In this article, I continue my musings about single-payer health systems. I share my experiences of working within the Canadian health care system as a physician (family medicine and psychiatry). I describe the back logs we did have and how we got around them, the lack of utilization review, how I could hospitalize anyone at anytime so long as there was a bed open, and how no one pushed me to discharge patients too early.
I wanted to continue my musing on single-payer health system, both extending my observations and responding to comments by interested readers on OpEd News.
One reader of my previous blog suggested that I was unfamiliar with the Canadian health care system. I wanted to assure that reader that I did work in Canada as a physician for four years within the Canadian system, so I do have some familiarity. I wanted to expound on some of the differences.
First, in Canada, we never worried about money or ability to pay. It wasn't an issue. It was never discussed. When Americans occasionally showed up in our clinic, we just treated them at no charge, because it was too hard to figure out how to bill them. We weren't very aggressive money collectors. I quite enjoyed never worrying about whether people could pay for their treatment or not.
Second, we had some back logs, but there were ways to work around them. For instance, a patient could wait up to six months for a non-emergency MRI or CT scan. We just didn't have as any scanners as an equivalently sized city in the United States. (I worked in Saskatoon, Saskatchewan, with a population of just above 200,000 -- the largest city in the Province). However, if I wanted a scan sooner, I just admitted the patient to the hospital and then I got it right away. That would never happen in the United States. That would never be permitted. In the United States, we have Utilization Review. The "UR" nurse can prevent admissions for which insurance would not be expected to pay or insist that patients be discharged immediately when their insurance runs out or the authorized number of days expires. That didn't exist in Canada. If a bed was empty, I could fill it. Perhaps there's a downside to that. Probably we should have met as a group and figured out how to get outpatient scans done more quickly without the need for hospital admissions, but we didn't.
Third, I could keep a patient in the hospital for as long as I wanted. That had some drawbacks, too. Mostly that happened because of a lack of rehabilitation beds and skilled nursing facility beds compared to the need. No money existed to build those facilities so people sat in the acute care hospital until a bed opened, which perhaps isn't the best use of acute care beds. However, I really appreciated the absence of nurses chasing patients out the door. (I don't blame nurses for this; they were just the ones hired to do this task.)
Fourth, we weren't as apt to do things as aggressively as in the States. For example, if someone had chest pain, they would get the usual workup as in the U.S., but once the EKG and cardiac enzymes came back normal, we would send them for stress testing next. A stress test is a test in which people walk on a treadmill while attached to an EKG. The person is taken through a graded protocol of increasing exercise intensity until they reach their personal maximum or the maximum of the protocol. If no chest pain or EKG changes occur during this procedure, then their coronary arteries are presumed to be reasonably clear. In Canada, this procedure cost about $300. It costs more in the United States, because everything health related costs at least double in the U.S. for reasons that I am still trying to understand. This stands in relation to consumer electronic costing much less along with automobiles, cell phone usage, gasoline, wine and beer, and a host of other commodities. What I have seen in the United States frequently, however, especially if a cardiologist is waiting in the wings, is for the person to be taken directly to the cardiac catheterization laboratory for an angiogram. By the time all is said and done, that costs about $20,000, including the emergency department visit. So the total cost in Canada could be around $2500 while the total cost in the U.S. could be around $20,000. In Canada, everyone got treadmill tests. In the U.S., only people with insurance coverage for cardiac catheterization got taken to the cath lab. The costs converge closer to each other because some people were billed $20,000 and others much less when their insurance didn't cover the fancier procedures. We used to joke that the indication for cardiac cath was that the insurance would pay for it. On a more serious note, at one University hospital at which I worked, the famous heart surgeon seemed to be willing to do a bypass operation on anyone, so long as they had insurance. I once saw a 99 year old man being taken to bypass. I spoke to him at length since he was part of a research project I was coordinating. I was pretty sure he had no idea what was happening to him. Nor was I surprised when he died on the operating table. Nevertheless, the surgeon and the hospital received their full fee for the operation and the hospitalization. I saw a man with a wasted heart from excessive cocaine use go to cardiac bypass only to have his heart literally melt on the operating table. He was hooked up with a cardiopulmonary machine, which is actually larger than the average size washing machine. Imagine the cost of that! He lived in the hospital for another four months, was discharged with his commercial washing machine on wheels, returned four months later for cardiac transplant and died on the table. That wouldn't have happened in Canada, or, at least, not in Saskatchewan. He would have been judged too ill for bypass surgery and would have been put on palliative care. Surgeons, however, make much less money in Canada than in the United States, while primary care doctors make more. We primary care physicians also worked many fewer hours in Canada for the same amount of money. Nor did surgeons work such long crazy hours because there were caps on their income.
Only once did I see a patient in Canada have a heart attack before going to cath lab that could have been averted had the surgeon been more aggressive. This, of course, also happens in the United States and definitely happens if they person has no insurance. In this case, I asked the cardiologist to take the person to the cath lab for unstable angina and instead I was told to add another medication and it would happen later in the week. The heart attack happened before the cath lab. American cardiologists are probably more aggressive because they make more money from heart catheterization, but these procedures also have serious side effects such as stroke and even precipitating a heart attack through the dislodging of a clot by the catheter. So nothing is perfect.
I was both a family physician and a psychiatrist in Canada (as I still am in the United States). One readers comments about psychiatry in Canada reflected a relative lack of awareness of the Canadian system (of which he accused me). Psychiatrists are consultants in Canada as are most specialists. Unlike the United States in which specialists take over the care of patients from the family doctor, in Canada, specialists consult to the family doctor who continues to manage the patient with input from the specialists. People tend to see the specialist (including the psychiatrist) at most once per year unless they are terribly unstable. The bulk of mental health is done at the primary care level (if it is done at all). In Saskatoon, the waiting list to see a psychiatrist was about one year long. There were less than 50 for the entire Province. Ironically in the rural First Nations communities I visited in Northern Saskatchewan, the waiting list was only one month long, because I came every month and saw everyone who needed seeing. The psychiatrist typically diagnosed and recommended treatment to the family physician who implemented that treatment. Unfortunately, that model is primarily medical. Psychiatrists were not really encouraged to do psychotherapy although some (including me) did.
Psychologists and psychotherapy was not covered in Saskatchewan unless they provided services through the local community mental health center. These services were regulated and primarily were for the most severe patients.
"Alternative" medicine was not covered by SaskHealth ( the single payer in Saskatchewan) unless if was provided by a physician as part of the visit that was covered, but not as an add-on. However, physicians were compensated for spending more time with patients. We could add billing codes for added length of service and for counseling time, but that is also true now in the United States, which has caught up with Canada on that front. In both countries, however, one can still earn a higher income by seeing more patients more frequently, thus encouraging shorter visits over longer ones for maximizing income. I believe we need to change this to improve quality of care. An hour visit for one patient should generate the same income as six 10 minute visits for 6 patients. Then we would have no incentive for moving people through quickly and we could concentrate on their chronic medical problems.
I call attention to the pro's and con's of Canada's system so that we not go blindly into single-payer and make the same mistakes. Health care is much more complex than who pays for it, though that is important. Regardless of who pays for it, some hard decisions are coming. No country can afford the exponentially increasing costs of health care. In Canada, I paid double what I pay in taxes in the United States and 51% of my tax dollar went for health care. Of course, here, at least until recently, 51% of my tax dollar went toward war. In that respect, I prefer Canada. However, other countries are recognizing that they can't afford their health care system. I recently attended a medical conference in The Netherlands, and learned that this country is cutting back on what is covered by their national health system. They have also gone to a two-tiered system in which private health insurance exists alongside government provided health insurance. Canada has always resisted this move (except for the Stephen Harper government), which I applaud. Canada has not wanted a two-tier system of the "haves" and the "have nots", which is where The Netherlands might be going. In the United States, we have a multi-tier system. The wealthy who can pay cash get whatever they want, whenever they want it. Then we have the people with really good private insurance (often government employees and well-paid corporate people). Then we have more ordinary insurance with deductibles varying by state and premium. In Vermont, for example, commonly families have a $5000 deductible each year, while in Ohio, for example, $250 is more common. Why is this? In Vermont, state law prohibits insurers from putting a cap on costs for any particular medical problem. Not so in Ohio. Let's say you have diabetes. In Vermont, you get covered by your insurance no matter what it costs for life. In Ohio, once you reach the contractual limit, you get no more coverage. In Ohio, you could suddenly run out of coverage for dialysis and then you could die. Not so in Vermont. However, for that added privilege, more money must be paid.
The most common reason for bankruptcy in the United States has been health care expenses. Again, that doesn't happen in Canada. Medical bankruptcy is much less likely to occur in Vermont than in Ohio. We can laud single-payer systems for completely preventing medical bankruptcies which both Canada and The Netherlands do.
However, where I perhaps differ from some of the readers but agree with other readers is in my assertion that our health care system is broken. It simply doesn't work very well. I was today at the American Psychiatric Association's annual meeting, and several psychiatrists told me that they were seeking alternatives because prescribing medication is (1) boring and (2) doesn't work. More and different is needed! Charles Elder, MD, MPH, FACP and Cheryl Ritenbaugh, PhD, MPH, in an editorial in The Permanente Journal (The Permanente Journal/ Summer 2007/ Volume 11 No. 3, pp. 79-82), write that patients value "non-specific, whole-person, or transformational changes as essential components of the healing process. Conventional medicine's limitations in appreciating such phenomena may represent an under-recognized root cause of chronic dissatisfaction with and within primary care." In conventional medicine, we have over-valued technology and under-valued human relationship, contact, and care. Technology costs much more than human care. We need to turn this around!
At the Center for Health Research in Portland, Oregon, they recently completed a National Institute of Health (NIH)-funded pilot trial assessing the feasibility and clinical impact of a novel, holistic intervention for newly diagnosed type 2 diabetics. They recruited and randomized 60 patients to either conventional medical care or ayurvedic care, the traditional health care system of India, ranking among the oldest continuously practiced systems of natural health care in the world. Patients in the ayurvedic arm of the trial were treated with a multimodality intervention including exercise, a lacto-vegetarian diet, a quality-controlled herb supplement, and instruction in the Transcendental Meditation technique. The conventional medical care group received standard diabetes education with primary care follow-up.
They found more improvement in the ayurvedic group than the conventional medicine group, but, also importantly, patients gained whole-person or transformational benefits from ayurvedic medicine that went beyond the narrow biomedical markers that we are accustomed to measuring.
As another example, they conducted a clinical trial assessing the impact of two mind-body interventions for weight-loss maintenance. One of the interventions tested was Qigong, a technique from traditional Chinese medicine tradition involving movement and meditation. Whereas patients in the Qigong group did not achieve benefit in terms of the measured biomedical outcomes (weight loss maintenance), in formal interviews these same patients reported significant improvements in overall well-being:
"Positive thinking and self-affirmation and all of that positive energy--that's what it amounted to. I don't know about weight loss or weight maintenance, but I did find a more positive outlook and peace. It would take the stress right out of you. I know that stress causes a lot of health problems. From that standpoint alone it's beneficial."
"It was really clear that after the class everyone felt energized. When everybody walks in they are rushing from work and then when they leave, they are like on a cloud floating out the door."
"There were so many other empowering and unique attributes of Qigong that [weight loss] really seemed like it went off the scope of things to consider, and yet I could very easily see the connection."
Here again, patients reported whole-person benefits that were not captured by the conventional biomedical outcome markers. Here is where I would like us to move -- in the direction of well-being and whole-person health instead of rationed illness care. While we will always need illness care, to the extent that we can promote whole --person health, we will need less of it. Illness care is always more expensive than whole-person health and wellness promotion. But how do we build this into our thinking about health care financing and how do we pay for it? It is commonly recognized that 80% of the costs for health care in a person's life are spent during their last year. Perhaps we need to ration that? Perhaps people could live longer and more healthy if we invest in whole-person care and wellness over last-ditch illness care for that last year? Making these choices will be hard!
Submitters Bio:Lewis Mehl-Madrona
graduated from Stanford University School of Medicine and completed residencies in family medicine and in psychiatry at the University of Vermont. He is the author of Coyote Medicine, Coyote Healing, Coyote Wisdom, and Narrative Medicine.