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INTERNATIONAL: . . . . and you thought doctors were difficult in the US

Word from the UK is that a leading neurosurgeon either took a refill of a bowl of soup or just some more croutons from the hospital cafe (depending on whether you believe him or the canteen staff) and he’s been suspended! This means that at least three operations in his hospital have been cancelled. And this is in England. You remember England, the place where like Canada where you have to wait forever for surgery and 10 months to get a hospital spot for a normal delivery.

On the other hand, it’s probably no skin off the nose of the surgeon, as he almost certainly makes more in his part-time role in the private sector than he does with the NHS, and most likely has been suspended on full pay. I know another British surgeon, who makes the odd appearance in THCB because, well, he’s my father, who was so browned off with the administrators at his hospital that he spent ages trying to figure out how to be suspended on full pay. I bet he never thought of pinching a packet of croutons. And of course now he’s retired–oh, the missed opportunity! Dad, if only you’d known!

PHARMA: Price controls and foreign imports–European style

Although drug prices are generally set by the government in Europe, there is significant price variation between different countries.  Savvy European entrepreneurs have therefore gone to wholesalers in the cheapers countries (like Greece) and imported drugs to be resold to pharmacists. As you might expect the drug companies are not happy about this importing of cheaper drugs (sound familiar to my North American readers?) and have successfully gone to court to enable themselves to limit their sales to wholesalers in any country to enough for that country only. Now the EU is calling on national licensing associations to make it easier for these traders that exploit price differences to buy and sell in new markets.  To American pharmas and patients dismayed (for different reasons) at the overall lower prices outside the US, this might all seem like a storm in a teacup, but it does go to show that these days maintaining high prices for drugs is not easy.

POLICY: France faces health budget crunch

Just to follow up on the news from the UK last week, there’s a report out from the French government suggesting that they might both charge more for prescriptions and increase the payroll tax that supports health care.  The government’s fear is that it may end up with a yearly deficit of 29 billion Euros (apprx. $35 bill) by 2010.  France is supposed to be keeping its budget deficit to a specified amount as part of a wider EU agreement (although neither it nor Germany has managed that so far!) and health care accounts for 20% of the overall deficit. 

In France drugs account for more than 20% of health care spending (compared to less than 10% in the US) and so reducing Rx consumption is a likely target of cost cutting.  Incidentally the only place that uses more prescription drugs per capita than France is Japan, where doctors traditionally make most of their incomes dispensing drugs–a little like oncologists in the US, who are now finding that source of income being switched off.

QUALITY QUICKIE: Letter from England, (with UPDATE Tues)

UPDATE: Don Johnson and I are having a friendly spat about the real cost of health care in Europe and another about the uninsured in the new comments section of The Business Word.  I hope that Don keeps support for his comments section up and that you’ll join me in commenting there. (I’m barely able to keep my blogging up, so no comments here for a while yet).

I’ve been in the UK for a few days and thought that it would be appropriate to give you some impressions of what I’ve been hearing about the state of health care over here. One of the most noticeable factors is that we’re not in France. The BBC reported last night that the French health service was about to have a doctors’ and pharmacists’ strike because of threats to reduce government finance of the system there.  The BBC reported with some incredulity that any French person can get any operation they like any time for free, but did point out that the French pay 30% more overall for their system, and that (stop me if you’ve heard this tune before) costs were going up faster than the economy can afford it, etc, etc.

The UK is also increasing its rate of health expenditure from what used to be a very miserly 5.5% of GDP on the way to 7-ish%.  In some ways they are having capacity constraints, with the result that some GP positions in London are vacant, and some patients are being sent to France for surgery to reduce waiting lists.  That’s possible because these days funding for primary (including Rx) and secondary care is organized via Primary Care Trusts (PCTs) which buy (or "commission" in New Labour-speak) hospital services from Trust Hospitals.  Although this might seem like the basis of a competitive market, in fact a PCT tends to cover virtually all the residents of one town, and the hospitals they purchase from usually have a catchment area that’s about the same size as the PCT.  In other words there’s more or less a single buyer (that looks something like a staff-model HMO) and a single seller (the local tertiary care hospital) — and there’s not real money flowing between them. Within the PCTs, the primary care is delivered by notionally independent GP practices, who behave much as they always did — although the minority which were "fundholders" under the previous reform environment probably have less control over hospital purchasing than the used to.

The most interesting development is the move towards what might be called intermediate risk sharing for chronic disease management. Starting in April 2004, GP practices will be putting up to one third of their revenues at risk, and be able to earn 1050 points by hitting a number of targets in certain therapeutic areas.  Each point will start off being worth up to 75GBP but will go up to 120GBP.  In other words each GP may have up to 120,000 GBP at risk for their practice, which may wind up to 30-40,000 GBP per doctor in real money. There are ten chronic disease states being targeted, many of them surrounding cardiac care, with some 75 metrics being measured. The measurement of the interventions, which are all the standard things of keeping the heart patients on the right drugs, making sure the diabetics get their eye exams, etc, etc, are being done from the information systems of the GPs themselves.  But this isn’t the gong show it would be in the US as by now the vast majority of GP practices have got primary care EMRs, and most GPs are taking electronic notes during consultations.

To this point, many GPs have just been coding office visits with electronic diagnoses that are the easiest to input rather than the most accurate (i.e. coding all visits from diabetics the same).  They don’t get paid any differently for different codes (unlike the US) so convenience had been the driving factor. Most of the GPs I talked with are fairly confident that the add-ons required, such as alerts to contact patients to make sure they’ve come in for an annual exam, or alerts to remind the GP in the middle of the consult that the hypertensive patient hasn’t had a blood pressure test, can be (or already have been) added to their systems – and that’s where they’re focusing the most effort. There’s also a presumption that some of the smaller one or two doctor GP practices with only a couple of thousand patients will merge to get better IT IT and admin support. Overall there’s some optimism about the system, as reflected in this American assesment from UCLA’s Paul Shekelle.

It’s also interesting to note that in the absence of the completion of the huge EMR in the sky projects that the government just awarded contracts for, the UK is already far ahead of the US in primary care IT.  However, this doesn’t really spread over to the hospital side.  In fact frequently the communication between GP and Hospital specialist breaks down (does this sound familiar?) and a patient may be put on a drug in the hospital and the GP either not be informed about it, or take them off it when they come for the follow up visit. As the GPs currently control their own drug budget they’ve been somewhat incented to under-prescribe – any savings there can be used in the rest of the practice to buy new computers, nicer chairs for the waiting room, etc. Additionally the end points that GPs are going to be rewarded on are based on intermediate outcomes, not on hospital measures.  So for example, getting the % of at-risk patients on statins up above a certain number will be rewarded and it’s just assumed that this will reduce costs down the line and in the hospital.  But at present no one’s counting and the information systems aren’t really able to talk to each other about it. However within the PCTs there are already guidelines that many GPs (are at least trying to) follow willingly, even though they’re paper based, and there is a system of clinical consultation over local guidelines at the PCT level itself.  As well as the NICE (national institute for clinical excellence) which creates national guidelines for technology and drugs based on cost-effectiveness analysis.

Additionally there was great familiarity with the Kaiser system, and the NHS has done a series of comparisons between the two, which in part inspired the new contracting system by showing that the lower use of hospital care and greater emphasis on overall patient management at Kaiser led to better and more cost-effective care.  But many people I talked to were aghast when I described the state of IT in the typical American doctors office – they just assumed that the rich Yanks must be well ahead of them!

TECHNOLOGY: CSC, Accenture Win Regional Pacts for NHS System

The remaining contracts in the UK’s NHS Care Record Service are being awarded.  The latest contracts are for the east and northwest regions and the big winners are CSC and Accenture. These are huge contracts of over $1.6bn each. In the 1990s Accenture (then known as Andersen Consulting) developed a bit of a bad reputation for not delivering as promised on IT contracts developing claims systems for various Blues plans.  And to be fair they were by no means the only systems house that dissapointed their plan client (for instance EDS as noted in this article). But those expenditures were in the tens of millions not the billions that the NHS will be spending. Now to be fair these huge projects are very difficult to run and manage, so you can’t always expect perfect results.

The UK is not unaware of the risks they’re running and the contracts come complete with fairly aggressive penalty clauses. As it’s such a prominent contract dealing with the UK’s most sacred political cow, you can bet that the government will be paying close attention.  And for those of us on this side of the Atlantic, well, we’ll be looking for clues to see if there are lessons for slower development of clinical records infrastructure in the US.

Meanwhile the NHS story is Health-IT World‘s top story for 2003.  Here are the rest of the Top 10

INTERNATIONAL/INDUSTRY–British Surgeons’ Private Fees Highest in World, really?

And in a fun story at the end of the year, Reuters claims that in their private practice British Surgeons charge the Highest fees in the World.  Now I know a little about this given that my father was, until his retirement last year, one of those NHS surgeons who worked 20% time in the private sector.  No question that the private sector was where he made the majority of his income (usually more than double there what he made in his relatively paltry NHS income), and there’s always been some controversy over this arrangement.  But although private fees were high there I’m very surprised that they were really higher than in the US, and specialists there make overall nothing like what specialists here do.  Last year the surgeon fee alone for my serious knee operation was, list price including assistant,  $21,500, and after I negotiated it down to roughly UCR, it was still around $12,000, or $10,000 for the surgeon’s fees alone.  Of course this didn’t count the tissue graft acquisition which was another $5,000 which I’m sure the surgeon’s office made a pass thru on. That was a for a three hour major but relatively routine surgical procedure.

So I asked my dad if he made 6,000 GBP equivalent of $10,000 for the average 3hr period he spent on this private operations and here’s the transcript of his response. "No (bleep) (bleep) (bleep) (bleep)(bleep) (bleep)ing (bleep), and you can (bleep) (bleep) in your (bleep)ing (bleep) and if I did I’d have (bleep)(bleep) (bleep)ing Ferrari, (bleep)(bleep) yacht (bleep)(bleep) house in south of France (bleep)(bleep) private jet (bleep)ing too".  So as they say in the medical literature, perhaps more research is needed!

POLICY: Oh Canada

This article is about Canada’s health system and its relationship to the US health policy debate.  It is not meant to be an endorsement of Canada’s system, or an endorsement of single payer for the US. From my personal point of view, while I think serious health care reform is unlikely in the next few years in the US, some foreign models of health insurance are very useful for the US debate. But the combined local/employer insurance systems seen in Japan, Germany and Holland provide a more likely and familiar model for the US, than the Canadian or UK single-payer systems. However, this article isn’t about what might happen here or which system is better. This article is about the distortions that are frequently heard in the US, and in Canada for that matter, about the Canadian system. It’s also a lot longer than the average post, such as my recent post on Canada, Steffi and Ken, and you can download it as a separate document here if you want to print it out and savor/criticize it over a cup of coffee.

This article is dedicated to the amazing Medpundit. Despite the fact that I disagree with a huge percentage of what she says, Sydney Smith manages to cover virtually all of health care and medicine in her excellent blog, while writing book reviews, keeping up a full time solo family practice, and claiming that she’s not posting as much as she used to.  Her article on Canadian physician emigration and the vigorous support she got from her commenters finally got me to get off the dime and put in my several cents worth.

Before I jump into this it’s worth noting that some of the differences between these health care systems are cultural. There have been several interesting descriptions of the international variations in medical practices. In one great book written in the 1980s, The Painful Prescription,  Aaron and Schwartz describe rationing of hospital care in Europe and the UK compared to the US. For instance they pointed out that  in the UK kidney dialysis was not used at nearly the levels among the elderly as it was in the US (or in fact in Europe).  So they concluded that care was rationed and as a direct consequence people died. (If you have ESRD and don’t get treatment eventually your kidneys shut down and you die). However, many other commentators, including Lynn Payer in her book Medicine and Culture which is very well described by Humphrey Taylor from Harris, have shown fairly conclusively that many cultures just regard "care" in a different way. In that sense the dialysis-use figures could be seen as the aggrandizement of hundreds of decisions not to over-tax elderly patients with a long and difficult treatment that wouldn’t help their quality of life, even as it extended it slightly. Indeed, it’s equally cultural relative to accuse Americans of "over-care" by doing CABGs on 95 year olds who are soon going to die anyway. So while you’re reading the rest of this article you need to bear in mind that some of the differences that are ascribed to policy are due to culture. Having said that; many are not. 

Before we start, recall that Canada has a single payer in each province that provides uniform health insurance to all its citizens. To provide that care it contracts directly and exclusively with physicians and hospitals, who remain largely autonomous but have no other customers. The US in contrast has a mixed-private-public system for which the government provides about half the money. Insurance is only universal for those over 65, and roughly 14% of the population has no insurance coverage, with very varying levels of coverage for the rest–mostly coming through employers. The latest comparable numbers have the US spending roughly 14% of GDP on health care while that number is around 11% in Canada. So at a macro level, the Canadians pay less as a share of their income to cover more of their people. (In fact as its GDP per capita is lower than America’s Canada spends considerably less per citizen). While single-payer advocates tout those numbers, many critics claim that Canada rations care, and that both patients and physicians are leaving Canada to give and receive care that’s not available at home.

Given that, it’s worth looking at two main aspects of the Canadian system that frequently come up for criticism. How are patients doing? What’s going on with physicians? And are they really all leaving the Great White North to escape its health care system?

The Patient Experience

It’s simplistic and true to say that Canadians have free access to basic health care. Americans have varied access based mostly on insurance. And it’s accepted that, as a corollary, all Canadians have less access to high-technology health care than do most Americans, However, googling around the web you’ll find indications that 18% of Canadians cannot get access to first contact care, (although only 10% have had trouble getting routine day time care). Still even 10% lacking access to care isn’t nothing, especially in a universal insurance system.  Luckily the Commonwealth Fund has over the years funded my old colleagues at Harris and Harvard, led by Bob Blendon, to do several studies over the years about these issues.  They asked consumers’ views in several countries, but we’ll concentrate on Canada and the US. (Note: When you open a link that is a powerpoint slide, hit the page down button as there might be 2 or 3 slides in that one link)

System satisfaction: Canadians were very happy with their system in the  late 1980s but were much less happy by 1998 and also in 2001, after a period of funding reduction.  But they are still happier than Americans, or at least only 18% want to completely rebuild the system, as opposed to over 28% of Americans. (The 2003 American number is over 30%–I don’t have the latest Canadian numbers, but they have been spending increasingly more and their incoming PM has promised to maintain that level. So as satisfaction went down due to less money you can expect that level to increase when there’s more. It’s also worth noting that the Canadians saved the rest of their economy some money, while during the large boom in the US in the 1990s, the health care sector stayed steady as a share of GDP.

Access to care: In terms of actually getting care and accessing doctors, both Americans and Canadians felt access was about the same. But in terms of access to care, by 2001 26% of Canadians thought it was getting worse, and only 6% getting better. 20% of Americans thought their access was getting worse too, but 17% thought it was getting better.

But then we get to some of the key issues. In Canada for elective surgery you have to wait; two thirds of Americans can get it within a month. Most Canadians have to wait more than a month and more than 25% have waited more than 4 months. No one waits that long in the US (presumably so long as they can qualify for coverage).

Costs matter: But in the US costs really matter. Over a quarter of Americans had out-of-pocket costs of over $1,000, compared to less than 5% of Canadians. Americans were two to five times more likely than Canadians to have an access problem due to cost, such as not getting a needed drug or not seeing a doctor. And when you look at those with below average incomes, in Canada only 9% failed to get recommended follow up care due to cost. In the US, over one third did not. More than a quarter of Americans (26%)–including 39% of those with below average incomes–didn’t fill a prescription because of costs, more than twice the number than in Canada. 21% of Americans have problems paying medical bills compared to only 5% in Canada, and that goes for 35% of Americans with below average incomes. So on a macro level it’s true that nationally Canadians sacrifice getting access to expensive resources (such as MRIs and surgeons). But in turn they don’t have to put up with the individual cost issues that are a problem for many Americans, especially the poorer ones.

If you look at the same type of indicators amongst those who are sick in similar study (also from Blendon’s group)  they are virtually all the same, with problems of access to specialty care and hospitals in Canada matched by access problems due to cost being 2-3 times worse for the sick in the US. Here are the sources for the full charts for the "healthys" and the "sick".

The impatient inpatient: This is where the arguments get anecdotal, and little ridiculous. I never understand, for instance, why American small business owners who have to buy insurance in the world’s most dysfunctional market complain so much about the prospect of Canadian-style health care. In 1993 I talked to a Rotary Club where, before I even got my international comparisons slide out, the small business owners in the room came after me with the classic anti-Canadian argument that goes something like "When he needed care the Prime Minister of Alberta/Nova Scotia/Yukon Territory/Canada came down to the US". There has always been an extremely limited number of Canadians getting new high-tech care in the US that isn’t available in Canada, almost always paid for by their province.  However this has been transposed into the argument that thousands of Canadians are flooding across the border to get care that is unavailable at home.  There is even the very occasional and underfilled patient bus trip coming down to get prescriptions and treatments unavailable in Canada, of course massively outnumbered by the buses taking Americans to buy cheaper drugs up north.

While the argument about Canadians flooding south to get medical care withheld from them up north is widely heard, it’s bullshit. Yup, lots of Canadians get care in the US, but that’s because, due to the better weather, the higher incomes, going to college or that NAFTA thing, they eitherlive here, or are on vacation in Florida to escape that terrible winter. Work done by a team led by Steve Katz at University of Michigan with  the Evans/Barer/Cardiff team at UBC which looked into this in obsessive detail found essentially no evidence of Canadians crossing the border to get care. (Incidentally plenty of Americans are still going up there for non-covered surgery like laser corrective eye surgery, which is cheaper and just as good up north). In fact according to Canadian insurers there appears to be no interest amongst Canadian consumers in commercial insurance products to cover care abroad, other than standard holiday cover. Note that this is not the case in the UK, where private insurance allows about 10% of Brits to jump the queue to get surgery in a private hospital. So it looks like the Canadians accept the fact that they have to wait for surgery, and not surprisingly don’t want to come down here to pay for it out of pocket.

The Grumpy Doctors

As mentioned earlier, I started working on this article partly because Sydney Smith over at Medpundit wrote a piece saying essentially that Canadian doctors felt that their system sucked, they all wanted to move to the US and that many of them already had–leading to a doctor shortage in Canada. She concluded:

    And why are Canadian physicians leaving their patients in the lurch? Not for the money. They leave for better research opportunities, for greater professional and clinical autonomy, better job choices, and better medical facilities. They leave, in other words, for all the advantages conferred by a free-market healthcare system–the same advantages that we American physicians take for granted when we yearn for a Canadian-style system. We should look to Canada, all right, but not as a role model. We should look to them instead as a warning. There but for the grace of God–and a strong independent streak–go we.

Before we look more at the emigration factor, again it’s worth looking at a relatively recent study by the Harvard team. In 2000 they asked a set of questions to doctors in the same five (English-speaking nations) nations where they surveyed patients in 1998 and 2001. It was indeed true that doctors in Canada were pretty miserable, and you certainly can trawl the Internet and easily find grumpy Canadian doctors, and many anecdotal stories of them leaving for the good life in the US. In the Harvard study, Canadian doctors did believe that their ability to provide quality care had got worse in the last five years, but only slightly more Canadian doctors believed this (59% v 56% for generalists and 67% v 60% for specialists) than did Americans. And Canadians were only slightly more pessimistic that the quality of care would decline (61% v 54%) in the future. But when asked about major problems in their practice, compared to Americans they were one-third less likely to regard external review of clinical decisions to control costs as a problem (13% v 36%), and less than one-half as likely to see limitations on drugs they could prescribe (18% v 43%), or to be concerned that their patients couldn’t afford necessary prescription drugs (17% v 48%). These of course are the typical hassles that make up the drudgery of a physician’s daily practice. The real concerns of Canadian physicians compared to Americans were, of course, limitations on specialist referrals (66% v 29%) and access to hospital care (64% v 8%) for their patients.

Then things get really interesting.  When asked, more directly if their actual patients often lacked access to newest drugs or medical technology only 26% of Canadian doctors said so–roughly the same as the 27% of Americans. And when asked if their patients get sicker because they are not able to get the health care they need, instead of the high numbers you might expect, only 12% of Canadian doctors said so, as opposed to 18% of Americans. So it appears that Canadian physicians think that by and large that Canadian patients do actually get the care they need, or if they don’t, it seems not to impact their health.

Then when asked about their satisfaction with their own practice 72% were very or somewhat satisfied compared to 68% of Americans.  And when you ask the classic three Harris questions about satisfaction with the system and the need for reform, Canadian docs are much less likely to want "complete rebuilding" (4% vs 12%), and similarly much more likely (25% vs 16%) to think that their system "works well." Here is the full physician chart set.

There’s no question that Canadian doctors are less happy than they were, but that’s more to do with the funding (and pay) cuts they saw over the previous decade (which were a symptom of the Canadian government getting its health care spending under control) than anything fundamentally wrong with the system.

The dissatisfied disappearing physician. But what about all those Canadian doctors fleeing the country? Well let’s first look at why they are fleeing. There are several Canadian researchers or specialists in the US taking advantage of bigger budgets for their research, or training in something Canada leaves to its bigger, richer neighbor. A 1994 survey of Canadian physicians living in the United States found that postgraduate training in the United States was associated with subsequent emigration–in other words they went there, they liked it and stayed or went back later. Other reasons for staying in the US included professional/clinical autonomy, availability of medical facilities and jobs, and remuneration, although this last factor was curiously considered equally important by Canada-based docs as a reason for staying behind. (They clearly hadn’t asked their √©migr√© colleagues what they were making!)

Now we’re starting to get somewhere. Just as Canada takes advantage of America’s over abundance of facilities to buy high-tech services for its patients on the margin (usually before it later adopts them in its own facilities) it also does the same for doctors who want to work in highly-specialized cutting edge technology areas. As in many other industries, the opportunities to do the coolest stuff tend to be here in the States. For an example, look to this somewhat tongue-in-cheek debate between Robert Califf, a Duke cardiologist and a Canadian colleague David Naylor which asked if American cardiac care is better than Canadian care?

By now you know the answer. If as a patient or a cardiologist you make it to Duke (or another high-end American institution), you find quicker access to more expensive technologies.

    Califf noted  that Americans experienced "differences in mortality over time largely because of the difference in the rate of revascularization between the countries"  Conversely, "simply stated, for people with heart disease, the US offers greater access, better technology, and greater creativity in solving clinical problems," Califf said. "There’s no question when you look at the systems, the US has better access to cardiologists, better access to technology-not because as cardiologists you’re not smart enough to use it, you’re just not allowed to use it when you want to-and very rapid access to new technologies."

But then he admitted some more interesting nuggets

    "Yes, we cost more to the patient, and we have problems with prescription drugs, but in the category of respect for cardiovascular practitioners, there’s no question who gets more respect, and if you want to make more money, just move south"

His debating partner, Dr David Naylor responded that:

    Revascularization may provide a mortality advantage. From a broader population perspective, though, these differences are unlikely to change the fact that in overall survival after the age of 65, Canadians come out ahead of the US. "The US does of course come out ahead in what is spent," he added, roughly double that spent in Canada on care of the elderly.

In the last part of what was a pretty funny debate for a bunch of dry heart docs, Califf got rather serious and actually came over as a fan of the Canadian system but felt that it just needed more money:

    "I would submit that the US is going to have to become more like Canada in terms of its healthcare system, because there’s no other solution in sight, but I would also submit that if you don’t ratchet up your expenditures on healthcare with the demographic that you and we share, you’re going to be facing an even more explosive situation than you currently have."

However part of what he said in jest is true. It is logical for Canadian doctors who need no additional qualifications to work in the US to go south for another reason.  It pays better; much better!  Canadian physician incomes averaged about C$135,000, and even surgical specialists get only about C$180,000. In the US specialists in groups averaged somewhere between $150,000 and $350,000, primary care around $150,000–and don’t forget that Canadian dollars are worth 1/3 less than their American namesakes! In fact this chart of international physician incomes shows that virtually any doctor would be better off moving to the US. (Actually FYI Japanese doctors make more than Americans).  So when Medpundit says that Canadian doctors are coming here in droves, you can’t exactly blame them.  Only one little thing is a bit strange; they are not!

The brave folks from UBC led again by my old colleagues Morris Barer and Bob Evans, as reported in this issue brief called The myth of Canadian physician emigration, show that although roughly 500 doctors a year are leaving to the US, somewhere between 250 and 300 were coming back the other way, and that the deficit was more than made up of other doctors immigrating to Canada–mostly Brits who thought that Canadian pay scales were pretty good compared to what they got at home! Even at its greatest extent Canada was losing 1.4% gross of its physicians and more than making it up through returning Canadians and importing foreigners.  And even though Canada has fewer docs per head than the US (2.1 per 1,000 v 2.6) it has more than the UK or Japan (1.7 & 1.6) so these numbers are not significant either as a share of all doctors or proportionally to the population. It is worth pointing out that the other 99% of Canadian doctors didn’t believe that doubling their salary was enough to compensate for the associated unpleasantness of having to move to the US!

Conclusion: There are No Easy Answers

My primary objective in writing this piece is not to deride the good work done by those on all sides of this issue.  Instead it’s to show that while looking at international comparisons is valuable, it’s not OK to look on the surface and ignore the many complexities underneath that surface. Worse it’s totally dishonest to take "facts" out of context or tell blatant lies–but there’s no tax on lying.

Health systems everywhere are under financial strain–always have been and always will be. Canada certainly limits access to high technology and specialists by limiting investment in them upstream. The US does not, but citizens living in Canada are very unlikely to run into severe financial trouble because of their health–not so here.  Meanwhile, poorer Canadians have a roughly comparable experience with their medical system as do other Canadians.  Poor Americans certainly do not enjoy the benefits of their system as much as their richer compatriots. You might also have a sneaking suspicion that as their health system is more popular with Canadians than with their doctors (while the opposite is true in the US) perhaps the Canadian system is actually run in favor of the consumers rather than the producers of health care!

There are certainly cultural differences between Americans and Canadians, as Michael Moore pointed out in Bowling For Columbine. But there are also structural ones that are creations of policy. We are heading into a period of policy discussion again, and inevitably the Canadian system will come up in the conversation. It would be nice if that conversation was based somewhat in reality.

POLICY: Oh Canada, implications for the US, part 1

Medpundit has written an article over at Techcentralstation basically saying that Canadian doctors hate the system there and are leaving for the US.  I’ve responded briefly in the comments there, but am working on a much longer piece that will explain that in general Canadians are happier with their health care system than are Americans, get as good or better care at a much cheaper cost to society in a much more equitable system, and that the few Canadian doctors who are leaving are doing it for the money and to escape that terrible winter.

While you are waiting with bated breath for that intellectual feast, to introduce the notion I’m linking to an email debate between two major players in the health policy wonk world, Steffi Wollhandler and Ken Thorpe. Steffi has argued for a Canadian-style single payer for years. Ken, who was an under-secretary of HHS under Clinton, argues for essentially a redux of Clinton’s plan–which despite much BS talked at the time–was not a single payer plan as they both make clear.

Personally speaking, either one of these reform solutions would be better than what we have now. But in this blog I’m tying to forecast what I think will happen not what I want to happen.  So while you’re pondering the merits of the debate, in considering its relevance you may notice that:

a) this debate is happening in the Newark Ledger-Journal,  not the New York Times. This is not an insult to the fine people of the Ledger-Journal, but it’s scarcely the first source for news and information for most Americans.

b) two left of center, politically-active health care wonks are finding plenty to disagree on, and stress very little the  common ground they share opposing the current system–scarcely the makings of the national consensus that would be required for health care reform. Note that such consensus was not built properly by the Clintons in 1993-4.

c) Health care reform that doesn’t in some way get the doctors, the pharmas, and the insurers to buy-in/be bribed-in is very unlikely to happen–definitely not with a Republican house. So if you are watching for it, you need to see a Democratic President, massive public discontent (which is building but not there yet), and a unified vision of what problems need to be fixed and a "good enough" solution to fix them.  My guess is that the most identifiable "problems" are uninsurance and out of pocket cost control.  Neither administrative costs (Steffi’s bugbear) nor care coordination (Ken’s concern) are likely to get the public’s passion raised enough to get reform underway.

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