Wednesday, June 24, 2009

CANADIAN 'SINGLE-PAYER' CARE = Sometimes it just doesn't pay

With all the talk these days about the pros and cons of government health care systems, especially on the Canadian or British models, there have been a couple of topics that I've never heard come up in the discussion -- something which perhaps is not discussed because it's kind of unimaginable.

First, let's make the distinction between the Canadian and British models. In Britain there is a "two-tiered" system, in which public and private medicine are practiced at the same time, with certain doctors, clinics, hospitals, and services operating in the private sector for fees that they determine for themselves. This means there is faster and more efficient medical service available to those who can pay for it. Persons of a left-wing bent find this as unfair as they find any and all things that money can buy for those who have it. In my view, all it means is that where there's a line-up for services in a public health system, private care helps to swiftly and dramatically shorten the queue.

In Canada on the other hand, with rare exceptions, private provision of publicly-funded services is not permitted. Or, if permitted to operate, may not charge more than the state is prepared to reimburse. In recent years, absolute desperation for MRI services has eroded the state's monopoly on them, allowing private clinics in some provinces, but that is the exception rather than the rule. Unless, of course, you're looking for an abortion. Abortion is considered an essential service which must be funded and available in every province, and private for-profit clinics operate in most provinces. Abortion advocates are quick to point out that private clinics deliver services more cheaply and efficiently than hospitals, but one is not allowed to apply that logic to most other medical procedures.

Dentistry, cosmetic surgery, and many therapies are not covered by the government, so practitioners may charge what the market will bear. In more prosperous times, non-critical procedures like electrolysis were once covered by the public system, but became casualties of cost-saving measures. Okay, fine: electrolysis an "essential service" yesterday -- not essential today. That seems reasonable enough. But what will be next on the chopping block when money gets tighter?

There was a time when independent specialists, like pediatricians or obstetricians, could determine their own fees, and the government would reimburse the patient according to its approved fee schedule. This was referred to as "extra billing" on the part of the doctor.

When my first child was born in 1980, doctors were still allowed to extra-bill, and my obstetrician charged a total fee of $500 for 9 months of pre-natal care, any type of delivery (normal, c-section, whatever), and all post-natal visits. She informed each patient that she charged what she thought was fair, and if anyone had trouble meeting that fee they should speak to her and she would work out some arrangement. The government fee schedule in 1980 considered all those services to be worth a mere $350, and we willingly paid the extra $150 for the services of one of Toronto's most dedicated obstetricians. By the time my second child was born two years later, extra-billing was illegal, and the doctor had to charge no more than what the government prescribed.

What this means is that all doctors become government employees. They can see as many or as few patients as they please, but their fees are determined by a government bureaucracy, as are the services to be covered. My experience is confined to the province of Ontario (each province runs its own health insurance scheme, within certain perameters dictated by the feds in exchange for federal funding -- effectiveness of provincial systems varies widely, especially as concerns wait times).

In Ontario, GP's are paid according to the number of patients they see and medical procedures they perform. This means that if you need a prescription renewed before you have a chance to see the doctor, the doctor can no longer issue a bill for speaking to you and your pharmacy on the phone. For awhile after this service was disallowed, doctors would renew and the patient would pay a fee the next time they came into the office. However, the doctors experienced long delays or even non-payment for services by phone (can you imagine a lawyer being prevented from collecting on these "billable hours"?). Before long doctors ceased to provide telephone services at all, except perhaps in an emergency.

Other services either ceased or were provided only for individual fees -- need a vaccination record for your kid's school or camp registration? That will be 25 bucks, please. It's not "extra billing" because the government doesn't pay the doctor anything for it, so he's on his own. Some pediatricians devised a plan whereby you could pay an annual fee per family (e.g. $100) for all such non-medical services, which is a big help to people with a number of young children. If your kids are older and less in need of such things, you can choose to pay a set fee for each service as it comes up.

And remember: you are paying these fees on top of a monster payroll deduction (a "premium") for your provincial health plan, plus the cost to yourself or your employer for private secondary coverage which might give you dental and orthodontic coverage, semi-private hospital room, prescription drugs, eyeglasses and annual eye exams, etc., none of which are covered by the province. [Standards change: annual eye exams were once covered, but in recent years were cut back to every second year for most of one's adult working life. Ontario grants women a mammogram every second year after age 50 -- I believe the American recommended standard is annually after age 40.]

There's something else that happens when doctors and nurses are all government employees. Every so often they decide it's time to STRIKE.

What this usually means is not a total collapse of the system, but a work-to-rule regime in which all elective surgeries are postponed (and since the patient may have waited months or years for such surgeries, like knee replacements, this could be both dangerous and crushing). Or in which the ordinary routine of TLC can go by the boards.

In 1989 I had what is called a "missed abortion": an embryo died not long after conception but instead of naturally miscarrying it remained attached in utero for another six weeks or so. Eventually the process of miscarriage began, and it was necessary to remove the conception by D & C (dilation and curettage). This occurred during a period of "work to rule" by hospital staff. My ob/gyn, true to form, did everything with her usual attention to detail -- even her kindest bedside manner was in full force (normally she was a crusty old dame).

But the nurses were at minimal staffing levels, and kept pretty much to their station, doing only the barest required rounds. Naturally, there were hardly any patients around because only emergency procedures were being done, but that didn't mean I got any real attention from them. Despite the fact that I could be expected to continue bleeding for some period of time, if I wanted a change of sanitary pad I had to ring for it, and then it was brought in and set down on my dining cart. The nurse then turned on her heel and made a fast exit, and I had to sit up and reach for the cart in order to get it. Had there been any unanticipated mishaps, such as excessive bleeding, perhaps even causing unconsciousness, they would never have known because they never looked and they never asked.

At some point my husband and I came to understand that my hospital stay was finished, though we were quite unclear as to what the check-out procedure should be. I got dressed on my own, gathered my goods, and headed for the desk at the nurses' station. We stood there perplexed, muttered something to the effect of, "Is that all there is?" and were abruptly sent on our way. Discovering that our pregnancy was dead, and having it surgically extracted, all within less than 72 hours, had been a numbing experience. The only thing that could have made it worse (and did) was feeling like the forgotten diner stuck at the dark corner table by the kitchens.

My obstetrician (bless her) learned that I had felt neglected during the work-to-rule, and wrote me a letter of apology. That's the thing -- I really have no complaints about Canadian doctors and nurses on the whole. They're as qualified and caring as anybody in the profession. We've been blessed with some fantastic personal physicians. But there are not enough of them, and they work, damn hard, under the constraints of an under-funded, over-managed, and over-stressed system. A staggering proportion of medical school graduates see no future at home, and high-tail-it to the U.S. to practice under freer conditions. American hospitals regularly attend Canadian job fairs and advertise in newspapers to recruit nurses with higher pay and better conditions than they could ever get in Canada. When it comes to both timely medical services and jobs, the flow is one-way: southward. If the United States adopts Obamacare, where will all these folks go???????

They won't go to Britain. Private practice is expensive to set up. And public hospitals -- well, let's put it this way: when I arrived in Toronto 35 years ago, I used to remark that the subway platforms and trains were so clean they were probably more sanitary than many a public hospital in the big cities of both Britain and the States. Public transportation infrastructure in "Toronto the Good" ain't what it used to be -- much of it is so grubby and run-down that you'd think it was a British public hospital. I have that on eye-witness authority.

The first thing most people think of when it comes time to tell horror stories of Canadian single-payer medicine is the wait-lists for both diagnosis and treatment. These are very real, much worse in some provinces than others, and, yes, people die marking their time in the queue for service. But the waits are not the only drawback. As Americans ponder the prospect of adopting a similar system and having the government attempt to manage it for a population TEN TIMES the size of Canada's, they should give some serious thought to how it feels to be nickeled and dimed by physicians trying to figure out how to juggle their overhead and make a decent living. And then they should give even more serious thought to how they will fare every time the doctors STRIKE.

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