of course, fundamental.

There are several priorities in order to manage the resources available, such as:

  • optimizing the system by rendering procedures paperless,
  • freeing patients up from the many administrative procedures linked to the management of healthcare.​​

​If the aim is to implement lasting improvements, the fight against error, fraud and abuse must, of course, must be included. Take, for example, the inadvertent effects or complications resulting from medical errors (treatment or advice), known as iatrogenesis. This is an issue of some magnitude.

In the United States, the total number of deaths due to iatrogenesis in 2001 reached 738,936. The number of deaths caused by cardiac disease was 699,697 and 553,251 deaths were caused by cancer (source: American Iatrogenic Association 2002).

In France, in 2004 the number of deaths resulting from iatrogenesis was higher than 10,000, and 3.19% of hospital stays were due to medical errors and medication errors.

A financial assessment of this issue is particularly difficult to carry out. No realistic study relating to the amounts involved was to be found. But the causes of the phenomenon are known. 

Iatrogenesis can be linked to many factors
such as doctors lacking information or training, patients lacking information or education, prescription errors (inappropriate medication: dose, protocol, treatment), over-prescription or incomplete prescription, a lack of information on the patient (allergies, symptoms not all taken into account, multiple pathologies), an under-estimation of drug interactions and self-medication.

Between 30% and 50%+ of iatrogenesis could be avoided (French Ministry of Health, July 2010). Better information systems could play a part in cutting this figure. This is one of the goals of the Personal Medical File.


Health care fraud is also a major challenge.

  • ​In the United States, between $75 billion and $250 billion according to the FBI are lost to fraud. In 2014,  $3,000 billion or  $3.0 trillion  and so 17,5% of GDP were dedicated to health care spending.
  • On average, around 6% to 10% of spending in the healthcare sector is lost to fraud, according to the European Healthcare Fraud and Corruption Network (EHFCN). 
  • In Europe which spent€1,400 billion on healthcare in 2014, this means nearly €140 billion was lost in that year alone.

Feedback from interviewees in a study we conducted in 2011 indicated that the higher EHFCN figure (10%) is closer to the true cost of this problem.

 

Healthcare professionals on patient health 

Focusing the work of Healthcare professionals on patient health 

Most programs in this area are aimed at :

facilitating information exchanges & helping healthcare professionals to concentrate on care and treatment rather than management.

This attempt to reorganize the relationships between patients, healthcare professionals and administration is greatly helped by the introduction of new digital technology for exchanges between healthcare or insurance organizations, and the creation of health cards. These factors can often lead to drastic improvements.

In France with the universal health care SESAM Vitale program, for example:

  • patients are now reimbursed after 5 days, rather than after 2-3 weeks (due to paperwork). 
  • ​1.2 billion electronic claim forms were used in 2014; 90% of all claim forms 
  • with administrative productivity and treatment costs divided by 6 for the claims in question.

​There's more.

The introduction of electronic claim forms and the cut in the number of statement sheets means that 3 billion A4 sheets of paper are saved. They are no longer produced, printed, distributed, stored or destroyed.

Personal medical files  

Coordinating & optimizing information-sharing

Ambition:  optimize the use of medical data.
A patient's "Personal Medical File" ensures that all their medical information can be accessed by healthcare professionals, whenever and wherever.

This record therefore cuts errors and hesitancy in emergency situations, and improves the quality of services provided. It also improves cooperation between all healthcare workers, pooling all available information on patients into a centralized file.

Personal Medical Files streamline healthcare systems.

Personal Medical Files limit the number of medical interventions, and ensure that care provided for patients is consistent. There are also advantages for government health policy: a well-treated patient does not have to keep coming back.

Telemedicine also presents fantastic opportunities. This refers to any situation where information is passed between healthcare professionals electronically (general practitioners or specialists, care workers, pharmacists, etc.). This information could be messages, letters, signals, results, images, administrative data, complete files, etc., for diagnosis, therapy or monitoring.

Chifa card 

Smart card technology assessment for health care

Using smart cards speeds up the transition to paperless, electronic procedures and data exchanges, which are 3 formidable catalysts for the modernization of systems. 

In terms of administration, the results obtained are impressive. 

Yet this technology is often under-used at present, in areas where it will produce excellent results.

Now:

  • Strong identification and authentication for patients and healthcare professionals are key features of micro controller card, and should be implemented in the healthcare sector. Yet this is not the case in many countries.
  • Implementing health care cards with an identification number and PIN or biometric authentication would enable the creation of personalized, online services, a quintessentially «patient-centric» approach, yet these initiatives are still in the development stages.
  • The ability to verify benefits, expiration dates, repeated and multiple uses is on the whole under- used. 
  • Thus far, the benefits of paperless, electronic medical data exchanges have not been fully tapped. Yet cards have a crucial role to play in creating consistent databases, with the automatic reading of data, and the temporary or permanent confidential local storage of additional data such as blood groups, allergies, chronic diseases and associated treatments.

Electronic services that have already been implemented in European countries for universal health care schemes and in the rest of the world—with identification systems, electronic signatures and electronic authentication - clearly show:

the key elements (microchip cards, public key infrastructure, authentication, etc.) of a modern healthcare system can rely on robust technology to rise to the challenges presented by fraud, abuse and errors.  

The best part?

This robust technology can strike at the heart of fraud mechanisms, often with minimal investment in infrastructures, and without major changes for patients and healthcare professionals.

Smart card technology is an invaluable asset to combat healthcare fraud and errors in the interest of all.​

Health care and health insurance system

Gemalto – a major health care systems provider

Gemalto provided technical services and products during the implementation of 11 national electronic health care systems, including the German Gesundheitskarte (picture above) or Chifa card, a eHealthcare solution in Algeria.

Our contribution to these electronic health care projects provides us with an excellent overview of the technology involved, its applications and the quality of information systems, as well as the social context of its use.

Furthermore, our experts have provided support for national debates on how to improve systems, in particular to fight fraud and cut the number of errors.

Finally, Gemalto is an active collaborator in European and global standardization organizations.​