As the 2008 election season gets underway, the American healthcare system is the focus of much attention. Many voters are concerned about the more than 40 million Americans who lack health insurance coverage, as well as about the perceived and real shortcomings in the American healthcare system compared to other countries, as portrayed in Michael Moore’s “SiCKO.” No doubt, 2008 Presidential aspirants will soon propose their “solutions” for the troubled American system.
The Canadian-type healthcare system has been proposed as a possible solution to America’s problems. Because few orthopaedic surgeons understand how such a system may affect us, as well as our patients, I have asked Alastair S.E. Younger, MD, FRCS(S), an orthopaedic foot and ankle surgeon from Vancouver, British Columbia, to provide us with a closer look at the Canadian healthcare system from the perspective of an orthopaedic surgeon and to discuss its advantages and drawbacks with regard to access to orthopaedic care “North of the Border.”
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Alan S. Hilibrand, MD
In 1947, Tommy Douglas, the father of the Canadian healthcare system and premier (governor) of the province of Saskatchewan, noticed that poor people had worse health than rich people. He deduced that this was due to lack of access to care. His noble plan to offer free hospital care to all citizens eventually evolved into the Canada Health Act, which was passed in 1984. Today, however, the health gap between the rich and the poor remains as prominent as it was when Douglas first identified the problem.
As does any health system, the Canadian healthcare system has its merits and drawbacks from both the patient’s and the surgeon’s perspectives. The Canadian health system is federally funded and administered through the provinces to health regions, and from there to hospitals. Most surgeons are paid on a fee-for-service basis; the provincial paying agency and the worker’s compensation boards are the sole providers.
Paying for care
To maintain equal access to care by both rich and poor, the law states that a Canadian physician cannot extra bill; if the physician bills the patient directly, he or she cannot bill for any more money than the government would have paid for that service. This makes Canada—along with Cuba and Korea—one of three countries that effectively ban private health care.
Without a private system, Canadian patients have nowhere to turn, which is why so many seek care in the United States. In fact, the United States is the private arm of the Canadian healthcare system. The Cleveland Clinic, for example, has an office in Toronto.
Hospitals are funded through a global budget. The hospitals then allocate clinic space, operating room (OR) time, beds, and other services to physician groups in return for services such as emergency call.
In his film “SiCKO,” Michael Moore contends that Canadian health care is free: This is absolutely not the case. Canadians pay out of their own pockets for about 30 percent of their health care for items—–such as physiotherapy, eye glasses, prosthetics, braces, dental care, podiatric care, and home help—that are often covered by insurance in other countries. They pay the other 70 percent through their taxes. As a Canadian taxpayer, I am upset that Mr. Moore or anyone else should call this “free” care.
Futhermore, in many provinces, Canadian citizens have to pay an insurance premium of about $100 per month for the average family. Although this is a nominal amount, it means the system isn’t “free.” In addition, in British Columbia, approximately 10 percent of residents fail to pay their premiums, which means that doctors must either deny care to them or provide the care for free.
Care on a “timely” basis
One of the benefits of the Canadian system is that—by and large—patients do get looked after. In my foot and ankle practice, that means after 4 years. Before September 2005, when I closed my practice to new referrals, patients had a 3-year wait for a consultation and a 1-year wait for surgery. I may, however, soon be able to start accepting new patients again.
I have spent many years on hospital committees trying to improve access to care for my patients, with little progress. If I performed more surgeries, the hospital’s global budget would be exceeded, which is against the hospital’s interest. This situation will continue unless a newspaper story, lobby group, or court case persuades the government to change. We presently have made the health ministry aware of our wait lists by the threat of job action. Nothing less than that has worked. Many surgeons have left Canada rather than take this step, and the problem remains unsolved.
This system benefits me as a physician, because I have a huge volume of patients seeking care, so finding patients is not a problem—at least within orthopaedics. I also submit my bills to the government’s paying agency and the cheque usually arrives 2 weeks later. Questions or requests for the operative report arise only occasionally. No big billing system or accounts receivable departments are needed. Malpractice issues are minimal.
Squeaky wheels get noticed
As a public system, the Canadian health system responds most effectively to the “squeaky wheel.” Patient groups that advocate get attention; those that don’t, get ignored. The Canadian system is great if you have human immunodeficiency virus (HIV): patients receive free drugs, free clinics, free food, free counseling, even free long-term disability. Ineffective complainers get left behind, and some services are too busy providing care to advocate for themselves.
The big losers in this race—among both patients and their physicians—are orthopaedics, obstetrics and gynecology, and psychiatry. Physicians lose training positions, time in the OR, resources, and reimbursement. Wait times for orthopaedic consultations in my practice have been more than 3 years because I can’t get OR time, clinic space, clinic support, or other services necessary for running an efficient practice.
Because surgeons—not hospitals—“own” the wait lists, the issue of long wait times for consultations has been invisible to the health system—unless patients can effectively advocate. Recently, OR wait lists have improved a bit because OR times allocated to surgeons with short lists have been partly reallocated to those with long lists.
Surgeons are often dissatisfied because of the loss of autonomy that results from working for a government-run monopoly, which sets reimbursements based on political factors, rather than market forces, and allocates resources in the same way. Many Canadian physicians left the healthcare system in the 1980s when provinces imposed a cap on billings.
In summary, the Canadian health system functions like most health systems—it struggles along, looking after most patients most of the time. Patients in the United States and Canada face different challenges; a Canadian will never have to declare bankruptcy for medical bills but may become bankrupt because he couldn’t get access to care and had to quit his job as a result of his condition. A Canadian surgeon doesn’t have to worry about where the next patient is coming from, but must advocate to get the resources needed for current patients. Some changes recently initiated in the United Kingdom would be welcome in Canada, such as the amalgamation of small, inefficient hospitals into larger facilities and the reimbursement of hospitals on a per capita basis to give more incentive to treating patients.
Things are just different—not necessarily better or worse. We, as orthopaedic surgeons, still have the privilege—and the satisfaction—of caring for patients. I think, however, that we owe it to the countries we work in to try and find a better way to care for all patients.
Alastair S. E. Younger, MD, FRCS(S), is an international affliliate member of the AAOS. He can be reached at firstname.lastname@example.org.