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Social Justice and a commitment to a fair distribution of finite resources has always been a core of who we are as physicians and as human beings. With the renewed emphasis on professionalism in medicine, it is being reintroduced as part of the core of our values as physicians. This is very welcome, but does not sit so well with some of our more conservative colleagues, as you'll see below.
Medical Professionalism in the New Millennium: A Physician Charter -- Project of the ABIM Foundation, ACP–ASIM Foundation, and European Federation of Internal Medicine* 136 (3): 243 -- Annals of Internal Medicine:
"Fundamental Principles:
"Principle of primacy of patient welfare. This principle is based on a dedication to serving the interest of the patient. Altruism contributes to the trust that is central to the physician–patient relationship. Market forces, societal pressures, and administrative exigencies must not compromise this principle.
"Principle of patient autonomy. Physicians must have respect for patient autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment. Patients' decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care.
"Principle of social justice. The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category. "
In the next section, A Set of Professional Responsibilities:
"Commitment to improving access to care. Medical professionalism demands that the objective of all health care systems be the availability of a uniform and adequate standard of care. Physicians must individually and collectively strive to reduce barriers to equitable health care. Within each system, the physician should work to eliminate barriers to access based on education, laws, finances, geography, and social discrimination. A commitment to equity entails the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician, without concern for the self-interest of the physician or the profession.
"Commitment to a just distribution of finite resources. While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources. They should be committed to working with other physicians, hospitals, and payers to develop guidelines for cost-effective care. The physician's professional responsibility for appropriate allocation of resources requires scrupulous avoidance of superfluous tests and procedures. The provision of unnecessary services not only exposes one's patients to avoidable harm and expense but also diminishes the resources available for others."
Response Letter in Annals of Internal Medicine, by Christopher Lyons, in part:
"In the charter's preamble, the concept of medicine's contract with society is discussed. To a large extent, the obligations of physicians to society in that contract are nicely laid out in the subsequent discussion. Given that a contract is usually created between two parties and each party has an obligation to the other, what is society's responsibility to physicians? As highly trained, caring members of society, aren't physicians entitled to certain assurances of financial stability? Should we be expected to withstand ongoing efforts to politicize the health care industry in attempts to garner votes while balancing the federal budget? Must we continue to withstand repeated attacks from trial attorneys who have little interest in the facts of a medical case and are interested only in the payoff? "
Another, by Jerome Arnett, in whole:
"I read with interest the article on medical professionalism in the new millennium (1), which proposed a new code of conduct for physicians comprising three principles and 10 responsibilities. As a proposed code of ethics, the charter is untenable for several reasons. Two of the three principles conflict. Patient welfare is predicated on individual rights while social justice is based on group rights (those of "society"). Since individual rights and group rights are mutually exclusive, the physician can follow one of these two principles but not both (2). In addition, at least 2 of the 10 responsibilities (public advocacy and just distribution of finite resources) place the interests of others ahead of those of the patient. Physicians will be less likely to subscribe to an ethical code that does not have the welfare of the patient as its highest objective.
"Equality of outcome is an undesirable and unattainable vision that invariably results in the loss of patients' rights. Only under socialism (government medicine or corporate socialized medicine) are health care resources finite, so that they must be rationed or justly distributed. Under other circumstances, the provision of services"necessary" or "unnecessary"to one patient does not diminish the resources available for others.
"The commitment to maintaining trust by managing conflicts of interest forbids physicians to pursue private gain or personal advantage. How then is it ethical for a group of physicians such as the Medical Professionalism Project to weaken our code of ethics in order to promote a political agenda (improving "the health care system for the welfare of society," promoting "the fair distribution of health care resources," or ensuring social justice)? These proposed changes in our time-honored, patient-centered ethics will worsen, not improve, the dilemma of today's physicians, who already are challenged by new technology, changing market forces, problems in health care delivery, bioterrorism, and globalization. But even more ominous, medicine without effective, patient-centered ethics is no longer a profession but merely a tradewhich was its status in ancient Greece before the Oath of Hippocrates.
Reference number 2 is:
2. Vazsonyi B. America's 30 Years War: Who Is Winning? Washington, DC: Regnery; 1998:79.
Two of the authors, Drs. Cruess and Cruess, reply, very diplomatically:
"IN RESPONSE:
"Although Dr. Arnett's points are well taken, the charter is not a code of ethics, nor is it intended to detract from or supplant the Hippocratic tradition that has long enriched medicine's history. It is a statement of contemporary responsibilities—medicine's understanding of its obligations under today's social contract. We strongly disagree that individual rights and group rights are mutually exclusive and that "the physician can follow one of these two principles but not both." We do not underestimate the difficulty of reconciling the two sets of responsibilities but believe passionately that medicine must attempt to do so. The alternative is for someone without medical knowledge or expertise to determine the societal rights in health care and how they are to be reconciled with the rights of individual patients. Do we really wish this to occur, or do we believe that it is better for individual physicians and their organizations to use their expertise to try to achieve the proper balance? The charter suggests the latter course. It does, however, state that physicians must put the welfare of the individual patient first, thus reaffirming our traditional fiduciary responsibilities. Our duties to individual patients must be carried out with a knowledge of the impact of our own decisions on the wider society, which we also serve. We also disagree that the allocation of resources to one patient does not diminish the resources available to others under a market-driven system. The attempts at cost containment seen throughout the world, no matter what the nature or structure of the health care system, indicate that this is not true. There is no question that contemporary physicians are expected to serve both their patients and society.
"A second point of some importance refers to "equality of outcome." We are not sure that equality of outcome can be termed "undesirable," as Dr. Arnett stated, but certainly such an objective is unrealistic. Nowhere does the charter advocate equality of outcome as an objective.
"Dr. Arnett interprets the charter as forbidding physicians' pursuit of private gain or personal advantage. Nowhere does it so state. The conflicts of interest section states that physicians must deal with these conflicts in an open and transparent way. We cannot eliminate conflicts of interest, but we must ensure that our integrity is preserved as we cope with and manage them and recognize the consequences of our decisions.
"We agree with Dr. Arnett that without effective patient-centered ethics, medicine is no longer a profession. As already mentioned, the charter is not a code of ethics but a freely given statement of medicine's commitments and responsibilities, essentially outlining where we should stand in complex times. It is aimed at restoring the feeling of pride in the profession and public trust that all observers have agreed is so essential to the proper functioning of a profession and distinguishes it from a trade."
Sphere: Related Content5 Podcasts on Healthcare Reform found at the University Channel Web Site
Access to Universal Health Care Pt 1: New Jersey (Podcasts/Podcasts)
...Daniel A. Notterman, MD, MA, Department of Molecular Biology, Princeton University UNIVERSAL HEALTH CARE IN NEW JERSEY - Senator Joseph Vitale, Senator and Chairman, Health, Human Servi...
Access to Universal Health Care Pt 2: Worldwide (Podcasts/Podcasts)
Pt 2 UNIVERSAL HEALTH CARE WORLDWIDE - Uwe Reinhardt, PhD, James Madison Professor of Political Economy, Princeton University - Maggie Mahar, PhD, Fellow, The Century Foundation -
Access to Universal Health Care Pt 3: Keynote (Podcasts/Podcasts)
Pt 3 LUNCHEON SPEAKER - Len Nichols, PhD, Director, Health Policy Program, New America Foundation
Access to Universal Health Care Pt 4: Statewide Efforts (Podcasts/Podcasts)
Pt 4 UNIVERSAL HEALTH CARE IN THE NATION – THE MASSACHUSETTS EXPERIENCE & OTHER STATEWIDE EFFORTS - Nancy Turnball, PhD, Associate Dean for Educational Policy, Harvard School of Pub
How the Next President Can Deliver on Healthcare Reform (Podcasts/Podcasts)
...ive Vice President for Policy, AARP; Robert Moffit, Senior Fellow, Heritage Foundation; Joanne Silberner, Health Policy Correspondent, National Public Radio (Sep 26, 2008 at the National Pr...
For this last one, I highly recommend watching the Video so you can see Uwe Reinhardt's slides.
I will give them a listen soon, but didn't want to lose the links...
Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries -- American College of Physicians, -- Annals of Internal Medicine:
"This position paper concerns improving health care in the United States. Unlike previous highly focused policy papers by the American College of Physicians, this article takes a comprehensive approach to improving access, quality, and efficiency of care. The first part describes health care in the United States. The second compares it with health care in other countries. The concluding section proposes lessons that the United States can learn from these countries and recommendations for achieving a high-performance health care system in the United States. The articles are based on a position paper developed by the American College of Physicians' Health and Public Policy Committee. This policy paper (not included in this article) also provides a detailed analysis of health care systems in 12 other industrialized countries.
Although we can learn much from other health systems, the College recognizes that our political and social culture, demographics, and form of government will shape any solution for the United States. This caution notwithstanding, we have identified several approaches that have worked well for countries like ours and could probably be adapted to the unique circumstances in the United States."
Think Big - Campaign Stops Blog - NYTimes.com:
"1) “Make no little plans. They have no magic to stir men’s blood and probably will not themselves be realized.” So said Daniel Burnham, the architect and urban planner (and fellow Chicagoan).
In health care, big plans are necessary not only to motivate people but as a matter of sound policy. The health care system is broken. It is not enough to just add more people to a broken system. Health care reform must reorganize the system to deliver higher quality care while keeping costs under control. Incremental change that just covers more people will not be sustainable. Reform must include changing the delivery system and how we pay for care. The health care system needs major surgery, not more Band-aids.
More important, as negotiation specialists note, you don’t begin with your compromise position. If we have to settle for incremental Band-aids, it should be only as a last resort."
A nice piece about how tinkering around the edges of healthcare is doomed to failure, and by failure, I mean more of the same in our dysfunctional system.
The companion piece, "Think Small" is typical right wing dreck. "Don't do too much," "Americans are conservative" , "Americans are happy with the current system", the usual stuff - you know, eschewing reality for the conservative echo chamber. The comments, however are anything but an echo chamber. No mercy shown, so well worth reading them!
Cheers,
Health Beat: Herzlinger’s Meme on Switzerland and Consumer Driven Medicine:
"Yet even if the Swiss are not the world’s most conscientious health care shoppers, individuals in Switzerland spend about a third less on health care than the average American. How can that be? Time and again, Herzlinger repeats the meme that consumer choice accounts for Switzerland’s lower costs. And if she says it often enough, without citing evidence, no doubt many Americans will believe her. But it just isn’t so.
Even a cursory glance at Switzerland’s system reveals that government-enforced price controls on virtually everything from drugs to doctors keeps a lid on health care inflation. The fees that providers charge “are negotiated by the cartel-like associations of insurers and clinicians under the watchful eye and heavy hand of government” Reinhardt observes. And “since all insurers are bound to the same prices for ambulatory care, and prices are negotiated between insurers and individual hospitals for inpatient care,” there is little room for the consumer to affect prices by comparison-shopping.
Finally, when it comes to ensuring that the Swiss are receiving effective care, Switzerland's Federal Department of Home Affairs establishes the formulary for prescription drugs that it believes give good value, while the Federal Department of Home Affairs decides which lab tests and medical devices are to be covered by compulsory insurance.
In the end, Reinhardt suggests that “what is most impressive about the Swiss health system is the role tight government regulation plays . . . . One can plausibly argue that this regulation is chiefly responsible for both the high quality and (relative to the United States) low cost of Swiss health care.” Determined to make the case for consumer-driven care, Herzlinger takes the opposite view arguing, in today’s WSJ that the Swiss government’s web of regulations, requiring “an extensive minimum benefit package,” while “micromanaging” both prices and products is precisely what keeps Switzerland from becoming the unfettered consumer’s paradise that she would like to see. "
A nice overview of the Swiss system and a Bronx cheer to the crapola that is "Consumer Driven Healthcare". Thanks to Ian Welsh of Firedoglake for the link from his piece on the Baucus Plan...
AMA It's not just about us:
Some excerpts from the address of AMA President Nancy Nielsen:
"We need fundamental change in our health care system for ourselves, for our patients, for our nation. Right now annual health care costs exceed $2 trillion. That's 16 percent of our nation's GDP. Costs are estimated to reach $4 trillion and 20 percent of GDP in 10 years.
Right now, annual health care costs are the number one reason for bankruptcy. Right now, Americans get about half the preventive services that are recommended. Right now, we rank 19th among 19 developed countries in mortality that could be helped by health care. That means deaths that might have been prevented by health care. Nineteenth out of 19.
Forty-six million Americans have no health insurance, and another 29 million are underinsured. Those 75 million Americans are delaying or failing to obtain preventive care.
In our nation's sick economy, job losses mean the loss of health insurance. Just yesterday, the government reported that employers cut 240,000 jobs in October alone. And so far in 2008, some 1.2 million jobs have been lost.
We as a nation have to do some serious soul searching. We are the most innovative, resilient, determined, self-reliant and creative nation in the world. Our health care system ought to be the best in the world but currently it is not.
Today we pay twice what other countries with better health outcomes pay. But we rank last or next to last in many health indices. And, that's compared with Australia, Canada, Germany, New Zealand and the United Kingdom.
Now, we can try to protect the status quo. But the status quo is not serving patients well, and doctors are angry and unhappy. It is high time we do something about it and I'm not talking about single-payer. I am, however, talking about comprehensive change. I'm talking about responsible change that builds on the strengths of the current system. Isn't it time to build a bridge to a new and better health system? A system where patients are better served and physicians are happier and more fulfilled in their work?"
...
But who will pay for this right, if that's the country's decision? Who will define the parameters of this right to health care? Because everyone cannot have everything, and society should not have to provide everything, nor can it afford to do so.
Take education as an example of setting parameters. Our society has decided that K-12 education is a right, but post-secondary education is a privilege and a responsibility.
Defining parameters for health care "rights" and "responsibilities" will require society's honest deliberation and some difficult decisions. For sure we have to define the expectations of personal responsibility. What is fair to expect the individual to do? What should be up to the individual, and what should be society's concerns?"
..."As we participate with the rest of society in this debate, we cannot allow the discussion to descend into ideology and inflammatory labels. If we do, if we allow reason to be trumped by rhetoric, then we will have lost our chance to shape the change, to build the bridge to a better health system.
So I ask you, are we prepared to participate in that societal debate? Because the debate is going to happen. This is not just about doctors. It is not just about us. But physicians and patients will have to live with the outcomes. That's why we have a central role to play.
We all use the commons and that is why we all have to do our part to protect it. Make no mistake, I am not in favor of a single-payer system. I am in favor of a health care system that works better for all of us, patients and physicians.
We're in a time when our country is demanding change. We need change. Let's harness that energy for our patients and ourselves. For sure, this is for us - we have to remove the sand from our shoes. But it is for so much more than us."
...Insure The Uninsured Project : Recent Reports
Health Care Systems Around the World
(November 2008)
Now I'm embarrassed. I just posted my summaries of the OECD summaries and get this in my inbox. Somebody who knows what they're doing spent some real time investigating and writing about 10 systems from around the world. I haven't read it yet, but wanted to get it up here, along with the one below:
The Healthy Americans Act (S. 334)
(October 2008)"
Cheers,
I have posted my summaries of OECD summaries of healthcare systems of the UK, The Netherlands, France, Germany, Denmark, and Sweden.
This link brings them all up in one window.
Otherwise, click on the links for the individual countries on the right.
Cheers,
Summaries of summaries of healthcare systems based on the Commonwealth Fund reports.
Author(s) of the originals are:
Karsten Vrangbaek, Isabelle Durand-Zaleski, Reinhard Busse, Niek Klazinga, Sean Boyle, and Anders Anell
UK/NHS
• The UK, along with Sweden, is a prototypical socialized system.
• Essentially everyone is covered and all the funding takes place through a federal government taxes.
• General taxes account for 76% of the funding and then there are national insurance contributions to account for 19% of the funding. (I do not understand what the national insurance contributions are or where this money comes from.)
• User charges also account for a further 5% of the funding.
• Cost-sharing amounts to small drug co-pays of $14 but this is only for about 12% of all prescriptions written so it is therefore relatively small amount. In other words 80% of prescriptions require no co-pay.
• Dental requires up to $400 per year out of pocket before reimbursement occurs (I think).
• Out-of-pocket expenses account for 12% of the total health care expenditure.
• Primary care physicians are paid directly by the primary care trusts through capitation, salary, and fee-for-service arrangements.
• Hospitals are run by national health service trusts.
• Consultants and specialists are salaried.
• The private system in Britain covers approximately 12% of the population. It is a mix of profit and not-for-profit providers as well as supplementary insurance.
Summaries of summaries of healthcare systems based on the Commonwealth Fund reports.
Author(s) of the originals are:
Karsten Vrangbaek, Isabelle Durand-Zaleski, Reinhard Busse, Niek Klazinga, Sean Boyle, and Anders Anell
Sweden
• The Swedish system sounds very much like the truly socialized systems that we have come to expect from right-wing fear mongers. Everyone is covered, everything is covered, and virtually everything is funded by the government through taxes.
• There are some co-pays and the deductibles and routine dental care for those over 18 is not generally covered.
• Co-pays for visits amount to about $20 for a general practitioner and $40 for a specialist. There is an approximately $12 per day co-pay for hospitalization and there is a deductible of about $140 annually for prescriptions. Once you go over this amount then there is a scaled re-payment or reimbursement (the higher the expenditure, the higher percentage the state pays.)
• Out-of-pocket expenses account for approximately 14% of total health expenditure.
• Funding is through federal and local taxes.
• The federal government is mostly responsible for prescription drug costs.
• County governments are responsible largely for hospitals, mental-health care, provider reimbursement etc.
• Municipalities are responsible for skilled nursing facilities and the like, as well as home care and some other things.
• Private insurance covers approximately 25% of the population and accounts for less than 1% of total health expenditures.
• Physicians are paid largely through capitation with some fee-for-service. Half of primary care physicians are private and half are employed or salaried.
• Hospitals are mostly county owned and the hospital-based physicians are generally salaried.
Summaries of summaries of healthcare systems based on the Commonwealth Fund reports.
Author(s) of the originals are:
Karsten Vrangbaek, Isabelle Durand-Zaleski, Reinhard Busse, Niek Klazinga, Sean Boyle, and Anders Anell
Netherlands
• The Netherlands will be experiencing major changes that began in 2006 due to dissatisfaction with the prior dual system of competing public and private health care.
• All residents are required to buy health insurance.
• Health insurance is "statutory" but provided by private health insurers and regulated under "private law".(?)
• Financing: statutory health insurance, or SHI or public insurance is funded by a 6.5% tax on taxable income up to €30,000. This 6.5% apparently must be reimbursed by the employer however.
• The self-employed pay a 4.4% rate of tax for their insurance on their income.
• The average annual premium as of 2006 was €1050
• The government completely covers children up to age 18.
• "Substitutive" private health insurance was abolished in 2006.
• The statutory health insurance fund distributes risk-adjusted funds to the insurers. These insurers also provide, for a fee, complementary/supplementary insurance. The premiums for these complementary policies are not yet regulated.
• Private insurers may be for-profit but must accept everyone in their geographic area. They are compensated for this by risk adjustment reimbursement by the government.
• 78% of total health care expenditure is public.
• The statutory health insurance covers usual healthcare and includes drugs but does not include routine dental care. The annual deductible is €150 per year.
• Out-of-pocket expenditures account for 8% of the total health expenditure of the Netherlands
• Physicians contract directly or indirectly with insurers. General practitioners income is a combination of capitation and fee-for-service and pay-for-performance is being tried. Specialists are two thirds self-employed even if hospital-based and one third are salaried.
• Hospitals are mostly private but not for profit.
• Cost controls: it sounds like they are working on a version of managed competition though I am not clear on that.
Summaries of summaries of healthcare systems based on the Commonwealth Fund reports.
Author(s) of the originals are:
Karsten Vrangbaek, Isabelle Durand-Zaleski, Reinhard Busse, Niek Klazinga, Sean Boyle, and Anders Anell
Germany
• Germany's system is based on public or social health insurance (SHI)
• SHI is mandatory for those with income less than €48,000 (this is about 75 to 80% of the population)
• The top quintile of income earners can opt in or out of SHI; 75% of these high earners opt in. (This matches up interestingly with the quintiles in the US, with the top 5% in Germany opting out of SHI it sounds like.)
• Also civil servants and the self-employed are excluded from SHI and make up the bulk of the 10% of privately insured individuals. (I don't understand the rationale of excluding the self-employed or, for that matter, civil servants except that I presume they just get these benefits paid for by the government anyway.)
• SHI covers the usual healthcare plus dental and drugs and more.
• Cost-sharing occurs through co-pays for outpatient visits, drugs and dental care. Apparently this is new since 2004. Cost-sharing max-out is 2% of income. Out-of-pocket expenses account for 13.8% of total health expenditure.
• SHI is operated by over 200 competing health insurers and these are called "Sickness Funds".
• The Sickness Funds are all autonomous and nonprofit but regulated.
• Funding comes from the employer at 8% of gross up to €43,000 and from the employee at 7% of gross.
• For those not in SHI, the sickness funds set rates but in 2009 the government will collect and regulate this as well. After 2009 the government will distribute to sickness funds based upon risk adjustment mix of their clients.
• Interestingly, private health insurance rates cannot change once you have been accepted into the plan.
• Private health insurance accounts for less than 10% of the total health expenditure of Germany.
• Physicians receive fee for service plus "fees per time period" (the latter sounds like capitation). Just a note here to refer to the NPR story about the fee-for-service money running out towards the end of every quarter
• Hospital-based physicians are salaried.
• Hospitals are split up into about 1/2 public, 1/3 private nonprofit and 1/6 private for-profit. The latter for-profit segment is apparently growing at this time.
• Hospital reimbursement is now a DRG based.
Summaries of summaries of healthcare systems based on the Commonwealth Fund reports.
Author(s) of the originals are:
Karsten Vrangbaek, Isabelle Durand-Zaleski, Reinhard Busse, Niek Klazinga, Sean Boyle, and Anders Anell
France
• 79% of all care is publicly financed
• Employer and employee payroll taxes account for 43% of the funding. The employer pays 12.5% of payroll and the employee pays 0.75% of payroll.
• Part of the national income tax goes to funding health care and accounts for 33% of the funding.
• Tobacco and alcohol taxes supply another 8% and state subsidies and other social security taxes provide another 10%
• Coverage includes everything except dental and eye.
• Cost-sharing occurs through coinsurance and co-pays and extra/balance billing
• Out-of-pocket expenditures account for 7.4% of the total health expenditure
• Private health insurance accounts for 12.8% of the total health expenditure
• The public funding goes to public health insurance funds with membership based upon occupation
• Benefits/prices/cost-sharing levels are determined, since 2004, by the national Union of health insurance funds (UNCAM)
• Low income persons also get free complementary-supplementary coverage including dental and eye and they qualify for no balance billing
• Private insurance is like our supplemental policies. It reimburses for the cost-sharing elements of the national plan. This is usually provided by employment-based insurers called "mutuelles" . 90% of the population gets this. So far there is only a minimum competition in this market.
• Physicians, non-hospital-based, are self-employed and fee-for-service. Hospital-based physicians are salaried.
• Two thirds of hospital beds are either government-owned or nonprofit.
• One third hospital beds are private located in for-profit clinics and, I believe, in hospitals as well.
• Hospital reimbursement is moving to a DRG style system. Hospitals do get subsidies for research and teaching and emergency care.
• There are some cost controls in place. Controlling formularies a big issue at the present time according to my interview with Dr. C'alloch in Paris.
Summaries of summaries of healthcare systems based on the Commonwealth Fund reports.
Author(s) of the originals are:
Karsten Vrangbaek, Isabelle Durand-Zaleski, Reinhard Busse, Niek Klazinga, Sean Boyle, and Anders Anell
Denmark
• The health-care system of Denmark covers all regular healthcare
• Insurance is universal and compulsory
• Cost-sharing occurs in dental and corrective eye care and drugs
• Out-of-pocket costs account for 14% of the total health expenditure
• There is a safety net for the poor and the chronically ill to limit their expenses
• The system is publicly financed
• Federal tax of approximately 8% of taxable income goes into the fund; this accounts for 82% of total health expenditure
• Private or complementary insurance is available. 30% of the population buys this through not-for-profit Danish Health Reimbursement Scheme plus some others. This is often a fringe benefit for employees.
• The system is organized into five regions. Each region owns and runs hospitals skilled nursing facilities etc.
• The various regions finance the practitioners dentists and "pharmaceuticals" (? Pharmacists)
• It was not clear to me whether practitioners get fee-for-service or rates or if they are able to negotiate.
• Some professionals, I'm not sure which, our salaried-perhaps hospital and clinic-based.
• Hospital-based physicians are salaried.
• Other physicians have a capitation arrangement which accounts for approximately 30% of their income plus fee-for-service for the rest.
