National Approaches Health Insurance

The phrase medical care resources is used to describe the many parts of the health care system that work together to improve or maintain a person's health. One of the most important resources is the medical workforce. These are the doctors, nurses, pharmacists, paramedics, and other professionals that treat people who seek care. Hospitals and pharmaceuticals are also important medical care resources. Regulatory institutions around the world face a difficult challenge in coordinating the supply of these important resources and allocating them efficiently.

In many countries with universal health care, such as France and the United Kingdom, the coordination of resources is primarily the responsibility of a central authority or government agency. In other countries, including the United States, many allocation decisions are dictated by economic forces in the marketplace. Nevertheless, even in the United States, many laws are in place to regulate or control medical resources. The characteristics of a health care system and the regulations of the medical workforce, hospitals, and pharmaceuticals impact the medical resources available in a country.

Medical workforce. There are many different types of care in which physicians may specialize. They may also choose whether to live and practice in urban or rural settings, or in hospitals as compared to private clinics. Nurses and other health professionals can typically make similar decisions about their work specialization and location. A health system can provide incentives such as student loans or grants for professionals to enter particular specialties or communities. Alternatively, such choices may be regulated directly by governing institutions.

Rules governing where doctors can practice and which doctors a patient can see vary from country to country. In the United Kingdom and Germany, general practitioners are almost always precluded from practicing in hospitals and can only practice in outpatient settings. In these countries, specialists provide most of the care in hospitals. In Canada and France, meanwhile, general practitioners can practice in both inpatient and outpatient settings. Such regulations sometimes influence the prevalence of a particular Table 4 Private Health Care Expenditures, 1998 SOURCE: OECD Health Data (2001) specialty in the medical workforce. In France, for example, the fact that patients can choose either a general practitioner or a specialist as their doctor has created an environment of competition between the two professions. One result is that some doctors that are technically specialists work as general practitioners.

Health care systems also vary in how physicians are paid. Under a fee-for-service payment system, physicians are paid for each service they provide. A capitated payment system gives physicians a fixed level of payment for each patient that may be treated over a set period of time. Alternatively, physicians can receive a salary. Each of these payment systems is used around the world, often regardless of the universality of their coverage or the level of government involvement. Fee-for-service is the dominant form of physician payment in France, where patients pay up front and are later reimbursed by the public system. In the United Kingdom's National Health Service, physicians are paid on a capitation basis. Meanwhile, physicians in the Swedish health system are paid a salary. Since the United States is dominated by a private system of care, the market has evolved to compensate physicians in each of these three ways depending on their specialty and the environment in which they practice. The different payment schemes may provide different incentives for physicians, thus impacting the availability of certain health care workers in a society.

Hospitals. Hospitals are another medical resource whose regulation varies between health systems. In countries that have public hospitals, such as the United Kingdom, the government can use its central authority to establish hospital capacities and services in a manner that is responsive to the distribution of health needs in the population. In other countries, such as Canada and the United States, hospitals are largely private and guided by the economic forces of the marketplace, though in Canada their budgets are regionally controlled. France, Germany, and Japan, meanwhile, have a more equal share of public and private hospitals.

Pharmaceuticals. The types of drugs that are legal to use in a country are often regulated at the national level. In the United States, the Federal Drug Administration (FDA) determines which drugs are safe and can be made available to patients. It is important to note that insurance providers in the United States and in other countries will often only pay (or help pay) for a portion of legally available drugs. From a patient's point of view, some legal drugs may still be unavailable for use, as the patient may not be able to afford expensive drugs without the help of his or her insurance company. On the other hand, in countries with universal health care, such as Sweden, it is often the case that all legal drugs are made available to all patients.

Health systems also vary in how pharmaceuticals can be obtained. In most countries, physicians prescribe medications but cannot sell them. An interesting exception is Japan, where physicians prescribe and sell drugs to their patients, acting as both physician and pharmacist. By affecting the availability of medical resources, pharmaceutical regulations such as these also affect a patient's use of health care.