SUPPLEMENT ARTICLE
Global Systems of Health Care and Trauma Dennis S. Lee, MD and Hassan R. Mir, MD, MBA, FACS
Summary: Health care policy continues to occupy the center of national debate in the United States. Exploration of international health care and trauma systems allows for better comprehension of our own policies. Four basic models of health care exist across the globe: Bismarck, Beveridge, National Health Insurance, and Out-ofPocket. Expectantly, disparities in trauma care necessarily follow inequities in overall health care and infrastructure. In this article, we aim to review several countries’ health care models and their respective trauma systems. Critical analysis of international solutions to deficiencies in overall health and trauma care may serve as a guide for issues in the United States. Key Words: international health, global health care, trauma, injury (J Orthop Trauma 2014;28:S8–S10)
INTRODUCTION Amid rising costs, millions of uninsured patients, and a fragmented infrastructure, health care policy in the United States continue to occupy the center of national debate. An understanding of health care and trauma systems abroad may provide insight into the volatile issues domestically. Review of the international community reveals several different health care models, each one a reflection of its nation’s history, politics, and culture. Four basic models exist: Bismarck, Beveridge, National Health Insurance (NHI), and Out-of-Pocket.1 Each has implications on how trauma care is delivered. Accordingly, examination of international health care models and their respective trauma systems provides context by which traumatologists can critically assess patient care in various populations within the United States.
THE BISMARCK MODEL The Bismarck model derives its origin from German inaugural chancellor Otto von Bismarck.2 In its classic form, the Bismarck model is comprised of privatized health care providers and insurance companies. Although privatized, the insurance companies are mostly nonprofit, highly regulated, and offer universal coverage.1 Germany’s current health care system continues to follow the Bismarck model, with Accepted for publication July 17, 2014. From the Division of Orthopaedic Trauma, Department of Orthopaedics and Rehabilitation, Vanderbilt Orthopaedic Institute, Nashville, TN. H. R. Mir is a paid consultant for Smith & Nephew and Acumed. The remaining author reports no conflict of interest. Reprints: Hassan R. Mir, MD, MBA, FACS, Division of Orthopaedic Trauma, Department of Orthopaedics and Rehabilitation, Vanderbilt Orthopaedic Institute, Suite 4200 MCE, South Tower, Nashville, TN 37232 (e-mail: [email protected]). Copyright © 2014 by Lippincott Williams & Wilkins
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| www.jorthotrauma.com
approximately 180 nonprofit “sickness funds” providing universal coverage. Patients pay a monthly premium as a fixed percentage of their income, and this premium is partially covered by patients’ employers.2 Since 2009, coverage by a sickness fund has been mandatory, and patients have their choice among general practitioners (GP’s), specialists, and hospitals. Hospitals are both publicly and privately owned. GP’s and specialists are by law, mandatory members of the aforementioned regional associations but work in their own private practices (60% solo practice). Pay-for-performance measures have yet to be established and access to specialists is prompt with no referral required by a GP (no gatekeeping).3 Total health care expenditure in Germany with the Bismarck model is 11.1% of its gross domestic product.4 Under the Bismarck model, trauma care in Germany has evolved into a highly developed and coordinated system. Injury prevention measures are commonplace, and emergency response is provided by any permutation of physician and paramedic-staffed helicopters and ambulances.5 In-hospital care is provided by specialized trauma providers in approximately 900 trauma centers that are part of some 55 trauma networks.6 Independent auditing and certification of trauma centers occur in an effort to maintain quality of care in accordance with standards set forth by the German Trauma Society.6 Such high-quality and reliable trauma care is universally available to the entire German population but comes at significant cost to the health care system.5 This has prompted intense scrutiny of total hospital spending.6 With publicly funded trauma centers comprising approximately one half of all available beds in Germany and the remainder provided by both non-profit and for-profit private centers,3 German trauma surgeons—much like their American counterparts— are faced with the task of advocating for financial support on both the administrative and political stage.
THE BEVERIDGE MODEL In 1942, British economist and social reformer Lord William Beveridge proposed a nationalized health system in his report Social Insurance and Allied Services.1 This concept was eventually implemented in the United Kingdom as the National Health Service by Minister of Health Nye Bevan in 1948. Contrary to the Bismarck model, all hospitals are nationalized, all specialists are government employees, and GP’s are private providers operating under a national contract.3 Insurance companies are nonexistent, and there are no fees for service except for prescription copays (waived for children, pregnant women, and the chronically ill).1 Funding is provided by sales, income, and social security taxes. GP’s are responsible for a population of patients and are financially incentivized to control access (gatekeepers) to
J Orthop Trauma Volume 28, Number 10 Supplement, October 2014
J Orthop Trauma Volume 28, Number 10 Supplement, October 2014
specialists. Although emergent care is prompt, waiting times for nonurgent issues and elective procedures have historically been unacceptably long. British health policy experts are the first to admit their system’s shortcomings with timely elective care, and recent changes in the past decade by the government have improved waiting times.2 With this model, total health care expenditure in the United Kingdom is 9.3% of its gross domestic product.7 Trauma care in the United Kingdom has been an evolving process since a 1988 seminal report by the Royal College of Surgeons of England highlighting several systematic deficiencies.8 Because of perceived financial and political disincentives,9 England has only recently implemented a regional trauma system. Prehospital emergency response was historically provided by paramedic-staffed ambulances but recently has included more physician-staffed care as performed in Germany.10 Government-funded major trauma centers are central hospitals that anchor a trauma network of smaller hospitals and coordinate management of trauma patients in a particular region. As in Germany and the United States, these trauma centers provide comprehensive trauma care from point of injury through rehabilitation.10
NATIONAL HEALTH INSURANCE NHI, as implemented by nations such as Canada, Taiwan, and Australia, represents a fusion of the Bismarck and Beveridge models. Hospitals, physicians, and other providers are privatized, but payment is provided by a single government-run insurance program. Canada’s NHI was initially championed by socialist reformer Tommy Douglas, who first implemented it in 1962 in Saskatchewan.1 Organization, accreditation, and licensure of privatized providers are the responsibility of the provinces and territories, with service standards set by the Canada Health Act. Collectively known as Medicare, universal health insurance programs are administered at the provincial/territorial level but funded by the federal government provided they meet certain criteria set by the Canada Health Act.3 Similar to the United Kingdom, however, Canada’s system is beset with long waiting times. In response, the Canadian government has initiated efforts to reduce waiting times and increase the physician workforce.1 Canada’s first regionalized trauma system was implemented in Winnipeg in the 1980’s as the brainchild of general surgeon Charles Burns.11 Declining federal health care payments stemming from national budget deficits in the 1980’s also coincided with the resultant consolidation of health services and regionalization of trauma care to large urban university centers.12 Over the ensuing decades, trauma care in Canada evolved to include the creation of the Trauma Association of Canada and nationally followed standards of care.11 Currently, prehospital emergency response services vary across the country, with urban regions served by Advanced Life Support–trained paramedics and the more remote regions served by lesser trained units.12 The Trauma Association of Canada has designated accreditation levels to trauma centers as level I, II, III, IV, or V based on descending ability to manage the polytraumatized patient.13 According to a 2010 Canadian study, 32 level I and level II trauma centers provide Ó 2014 Lippincott Williams & Wilkins
Global Systems of Health Care and Trauma
definitive care and coordinate the efforts of their surrounding trauma systems. About 77.5% of Canadians reside within 1-hour road travel catchments of level I or level II centers. However, marked geographic disparities in access persist, particularly in rural and remote regions.14 Funding for trauma centers across Canada is through federal transfer payments administered through their respective provinces.1,12
THE OUT-OF-POCKET MODEL Many of the world’s poorest countries have no or poorly established health care payment systems and instead rely on out-of-pocket payment and charity services. Here exists a global disparity, where those with the least developed health infrastructure are sometimes those who remain in the most direst need for health care. Countries like India, Pakistan, and Cambodia operate with out-of-pocket health expenditure accounting for more than 75% of total health care spending (compared with 3.1% in the United Kingdom).1 Disparities in care are particularly evident with regard to injury. Patients in low- and middle-income countries sustain a disproportionately higher burden of injury-related deaths, with 89% of the total number of world deaths because of injury occurring in these countries.15 Furthermore, injuries from road traffic accidents in low- and middle-income countries contribute to the highest death rates.16,17 Although rates of injury have been declining in high-income countries because of injury prevention and improving trauma systems, rates of injury-related death and disability have been rising in most low- and middle-income countries.18 Despite the overwhelming burden of trauma in many of these countries, care of the traumatized patient remains disorganized, sporadic, and unreliable. In India, road traffic accidents contribute to more than 10% of all deaths, with an accident occurring every 3 minutes and a death every 10 minutes on Indian roads.19 Even with such a high burden of injuries, no formal infrastructure exists for the prehospital, hospital, or postinjury care of the injured patient. Organized emergency response is essentially nonexistent in most rural and semiurban areas. The isolated ambulance services present in urban regions are run by a combination of government, police, fire brigade, hospital, and private agencies. Definitive trauma care is provided by government-run and corporate hospitals, which operate without the oversight of a standards committee. Moreover, dedicated general trauma surgeons are in rare supply in India, and orthopaedic surgeons lead the trauma response in 50% of facilities.19
HEALTH AND TRAUMA CARE IN THE UNITED STATES Understanding health care systems and the implementation of trauma care across the globe provides a unique lens through which to view the plight of health policy in the United States. Table 1 summarizes how the United States compares with other members of the international community with regard to key health care statistics. As noted by journalist Reid,2 the United States health care system can be thought of www.jorthotrauma.com |
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J Orthop Trauma Volume 28, Number 10 Supplement, October 2014
Lee and Mir
TABLE 1. Life Expectancy, Mortality From Injury, and Health Care Expenditure as Percentage of Gross Domestic Product of Various Countries4,7,20–24
Country United States Germany Japan United Kingdom Canada India
Life Expectancy Mortality From Health Care at Birth M/F, Injury (per 100,000 Expenditure 2011 (y) Population), 2008 as GDP%, 2011 76/81 78/83 79/86 79/82
53 25 36 25
17.9 11.1 9.3 9.3
80/84 64/67
32 99
11.2 3.9
Adapted from: World Health Organization Country Profiles, www.who.int/ countries/en/, World Health Statistics 2013, World Health Organization Press. Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation.
as a hybrid of several international models. The Bismarck model is observed in those younger than 65 years who are covered by employer-based health insurance. The Veterans Affairs and military personnel administer care are in accordance with the Beveridge model. Those older than 65 years and covered by Medicare follow the model of NHI. Finally, the uninsured, with no formal payment structure, are subject to an out-of-pocket model.1 The current state of health care in the United States can therefore be viewed as a microcosm of the wide spectrum of health care across the globe, subject to an array of political pressures and socioeconomic limitations. Disparities in trauma care necessarily follow inequities in overall health care and infrastructure. In this light, critical analysis of international solutions to deficiencies in trauma care may serve as a guide for domestic issues. Lawmakers and health care providers alike should remain receptive to lessons learned domestically and internationally. REFERENCES 1. Reid TR. The Healing of America. New York, NY: Penguin Group; 2010.
S10
| www.jorthotrauma.com
2. Palfreman J. Sick Around the World. Boston, MA: WGBH Educational Foundation, PBS Home Video: United States of America; 2008. 3. Thomson S, Osborn R, Squires D, et al, eds. International Profiles of Health Care Systems, 2012. New York, NY: The Commonwealth Fund, New York, NY; 2012. 4. Country health profile: Germany [WHO Web site]. 2011. Available at: http://www.who.int/countries/deu/en/. Accessed February 19, 2014. 5. Westhoff J, Hildebrand F, Grotz M, et al. Trauma care in Germany. Injury. 2003;34:674–683. 6. Sturm JA, Pape HC, Dienstknecht T. Trauma care in Germany: an inclusive system. Clin Orthop Relat Res. 2013;471:2912–2923. 7. Country health profile: United Kingdom [WHO Web site]. 2011. Available at: http://www.who.int/countries/gbr/en/. Accessed February 19, 2014. 8. Management of patients with major injuries. Lancet. 1988;2:1291–1292. 9. Albert J, Phillips H. Trauma care systems in the United Kingdom. Injury. 2003;34:728–734. 10. Lendrum RA, Lockey DJ. Trauma system development. Anaesthesia. 2013;68(suppl 1):30–39. 11. Evans DC. From trauma care to injury control: a people’s history of the evolution of trauma systems in Canada. Can J Surg. 2007;50:364–369. 12. Kortbeek JB, Buckley R. Trauma-care systems in Canada. Injury. 2003; 34:658–663. 13. Trauma System Accreditation Guidelines [TAC Web site]. 2011. Available at: http://www.traumacanada.org/Default.aspx?pageId=829755. Accessed February 19, 2014. 14. Hameed SM, Schuurman N, Razek T, et al. Access to trauma systems in Canada. J Trauma. 2010;69:1350–1361. 15. Norton R, Kobusingye O. Injuries. N Engl J Med. 2013;368:1723–1730. 16. The global burden of disease: 2004 update [WHO Web site]. 2008. Available at: http://www.who.int/healthinfo/global_burden_disease/ 2004_report_update/en/. Accessed February 19, 2014. 17. Spiegel DA, Gosselin R, Coughlin R, et al. The burden of musculoskeletal injury in low and middle-income countries: challenges and opportunities. J Bone Joint Surg Am. 2008;90:915–923. 18. Mock C, Cherian MN. The global burden of musculoskeletal injuries: challenges and solutions. Clin Orthop Relat Res. 2008;466:2306–2316. 19. Joshipura MK, Shah H, Patel P, et al. Trauma care systems in India. Injury. 2003;34:686–692. 20. Country health profile: Japan [WHO Web site]. 2011. Available at: http:// www.who.int/countries/jpn/en/. Accessed February 19, 2014. 21. Country health profile: India [WHO Web site]. 2011. Available at: http:// www.who.int/countries/ind/en/. Accessed February 19, 2014. 22. Country health profile: United States [WHO Web site]. 2011. Available at: http://www.who.int/countries/usa/en/. Accessed February 19, 2014. 23. Country health profile: Canada [WHO Web site]. 2011. Available at: http://www.who.int/countries/can/en/. Accessed February 19, 2014. 24. World health statistics 2013 [WHO Web site]. 2013. Available at: http:// www.who.int/gho/publications/world_health_statistics/2013/en/. Accessed February 19, 2014.
Ó 2014 Lippincott Williams & Wilkins
Global Systems of Health Care and Trauma Dennis S. Lee, MD and Hassan R. Mir, MD, MBA, FACS
Summary: Health care policy continues to occupy the center of national debate in the United States. Exploration of international health care and trauma systems allows for better comprehension of our own policies. Four basic models of health care exist across the globe: Bismarck, Beveridge, National Health Insurance, and Out-ofPocket. Expectantly, disparities in trauma care necessarily follow inequities in overall health care and infrastructure. In this article, we aim to review several countries’ health care models and their respective trauma systems. Critical analysis of international solutions to deficiencies in overall health and trauma care may serve as a guide for issues in the United States. Key Words: international health, global health care, trauma, injury (J Orthop Trauma 2014;28:S8–S10)
INTRODUCTION Amid rising costs, millions of uninsured patients, and a fragmented infrastructure, health care policy in the United States continue to occupy the center of national debate. An understanding of health care and trauma systems abroad may provide insight into the volatile issues domestically. Review of the international community reveals several different health care models, each one a reflection of its nation’s history, politics, and culture. Four basic models exist: Bismarck, Beveridge, National Health Insurance (NHI), and Out-of-Pocket.1 Each has implications on how trauma care is delivered. Accordingly, examination of international health care models and their respective trauma systems provides context by which traumatologists can critically assess patient care in various populations within the United States.
THE BISMARCK MODEL The Bismarck model derives its origin from German inaugural chancellor Otto von Bismarck.2 In its classic form, the Bismarck model is comprised of privatized health care providers and insurance companies. Although privatized, the insurance companies are mostly nonprofit, highly regulated, and offer universal coverage.1 Germany’s current health care system continues to follow the Bismarck model, with Accepted for publication July 17, 2014. From the Division of Orthopaedic Trauma, Department of Orthopaedics and Rehabilitation, Vanderbilt Orthopaedic Institute, Nashville, TN. H. R. Mir is a paid consultant for Smith & Nephew and Acumed. The remaining author reports no conflict of interest. Reprints: Hassan R. Mir, MD, MBA, FACS, Division of Orthopaedic Trauma, Department of Orthopaedics and Rehabilitation, Vanderbilt Orthopaedic Institute, Suite 4200 MCE, South Tower, Nashville, TN 37232 (e-mail: [email protected]). Copyright © 2014 by Lippincott Williams & Wilkins
S8
| www.jorthotrauma.com
approximately 180 nonprofit “sickness funds” providing universal coverage. Patients pay a monthly premium as a fixed percentage of their income, and this premium is partially covered by patients’ employers.2 Since 2009, coverage by a sickness fund has been mandatory, and patients have their choice among general practitioners (GP’s), specialists, and hospitals. Hospitals are both publicly and privately owned. GP’s and specialists are by law, mandatory members of the aforementioned regional associations but work in their own private practices (60% solo practice). Pay-for-performance measures have yet to be established and access to specialists is prompt with no referral required by a GP (no gatekeeping).3 Total health care expenditure in Germany with the Bismarck model is 11.1% of its gross domestic product.4 Under the Bismarck model, trauma care in Germany has evolved into a highly developed and coordinated system. Injury prevention measures are commonplace, and emergency response is provided by any permutation of physician and paramedic-staffed helicopters and ambulances.5 In-hospital care is provided by specialized trauma providers in approximately 900 trauma centers that are part of some 55 trauma networks.6 Independent auditing and certification of trauma centers occur in an effort to maintain quality of care in accordance with standards set forth by the German Trauma Society.6 Such high-quality and reliable trauma care is universally available to the entire German population but comes at significant cost to the health care system.5 This has prompted intense scrutiny of total hospital spending.6 With publicly funded trauma centers comprising approximately one half of all available beds in Germany and the remainder provided by both non-profit and for-profit private centers,3 German trauma surgeons—much like their American counterparts— are faced with the task of advocating for financial support on both the administrative and political stage.
THE BEVERIDGE MODEL In 1942, British economist and social reformer Lord William Beveridge proposed a nationalized health system in his report Social Insurance and Allied Services.1 This concept was eventually implemented in the United Kingdom as the National Health Service by Minister of Health Nye Bevan in 1948. Contrary to the Bismarck model, all hospitals are nationalized, all specialists are government employees, and GP’s are private providers operating under a national contract.3 Insurance companies are nonexistent, and there are no fees for service except for prescription copays (waived for children, pregnant women, and the chronically ill).1 Funding is provided by sales, income, and social security taxes. GP’s are responsible for a population of patients and are financially incentivized to control access (gatekeepers) to
J Orthop Trauma Volume 28, Number 10 Supplement, October 2014
J Orthop Trauma Volume 28, Number 10 Supplement, October 2014
specialists. Although emergent care is prompt, waiting times for nonurgent issues and elective procedures have historically been unacceptably long. British health policy experts are the first to admit their system’s shortcomings with timely elective care, and recent changes in the past decade by the government have improved waiting times.2 With this model, total health care expenditure in the United Kingdom is 9.3% of its gross domestic product.7 Trauma care in the United Kingdom has been an evolving process since a 1988 seminal report by the Royal College of Surgeons of England highlighting several systematic deficiencies.8 Because of perceived financial and political disincentives,9 England has only recently implemented a regional trauma system. Prehospital emergency response was historically provided by paramedic-staffed ambulances but recently has included more physician-staffed care as performed in Germany.10 Government-funded major trauma centers are central hospitals that anchor a trauma network of smaller hospitals and coordinate management of trauma patients in a particular region. As in Germany and the United States, these trauma centers provide comprehensive trauma care from point of injury through rehabilitation.10
NATIONAL HEALTH INSURANCE NHI, as implemented by nations such as Canada, Taiwan, and Australia, represents a fusion of the Bismarck and Beveridge models. Hospitals, physicians, and other providers are privatized, but payment is provided by a single government-run insurance program. Canada’s NHI was initially championed by socialist reformer Tommy Douglas, who first implemented it in 1962 in Saskatchewan.1 Organization, accreditation, and licensure of privatized providers are the responsibility of the provinces and territories, with service standards set by the Canada Health Act. Collectively known as Medicare, universal health insurance programs are administered at the provincial/territorial level but funded by the federal government provided they meet certain criteria set by the Canada Health Act.3 Similar to the United Kingdom, however, Canada’s system is beset with long waiting times. In response, the Canadian government has initiated efforts to reduce waiting times and increase the physician workforce.1 Canada’s first regionalized trauma system was implemented in Winnipeg in the 1980’s as the brainchild of general surgeon Charles Burns.11 Declining federal health care payments stemming from national budget deficits in the 1980’s also coincided with the resultant consolidation of health services and regionalization of trauma care to large urban university centers.12 Over the ensuing decades, trauma care in Canada evolved to include the creation of the Trauma Association of Canada and nationally followed standards of care.11 Currently, prehospital emergency response services vary across the country, with urban regions served by Advanced Life Support–trained paramedics and the more remote regions served by lesser trained units.12 The Trauma Association of Canada has designated accreditation levels to trauma centers as level I, II, III, IV, or V based on descending ability to manage the polytraumatized patient.13 According to a 2010 Canadian study, 32 level I and level II trauma centers provide Ó 2014 Lippincott Williams & Wilkins
Global Systems of Health Care and Trauma
definitive care and coordinate the efforts of their surrounding trauma systems. About 77.5% of Canadians reside within 1-hour road travel catchments of level I or level II centers. However, marked geographic disparities in access persist, particularly in rural and remote regions.14 Funding for trauma centers across Canada is through federal transfer payments administered through their respective provinces.1,12
THE OUT-OF-POCKET MODEL Many of the world’s poorest countries have no or poorly established health care payment systems and instead rely on out-of-pocket payment and charity services. Here exists a global disparity, where those with the least developed health infrastructure are sometimes those who remain in the most direst need for health care. Countries like India, Pakistan, and Cambodia operate with out-of-pocket health expenditure accounting for more than 75% of total health care spending (compared with 3.1% in the United Kingdom).1 Disparities in care are particularly evident with regard to injury. Patients in low- and middle-income countries sustain a disproportionately higher burden of injury-related deaths, with 89% of the total number of world deaths because of injury occurring in these countries.15 Furthermore, injuries from road traffic accidents in low- and middle-income countries contribute to the highest death rates.16,17 Although rates of injury have been declining in high-income countries because of injury prevention and improving trauma systems, rates of injury-related death and disability have been rising in most low- and middle-income countries.18 Despite the overwhelming burden of trauma in many of these countries, care of the traumatized patient remains disorganized, sporadic, and unreliable. In India, road traffic accidents contribute to more than 10% of all deaths, with an accident occurring every 3 minutes and a death every 10 minutes on Indian roads.19 Even with such a high burden of injuries, no formal infrastructure exists for the prehospital, hospital, or postinjury care of the injured patient. Organized emergency response is essentially nonexistent in most rural and semiurban areas. The isolated ambulance services present in urban regions are run by a combination of government, police, fire brigade, hospital, and private agencies. Definitive trauma care is provided by government-run and corporate hospitals, which operate without the oversight of a standards committee. Moreover, dedicated general trauma surgeons are in rare supply in India, and orthopaedic surgeons lead the trauma response in 50% of facilities.19
HEALTH AND TRAUMA CARE IN THE UNITED STATES Understanding health care systems and the implementation of trauma care across the globe provides a unique lens through which to view the plight of health policy in the United States. Table 1 summarizes how the United States compares with other members of the international community with regard to key health care statistics. As noted by journalist Reid,2 the United States health care system can be thought of www.jorthotrauma.com |
S9
J Orthop Trauma Volume 28, Number 10 Supplement, October 2014
Lee and Mir
TABLE 1. Life Expectancy, Mortality From Injury, and Health Care Expenditure as Percentage of Gross Domestic Product of Various Countries4,7,20–24
Country United States Germany Japan United Kingdom Canada India
Life Expectancy Mortality From Health Care at Birth M/F, Injury (per 100,000 Expenditure 2011 (y) Population), 2008 as GDP%, 2011 76/81 78/83 79/86 79/82
53 25 36 25
17.9 11.1 9.3 9.3
80/84 64/67
32 99
11.2 3.9
Adapted from: World Health Organization Country Profiles, www.who.int/ countries/en/, World Health Statistics 2013, World Health Organization Press. Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation.
as a hybrid of several international models. The Bismarck model is observed in those younger than 65 years who are covered by employer-based health insurance. The Veterans Affairs and military personnel administer care are in accordance with the Beveridge model. Those older than 65 years and covered by Medicare follow the model of NHI. Finally, the uninsured, with no formal payment structure, are subject to an out-of-pocket model.1 The current state of health care in the United States can therefore be viewed as a microcosm of the wide spectrum of health care across the globe, subject to an array of political pressures and socioeconomic limitations. Disparities in trauma care necessarily follow inequities in overall health care and infrastructure. In this light, critical analysis of international solutions to deficiencies in trauma care may serve as a guide for domestic issues. Lawmakers and health care providers alike should remain receptive to lessons learned domestically and internationally. REFERENCES 1. Reid TR. The Healing of America. New York, NY: Penguin Group; 2010.
S10
| www.jorthotrauma.com
2. Palfreman J. Sick Around the World. Boston, MA: WGBH Educational Foundation, PBS Home Video: United States of America; 2008. 3. Thomson S, Osborn R, Squires D, et al, eds. International Profiles of Health Care Systems, 2012. New York, NY: The Commonwealth Fund, New York, NY; 2012. 4. Country health profile: Germany [WHO Web site]. 2011. Available at: http://www.who.int/countries/deu/en/. Accessed February 19, 2014. 5. Westhoff J, Hildebrand F, Grotz M, et al. Trauma care in Germany. Injury. 2003;34:674–683. 6. Sturm JA, Pape HC, Dienstknecht T. Trauma care in Germany: an inclusive system. Clin Orthop Relat Res. 2013;471:2912–2923. 7. Country health profile: United Kingdom [WHO Web site]. 2011. Available at: http://www.who.int/countries/gbr/en/. Accessed February 19, 2014. 8. Management of patients with major injuries. Lancet. 1988;2:1291–1292. 9. Albert J, Phillips H. Trauma care systems in the United Kingdom. Injury. 2003;34:728–734. 10. Lendrum RA, Lockey DJ. Trauma system development. Anaesthesia. 2013;68(suppl 1):30–39. 11. Evans DC. From trauma care to injury control: a people’s history of the evolution of trauma systems in Canada. Can J Surg. 2007;50:364–369. 12. Kortbeek JB, Buckley R. Trauma-care systems in Canada. Injury. 2003; 34:658–663. 13. Trauma System Accreditation Guidelines [TAC Web site]. 2011. Available at: http://www.traumacanada.org/Default.aspx?pageId=829755. Accessed February 19, 2014. 14. Hameed SM, Schuurman N, Razek T, et al. Access to trauma systems in Canada. J Trauma. 2010;69:1350–1361. 15. Norton R, Kobusingye O. Injuries. N Engl J Med. 2013;368:1723–1730. 16. The global burden of disease: 2004 update [WHO Web site]. 2008. Available at: http://www.who.int/healthinfo/global_burden_disease/ 2004_report_update/en/. Accessed February 19, 2014. 17. Spiegel DA, Gosselin R, Coughlin R, et al. The burden of musculoskeletal injury in low and middle-income countries: challenges and opportunities. J Bone Joint Surg Am. 2008;90:915–923. 18. Mock C, Cherian MN. The global burden of musculoskeletal injuries: challenges and solutions. Clin Orthop Relat Res. 2008;466:2306–2316. 19. Joshipura MK, Shah H, Patel P, et al. Trauma care systems in India. Injury. 2003;34:686–692. 20. Country health profile: Japan [WHO Web site]. 2011. Available at: http:// www.who.int/countries/jpn/en/. Accessed February 19, 2014. 21. Country health profile: India [WHO Web site]. 2011. Available at: http:// www.who.int/countries/ind/en/. Accessed February 19, 2014. 22. Country health profile: United States [WHO Web site]. 2011. Available at: http://www.who.int/countries/usa/en/. Accessed February 19, 2014. 23. Country health profile: Canada [WHO Web site]. 2011. Available at: http://www.who.int/countries/can/en/. Accessed February 19, 2014. 24. World health statistics 2013 [WHO Web site]. 2013. Available at: http:// www.who.int/gho/publications/world_health_statistics/2013/en/. Accessed February 19, 2014.
Ó 2014 Lippincott Williams & Wilkins
