In a world where lives are being unnecessarily lost in broken healthcare systems, and governments are moving achingly slowly to react; we need optimized health systems, drawing on global best practice, and for them to be enacted urgently by capable tech companies such as Amazon, Carbon Health and Aledade. Amazon is notable for its global scale and last-mile delivery, Carbon Health for its advanced EHR capabilities, and Aledade for bringing together independent primary care practices to improve care in communities.
I am an eye-witness, as a practicing UK GP, to a system past its breaking point. When I imagine what really good healthcare looks like, I ask myself where in the world health systems are working effectively, or at least parts of them, and what can we learn from those countries. Whilst many global health system rankings are available: WHO, Bloomberg and King’s Fund to name a few, there is no gold standard framework to compare countries. There is a missed opportunity for tech to universalize best practice, and leverage big data in an era of exponential compute. In this article, I take a magnifying glass to quality indicators including access, affordability, healthcare inequalities and population health, staffing and equipment, and patient and provider experience to discuss how we can shape up. I start in the UK and then delve into health systems across the globe, namely Australia, Japan, Sweden and Singapore.
Chart 1: Comparison of Countries
United Kingdom
Let’s start with my home turf. The UK National Health Service (NHS) was born out of the trenches of World War II; envisage food rations, a harsh winter, a shortage of housing and widespread tuberculosis. Seventy-five years on, the NHS has remained largely a single-payer system, funded by taxpayers and free at the point of use. All residents register with a primary care (GP) practice and practices receive a capitated fee per patient. Further payments are received for improving health outcomes, and the provision of enhanced services such as contraception and immunizations. Antenatal care, social care (for those under an income threshold), and population health initiatives such as cancer and cardiovascular screening are covered. Integrated Care Systems bring together primary care practices, hospital groups and community services in regions of around 1.5 million patients to collectively manage care. Around 13% of the population has private medical coverage which does not include emergency care.
The UK healthcare spend is 11.94% of GDP, while average life expectancy is 81.77 years; and the maternal mortality rate is 10 women per 100,000 live births (Chart 1). For patients, there is dissatisfaction due to long waiting times for secondary care appointments, delays in assessment and treatment for suspected cancer referrals, and prolonged ambulance waiting times. Equipment wise, there are relatively low numbers of CT and MRI scanners contributing to delays. Clinician burnout is high, and morale is low due to unmanageable workloads and low compensation. There is a significant shortage of GPs and nurses, and many have been replaced by allied health professionals to reduce costs. Sectors such as dentistry have become largely privatized. The system is not accessible and health outcomes are declining. This health system is in need of increased funding, attention to skilled workforce retention and more opportunity for people to directly access care without an initial appointment with their GP.
Australia
On to the Southern hemisphere now, to Australia. Touted as one of the best health systems in the world, Australia has a federal health insurance program for everyone, known as Medicare. It covers public hospitals, medical services and prescriptions. The Medicare Benefits Scheme covers medical services and the Pharmaceutical Benefits Scheme covers medicines. The government sets the fees for GP and specialist appointments, and pays 100% of GP fees and 85% of specialist fees. Patients are required to pay the remaining 15% of specialist fees plus any surcharges — although primary care and secondary care can charge above the set fees, out-of-pocket fees are capped at USD $57.00 per service. Up to 50% of the population has private hospital coverage and private general treatment coverage for their out-of-pocket costs and for a greater choice of providers. Antenatal care is mostly funded by Medicare. Immunizations are covered for targeted population groups and there is a national cancer screening register which invites those who are eligible for free screening.
Australia’s health spend is approximately 10.65% of GDP, the average life expectancy is 83.94 years. Maternal mortality rate is very low at 3 deaths per 100,000 live births (Chart 1). Like the UK, primary care is the gatekeeper, creating an access problem. Notably, all citizens have a national health record, which includes their medical notes, prescriptions, referrals, and diagnostic imaging reports; invaluable for patients to keep track of their health and care.
Japan
Crossing the Pacific Ocean now to Japan. Japan has a statutory health insurance program which can either be in the form of an employment-based plan or a residence-based plan (for the elderly and unemployed). The government sets the fee schedule for these plans and pays at least 70% of medical fees. The remainder is paid for by the patient, or the government according to the person’s age and family income. Over 70% of the population has a secondary, voluntary health insurance to cover individual contributions and out-of-pocket costs. Antenatal care is subsidized and immunizations are covered. Cancer screening is chargeable at a subsidized rate or free for target populations. There is no system of GPs, patients go straight to a specialist of their choice, and hospitals are run by physicians as non-profits.
Healthcare spend in Japan equates to 10.9% of GDP. Japan has one of the highest average life expectancies in the world, at 85.03 years. Meanwhile it has a low mortality rate from cancer and ischemic heart disease and a low prevalence of obesity. This is associated with dietary patterns, including a low intake of red meat, and a high intake of fish, plant foods and sugar free beverages such as green tea. Community wide physical activity interventions have been introduced to encourage older adults to keep active and stay healthy.
Maternal mortality is low at 4 deaths per 100,000 live births (Chart 1). Whilst there are relatively higher numbers of CT and MRI scanners, the lack of GPs means that there is a shortage of specialist doctors, and low risk patients with minor ailments are flooding the system. There are also horror stories of ambulance crews being turned away by hospitals due to bed shortages. This is due to low hospital reimbursement rates and hospitals needing to maintain high occupancy rates to stay afloat. Unfortunately, despite community diet and exercise interventions for healthier living, intergenerational cohabitation is declining and levels of loneliness are high.
Sweden
Over to Scandinavia now to Sweden, famously ranked number 6 in the world happiness ratings. Although Sweden provides universal and automatic healthcare coverage, there are co-pays to be made. Fees are approximately USD $16-33 for a GP visit, $22-44 for a specialist visit and $11 per day for the hospitalization of an adult. Total consultation fees are capped at $120, and prescription fees are capped at $246 per person per year. In Sweden, the political agenda is determined at national level, whilst care is financed and delivered at regional level via county councils. At the local level, municipalities provide social welfare services, such as hospital discharge care for the elderly. Around 13% of employed residents have private supplemental health coverage, largely to access private specialists. Value-based care involves a tendering process between regions and private providers. Antenatal care and postnatal care is government funded. Like the UK, payment models include global budgets, volume caps, capitation formulas and contracts. Akin to Australia, Sweden is described as a world leader in e-health with an electronic health record for all residents.
In Sweden, health expenditures account for approximately 11.28% of GDP and life expectancy is 83.33 years (Chart 1). Maternal mortality is 5 deaths per 100,000 live births and there is a dedicated system for investigating incidents in maternal care. Notably, parents in Sweden are entitled to 480 days of paid parental leave when a child is born or adopted. Each parent – if there are two, is entitled to 240 of those days. It has been suggested that making parental leave non-transferable between partners would help to promote equality among genders.
Singapore
Onwards to Asia, to Singapore which has a multiplayer healthcare financing arrangement. Here multiple schemes pay for healthcare: 1) MediShield Life, a mandatory universal basic healthcare insurance that provides protection against large medical bills; 2) Medisave, a national medical savings scheme with personal and employer salary contributions (used to cover out-of-pocket expenses) and; 3) MediFund a government fund for individuals who are unable to cover their out-of-pocket expenses with MediSave. Primary care appointments are subsidized to around USD $9.60 per visit for an adult and $5 for children or the elderly. Specialist appointments are also subsidized and cost around $28.60. MediShield Life insurance is for larger hospital bills and requires the policy holder to pay an annual deductible of $1,095-2190 and then co-insurance which is 3-10% of remaining balance. The deductible and coinsurance can be paid from an individual’s Medisave account. Additional grants and subsidies are available for assistance with daily living. Around 60% of residents report being satisfied with the health system in 2019.
Singapore health expenditure is only 6.05% of GDP, life expectancy is high at 84.07 years, and maternal mortality rate is low at 7 per 100,000 live births (Chart 1). IT systems are integrated across healthcare organizations, and a dedicated Integrated Care Agency provides care-coordination in the community. Like Japan, there is a Health Promotion Board for health policies around school and workplace health, healthier food products and disease prevention programs.
Conclusion
Drawing on the best practice and lessons learnt from each of these systems, I reflect on what a more optimized system would look like, and of the gap that digital health companies can urgently fill.
Few would disagree that a national level health service should be available to all of a country’s residents, including: primary care, contraception, immunizations, urgent and emergency care, health promotion, cancer screening and disease prevention programs. Access to good healthcare is not just for the employed, or the elderly, or those with certain chronic diseases. Healthcare cover when tied to employment creates an access problem for the unemployed; unfairly binds people to their jobs and creates inequality due to varying benefits between employers. It puts pressure on employers to provide competitive benefits, and on employees to contribute to premiums and copayments. In the US where healthcare is largely employer rather than government sponsored, medical bills are the leading cause of bankruptcy. Japan navigates this problem with a residence-based insurance plan for those who are unemployed or are elderly. Nevertheless, government funded national health insurance programs are essential to make healthcare equitable. Digital health companies have the opportunity to contract with governments to deliver core reimbursed healthcare services to its residents.
As we have seen in the UK and Australia, making GPs the gateway to primary care leads to an unmanageable workload in primary care and clinician burnout. The introduction of allied roles to address the workload challenges in primary care has perpetuated the burnout of GPs who supervise these roles on top of caring for patients. Not having GPs at all, as in Japan, leads to minor ailments flooding the system and delays in care for those who need it most. Interestingly in Denmark, there are two public insurance options: Group 1 (98% of policies) where GPs act as gatekeepers and patients need a referral to be seen by specialists and; Group 2 (2%) which allows access to specialists without a referral, although copayments apply. In my view, a primary care first model works best, with the addition of direct access to secondary care for certain conditions -to better manage demand, leverage expertise and prevent delays in care.
People need to be able to access their electronic health records, to understand their health better and make informed decisions about their care. National electronic health records that move within and across health systems and even across countries will be the key to solving this. Digital health companies meeting data privacy and security requirements have the opportunity to own the relationship with the patient and to a deeper extent than patients have with their clinicians. Data sharing across health care organizations in secure networks enables cross organization collaboration and better coordination of care. There needs to be more functionality in patient held records, for people to book and view appointments, view their consultations, view their laboratory and imaging results, request their medication, gain insights from their personalized health data, learn about community services, compare services and pay for out-of-pocket costs. The personal health record is essentially the key that enables people to do more for themselves.
Investment in population health, health promotion, disease prevention and cancer screening leads to a reduction in health inequalities and in turn healthier residents with reduced long-term costs of care. We need to implement national health promotion and disease prevention programs at regional and national level, including education around diet, alcohol and smoking. We also need to see policy change and funding for nutritionally balanced meals including whole foods, and a reduction in ultra-processed foods and sugar beverages. More awareness and attention from health systems needs to be given to regular exercise, sleep and positive relationships: an important partnership opportunity for digital health companies.
Table 1: Comparison of Costs (estimated)
How much should we be paying for healthcare? It is a difficult question (See Table 1). The single-payer National Health Service may be equitable, but it is not accessible. UK citizens with relatively low out-of-pocket expenses, have little control over the quality of services that their taxes are spent on, and system-wide failures have led to a tier 2 service for everyone. Healthcare systems in Australia, Sweden and Singapore have government funded healthcare plus income-assessed, subsidized, out-of-pocket costs. These costs are funded with supplemental coverage or a national medical saving scheme. Whilst un-popular, out-of-pocket fees go some way to giving consumers autonomy to make decisions about the care they receive from specialist to hospital, and the capping of out-of-pocket expenses protects consumers from exorbitant fees. If there is an out-of-pocket contribution to be made to a health system, it needs to enable choice, be comprehensive, easy to understand, price transparent and affordable.
Health plans provide a more accurate way of predicting costs across medical services and prescriptions, with the provision to combine multiple payers, including government, employers and individuals. As more and more care moves into the community, health plans will need to provide hospital-at-home services, social care support and out-of-hours cover for elderly people and those with complex care needs. Cross organization collaboration and data sharing will reduce the acute deterioration of patients in the community and subsequent unplanned hospital admissions. Wider determinants of health and those who are digitally excluded must be recognized.
Maternal mortality in the US is alarmingly high at 21 deaths per 100,000 live births. Government funded maternal care is associated with lower maternal death rates. In the US, 41% of births in 2021 were financed by Medicaid, whilst in Sweden and Australia, government funding or subsidies for antenatal care, childbirth and postpartum care were available to all resident women. Investigations into maternal deaths are important as is the retention of highly skilled staff. Shockingly in the US, up to 23% of employed mothers return to work within 10 days of giving birth, to pay for their expenses. Paid maternity leave needs to be a national health program not an exclusive employee benefit. Health outcomes associated with paid maternity leave include: lower rates of post-partum depression; improved attachment and child development; lower re-hospitalization rates of mothers and infants and; lower infant mortality.
Whilst some countries do better than others, no country has it all. Digital health companies can leverage big data to learn from global best practice. From electronic health records, to national cancer screening programs to comprehensive health plans; tech companies can seize the opportunity to work with health systems to deliver regional and country-wide standardized care. Now is the time to build platforms that take into account the local health needs of communities and deliver valuable care at scale.
Editor’s Note: The author has no financial relationship with any of the companies named in the article.
