Models and forms of health care financing
Great Britain - system of provided care by pharmacists Provided
services by pharmacists
WWHAM protocol
SYLLABUS of 4th LECTURE
4. 11. 2019
PharmDr. Bc. Dana Mazankova, Ph.D.
Models of health care financing
1. The Beveridge Model
• health care is provided and financed by the government through tax payments
• state budget
• National Health Service
▫ medical treatment is a public service
- many hospitals are owned by the government
- some doctors are government employees
- government controls costs as the sole payer
• Great Britain, Spain, most of Scandinavia, Estonia
• New Zealand, Hong Kong
• U.S.A. - Department of Veteran Affairs
• Cuba
2. The Bismarck Model
- healthcare is provided and financed by insurance system through insurance companies
- compulsory public health care insurance
- financed by employers and employees - payroll deduction
- the insurers are called “sickness funds”
- the plans cover everyone
- doctors and hospitals are private
- cost control: regulation of provided medical services and fees
• Germany, France, Austria, Belgium, Netherlands, Switzerland, Czech Republic, Slovakia, …
• Japan
• Greece
• Latin America
3. The National Health Insurance Model
- healthcare is provided and financed by government-run insurance program that every
citizen pays into
- compulsory public health care insurance operated by state
- National Health Insurance plans:
- providers are private
- government has considerable market power to negotiate lower prices
- cost control by:
- limiting the medical services they will pay for or
- making patients wait to be treated
• Canada
• Taiwan, South Korea
4. The Out-of-Pocket Model
- provided healthcare is financed by:
- direct payments
- private insurance
• USA
- government - selected group of patients:
I. Medicare
II. Medicaid
III. Department of Veteran Affairs
• Belarus
• rural regions of Africa, India, China and South America
- absence of insurance or government plans
- people recieve medical care if they can pay the bill out-of-pocket at the time of
treatment
Forms of health care financing
Health care financing according to type of payer
Non-direct payments - payments by 3rd side
Direct payments - payments by patient
Health care financing according to structure of health care facility and
principle of payment
Payment per capita, capitation
- prospective fixed payment
→ ratio of registered patient according to age
• primary care physicians: general physicians (for children, for adults)
Fee for service
- payment per provided service, retrospective
- Tarif of Health Services with point valuation
• secundary care physicians: ambulatory specialists (allergologist, orthopaedist,
dermatologist, ophtalmologist, ..)
• hospitals – only partly
Budget (fixed payment tariff)
- in advance specified (settled) budget for hospital, prospective
- historical budget
• tertiary care: hospitals
Presently, there is tendency to move to more effective systems of financing hospitals:
DRG system
Diagnosis Related Groups (DRG system)
- financial limits for the diagnosis
- clinical and economical homogenous groups / cases = Diagnosis Related
Groups
- average duration-of-stay
- MDC (Major Diagnostic Categories)
• tertiary care: hospitals
Payment for drugs
- covered drugs
- reimbursement from health insurance company
- non-covered drugs
- direct payments
Pharmacists – payment for pharmaceutical care (Fee for service)
Great Britain
- provided heath care payed by: National health Service (NHS)
- funding for the NHS comes directly from taxation
Payments for pharmacists from NHS:
1. Drug reimbursement:
2. Fixed payments:
3. Payments for provided services
(4. Direct payments from patients)
Provided services by pharmacists in UK
Medicine Use Review (MUR) Service
- pharmacist control of patient's used drugs
- limit: 1 patient / a year
New Medicine Servis
- asthma
- chronic obstructive pulmonary disease (CHOPD)
- type 2 diabets mellitus
- high blood pressure
- people who have been given a new blood-thinning medicine
- limit: 3 appointments (per 10-15 minutes)
Pharmacy First Advice
- treatment of minor ailments
- patient receive pharmacist's consultation and 1 OTC
- limit: 1 patient can receive 1 OTC / indication, maximum 3x per 6 months
Smoking Cessation Service
- limit - within 1 week: 6 appointents, 1 OTC (nicotine gum, patches, …)
Supplementary and independent prescribing
Flu jab
- Flu vaccination by injection (annual injection)
- Flu nasal spray vaccination (annual nasal spray)
Exchange needle
Methadon program
- for drug addicted
And many other pharmacist 's services…
WWHAM protocol
- mnemonic used by pharmacists to gather information to help them in
diagnosing a patient's presenting complaint
The WWHAM Pathway
01: Listen
02: The way you say it
03: The WWHAM Questions
• W: Who is the medicine for?
• W: What are the symptoms?
• H: How long have you had the symptoms?
• A: What action has been taken?
• M: Are you taking any other medication?
04: Check your understanding
05: Recommend or Refer?
06: Final words