I am a retired Canadian general practitioner and have many comments about how Americans provide medical care. It is surprising that I have never seen any opinion solicited about the Canadian system despite that the US has many things to learn from a system that is highly valued by the Canadian public and produces superior health care at a much lower cost. When polled about what Canadians most valued in their country, the medical system was #1. Tommy Douglas, the then premier of Saskatchewan, who was responsible for the introduction of a government sponsored plan that covered all citizens, in another poll, was voted the most influential Canadian of all time. Most Americans believe they have the best health care in the world despite the fact that the USA ranks lower than at least 30 other countries in longevity, infant mortality and mortality in children under 5. Canada routinely ranks in the top 10 at a cost of 9.8% of GNP versus about 18% for the US.
Having 41 million uninsured Americans denies a basic right. Canceling medical coverage because of new health concerns and denying coverage because of past health is amoral. Medical costs are the highest cause of bankruptcy in the US. Americans have opted to support a huge military industrial complex instead of supplying the basic rights of good health care and a good education system to their citizens. 100% of Canadians receive complete medical care and bankruptcy for medical costs is rare. The Canadian system is constantly criticized as part of the fear mongering that is so prevalent by detractors of a government run medical system. Most Americans believe that if Canadians have something serious wrong with their health, then they immediately pack their bags and head to the US, but that must be rare because of the exorbitant costs.
As with all government run systems, we have our share of problems. Due to the federal government cutting their contribution by 50%, our system was seriously underfunded but many of those problems have been addressed. Waiting for elective tests and procedures is not unreasonable and a necessary part of a well functioning system. Being able to provide virtually instantaneous testing and procedures requires significant over capacity that is expensive. Emergencies and serious problems are dealt with in as an expedient manner as in the US. Canada has the most stringent licensing requirements for physicians in the world.
The major issue with your system is the high profit motive of the private medical insurers, large administrative costs inherent in your system, inadequate control of expensive non cost effective tests and drugs, and high physician cost (who also often have a conflict of interest when they receive income from tests). Insurers only are responsible to their investors and have little interest in preventative health. They encourage inappropriate use of tests and unproven therapies to increase profits. Whole body MRIs probably produce more problems than they solve. Benign findings result in more testing as everything discovered must be investigated. Now getting a complete gene sequencing of your DNA has become popular. Because of fears of litigation, and huge patient demand, few physicians practice evidence based investigations. Costs are out of control.
Huge numbers of employees are necessary to deny claims and process claims. I worked in a doctor owned clinic and we had one half time employee doing all of our billing for 7 doctors as we only billed to the provincial health plan, WCB and the provincially owned auto insurance plan. The average American physician bills to 37 different insurers and probably has at least one full time employee to process those claims. As a result our overhead was always very low – in the 20% range. I had less than 1% bad debt in my entire career and received almost all my billables within one month of submission. Every one has medical insurance.
High physician income partially reflects high malpractice costs. All Canadian physicians belong to a single malpractice insurance company owned by the same physicians who receive legal care. Most cases end at discovery, few cases are settled out of court (and then with sure losers, the award can be affected). All others are litigated by lawyers extremely skilled in malpractice law. My premiums were a fraction of my American counterparts. Tort reform is necessary to contain the out of control litigation that plagues American medicine. With the courts bogged down for years, and high court and legal costs, it is often cheaper to settle out of court. Despite physicians having practiced with “due diligence”, the verdicts usually don’t favor them. Jury trials tend to decide for the patient and awards for damages are high.
The much higher physician fees in the US reflect all these inefficiencies. Factoring for high overhead, bad debt, and malpractice premiums, income is eroded significantly. I have never seen a study that examined take home pay of Canadian and American physicians. I believe they would be much closer than imagined.
All patients have general practitioners, and specialists see no patients without a referral. I had no restrictions on the specialist to whom I referred, unlike many HMOs in the US. Internists, pediatricians and ob/gyn physicians do not do primary care, see patients only by referral, and as all patients are screened see their enhanced skills put to more efficient use. A family physician based system is much more cost effective.
All Canadian hospitals are nonprofit and owned by the government. Budget cuts in the past have produced efficient operations. Rationing of elective services is common and a necessary part of any national health service. Oversupply in the US often results in unnecessary surgery, testing and high costs.
I will give three personal episodes that show how bankrupt the American system is. With my girlfriend sleeping in the back unrestrained, I feel asleep at the wheel doing 80 miles/hour on cruise control. It was on an overpass crossing another interstate (!-15 crossing I-80 in northern Utah), and the rumble strip on overpasses is not on the white line but right before the guard rail. I woke up just before the guard rail, swerved to the other side, went through the guard rail on the left, rolled the vehicle six times and landed on my wheels facing the right direction down a steep cement bank on I-80. All the windows were gone and everything was outside the vehicle except the two of us. You can only imagine the ride she had. We were taken to a small town emergency. I was basically fine but the Dr strongly recommended several CT scans of my head and neck which I refused ($2500 worth of tests). Her only serious injury was a fracture of her right humerus and she had an open reduction and fixation by an orthopedic surgeon. She suffered a complete radial nerve palsy of her radial nerve as a complication of the surgery and could not dorsiflex her right wrist or fingers for nine months. The hospital and Dr. bills came to $23,000 for 3 days in the hospital. Everything was itemized but in the middle of the statement was an additional $11,500 for medical/surgical supplies when it appeared that everything had already been included. The surgeon never sent a bill. One year later, she had a non union of the fracture, had to have an open fixation of the fracture with a bone graft, and eventually had a satisfactory result with no complications at no personal cost – in a Canadian hospital in a small town. It was apparent to me that the surgeon did not know what he was doing. The method of fixating the fracture was totally inappropriate. We would have won a law suit.
The second case was a Canadian man we met at Bahia Los Angeles in Baja Mexico. He wintered there every winter for several years. Two years previously, he had had several syncopal (fainting) episodes and was evacuated to a hospital in San Diego. He had every test known to man including coronary angiograms of his coronary and carotid arteries and an MRI of his head. Nothing abnormal was found. But despite that, it was strongly recommended that he have coronary artery stents inserted, just in case! The bill would have been $250,000. He declined all therapy and was fine two years later.
The third example was about two young specialists recently trained in the US at good reputable hospitals (one was a general internist and the other a pulmonary specialist). Despite having just passed their specialist boards in the US, after three attempts to pass their Canadian specialist boards, they failed and could not practice in Canada. They are both now working in the US.
The conclusions that I drew from these are. Medical care in rural American may not always be at a high standard (in contrast to the blue ribbon clinics like Mayo, Cleveland, Stanford and many big cities). Unnecessary testing is done routinely to cover them in case of litigation at high cost. Hospitals pad their bills (doubling ours) in people with medical insurance. Specialist training is not to the standard of Canadian training. The system is very expensive, with a high profit motive.
All health care insurance systems throughout the world have their individual problems. None is perfect. However mot first world countries cover all their citizens, get better results and at a fraction of the cost of the American system.
