1. New Zealand – The “Beveridge” Model

Other countries: UK, Cuba, Spain

How it works: Healthcare is provided and financed by the government. The government owns hospitals and clinics and doctors may either be hired by the government or privately but are paid by the government. 

Benefits: Universal coverage, lower cost of healthcare, fewer disparities

Drawbacks: Long wait times, limited available treatments/therapies, and lower $$ for doctors

Physician compensation: Paid by government. Average EM physician makes $71k-$120k

During COVID: NZ is so centralized so they were able to coordinate vaccine roll out and lockdowns well leading to relatively low caseloads. However, in the UK, another country with the model, the system became overwhelmed due to capacity limits.

Fun facts: Cuba is one of the most extreme examples of the Beveridge model but has really amazing health outcomes despite not being a high income country. 
You can do Locums in New Zealand. 

2. Germany – The “Bismarck” Model

Other countries: Japan, Switzerland, France

How it works: This system uses insurance companies, but the companies must cover everyone  and must be non-profit, and everyone must be insured. There’s also a lot of government oversight in how costs are determined. Employers and employees both pay into insurance. 

Benefits: Everyone is covered but patients still get to choose between competitors and providers

Drawbacks: Costs can be high, especially for employers

Physician compensation: usually salaried by private hospitals or fee-for-service. Average EM physician makes $213k yearly

During COVID: Robust healthcare infrastructure allowed for scaling of resources well, but navigating different insurance companies sometimes led to disparities

Fun facts: Japan has more private hospitals than the US! 

3. Canada – The National Health Insurance Model

Other countries: Taiwan, South Korea

How it works: Clinicians are private but health insurance is public and single payer. Every citizen contributes to health insurance via taxes.

Benefits: Universal coverage with fewer administration costs from being single payer

Drawbacks: Really long wait times and not great physician compensation

Physician compensation: Mostly capitation/fee-for-service. EM physicians can make about $100-$200k per year.

During COVID: South Korea and Taiwan were able to roll out vaccines efficiently, but Canada had logistical and funding issues.

Fun facts:  An Epipen is about $600 in the US. It’s about $80 in Canada thanks to the strong negotiating power of the single payer.

4. India? Ethiopia? Guatemala? Kenya? – The Out-of-Pocket Model

Other countries: Think really rich people in rich countries and most people in poorer countries

How it works: There’s no system really. No public insurance, a mix of private sector hospitals, and often a lot of care through NGOs and charity organizations.

Benefits: No overhead fees?

Drawbacks: Really horrible access to care and disparities

Physician compensation: Very little to none. Depends on who is employing the physician that is there.

During COVID: Many of these countries relied on NGOs for vaccination roll out. 

Fun facts:  All of the countries I listed aren’t entirely out-of-pocket. Many have started forms of government health insurance as a safety net but it’s mostly not reliable. In Kenya, I remember rounding and the attending telling the family member of a patient to go out and buy medication and return with it to administer it to the patient. 

5. So what’s the US?

Great question! We’re a hybrid model. For most people, we’re kind of like the Bismarck model with multiple private insurance companies (but our companies can be for-profit). For Indian Health Services/Veteran Services, you could say we’re the Beveridge, where the government is the payer and provider. If you’re using Medicare, we’re similar to the National Health Insurance Model of Canada, kind of? And if you’re uninsured or buying a bed on 11 West, you’re out of pocket. 

This leads to disparity, inefficiency, high overhead costs, and a confusing system so that whenever a patient in the emergency department asks us how much their care will cost, we always answer “I have no idea”. 

May 2024