A pretentious title, and a long diary. As one of the 6 million Americans living abroad, my expertise is as a patient here for many years + a little web-searching. I’ve been thinking of diarying my experiences with the system in Norway; YoyogiBear beat me to it with a good diary on the Japanese system. Perhaps others will follow suit from other countries.
In short, with the exception of dental, visual and physiotherapy for adults, some prescriptions and a limited co-pay, our health care is paid for by our taxes. Hospitalization is free. All residents are covered, as are citizens of EU and certain other countries.
First, the limited co-pay thing. When you visit a doctor (about US$25) or fill an approved prescription for the first time at the beginning of a calendar year, you are issued a "receipt card". You present this card at future appointments, tests and purchases until you’ve paid the limit for the year as decided annually by Parliament; for 2007 it’s US$275. You're then issued a "free card" and don’t have to pay for these things the rest of the year. Most people never earn a "free card" most years. When the "receipt cards" for all children in a family (under 16) plus one of the parents, combined, reach the same limit, each of them is issued a "free card".
Travel expenses outside the immediate area are also refunded, if one bothers to save the documentation. I usually don’t, but people in rural areas who have to follow a child to a specialist in a city do appreciate that feature. It includes hotel expenses, if necessary.
The Essential GP
Norwegian GPs are the gateway and the spine of the system. They are their patients’ agents within the various health and welfare services and refer patients to specialists. Some few have private practices, and they can charge as much as they like. Most are self-employed and under contract to the government. They each have a list of patients, maximum 2500 names though most have chosen a lower number, and are paid a sum (presently about US$50 per year) by the local government for each name on that list. They can only charge the approved amounts for visits and procedures and are otherwise reimbursed fee-for-service by the government.
The system of doctor’s lists was new in 2001 and all residents were encouraged to choose a doctor; we can change to another doctor up to two times per year. The system is voluntary for the patients, and 98% of us have chosen a GP. I’ve been going to mine for more than 15 years, and I was quick to sign up, fearing he might fill up his list. This system was chosen to encourage an enduring doctor/patient relationship and to discourage doctor-shopping. Patients have the right to a second opinion from another GP.
Most doctors other than GPs are salaried by publicly owned providers, though there are many specialists in private practice. Some of them have government contracts.
Prescriptions
There are three categories of medications. Non-prescription medications are not price-regulated. The patient has to pay for prescriptions on the "white" list - these are non-essential or for short-term use and price is standardized. Necessary medications for chronic conditions, the "blue" list, are subsidized (64%) until the patient has a "free card" and free after that.
Direct-to-consumer advertising of prescription drugs is not allowed in Norway.
Some International Comparisons,
countries almost randomly chosen, with apologies to a couple of continents. These figures are from the UN's Human Health 2005 (PDF).
A) The first figure is Life Expectancy at Birth, 1980-1985.
B) The second is Life Expectancy at Birth, 2000-2005.
C) The third is the Number of Physicians per 100,000 population, including those in teaching and research positions as well as in practice.
D) And the fourth figure shows health-care expenditures, government spending as % of total, 2001. (Private spending includes expenditures by prepaid plans and risk-pooling arrangements.)
A B C D
World 61 65 157 55
Japan 77 82 201 78
Australia 75 79 249 68
India 55 64 51 51
Iraq 62 61 54 32
USA 74 77 549 44
Germany 74 78 362 72
Norway 76 79 356 86
Health Systems in Transition
World Health Organization puts out reports called HiT, so far for four dozen countries, not including the USA. The one on Norway (2006) is a 187-page PDF. Much of the info which follows is from that report.
The health care system is organized on three levels, and has been increasingly decentralized the last decades. The national level has overall responsibility including maintaining the principle of equal access to public services and, in practice, delegating power and the most of the funding to the lower levels. The five regional health authorities have responsibility for specialist health care and the teaching hospitals. The 431 municipalities (counties) are responsible for primary health care including home nursing and nursing homes. In 2003, government health care expenditure was 10.3% of GDP, $3572 per capita. The average among EU member states which joined before May 2004 was 9.0% of GDP.
Changes in the systems for funding and management of hospitals the last 10-15 years have lead to reduced waiting lists. We now have a wait list guarantee: a patient accepted for major treatment such as surgery is guaranteed a time limit, a deadline for the system. The government pays for treatment in a private or foreign hospital if the deadline cannot be met. Patients have many other rights, too much to try to cover here.
Tuition for students of medicine, as for other students, is paid for by the government. Student loans are usually necessary for equipment and living expenses.
Private profit-making providers play a small role: 2% of somatic hospital beds, 3% of nursing homes, many radiology and laboratory services which supplement the government-owned capacity and the pharmacy chains. Most of the services are paid for by the government, but long-term nursing care must be paid for by the patients, up to around 80% of their incomes, usually their pensions.
The government and the citizenry are committed to ever-improving health care. To illustrate: GDP growth 1990-2001 was 2.8% and in the same period the real annual per capita growth rate in health spending was 3.5%.
Health Expenditure by Function, percent:
Inpatient and day cases of curative care, 28.6
Outpatient curative care, 17.7
Inpatient long term nursing care, 15.2
Medical goods dispensed to outpatients, 13.9
Long term nursing, home care, 7.5
Capital formation of provider institutions, 7.2
Clinical laboratory and diagnostic imaging, 3.3
Prevention and health administration 2.8
Patient transport and emergency rescue, 2.3
Rehabilitative care, 1.4
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Some Personal Experiences
The last 3-4 years I’ve had one CAT scan at a hospital, another scan and an MRI at two different facilities and one x-ray at a private for-profit facility. The wait to get in was from 4 to 14 days, the price I paid was from zero to $30.
One doesn’t have to remember to schedule such recommended tests as mammography - one is automatically sent an appointment at recommended intervals.
I have a chronic sleep-phase disorder. (My blog.) My specialist is an MD and PhD; I see him every 6th week. I pay him the specialist fee of $30 until I’ve earned my free card. He’s not exactly in the neighborhood, so transportation is covered at bus fare rates. When he ordered my free (long term loan) light therapy lamp, I was surprised to see that it was delivered by taxi one rainy day a good week after the order was sent.
Home nursing visited my elderly, mostly bedridden, downstairs neighbor five times a day. When all the windows and outside doors in this building were going to be replaced, a very noisy and chilly process, I informed her GP (coincidentally also my GP). Two days later she was moved to a nursing home for three weeks. (As usual after such visits, she came back somewhat fattened up and more mobile.)
‘Twould be very nice if dentistry and glasses were included! Oh, and the physiotherapists have long waiting lists in spite of the expense. I’ve otherwise no complaints.