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INTERNATIONAL: Rational talk about Canadian Health Care

I’m very happy to relate that one of the best pieces ever by me on THCB, Oh Canada, (written when THCB was just finding its feet in 2003) is still as relevant as ever. There are still inordinate amounts of crap talked about the Canadian system by defenders of the current US status quo (not that the far right loonies who dredge this stuff will say that’s what they’re doing). This is dspite the fact that no major US Presidential candidate, with the possible exception of Harry Truman, has ever proposed introducing such a system here.

But over on liberal blog Campaign For America’s Future (the guys who are backing  Jacob Hacker’s work and by the way taking credit for the Edwards, Clinton and some of Obama plan) Sara Robinson—a self described “health-care-card-carrying Canadian resident and an uninsured American citizen who regularly sees doctors on both sides of the border”—has written a very balanced piece called Mythbusting Canadian Health Care.

I can see the Canadian ex-pat trio of Pipes, Gratzer & Graham going into apoplectic fits even as I type!

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  1. I’m not seeing anything on this blog about the Nurse Practitioner clinic initiative in Canada. There has been a key development here: a group of Nurse Practitioners (NPs) in Sudbury (Ontario)is preparing to open a 2nd site as we speak. This is the first NP-Led clinic to open in Canada, and was championed by pioneer NPs Marilyn Butcher and Roberta Heale. All eyes here are on this historic development in access to care for orphan patients.
    The Sudbury region has 30,000 patients without access to Primary Care. In our system, Primary Care is care provided by Nurse Practitioners and Physicians, for the most part. It is the care you need on an ongoing basis to help you stay healthy or get treated for illnesses and injuries. You need Primary care when you are a newborn baby and through all your life stages. You need it when when you are pregnant, well, ill and dying. You need Primary Care when you have a sexually transmitted disease or other infection, mental illness, chronic disease and to learn to prevent complications after a stroke. And so on. Without Primary Care, you are forced to visit walk-in clinics, Emergency Departments or fend for yourself.
    Thanks to this effort (see http://sdnpc.ca for the actual 1st clinic), 5000 orphan patients will now have access to Primary Care. At the 1st site, 2000 patients already now ‘belong’ to an NP, who is able to provide their care, along with collaborating physicians when the case is beyond their scope of practice. The care NPs provide includes comprehensive assessments, prescribing medications, suturing wounds, ordering lab tests, ultrasounds and xRays, referring you to a specialist or collaborating physician and more. All 5000 patients will also have access to a Social Worker, Registered Nurse, Dietitian and Pharmacist. The 2nd site, in a small community (Lively Ontario) nearby, is slated to open in October of this year.
    The need is great for these patients, many of whom have not ‘had a doctor’ for many years. Many currently live in fear of having a major health problem, or complications of their existing chronic illness, as they wander from walk-in clinic to walk-in clinic trying to get prescriptions renewed or xRay results. There is an actual patient’s story on video at the SDNPC web site. This senior’s testimonial is an eye-opener, to say the least.
    Northern Ontario has reached the tipping point on ALC (Alternate Level of Care – patients waiting weeks and months in a hospital bed for a long term care placement), with a higher than normal percentage of the aging population, and lack of primary care. This NP thing is a major positive change initiative. With the Sudbury NP-led clinic as the model, 25 more Nurse Practitioner clinics are slated to open in Ontario. I have been in health care (nursing/academia/public health/management/hospital CEO/consulting) and consulting for over 30 years, and know that this NP initiative can literally transform the health care system, especially for any community with a primary care shortage. Gisele Guenard, CEO http://www.visionarease.com

  2. The title of the story is called:
    Deficiencies within the Canadian HealthCare System: one woman’s story of how the Canadian Healthcare System let her down.

  3. “Nationalized HC systems don’t work”
    “Every country which has one is slowing scrapping it.”
    Really? Scapping, a bold statement that has no proof.
    There is pressure on public systems to balance health budgets and provide more healthcare as the same aging populations in those counties strain health systems. How they do that may involve some private alternatives but certainly not the “scrapping” of the entire system. How much private and who pays is the argument. In Canada each province determines a large part of the county’s health policy guided by the Federal, Canada Health Act. Here is a link to a study on private care done in 2006 by McCleans Magazine:
    http://www.macleans.ca/article.jsp?content=20060501_125881_125881&source=srch
    Wait times (much of the reason for private care) in Canada has been a growing issue that is being addressed by provincial governments. Here is the introduction to a CIHI study on wait times:
    “Improving access to care has consistently been identified as a priority for Canadians from coast to coast. When the First Ministers met in the fall of 2004, they listed timely access to quality care at the top of their collective agenda. They committed to
    achieving “meaningful reductions in wait times in priority areas such as cancer, heart, diagnostic, imaging, joint replacements, and sight restoration.In December 2005,health ministers agreed to benchmarks for medically acceptable wait times for these priority areas. As part of the 10-year plan, the Canadian Institute Health Information (CIHI)was asked to report on progress on wait times across jurisdictions.”
    In Ontario there has been major efforts to increase budgets in problem areas of wait times for treatment which reflect the aging population and the particular care it requires. The system IS being managed, not thrown to the privatization wolves.
    If you read the entire article you provided in the link to Melanie Phillips you’ll see this is not a story about the scrapping of the NHS but a contractual dispute with the GPs to provide greater access within the FREE NHS system. It also appears the GPs are trying to prevent competion for services that the government PAYS for in an effort to improve access and
    standards.
    Here is a telling statement:
    “The result was widespread public fury as GPs, now earning on average more than £100,000 per year, provided less time for patient care. Patients needing a doctor at weekends found themselves fobbed off with an often wholly inadequate locum service.”
    Where in the U.S. can you get evening and weekend care by YOUR GP?
    Ms. Phillips also makes this statement:
    “The way to lift this threat is to raise primary care standards. And that means opening up the free NHS system to healthcare provision from private companies.”
    Notice she said, opening up the “free NHS system”, not going to a private, patient pay system.
    Mismanagement of healthcare is certainly not restricted to governments. As we see here in the U.S. no one is at the helm as cost looms to drown us in unaffordable access and care.

  4. Here’s an interesting piece on the current travails of the NHS (by an admittedly conservative columnist):
    http://www.melaniephillips.com/articles-new/?p=564
    Did you know that Virgin Healthcare and other private clinics are setting up shop in the UK? Nationalized HC systems don’t work. Every country which has one is slowing scrapping it.

  5. “We have runaway costs,… Here’s an example Jeff Margolis often gives: let us say you are given a credit card and are told you may buy whichever suit you wish, and the bill will be paid. Almost everyone would head over to the Armani section at Nordstrom’s rather than to the men’s suit department at Walmart. No?”
    No. If we all paid cash for our healthcare, transparency for patients would be an issue, unless the guilds do what they do best – control access and price. But most of our bills are paid by/through insurance. So who’s picking the “Armania section”? It certainly is not the patients. Patients go where their doctor sends them or where it is convenient to go. And patients largely don’t pick their own treatment, docs do. So does the doctor pick the Armani; I didn’t think U.S. healthcare had anything else but the Armani section to choose from . And what incentive would doctors have in looking for a cheaper alternative? And would you shop price for YOUR healhcare, I don’t think so.
    If anything might come close to the free credit card example you give it would be a single-pay government system. After all, IT”S ALL FREE! But those systems are providing healthcare at about 1/2 the cost. So why isn’t OUR free market system giving greater efficiency, more access, with less cost?
    By the way, I went to Canada for excellent treatment and price.

  6. “We have runaway costs, but that has to do with a lack of transparent pricing.”
    Adam – It is not nearly as easy as you are asserting to price an overwhelming majority of medical services (inpatient and outpatient). Plus, if you look at the most recent report from the Congressional Business Office on what is driving healthcare costs, it is the cost of medical technology.

  7. While I disagree with a number of Adam’s assertions including this ridiculous point about the quality of medical care delievered to Americans, Adam does a point about increasing healthcare costs being a problem worldwide:
    “WASHINGTON, D.C., February 6, 2008 — Medical cost” increases for employers throughout the world are expected to accelerate over the next five years, according to a poll of insurance companies conducted by Watson Wyatt Worldwide, a leading global consulting firm. The poll also found that, in a vast majority of countries, medical cost increases are outpacing the general rate of inflation.
    Nearly three-fourths (71 percent) of respondents expect higher or significantly higher medical cost trends over the next five years. Additionally, more than eight of 10 (81 percent) report that medical costs are eclipsing the general rate of inflation in their country. The results are based on a Watson Wyatt survey of 85 insurance companies that provide medical insurance to employers throughout Asia, Africa, Europe and the Americas.
    “Rising medical costs have rapidly become a global issue that reaches far beyond the United States and other developed economies,” said Francis Coleman, a senior international health care benefits consultant with Watson Wyatt. “Many of the factors causing U.S. employers to experience significant increases in their health care costs — such as increased utilization, expensive medical technology and an aging population — are having comparable effects throughout the world.”
    Insurance companies in Asia and Africa are expecting double-digit increases in employer medical costs in 2008, with the exception of companies in Hong Kong and Singapore, according to the poll. The same is true in Latin America, except for Brazil and Chile, where costs are expected to increase by around 7 percent. In Europe, most insurers – except those in Italy – are projecting increases in the single digits, although respondents in all European countries said they expect higher trends over the next five years.”

  8. MH: We have runaway costs, but that has to do with a lack of transparent pricing. Here’s an example Jeff Margolis often gives: let us say you are given a credit card and are told you may buy whichever suit you wish, and the bill will be paid. Almost everyone would head over to the Armani section at Nordstrom’s rather than to the men’s suit department at Walmart. No?
    So, most of us treat ourselves to Armani-quality HC (particularly once we have met the deductible). Give me the ultra, CT, MRI, full lab workup, toss in some physical and message therapy, a bit of chiropractic and something fancy for my acid reflux. You see, cost is no object because we don’t see or feel the true cost as we would when buying a suit with our own money.
    BTW, I totally disagree with your characterization of American HC service as poor in the vast majority of cases (as would the vast numbers of foreigners who come here for treatment, including lots from Canada).
    BTW: have you ever worked at a VA facility? It’s easy to love the VA if you don’t have to receive care there. If the Democrats force everyone into a nationalized VA-style system, the experiment will be short-lived, believe me.
    I just copied Jeff’s quote from the conference call. Are you calling the most successful entrepreneur and manager in the payer IT world a fool or a liar? God, I hope not.

  9. “If you have to have a serious operation or something done how does a 9 month waiting period sound?? Do your research properly and once you see the other side of the coin you won’t think the Canadian system is all that great.”
    Jeremy, here’s some research for you to do:
    Study on Canadian wait times:
    http://secure.cihi.ca/cihiweb/en/downloads/aib_provincial_wait_times_e.pdf
    From American Prospect:
    http://www.prospect.org/cs/articles?article=ten_reasons_why_american_health_care_is_so_bad
    •3. Our wait times are low because many of us aren’t getting care at all. It’s true, Americans do have short waits for non-elective surgeries. Only 4 percent of us wait more than six months. That’s more than in Germany and the Netherlands, but considerably less than the Canadians (14 percent) or the Britons (15 percent). But our high performance on the waiting times only account for individuals who get the care they need. Our advantage dissipates when you see the next question, which asks how many patients skip care due to cost. And here, America is far worse than anywhere else.
    In just the past year, a full 25 percent of us didn’t visit the doctor when sick because we couldn’t afford it. Twenty-three percent skipped a test, treatment, or follow-up recommended by a doctor. Another 23 percent didn’t fill a prescription. No other country is even close to this sort of income-based rationing. In Canada, only 4 percent skipped a doctor’s visit, and only 5 percent skipped care. In the U.K., those numbers are 2 percent and 3 percent. Few of our countrymen are waiting for the care they need, that much is true. But that doesn’t mean they’re getting it quickly. Rather, about a quarter of us aren’t getting it at all.
    Indeed, 19 percent of Americans were unable, or had serious problems, paying medical bills in the last year. Comparatively, no other country was even in the double digits. This is part of why we perform well on the waiting-times metric. In other countries, the disadvantaged wait longer for their care, and so show up in the data tracking wait times. In our country, they disappear from that measure, because they never get the care at all. You don’t wait for what you’re not receiving. So their wait times show up as “zero,” when they should really be something akin to infinite. And would you prefer to wait four months for your surgery, or never get it at all?
    And from MSNBC:
    http://www.msnbc.msn.com/id/22667311/
    Not so simple is it?

  10. While I can agree with the poor service and inflated cost comments if we had Canada’s health care system we would be taking on even greater problems that many don’t even realize. If you have to have a serious operation or something done how does a 9 month waiting period sound?? Do your research properly and once you see the other side of the coin you won’t think the Canadian system is all that great.

  11. “while the debate for socialized medicine may find some fans here and there”
    Just the rest of the industrialized world.
    “where its being practiced socialized medicine is losing control of its own costs.”
    If that’s true they’re doing it at half the cost.
    “They don’t know where the payments are being made, they don’t know who they are being made to and they don’t know what they are getting.”
    Ya, we could show them a thing or two. Is this guy on drugs?

  12. Runaway costs? Poor service? Exactly which part of that description doesn’t fit the US system to a tee?
    For that matter, which part of the US system best fits the description managed care. Oh, perhaps it’s the VA. Run by, let’s see, the government.
    Your (and presumably Jeff’s but I give him some slack) understanding of what the UK and Scandinavia want to adopt from the US health care system is, at best, limited.

  13. Jeff Margolis, CEO of Trizetto, has talked quite a bit recently about inquiries from government-run HC systems in Europe. He’s what he said on this week’s conference call:
    “We are actually seeing a fair number of opportunistic inquiries back towards us from countries lets just say in the EU that are working towards more US-looking managed care systems because, while the debate for socialized medicine may find some fans here and there, where its being practiced socialized medicine is losing control of its own costs. They don’t know where the payments are being made, they don’t know who they are being made to and they don’t know what they are getting.”
    JM also says that the US spends more than enough on HC at present, and that appropriate pricing incentives would rationalize the cost structure. I am not sure, but I believe he’s a Democrat.
    As we all know, Glen Tullman of Allscripts is an Obama supporter, and likely participated in the construction of the candidate’s HC plan. Obama has not called for a Canadian-style system.
    Countries in Western Europe, such as Sweden and the UK, are looking more and more to incorporate market forces into their HC systems, in large part due to runaway costs and/or poor service.

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