Monday, September 21, 2009

The Norwegian System

Today we lay out the case for the Norwegian Healthcare system and again taken from the CATO institute. The Grass Is Not Always Greener: A Look at National Health Care Systems Around the World Michael D. Tanner Cato Institute: Policy Analysis

Norway

Norway has a universal, tax-funded, single payer, national health system. All Norwegian citizens, as well as anyone living or working in Norway, are covered under the National Insurance Scheme. Norwegians can, however, opt out of the government system by paying out of pocket. In addition, many Norwegians go abroad for treatment to avoid the waiting lists endemic under the government program. (151)

The system is financed through general tax revenues, with no earmarked or dedicated tax for health care. (152) Thus, health care becomes one large contributor to a tax burden that consumes 45 percent of GDP. Among industrialized countries, only Sweden has a higher tax burden. (154)

Benefits are extensive and include inpatient and outpatient care, diagnostic services, specialist care, maternity services, preventive medicine, palliative care, and prescription drugs. At public hospitals, there are no charges for stays or treatment, including drugs. However, small co-payments may be charged for outpatient treatment and for treatment by a general practitioner, psychologist, or psychiatrist. The program also provides “sick pay” and disability benefits. (155) As Michael Moore has noted, the Norwegian system will even pay for “spa treatments” in some cases. (156)

Although the central government retains overall responsibility for and authority over the system, some management and funding responsibilities have devolved to regional and municipal governments. In general, municipal governments are responsible for primary health care, while four regional health authorities are responsible for specialist care. (157) Prior to 2002, public hospitals were run by local or county governments. In the face of chronic problems, notably long waiting lists and rising costs, the central government took direct control of all public hospitals in January 2002.(158) A small number of private hospitals do exist outside the public system.

The government sets a global budget limiting overall health expenditures, and setting capital investment expenditures for hospitals. Most general practitioners and physician specialists outside hospitals receive a fixed salary, although some specialists working on a contract basis receive both an annual grant and fee-for-service payments. Reimbursement rates are set by the government and balance-billing is prohibited. Most other health care personnel are salaried government employees. (159)

Patient choice of physician is constrained. All Norwegian citizens must choose a general practitioner from a government list. The GP acts as a gatekeeper for other services and providers. Patients may switch GPs, but no more than twice per year and only if there is no waiting list for the requested GP. (160) Specialists may only be seen with a referral from the GP.

The Norwegian health care system has experienced serious problems with long and growing waiting lists.(161) Approximately 280,000 Norwegians are estimated to be waiting for care on any given day (out of a population of just 4.6 million).(162) The average wait for hip replacement surgery is more than four months; for a prostatectomy, close to three months; and for a hysterectomy, more than two months.(163) Approximately 23 percent of all patients referred for hospital admission have to wait longer than three months for admission.(164)

The Norwegian government has responded by repeatedly and unsuccessfully attempting to legislate waiting lists out of existence. For example, under the 1990 Patients’ Rights Act, patients with a condition that would lead to “catastrophic or very serious consequences” have a right to treatment within six months, if the treatment is available.(165) In 2001, after several government reports had documented repeated violations of this policy, the government passed a new mandate requiring that a patient’s medical condition be at least “assessed” within 30 days.(166) Despite these paper guarantees, waiting lists have not been substantially reduced.(167)

Moreover, such delays may represent only the tip of the iceberg when it comes to rationing care in Norway. In some cases, care may be denied altogether if it is judged not to be cost-effective. As Knut Erik Tranoy, Professor Emeritus at the Centre for Medical Ethics of the University of Oslo and an original member of the government’s Health Care Priorities Commission, explains:

It is important to see (a) that, in a public health service of the Nordic type, any given amount of resources always has alternative uses. And (b) it is neither medically nor morally defensible to put scarce resources to uses which will foreseeably yield less favorable outcomes than other uses—save fewer lives, cure fewer patients.(168)

Tranoy differentiates between Norwegian style systems of national health care and “a health care system where patients buy services in a market, and where justice means equality of opportunity to buy what you need. Decisions about alternative use are then (largely) patients’ decisions.”(169)

While Norwegians generally report that they are “fairly satisfied” with the way their health care system is run, there has been growing discontent over such issues as the ability to choose a health care provider, involvement in decisions regarding care or treatment, and waiting times—which has been an ongoing issue in Norwegian politics. (170) However, at this time there doesn’t appear to be any widespread movement for larger reform.

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