Socialized Medicine in Denmark

Thomas Emil Christensen, MD, PhD

In Denmark, medicine is socialized: all citizens have equal access to medical care, at an affordable price which costs about 7,700 USD per taxpayer per year. This covers everything from general practitioner visits to highly specialized care in the hospital, with nothing paid out of pocket by the patient. Many additional expenses are also subsidized, for example, medication, physiotherapy (also known as physical therapy), and psychiatric care. Patients are only responsible for a fraction of these costs.

How does socialized medicine work?

Consider “Mr. Hansen”, a wealthy lawyer living in a waterfront mansion just north of Copenhagen. He’s careful with his diet, doesn’t drink or smoke, and he’s training for his 15th marathon. Mr. Hansen has chest pain. On primary assessment in the ambulance, he appears to have a clogged coronary artery. This is considered urgent in Denmark, so he is transported by ambulance directly to the best hospital in the city where highly skilled specialists will do an acute coronary intervention to restore blood supply to the heart. Then he will be transferred to a local hospital for further care and followup assessments. After discharge, Mr. Hansen will receive cardiac rehabilitation via the hospital’s outpatient clinic. For all of this, Mr. Hansen is charged nothing. All costs are covered by the public health care system.

What happens if a lower-income citizen has a myocardial infarction? “Mrs. Jensen” lives in public housing just south of Copenhagen. She’s unemployed, smokes heavily, and eats poorly. The level of care provided to Mrs. Jensen is exactly the same as the care provided to Mr. Hansen, also at no additional cost to her.

In many ways, the system makes perfect sense. Most health-related issues are present in poor socioeconomic status groups so socialized medicine provides optimal care to patients who need it most.

But the system is also beneficial to wealthier patients because it keeps expenses low. There is a built-in incentive for rational spending because funding is fixed, decided in the yearly federal budget act.

In a consumer-driven healthcare system, like that in the USA, there is an incentive to offer medical services to a patient even with no documented research showing it improves patient mortality or morbidity. For example, in Denmark, preventative screening of healthy individuals is kept to a minimum. Only a few programs exist, mainly screening for cervical and breast cancers. This is because very few screening programs have actually been documented to show improved patient outcomes. In addition, the Danish healthcare system is reactive, not proactive: no annual physicals – testing is kept to a minimum. This means no easy access to imaging tests (CT scan, MRI) and no colonoscopies in the absence of symptoms.

Most healthcare-related issues in Denmark are handled by general practitioners; seeing a specialist requires a referral. On average, every Dane is seen by his family doctor seven times a year, and most issues are handled in the office. Only a small fraction of visits lead to a specialist referral. Thus, specialists can focus on patients who actually need specialized care. This increases the rational use of resources, providing costly specialized care to patients who need it.

The Danish system avoids consumer-driven demand for services which increases testing and treatments even with no documented positive effect on outcomes.

”Mr. Olsen” from Aarhus schedules a visit with his GP because of a backache with no additional symptoms. The GP provides Mr. Olsen with a referral to a physiotherapist and a few weeks later Mr. Olsen’s back pain has markedly improved. In a consumer-driven healthcare system, Mr. Olsen –who is well-insured – may schedule an appointment with a rheumatologist. Mr. Olsen will receive a physical as well as a CT and MRI of the spine. The images are then scrutinized by a radiologist who finds a herniated disc. Next, Mr. Olsen sees a back surgeon to discuss surgical vs. conservative treatment. The surgeon recommends physiotherapy. A few weeks later Mr. Olsen’s back pain has markedly improved. Consumer-driven health care is a very expensive way of ending up with the same outcome. Also, while the specialists are attending to minor issues of the well-insured, access is reduced for the uninsured “Mrs. Sorensen” who has a spinal tumor requiring highly specialized care.

Even worse, in consumer-driven health care the doctors might recommend more advanced treatments than necessary and actually harm patients. The back surgeon might recommend surgery to a patient even though evidence shows similar improved outcomes with less risky physiotherapy.

In summation, the pros of socialized medicine are: a) better access to health care for patients needing it the most, b) cheaper overall health care services because of the incentive to minimize costs, c) minimized overdiagnosis and overtreatment that pose threats to well-insured patients in private health care.

Are there downsides to this socialized system? |Unfortunately, yes. It is subjected to political intervention that, contrary to its purpose, obstructs operations. This aside, the main problem is that there is no mechanism to balance supply and demand. When expenses increase, funding remains fixed, hence the system is subjected to constant budget cuts negatively impacting the quality of care. Furthermore, the load is not evenly distributed, but predominantly carried by patient groups with the least powerful lobbyists. In this, cancer and heart patients are at the top of the hierarchy, whereas psychiatric patients are at the bottom.

Also, recruitment and retention are difficult. Danish nurses and doctors are paid a fraction of their American counterparts. It’s becoming especially difficult to recruit and retain nurses. There is a large efflux of nurses to non-related professions where pay and working conditions are better.

This is also true for recruitment to less popular rural areas. It is difficult to offer any incentive to lure much-needed healthcare workers away from the major cities for a longer commute to work with multimorbid, non-resourceful patients in small, understaffed hospitals.

So, which is better? Socialized medicine or privatized health care? Each offers its own challenges and advantages. Socialized medicine is cheap, accessible for patients who need care the most, and has less over-diagnosing and overintervention. And for now, the system has overwhelming public support in Denmark.

Thomas Emil Christensen, MD (Cardiology), PhD works at Hvidovre Hospital in Hvidovre, DenmarkEmail: thomasemilchristensen@gmail.com