2. The Association believes in free choice of location and type of practice by the physician. 3. The Association believes in fee-for-service practice, and believes the Medical Association should set the "normal" fees. 4. The Association is opposed to the assumption of economic risk by the patient as a result of illness. Principles (3) and (4) deserve close examination. Norway, like other Scandinavian countries, has a National Health Insurance system, which is part of a general system of social insur ance. Reimbursement for physicians' fees is made to the patient by the health insurance fund according to a fee schedule. (See Table A.) The Norwegian Medical Association publishes a parallel schedule of "normal" fees. (See Table B.) The health insurance reimbursement is generally about 70 percent of the "normal" fee. The Medical Association conducts informal negotiations with the Health Insurance Board every two years. At these informal sessions, new "normal" fees and reimbursement rates are negotiated. Because of Norwegian Medical Association princple Number 4, concern for the financial welfare of the patient, fees are not raised unless there is a proportionate use in reimbursement rate by the government. This system has been developed and worked well over the years. The language and general tone of this process are worth noting. The NMA prefers the term "normal" fee to "mandatory" fee. There is no statutory requirement that physicians adhere to the "normal" fee schedule. However, if a physician persists in charging more than the "normal" fee, the NMA takes action against the offending physician. Such action can include expulsion from the NMA. This policy, together with the refusal of the NMA to raise the normal fees unless the health insurance board can raise rates of reimbursement, has enabled Norwegian physicians to retain a high degree of independence compared to some of their Scandinavian colleagues. The NMA negotiating position attempts to maintain equality between the salary of a hospital physician and the income of a practicing physician working a comparable work-week. This basic principle guides their negotiations. Throughout their activities the recurring theme of the NMA is one of equity. Norwegian physicians are well-paid by Norwegian standards. They occupy a place of great prestige in Norwegian society, and in return recognize a responsibility on their part to their society as a whole. They act responsibly and in the public interest, and have in return, a substantial share of responsibility for determining health policy. The gearing of the "Standard Rates for the Norwegian Medical Association" to the rate of remuneration to patients for physician serv ices by the National Health Insurance Board is demonstrated by Tables A and B, taken from Norwegian Government publications. It is of interest to note that the proportion of the fee reimbursed by insurance increases as the number of consultations for a particular spell of illness increases. Patients requiring numerous professional consultations are, therefore, not penalized. TABLE A.-STANDARD RATES FOR THE NORWEGIAN MEDICAL ASSOCIATION (Suggested rates) Adopted by the Central Board June 19, 1970, Effective as of 3. Subsequent consultation with general practitioner.. 4. First consultation with specialist__ 15.00 40.00 5a. Second consultation with psychiatrist, children's psychiatrist and neurologist 35.00 b. Second consultation with other specialist__ 25.00 6a. Subsequent consultation with psychiatrist, children's psychiatrist and neurologist 25.00 7. Consultation by message, letter or telephone___ 7.00 8. Renewal of prescription, change of bandages etc. application of drops, swabbing, injections and urine tests without consultation at the same time 9a. Additional fee for psychiatric examination by psychiatrist or children's psychiatrist b. Additional fee for complete neurological examination by neurologist and neuro-surgeon---. c. Additional fee for complete examination by specialist in disability rehabilitation medicine, internal medicine, surgery, orthopedics or pediatrics 7.00 60.00 50.00 30.00 NOTE: A complete examination shall correspond to the first clinical examination of a patient upon initial admittance to hospital, with detailed case record, which shall include exact anamnesis, complete status praesens and any report ("epicrisis" that may have been sent to the physicians who referred the patient to the specialist, with an account of diagnosis, treatment and prognosis, if any, (About one hour's work) Rates 9b and 9c are applicable only when such examination has been made during the first consultation. Rates 9a, 9b and 9c may be charged again after one year. 10. Transcript of case record (no extra charge for consultation) kr. 10.00-30.00. 21. First home call by general practitioner__ Fee (Krona) 40.00 22. Second home call by general practitioner.. 35.00 30.00 24. Home call by specialist___ 60.00 25. 26a. Additional fee for psychiatric examination by psychiatrist or children's psychiatrist-- 60.00 b. Additional fee for complete neurological examination by neurologist_ 50.00 NOTE: The note under Section A is applicable in like manner to rates 26a and 26b. NOTE 1. The rates for consultations and home calls include: a. Simple tests, eg. uterine catheter tests, vaginal tests. b. Simple treatment such as: Intramuscular and intravenous injections of the usual medicaments. Anesthesia induced by swabbing, drops or freezing. Removal of surface foreign bodies in skin or mucuous membrane. Jaw luxation reposition and simple bandaging or rib fractures, ulcus cruris etc. Opening of minor abscesses, puncture of bursae, ganglions and hematomas. Vaginal swabbing. Tests for prescription of glasses. NOTE 2. Consultations and home calls are reckoned together. In the case for example, of two consultation followed by one home call for the same disease, the home call fee shall be computed on the basis of the rate for subsequent home calls. Consultations by message, letter or telephone shall not be counted. NOTE 3. After a period of three months from the last consultation or home call for the same disease, fee shall be charged as for a first consultation or home call. NOTE 4. For sickness which occurs during the course of another sickness, the fee shall be the same as for a new sickness, when the two are unconnected. However, for the same consultation or home call fee can not be charged for more than one sickness. NOTE 5. Where more than one person in a family are attended to at the same time, fee for home call and any travel and transport expenses shall be charged for one patient only. For the others the rates for consultations apply. This rule applies likewise to hospitals, pensions, homes for the aged, ships etc. Calls on patients in the house where the doctor lives has his office or works, or on ships where the doctor is or works, are counted as consultation. For large buildings in cities or urban districts the latter rule applies to home calls only in the apartments located in the same part of the building where the doctor has his office TABLE B.-REIMBURSEMENT RATES-NORWEGIAN NATIONAL HEALTH INSURANCE A. CONSULTATIONS 1. First consultation with general practitioner... Fee (Krone) 15.00 2. Second consultation with general practitioner.. 15.00 3. Subsequent consultation with general practitioner.. 4. First consultation with specialist-- 15.00 25.00 5a. Second consultation with psychiatrist, children's psychiatrist and neurologist 25.00 b. Second consultation with other specialist.. 15.00 6a. Subsequent consultation with psychiatrist, children's psychiatrist and neurologist 20.00 b. Subsequent consultation with other specialist. 7. Consultation by message, letter or telephone_.. 15.00 7.00 8. Renewal of prescription, changing of bandages, etc., application of drops, swabbing, injections and urine tests without consultation at the same time. 9a. Additional payment for psychiatric examination by psychiatrist or children's psychiatrist--- b. Additional payment for complete neurological examination by neurolo gist and neuro-surgeon_-_ c. Additional payment for complete examination by specialist in disability rehabilitation medicine, internal medicine, surgery, orthopedics or pediatrics 7.00 60.00 50.00 30.00 NOTE: A complete examination shall correspond to the first clinical examination of t patient upon initial admittance to hospital, with detailed case record which shall include exact anamnesis, complete status praesens and any report ("epicrisis") that may have been sent to the physician who referred the patient to the specialist with an account of diagnosis. treatment and prognosis (about one hour's work). Rates 9b and 9c are applicable only when such examination has been made during the first consultation. NOTE: Rates 9a, b and c will be paid once only for one and the same disease. After a period of more than one year from the last examination, payment may again be made on the basis of rates 9a, b and c. 26a. Additional payment for psychiatric examination by pschiatrist or children's psychiatrist_-- 40.00 b. Additional payment for complete neurological examination by neu rologist 60,00 50.00 NOTE: The note under Section A is applicable in like manner to rates 26 a and b NOTE 1: The rates for consultations and home calls include: a. Simple tests, eg. uterine catheter tests, vaginal tests. b. Simple treatment such as: Intramuscular and intravenous injections of the usual medicaments. Anesthesia induced by swabbing, drops or freezing. Removal of surface forei bodies in skin and mucuous membrane. Jaw luxation reposition and simple bandaging rib fractures. ulcus cruris etc. Opening minor abscesses, puncture of bursae, ganglions and hematomas. Vaginal swabbing. Tests for prescription of glasses. NOTE 2: The social security office may require that referral note from physician to specialist be produced for payment under the specialist rates. NOTE 3: Consultations and home calls are reckoned together. In the case, for example. of two consultations followed by one home call for the same disease, the home call will paid on the basis of the rate for subsequent home calls. Consultations by message, letter or telephone are not allowed for. NOTE 4: After a period of three months from the last consultation or home call for the same disease, payment will be the same as for first consultation or home call. NOTE 5: For sickness which occurs during the course of another sickness, payment w be the same as for a new sickness, when the two are unconnected. However, for the same consultation or home call payment can not be made for more than one sickness. NOTE 6: Where more than one person in a family are called on at the same time, payment for home call and any travel and transport expenses is made for one patient only. For the others, the rates for consultations apply. This rule also applies to hospitals, homes for the aged, pensions, ships etc. Calls on patients in the house where the doctor lives or has his office o works, or on ships where the doctor is or works, are counted as consultations. F large buildings in cit ies or urban districts the latter rule applies to home calls only in the apartments located in the same part of the building where the doctor has his office or home (For a more extensive description of aspects of the Norwegian Health Services system, see Appendix 6.) HEALTH CARE IN FINLAND The attitude of the Finnish people toward the responsibility of their society for the provision of health services is the most important fundamental difference between Finland and the United States in the health care area. Their philosophy comes through very clearly in Dr. Haro's paper. Description of Non-Quantifiable Aspects (By Dr. A. S. Haro) INTRODUCTORY REMARKS Information provided on health and health services for national and international purposes usually falls short of a systematic description of the health services system. One reason for this is that the description and analysis of a system requires special orientation in the social sciences which has not necessarily been among the tools of those compiling traditional statistics. There have been very few serious attempts at international comparisons of these aspects of health services and hardly any theoretical framework exists. Recently, however, especially in the context of international comparative studies and other international activities such as those connected with WHO, the need for more complete analytic descriptions of existing systems has increased markedly. While there are areas where pertinent information is lacking, enough data exists concerning some of the very basic aspects. Even they are meaningless, however, without a proper understanding of the values and attitudes which underlie the stated goals and working principles of the system. WHO, for example, publishes its report on the "World Health Situation" periodically, but nformation on systems is superficial and difficult to interpret. Any attempt to describe the "ideological" aspects of a system is vrought with many difficulties some of which are mentioned below: It is difficult to see the essential ideological elements of a system of which the observer is a part. It is, however, at least as difficult to describe objectively a system without having studied it thoroughly and without practical experience with the system. It is very difficult or even impossible to detect and present some ideas in an objective verbal form because they are not always conceptualized. It is difficult to avoid the fact that the observer's vocabulary and accepted terminology is biased due to his national and political traditions, educational background, etc. It is hardly possible to standardize this in such a way that the given picture would be perfectly correct from the reader's point of view. All "facts" concerning the non-material aspects of services are therefore only relatively reliable. Accordingly, it is appropriate to warn the reader before he addresses himself to this kind of study. THE ROLE OF SOCIETY IN THE HEALTH FIELD The Constitution of Finland contains no provisions concerning health or health related goals but the spirit of the law as well as long democratic traditions clearly indicate that health care is a natura right of the citizen and that society has an obligation to organize needed health services. The individual, on the other hand, haxa obligation to participate in the financing of services according to his capability. He must also participate in preventive or other measures which serve the common good. [Emphasis added.] Three main aspects which must be taken into account when one is attempting to evaluate the implementation of these principles are the quality of services, the volume of services and the proper distribution of services. In Finland health services consume about 6.1% of GNP at the present time. (In 1969 the GNP was $1940 per person.) No way of measuring qualitative comparisons exists, but standards accepted in other Scandinavian countries serve as guidelines in Finland. The volume of services is, of course, readily quantifiable. The third aspectproper distribution-has many facets which will be discussed in more detail later on. The agency legally responsible for organizing health services is the local authority (commune, municipality). Services provided by local authorities must fulfill minimum requirements laid down by the cen tral authorities, for these services are heavily subsidized by the central government (averaging about 50%). Local authorities have the right to levy income taxes and they can, or sometimes are required, to merge or cooperate in order to fulfill their obligations. Regional differences in the level of services should be as minimal as possible according to egalitarian values. Democracy and the independ ence of local communes has long been a cherished tradition in Finland. The citizen's freedom to choose his place of residence has also long been a cherished tradition. Great regional differences in population density and in economic activities make it difficult to achieve com plete uniformity in the quality and quantity of health services. There are great differences in this respect between urban and rural areas and between various regions. This is especially true in relation to ambula tory care, including that by general practitioners. The shortage of medical manpower is such that no acceptable solution for this problem is forseeable in the near future. The increased output of physicians is not estimated to fulfill even the most urgent needs for medical manpower until 1980. The Finnish Health Service is basically a public service, but it has not given rise to a monopoly by the public sector. Private practice is permitted for every physician, except the local G.P. employed by the commune and some higher ranking state health officers. A great many physicians, salaried by hospitals, have a part-time practice. Their charges are regulated by the professional organization of physicians, The health insurance agency compensates patients according to agreed upon schedules. Private hospitals exist and are legally sanctioned but |