Better Health: Smart Health Commentary Better Health (TM): smart health commentary

Article Comments (4)

What’s Wrong With Canada’s Healthcare System?

This post is a continuation of my discussion of foreign healthcare systems, and what the US can learn from them… I’ve summarized one particularly provocative and outspoken Canadian’s opinion below:

Is Canada’s healthcare system a political monopoly?

Dr. Brian Crowley is the Founder and President of the Atlantic Institute for Market Studies in Halifax, Nova Scotia. He describes the Canadian healthcare system this way:

Canadian Medicare operates in an unregulated, tax-financed, pay-as-you-go model. Our provincial governments are our monopoly provider. They not only pay for necessary care, but they also govern, administer, and evaluate the services that they themselves provide. They define what we call “medically necessary services” and pay for 99% of all physician services. They also forbid the use of private insurance for medically necessary services. They set the budgets for nominally private healthcare institutions. They appoint the majority of their board members and have explicit power to override management decisions.

Under these circumstances, no hospital or hospital administrator can be expected to take any responsibility or initiative because decisions will always be second-guessed by those in political power.

Before the advent of competition in our telephone industry, dissatisfied customers faced the massive indifference of a bureaucracy that took their business for granted, despite some theoretically powerful regulatory agencies. Administrators of the Canadian healthcare system likewise suffer no direct consequences for poor customer service. They aren’t even answerable to a regulatory agency. Accountability is a vague political concept which cannot be enforced in any meaningful way. Like all monopolists, Canada’s healthcare authorities abuse their positions of power.

Dr. Crowley argued that the provincial governments have no desire to measure how many people are waiting for health services, how long they’ve been waiting, or how many people leave Canada to get treatment south of the border. (He claims that the US is Canada’s secret safety valve.) Apparently the province of Ontario contracted with New York State for cancer care for their patients when wait times became politically untenable.

A couple of years ago, the Supreme Court of Canada ruled that the healthcare system violates Quebec’s charter of rights because it collects taxes, promises healthcare in return, forbids competing suppliers and then often doesn’t deliver the care. The justices summarized the situation this way: “A place in a queue is not healthcare.”

Canada-wide average wait times for surgery is 17.8 weeks, though in Saskatchewan, wait times for hip replacements are as long as a year and a half. That’s after a physician has ordered the surgery. Getting to see a physician in the first place is very difficult. Statistics Canada reports that 1/5 of Canadians do not have a family doctor.

In Canada, family physicians are the gatekeepers of the health care system. Patients cannot obtain access to specialist services without having a general practitioner referral. The doctor shortage is so severe now that doctors have begun resorting to lotteries to kick people off their patient rosters, (see Tom Blackwell, MD Uses Lottery to Cull Patient ListNational Post, August 06, 2008); and Canada is about to face a wave of retirements in the system that will greatly exacerbate the shortage.

As for the comparability of wait times in the US and Canada, Dr. Crowley suggests reviewing a letter from a US physician published in the Wall Street Journal a few years ago (Susan Weathers, MD, published April 30th, 2004). Dr. Weathers works in a county hospital and in reference to her  uninsured patients she writes,

[The Canadian health care system] resembles the county hospital where I work. Our patients pay little or nothing. They wait three months for an elective MRI scan and a couple of months to get into a subspecialty clinic. Our cancer patients fare better than the Canadians, getting radiotherapy within one to three weeks. The difference is that our patients are said to have no insurance (a term used interchangeably with “no health care”), whereas Canadians have “universal coverage.”

Dr. Crowley suggested that the Canadian healthcare system has become an unresponsive monopoly though it wasn’t supposed to be that way. It was designed to usher in a “grand era of choice.” It was supposed to be a healthcare system in which people would be able to get all the healthcare they needed without having to “worry about the cost.” Dr. Crowley concluded that “some of the ideas bandied about in Washington will lead to the worst features of the Canadian system without that having been anybody’s intention.”


You may also like these posts

Read comments »


4 Responses to “What’s Wrong With Canada’s Healthcare System?”

  1. dr nic says:

    Even more telling to me with regard to the gaps in the Canadian Healthcare System come from living in a border city. We often see Canadian patients on this side of the border paying out of pocket for surgeries they couldn't/wouldn't wait for in Canada.

  2. dr nic says:

    Even more telling to me with regard to the gaps in the Canadian Healthcare System come from living in a border city. We often see Canadian patients on this side of the border paying out of pocket for surgeries they couldn't/wouldn't wait for in Canada.

  3. PM says:

    The big failing in Canada is an underfunding of the system, and not so much the system itself. We spend about 1/2 of what the US spends as a portion of its GDP. And here, it's important to recall, no one will ever pay out of pocket for their care, unless they do decide to jump the queue to get speedier care somewhere else. Were the Canadian govt to spend more on healthcare (and bring us closer in line with what European countries spend as a portion of their GDP) many of these issues would be addressed.

    Despite the current gaps and shortcomings of the Canadian system, Canadians live longer than Americans, have a much lower infant mortality rate, and will never go bankrupt or suffer serious financial distress if they suddenly need medical care. More importantly, especially at this time of economic crisis, Canadians never have to worry about losing their health coverage if they lose their jobs.

  4. PM says:

    The big failing in Canada is an underfunding of the system, and not so much the system itself. We spend about 1/2 of what the US spends as a portion of its GDP. And here, it's important to recall, no one will ever pay out of pocket for their care, unless they do decide to jump the queue to get speedier care somewhere else. Were the Canadian govt to spend more on healthcare (and bring us closer in line with what European countries spend as a portion of their GDP) many of these issues would be addressed.

    Despite the current gaps and shortcomings of the Canadian system, Canadians live longer than Americans, have a much lower infant mortality rate, and will never go bankrupt or suffer serious financial distress if they suddenly need medical care. More importantly, especially at this time of economic crisis, Canadians never have to worry about losing their health coverage if they lose their jobs.

Return to article »

Latest Interviews

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

Read more »

How To Make Inpatient Medical Practice Fun Again: Try Locum Tenens Work

It s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction burn out and even suicide. In fact some believe that up to a third of the US physician work force is planning to leave the profession…

Read more »

See all interviews »

Latest Cartoon

Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

***

Click here for a musical take on over-testing.

See all cartoons »

Latest Book Reviews

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

Read more »

Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

Read more »

Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

Read more »

See all book reviews »