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most of the world has centralized care

Heritage:  Healthcare in Other countries

Denmark. The Danish health care system is completely state-funded, with public provision of hospital beds representing more than 90 percent of the hospital sector. Under the Healthcare Act, citizens are covered for all or part of expenditures for treatment, including reimbursement for all pharmaceutical products listed with the Danish Medicines Agency. Therefore, there is no need for price regulation of drugs. With central and municipal government having significant control of the funding and provision of health care, the acquisition of new technology is left initially to the five regions that run the hospitals.

Denmark's national HTA system was explicitly established on the basis of its making prioritized resource-allocation decisions. Carried out by the unit known as the Danish Centre for Evaluation and Health Technology Assessment (DACEHTA), it operates within the framework of the National Board of Health (NBH), itself a part of the Danish Ministry of Health.[26] In reality, this means that "[t]he Ministry keeps a close watch on it in order to neutralize 'expensive' healthcare technologies, as their adoption results in requests for extra funding from the regions."[27]

France. In France, health care is a statutory right enshrined in the Constitution of the Fifth Republic. Unlike in Denmark or the United Kingdom, however, French health care is financed mainly by social insurance and delivered by a mixture of public and private providers. While two-thirds of French hospitals are state-owned, one-third are private, with half of the latter group being not-for-profit.

There have been various attempts in recent years to extend government control of health care costs. In 1991, the French government extended its Health Map system by which it controls the capital construction of all hospitals as well as their budgets, the purchase of medical equipment, the rates charged by private hospitals, the number of pharmacies per head, and even the price of drugs.[28]

In 2005, the government went a stage further with the establishment of a centralized High Health Authority. While this body has had only a limited impact--and France continues to enjoy a comparatively higher diffusion rate for new technologies than is found in many other countries in Europe-- it is nevertheless designed to stipulate the benefits of medicines and determine their price-reimbursement levels. As such, it is set to raise the focus on cost-containment and bring its decision-making under closer state control.

Germany. As in France, health care in Germany is financed primarily by social insurance and provided by a mixture of public and private providers. While all services are contracted instead of being provided directly by the government, more than 10 percent of Germans opt for full private medical insurance.[29]   Providing a potent source of exit from the state, the regulated private sector puts pressure on the government to ensure that the sectoral differences in service do not become so wide that ever-larger numbers of young, high-income consumers defect by going private and delegitimizing a central pillar of the Bismarckian philosophy.

While the pressure to maintain some semblance of parity with the private sector meant that state spending rose dramatically for many years after the introduction of a formal reference pricing system in 1989, the strategic objective of the German Ministry of Health has been to reduce supply, particularly through the use of published positive and negative lists concerning medicines and treatments. Through these lists, pressure is applied to the statutory sick funds to control costs.[30]

It is in this context that health technology assessment has played an ever-greater role in German health policy since the 1990s. In 1990, the Office of Technology Assessment at the German Parliament (TAB) was established, and in 2004, the government set up the Institute for Quality and Economic Efficiency in the Healthcare Sector (IQWiG).

Tasked with the central goal of efficiency, IQWiG investigates and stipulates which therapeutic and diagnostic services are appropriate.[31]   Disseminating its pronouncements to various self-governing bodies, its information is used concerning the coverage of technologies in the benefits catalogue. With such ventures being funded primarily by the German Ministry for Health and Social Affairs, assessment bodies can refuse a hospital's claim for reimbursement for the unauthorized use of new technology.

Lessons for American Policymakers

There is a pervasive European mythology: a widespread belief that American health care is rooted in the free market. In reality, much of American health care is a highly planned, regulated, and government-funded system. Through major entitlement and welfare programs such as Medicare and Medicaid, which contribute to rapidly growing American health care costs, government takes a historically higher proportion of gross domestic product than does even the British NHS. Moreover, by virtue of the structure and financing of private-sector health insurance, there is little consumer control over health care dollars