by James Channing Shaw
I have practiced medicine in Canada and the United States. I know both systems well. My mother-in-law recently spent 12 hours in the emergency room of an academic New York City hospital. She had suffered a small stroke. She received excellent care, I.V. fluids, an MRI, and close observation over night. I asked approximately 20 of my American friends what they thought the cost of her ER visit might have been. Assuming I was searching for a high number, they guessed between $3000 and $9000. The actual bill: $19,800.
A little more than a year ago, my stepfather-in-law underwent abdominal surgery, an emergency second surgery, spent two weeks in intensive care and two months of rehab in hospital. The total bill for his three months of first rate inpatient care: $25 (for the television in his room). The difference: he lived in Canada.
Well-informed Americans continue to be confused about health care reform. Even the most highly educated have fear that reform will reduce what they get now. Institutions that oppose reform have been remarkably effective in instilling fear of change, of systems like Canada. Clarification and understanding are sorely needed if change is to occur. While no one knows precisely what reform will look like, everyone should at least know the principles that drive the current U.S. system.
1. Most health care in the U.S. is all business. Americans seem to view medical care not as a societal priority similar to, say, police and fire protection, but as a commodity. Insurance companies have a responsibility to their stock holders, not patients, doctors, or hospitals. It is good business for them to reject applicants with pre-existing illnesses. The system is analogous to fire departments that charge for putting out your fire, or don’t come at all if you have had a previous fire.
2. For-profit medicine does not translate to best medicine. The U.S., while having by far the most expensive per-capita health care in the world, ranks 37th internationally overall, 14th in preventable deaths, and 24th in life expectancy. Over-treatment is routinely practiced by doctors as a source of revenue production. While any health system is susceptible to abuses, the American structure enables such ethically corrupt practices through its acceptance of entrepreneurialism in medicine. Most countries that fund health care out of tax revenues try to restrict entrepreneurial ventures in medical services.
3. American insurance companies usually limit the dollar amount they cover. Catastrophic illness, for all but the most affluent, still results in bankruptcy. In 2007, over 60 per cent of bankruptcies in the U.S. were medical, either from medical debt or loss of income from illness.
4. For-profit health care generates enormous administrative costs that could otherwise be spent on the delivery of care. Picture a large hospital with thousands of patients, each with different insurance red tape, versus one standardized plan for billing. Administrative costs are factored into the fee schedules and passed along to patients in the form of premiums or exclusions. Stock holders win, patients lose.
The rest of the world does it differently and, according to most sources, better than the United States, for less cost. The two main questions are whether Americans wish to provide health care insurance for everyone, analogous to police and fire protection, and whether they think for-profit insurance companies can be trusted to broker such a service. Republicans put their trust with corporate insurance companies, the same ones that have exercised their power to derail reform. Republicans in Congress have given a clear signal that they care more about corporate America than health care for Americans.
Surprisingly, many Americans who would be best served by health reform, and are in most need of it, continue to go along with the distorted arguments and anti-reform rhetoric from conservatives. That was true in Saskatchewan in the 1960s when a public system was first introduced and insurance companies were, by decree, eliminated from the government insurance plan. The new system was so successful and popular that it later was implemented throughout Canada.
If Americans who oppose reform could get over their aversion to centralized insurance funded by taxes, and embrace health care as a moral enterprise instead of a business venture, the United States could begin the process of improving overall quality of care, and at the same time start to reduce its per capita health care costs.
James Channing Shaw is an American physician currently at the University of Toronto.
Hi Jim, Interesting piece -- and as you know I am 100% for a "Single Payer." While your mother-in-law's bill was $19,000, how much was she responsible for after Medicare paid? The greed as I see it is across the board (Physicians, Hospitals, Insurance co etc) in the U.S; while in Canada only the physicians are greedy. From what I've seen, docs in Canada have learned how to maximize their income by seeing more patients and charging patients for some things that are covered by insurance here. Such as driving license physicals, drug refills, reviewing records from other docs. etc (I've seen a letter to patients from Martha's parent's doc to his patients). Canada has taken hospitals, insurance co, Big Phrma to some extent out of the greed loop. The Medical Industrial Complex is the Evil Empire in the U.S. With re: docs, I have not been impressed that Canadian docs are more altruistic than their U.S. counterparts. And, I suspect that drug co are allowed to give more perks to Canadian docs than they can in the U.S. There are probably as many good apples here as in Canada and as many Greedy Bastids on both sides of the border. Just my thoughts. Dave
ReplyDeleteDave, I agree with you entirely. Canadian doctors are as greedy as American doctors. And interestingly, Canadian doctors often earn more than American doctors. The limitations in health care costs have to come from regulations. Part comes in the form of established fixed fees for all procedures that are much lower than in the U.S. (some, such as neurosurgery are insultingly low). However, the fee is paid in full, unlike the U.S. where a fee is whittled away by the insurance companies. Doctors in Canada try to use patient volumes to make up for low fees.
ReplyDeleteLimitations also come in the form of excluding what is covered. When there is a new drug, Canada doesn't cover the cost until it has been shown to be cost-effective.
A third way is by eliminating the profit incentive. When all the PET scanners are owned by tax payers instead of private partnerships of doctors,the test is ordered only when medically indicated.
The drug company influence in Canada is an embarrassment, and doctors just say 'bring it on'. One doctor when asked by a drug rep, what it would take to prescribe Drug X, he said, "Leafs tickets, but that would leave the summer open, so I would need Blue Jays tickets as well."
It seems clear that doctors need to be regulated by someone other than themselves.
There is much more to discuss. Thank you for your comments.
Jim
p.s. my mother in law's case is not settled. she has supplemental insurance in Canada and they are demanding an itemization of services from the NYC hospital to justify the charges. I don't know how much of the bill was covered by OHIP, but i'll find out.
Hi Jim, I didn't realize that your mother-in-law was a Canadian in the States w/o health insurance. On the other side... A patient of mine got swine flu while visiting his daughter in PEI (where she is doing a Veterinary Med fellowship and wound up in hospital there. He was there for three days and had to pay something like $20,000. Cheap by U.S. standards; but not cheap if one considers the out of pocket costs. Martha's parents won't come to the States w/o expensive riders.
ReplyDeleteYeah. I think the evil is the Med-Industrial Complex here -- In Canada some of the doctors are the rogues.