President Obama’s initiative to reform the American health care system has stirred vigorous debate about the best way to accomplish the objectives of reining in costs and expanding coverage to the uninsured and underinsured.
Some individuals believe the country should emulate Canada and adopt some type of single-payer system of universal coverage. Opponents claim such a system would result in long delays for care. Is this the case? And how do the American and Canadian systems compare with regard to the quality of patient care and the effect on medical practice?
To find out, Renal & Urology News interviewed Canadian urologists and nephrologists who have practiced on both sides of the border. Overall, they indicated that although the Canadian model is not perfect, it is a good system in which patients generally receive timely and competent care and physicians have fewer practice hassles compared with their American counterparts.
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“I think universal coverage works,” said Hesam Farivar-Mohseni, MD, of Ontario’s Brampton Civic Hospital, a Canadian citizen who spent nearly 11 years in the United States. Following a two-year fellowship at Memorial Sloan-Kettering Cancer Center in New York, he spent time working in New York and at West Virginia University Hospitals in Morgantown.
Misconceptions on both sides
“Patients in Canada are not being denied anything,” he said. “People in the U.S. think that patients here [in Canada] are waiting outside the hospital, they have no access to the hospital, and they’re dying because this is government-sponsored health care. That’s not true at all. If there’s a serious disease the family doctor calls a specialist and the person is seen right away. If a patient has a kidney stone or something similar, they may wait for eight hours, but that’s true in the States, too. Such patients don’t get seen in the emergency room there right away, either.
“And the funny thing,” he continued, “is that people here think people in the States are dying on the street corner because they have no insurance, and that’s not true, either. They go to a university hospital and get the same treatment that most patients get.”
Dr. Farivar-Mohseni said he believes the Canadian health-care model could be successfully implemented in the United States. “I have no doubt in my mind,” he said. “The good thing about the Canadian system is it’s much cheaper and provides the same quality of health care in general. In the U.S. there are middlemen: You have the insurance companies and the hospitals, which need to make money. Here, only the physician and the pharmacy need to make money. So that’s a totally different attitude, and the cost is definitely lower because there’s no profit there.”
Because Canada’s coverage is not only free but portable, there is no such concept as going out-of-network. “You can go anywhere in the country and should not be denied any treatment by any doctor,” Dr. Farivar-Mohseni said. “You can ask to be referred to a particular doctor or location. For example, if you are from Toronto, you can go to London, Ontario, or to Ottawa if you want. That’s one of the advantages here.”
Despite the disparities in the Canadian and U.S. medical infrastructures, “there’s not much difference between the two systems,” Dr. Farivar-Mohseni said. “We treat the patients exactly the same way—the same medications, the same surgeries, the same instruments.”
Sometimes, fewer options
Still, the medical system in Canada can be more restrictive than in the United States, he said. “Here [in Canada] the government decides that this hospital does this, that hospital does that,” he said. “In the U.S., if you want to do something, and you’re capable of doing it, nobody stops you. And I think that makes things more accessible to the patient.”
Lithotripsy is among the procedures that are more readily available in the United States than in Canada, he noted. In New York State, for example, lithotripters are available in more cities compared with Ontario, and some hospitals that do not have the devices can have mobile lithotripters come to the hospital on certain days, according to Dr. Farivar-Mohseni.
“In Ontario, however, patients can undergo lithotripsy in only one of two places throughout the entire province: downtown Toronto or London, Ontario,” he said. “And I think that’s bad for the patient and also bad for the physician, because then you’re only letting certain physicians do [the procedure],” Dr. Farivar-Mohseni said. “That’s, in fact, a major problem.”
In addition, Dr. Farivar-Mohseni, who also is in private practice, said it is not easy in the Canadian system to introduce a new technique or obtain a new technology, such as robotic prostatectomy or brachytherapy for prostate cancer. “You have to go through a lot of hoopla, and eventually the response is, ‘No, we don’t have the money,’ or, ‘We’re not the place to do this. The government says another place has to do it.’”
Patients never see a bill
The major distinction in patient care between the United States and Canada is the fact that Canadians incur no charges for services. Patients never see a bill in this taxpayer-funded system. The Canadian system gives a per-person allotment to each province, and then each province decides how it is going to pay for health care. In Canada, every patient has a family physician who serves as the conduit between all patients and specialists. Rulan Parekh, MD, MS, a nephrologist at the University of Toronto and who formerly worked at Johns Hopkins University in Baltimore, noted that in Canada, all patients need to be referred to specialists by their family physician.
“So everybody has a gatekeeper, and that gatekeeper takes care of them from a general point of view,” said Dr. Parekh, who is on the Editorial Advisory Board of Renal & Urology News. “Canadians are willing to wait to see the specialists and just see their family physician instead. They want to try to do as much as they can with the family physician. As a result, in Canada, you have many more family physicians and fewer consultants. In the States, it’s the opposite.”
Dr. Parekh returned to Canada after 20 years of practicing adult and pediatric nephrology in the United States. Although Dr. Parekh has not been in private practice in either country, she said she can still relate to the obstacles faced by American patients.
“I feel that the burden to the patient in dealing with all the health-care bureaucracy in the States is enormous,” she said. “[In Canada], you walk in, you give your health card, and that’s it. Nobody asks you to sign your life away, nobody asks you to make sure you pay for the bill, nobody asks you about co-pays, nobody tells you that your insurance won’t cover this so you have to pay for it. I don’t think Canadians realize how much stress there is in the United States for patients who are really ill.”
Dr. Parekh said she doubts that the Canadian model would translate easily to the United States because of inherent differences between the two systems. “For example, U.S. medical students graduate with a huge burden in loans, so they have to become specialists,” she said.
“How else are you going to pay off those loans unless you join a medical field which is procedural based to obtain an adequate income? You have to opt out of Medicare because if you’re in general practice or an internist, you can’t make the money to support your practice with only Medicare patients.” In contrast, most medical students enter family medicine and thus provide general medical care to patients. In Canada, “the reimbursement to family physicians and to specialists may be lower but the fact that you get 100% reimbursement and not a discounted amount allows you to plan your practice,” Dr. Parekh said.
“[All] physicians can do very well financially regardless if your clinical practice is procedural based or not.” Reimbursement amounts in Ontario in general seem small because services cost less, particularly without the overhead and markups associated with American medical care, she added. At the same time, however, all types of physicians in Ontario have heavy patient loads because of a shortage of both generalist and specialist physicians.
Another major feature of the Canadian system is the regionalization of medical care. Certain facilities serve as centers of excellence to which patients are referred for particular types of specialty care, she explained. By caring for large numbers of patients with specific medical problems, these centers develop an expertise in certain treatments that might not be possible at smaller centers caring for fewer patients.
