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The Health systems of Canada & the USA
1. The Health systems of Canada & the USA
THE HEALTHSYSTEMS OF
CANADA & THE USA
Pauline Vaillancourt Rosenau, Ph.D.
Division of Management, Policy, and
Community Health
UT Houston School of Public Health
[email protected]
for
Doctor of Nursing Practice students
Room 706
University of Texas School of Nursing
Thursday, February 17, 2011
2. OVERVIEW
OVERVIEWDescribe the Canadian health system and
clear up some myths
Compare the two countries on Costs
How patients experience it
How hospitals and doctors experience it
Judging Canada and the USA on performance
Strengths and Weakness of each
Try to figure out why
2
3. The Five Pillars of the “Canada Health Act”
THE FIVE PILLARS OF THE“CANADA HEALTH ACT”
Public administration
Comprehensiveness
Portability
Universality
Accessibility
3
4. Living and Working in the Canadian System
LIVING AND WORKING INTHE CANADIAN SYSTEM
With few exceptions, Canadians NEVER worry
about incurring health care expenses.
Nor do Canadians have to submit claims to
insurers.
Providers have ONE payer to submit claims to:
the provincial government.
Canadian system is largely funded by general
tax revenue 2550% federal.
4
5. The Canadian Health System: True or False?
THE CANADIAN HEALTHSYSTEM:
TRUE OR FALSE?
Canada is “single payer” system?
False: it is 10 payer provincial health systems with
“portability”
Each province is like one big HMO: True
The Canadian health system is “socialist”:
False, most providers do not work for the government but
are rather paid by a piece rate system and hospitals are not
owned by the government
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6. The Canadian Health System: True or False?
THE CANADIAN HEALTHSYSTEM:
The Canadian government controls the health
TRUE OR FALSE?
system top – down
False: federal – provincial authorities negotiate the basics ;
for example privatization
In Canada the bureaucracy wastes precious
health care resources?
False:
The % of $ used for administration is much lower in
Canada than in the USA
Billing is straightforward and electronic with 95% of
requested reimbursements completed.
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7. The Canadian Health System: True or False?
THE CANADIAN HEALTHSYSTEM:
TRUE OR FALSE?
In Canada the government controls prices?
Canadians ration care by age, need, and SES
False: The government sets a budget, the doctors set
the payment rates in most provinces
False: there are no policies that restrict care on the
basis of age, need, or socioeconomic status. Such
discrimination is illegal
Canada allows euthanasia.
False: Some US states have laws permitting
euthanasia but none of the provinces in Canada do.
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8.
USA COSTS WAY MORETHAN OTHER COUNTRIES
8
9.
Health expenditure per capita varies widely across OECDcountries.
The United States spends almost twoandahalf times the OECD
200
Average
7
1. Health expenditure is for the insured population rather than resident population.
2. Current health expenditure.
Source: OECD Health Data 2009, OECD
(http://www.oecd.org/health/healthdata).
9
10.
10See slide : Commonwealth Fund International Health Policy Survey: Adults’ Health Experiences in seven
Countries, 2007 – for methodology
11. International Comparison of Spending on Health, 1980–2008
INTERNATIONAL COMPARISON OF SPENDING ON HEALTH, 1980–2008
Average spending on health
per capita ($US PPP)
Source: OECD Health Data 2010 (June 2010).
Total expenditures on health
as percent of GDP
12.
12See slide : Commonwealth Fund International Health Policy Survey: Adults’ Health Experiences in seven
Countries, 2007 – for methodology
13. Why is Does the US Health System Cost so Much?
WHY IS DOES THE US HEALTHSYSTEM COST SO MUCH?
Administration accounted for the largest
share of this difference (39%),
Payments to MDs and hospitals accounted for
(31%) of the next most important variables
explaining difference
More intensive provision of medical services
accounted for the was the third most
important variable in explaining the
difference (14%).
Research by professors from Harvard and Un. Of California in
summer 2010; Inquiry
13
14.
14Pozen and Cutler. Inquiry. 2010 Summer;47(2):124-34
15. Exhibit 12. High U.S. Insurance Overhead: Insurance-Related Administrative Costs
EXHIBIT 12. HIGH U.S. INSURANCE OVERHEAD:INSURANCERELATED ADMINISTRATIVE COSTS
Spending on Health Insurance Administration
per Capita, 2007
Fragmented payers + complexity =
high transaction costs and overhead
costs
McKinsey estimates adds
$90 billion per year*
Insurance and providers
Variation in benefits; lack of
coherence in payment
Time and people expense for
doctors/hospitals
* 2006
Source: 2009 OECD Health Data (June 2009).
* McKinsey Global Institute, Accounting for the Costs of U.S. Health Care: A New Look at Why Americans Spend
More (New York: McKinsey, Nov. 2008).
16. And it is also about Government Intervention and regulation
AND IT IS ALSO ABOUTGOVERNMENT INTERVENTION
AND REGULATION
Canadians think they have “good
government”
Americans distrust their government
Canadians are comfortable with price
controls in the health sector
Price controls in the health sector yield
lower costs
Unlike other economic sectors unfettered
market competition does not lower costs
16
17. Pharmaceutical Spending per Capita: 1995 and 2007 Adjusted for Differences in Cost of Living
PHARMACEUTICAL SPENDING PER CAPITA: 1995 AND2007
ADJUSTED FOR DIFFERENCES IN COST OF LIVING
*
* 2006
Source: OECD Health Data 2009 (June 2009).
18. Annual Salary Range for Registered Nursing Jobs in Canada
ANNUAL SALARY RANGE FORREGISTERED NURSING JOBS IN
CANADA
Province
step One
Top of scale
Quebec
$40,927
$60,319
Ontario
$57,252
$81,315
$82,258 after 25 yrs of service
18
19. How Medicine Is Practiced in Canada and the USA: From the Patient’s point of view – about the same
HOW MEDICINE ISPRACTICED IN CANADA
AND THE USA: FROM THE
PATIENT’S POINT OF VIEW –
ABOUT THE SAME
19
20.
20See slide : Commonwealth Fund International Health Policy Survey of Primary Care Physicians, 2006– for
methodology
21.
21See slide : Commonwealth Fund International Health Policy Survey of Primary Care Physicians, 2006– for
methodology
22.
22See slide : Commonwealth Fund International Health Policy Survey of Primary Care Physicians, 2006– for
methodology
23.
23See slide : Commonwealth Fund International Health Policy Survey of Primary Care Physicians, 2006– for
methodology
24. How do Doctors And Hospitals Get Paid in Canada and the USA
HOW DO DOCTORS ANDHOSPITALS GET PAID IN
CANADA AND THE USA
24
25. Payments in Canada
PAYMENTS IN CANADAhttp://www.health.gov.bc.ca/msp/infoprac/physbilling/payschedule/index.html
http://www.health.gov.bc.ca/msp/infoprac/physbilling/payschedule/pdf/26.%20obstetrics_
gynecology.pdf
25
Fee for service for most primary care and specialists bills
sent to the province
Extrabilling of patient is NOT permitted
No individual bills are prepared for patients
Hospitals (largely private nonprofit) are paid on global
budget system with funds sent by the province; some
regional health authorities obtain populationbased
funding (west) (HiT 2004)
Payment for pharmaceuticals varies by province and
formularies are set up at the provincial level
What Canadian doctors are paid for treatments and
procedures: ex. Gynecologist paid $45 for visit in B.C.
26. How Doctors Bill in Canada
HOW DOCTORS BILL IN CANADABilling is straightforward but lots of variation
across provinces as each takes care of its on billing
Doctor must be registered as a practitioner in the
province
Doctor must have a billing number – and not
automatic
Doctor must be eligible and qualified to bill for the
specific code indicated: ex. neurologist won’t be paid
for doing an appendectomy.
The amount billed must be for the amount allowed
by the fee schedule (Medical Services Plan)
26
27. How Doctors Bill in Canada (Cont..)
HOW DOCTORS BILL IN CANADA(CONT..)
Bills are submitted electronically on forms online
through the web or via a direct connection to the
MSP office – daily or weekly and 98% reimbursed
The provincial payer organization sends payment
twice monthly directly to the MD and pay interest
on reimbursements that are delayed more than 30
days.
Ease of billing is a big plus in Canada and doctors
who have billed in both Texas and Canada are in
agreement on this : “One insurer, one fee
schedule, rarely any question of eligibility
and no incentive to withhold payment – its
heaven compared to the US”.
27
28. Outcomes in the Canadian Health System:Canada Doesn’t do too badly…
OUTCOMES IN THECANADIAN HEALTH
SYSTEM:CANADA
DOESN’T DO TOO
BADLY…
28
29. Overview: Americans and Canadians on Access and health Outcomes
OVERVIEW: AMERICANS ANDCANADIANS ON ACCESS AND
HEALTH OUTCOMES
Very poor Americans are in poorer health than
their Canadian counterparts
Wealthy Americans and Canadians – equally
healthy
Little difference between insured Americans and
Canadians as a whole on access to health care
and health status
Americans without health insurance are –
different, with low access to health care and more
“unmet health care needs”
Alexis Pozen, David M. Cutler (2010) Medical Spending Differences in the United States and Canada: The Role of Prices, Procedures, and
Administrative Expenses. Inquiry: Summer 2010, Vol. 47, No. 2, pp. 124134.
29
30. But there are wide variations on Health Lifestyles
BUT THERE ARE WIDE VARIATIONS ON HEALTHLIFESTYLES
30
Reference: Krueger, Bhaloo, & Rosenau; “Health Lifestyles in the U.S. and Canada: Are We Really So Different?
“Forthcoming Social Science Quarterly, December 2009
31. Comparison of U.S. and Canada: Outcomes
COMPARISON OF U.S. AND CANADA:OUTCOMES
Indicator
Canada
United States
Low Birth Weight Babies
6%
8%
MDs per 10,000 population
19
27
Nurses and Midwives per
10,000
100
98
Infant Mortality Rate
5.04
6.26
Life Expectancy – Female
83
81
Life Expectancy – Male
79
76
31
http://www.globalhealthfacts.org
32.
The BEST Outcomes Measure32
See slide : Measuring The Health of Nations: Mortality Amenable to Health Care, 2008– for methodology
33. Specific Outcomes - Mortality Rates
SPECIFIC OUTCOMES MORTALITY RATES
Seven diseases favored Canada
Colorectal cancer
Childhood leukemia
Kidney transplants
Liver transplants
One disease favors the U.S.
Breast cancer
Hussey, P. et al, “How Does the Quality of Care Compare in Five
Countries?” Health Affairs 23(3) May/June 2004
33
34. Specific Outcomes- Mortality Rates
SPECIFIC OUTCOMESMORTALITY RATES
Overall RR of mortality 0.95 in favor of
Canada (CI 0.92 to 0.98)
Results quite heterogeneous
No explanation for heterogeneity
Guyatt, G. et al, “A Systematic Review of Studies Comparing Health Outcomes in
Canada and the United States”, Open Medicine 2007;1(1):E2736
34
35. Wait Times
WAIT TIMESHistorically this has been the Achilles
heel of the Canadian system
Result of budget cuts 1990’s
Today the situation is much improved
But the U.S. also has a “waiting times”
problem, but for different reasons
In the US we wait because of cost…..
In Canada patients because of scarcity
35
36.
36See slide : Commonwealth Fund International Health Policy Survey: Adults’ Health Experiences in seven
Countries, 2007 – for methodology
37.
37See slide : Commonwealth Fund International Health Policy Survey: Adults’ Health Experiences in seven
Countries, 2007 – for methodology
38. Summing It All Up
SUMMING IT ALL UPStrengths and Weaknesses
And figuring out why….
39. Canada – Health Policy strengths
CANADA – HEALTH POLICYSTRENGTHS
Federal leadership, with state
autonomy on implementation, is a
workable compromise
Access is best when it is universal
Choice is ok – one big HMO
Primary care emphasis is important
Electronic medical records are not
essential
39
40. What Canadians see as their Systems Weaknesses
WHAT CANADIANS SEE AS THEIRSYSTEMS WEAKNESSES
Waiting lists can be overused as “supply side”
control mechanisms even if the MDs are in
charge.
“Costs in Canada are too high.” Really? I
guess it is always relative to your perspective.
Tolerance of a private sector “safety valve”
may be essential if universal access is to be
preserved
http://www.oecd.org/dataoecd/51/48/41925333.pdf
40
41. USA - Strengths
USA STRENGTHSQuality generally high
Lots of evidence that “more is not always
better” when it comes to healthcare
But many patients don’t understand this or
believe it.
if you are well insured…
if not insured or underinsured… ?
No waiting if you pay out of
pocket.
41
Medical technology is available…
42. USA - Weaknesses
USA WEAKNESSESCost are way higher than in
every other industrialized country
with little to show for it.
Accessibility – may get better after
2014 ?
Administrative costs are high and
this is unlikely to change after
health reform is implemented.
42
43. Why do the Two Countries differ as to Health system preference?
WHY DO THE TWO COUNTRIES DIFFERAS TO HEALTH SYSTEM PREFERENCE?
Culture – maybe but USA and Canada are converging; media,
proximity, culture diffusion, geographic mobility and immigration
History – Yes
More distrust of government in US
More emphasis on individual liberty
Form of government – yes
Presidential system in the USA
Roots in the constitution
Designed to require incremental policy rather than comprehensive
policy
Parliamentary system in Canada
Good at implementing comprehensive change quickly and
efficiently
Responsible party model
Important role for party leadership
43
44. Senator Mitch McConnell said Canadian Shona Holmes had “brain cancer” http://patientsunitednow.com/?q=search/node/enter%20keywords
SENATOR MITCH MCCONNELL SAID CANADIAN SHONAHOLMES HAD “BRAIN CANCER”
HTTP://PATIENTSUNITEDNOW.COM/?Q=SEARCH/NODE/ENTER%20KEYWORDS
"I knew in my gut that I had to see someone
and could not wait five to six months," she
says. So she called Mayo Clinic and got an
appointment the same day.
Featured on the Mayo
clinic website
.http://www.mayoclinic.org/patientstories/story
339.html
Diagnosis: Rathke’s
Cleft Cyst on pituitary
gland a benign cyst
Wait time in Canada
would have been three
months with no copay,
no deductible
Cost for removal at
Mayo Clinic = $97,000
44
45. Example of Media coverage in the USA
EXAMPLE OF MEDIA COVERAGE INTHE USA
The Case of Shona Holmes:
http://www.youtube.com/watch?v=cahvnCBVXXU&feature=related
http://factcheck.org/2009/08/dyingonawaitlist/ same as above with Fact
Check information
Mayo clinic charged 100,000$ Shona’s story is no longer posted at Mayo
Clinic’s website
Dr. Jason Huse, a pathologist at the SloanKettering Cancer Center, in
the USA . Factcheck.org says: “He told us something different.” "By strict
definitions it’s not even a tumor," he said, but a remnant of embryological
structures that eventually develop into the pituitary gland. Huse stressed
that without having examined Holmes, he couldn’t know the prognosis of
her RCC: "It is not out of the realm of possibility," he told us, "that this
could have been impeding her hormone secretions to the extent that it was
a lifethreatening situation." And of course, we don’t know what Holmes’
American doctors told her. However, Huse said, RCC "is not typically a
malignant lesion and it is not typically lifethreatening."
45
46. “U.S. Newspaper Coverage of the Canadian Health System: A Case of Seriously Mistaken Identity” Amer. Rev. of Canadian Studies – Spring 2006, pp 27-58
“U.S. NEWSPAPER COVERAGE OF THECANADIAN HEALTH SYSTEM: A CASE OF
SERIOUSLY MISTAKEN IDENTITY” AMER. REV. OF
CANADIAN STUDIES – SPRING 2006, PP 2758
Objective: This study assesses the fairness,
accuracy, and comprehensiveness of U.S.
newspaper coverage of the Canadian health
system in two of the most influential newspapers
published in the U.S.
Methods: Quantitative methods, interpretative
assessments, and thematic analyses are
employed to evaluate coverage of the Canadian
health system in the New York Times and the
Wall Street Journal between 2000 and 2005
46
47. U.S. Newspaper Coverage …2
U.S. NEWSPAPER COVERAGE …2Findings: U.S. newspaper reporting on the topic of the Canadian health
system is found to be poor. Points of misinformation are indicated,
misrepresentations are specified, and inadequate explanations are
denoted.
Overall, ongoing themes and controversial issues regarding the Canadian
health system receive almost as much notice in U.S. newspapers as actual
news events.
Anecdotal information plays nearly as great a role in coverage as facts
and evidence.
U.S. newspaper reports about the Canadian health system are found to be
oversimplified.
Information, all too often, is presented out of context and sources are not
always sufficiently identified.
Coverage is incomplete: all provinces are underrepresented in the U.S.
newspapers studied, except Ontario.
Some articles are confused and a few were found to contain errors.
Conclusions: These inadequacies in newspaper coverage mean that the
U.S. public is sadly misinformed with regard to the Canadian health
system.
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48. References for learning more
REFERENCES FORLEARNING MORE
And documentation for this lecture
48
49. Resources for Learning more about Canada
RESOURCES FOR LEARNING MORE ABOUTCANADA
Listen or View: “Does Canada's Health Care System Need Fixing? 10 August
2009” NPR http://www.npr.org/templates/story/story.php?storyId=111721651
Read: Ross and Detsky “Health Care Choices and Decisions in the U.S. and
Canada”; JAMA 10/28/2009 ; 2009;302(16):18034,
http://jama.amaassn.org/cgi/reprint/302/16/1803
Read; Sanmartin, et al “Comparing Health and Health Care Use In Canada
and the United States,” Health Affairs, vol. 25, July/August 2006 “ (Abstract )
http://content.healthaffairs.org/cgi/content/abstract/25/4/1133
View : “Sicko” by Michael Moore; Scene Selection # 7 Only “Canada!”: about 10
minutes that begins at minute= 40. See especially the Conservative
party member (golfer interview) at Minute 48
http://freedocumentaries.org/teatro.php?filmID=133&lan=undefined&s
ize=undefined
Listen: Audio Interview and Review of “Sicko” by Jonathan Oberlander –
University of North Carolina; for ‘NPR’s program, Fresh Air” 2007. only the
first 15 minutes are relevant about Sicko’s presentation of Canada
http://www.npr.org/templates/story/story.php?storyId=11826524
And investigate other countries such as Britain, Germany, Japan, Taiwan,
Switzerland at: http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/view/
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50. Methodology: Commonwealth Fund International Health Policy Survey: Adults’ Health Experiences in seven Countries, 2007
METHODOLOGY: COMMONWEALTH FUNDINTERNATIONAL HEALTH POLICY SURVEY:
ADULTS’ HEALTH EXPERIENCES IN SEVEN
COUNTRIES, 2007
Survey of comparing Adults’ health care experiences in Australia, Canada,
Germany, New Zealand, the Netherlands, the United Kingdom and the
United States.
Method:
Interviews with representative sample of adults, Age >17years, 2,500 in the United States
and 3,000 in Canada. Funded by the Commonwealth Fund, partnered with the Health
Council of Canada to expand Canadian Sample.
Interviews conducted by telephone between 6 March and 7 May 2007 by Harris Interactive
and Country affiliates
Conducted in different languages; French and English for Canada while Spanish and English
in US
The margin of sample error for country averages is approximately + 2 percent for the US and
Canada and + 3 percent for other five countries, at 95% confidence interval.
Peer Reviewed Publication Citation: Schoen, C., Osborn, R., Doty, MM., et al. Toward Higher
Performance Health Systems: Adults’ Health Care Experience in Seven Countries, 2007.
Health Affairs (2007) 26(6) w717w734
50
51. Methodology: Commonwealth Fund International Health Policy Survey of Primary Care Physicians, 2006
METHODOLOGY: COMMONWEALTHFUND INTERNATIONAL HEALTH
POLICY SURVEY OF PRIMARY CARE
PHYSICIANS, 2006
Countries involved are Australia, Canada, Germany, New
Zealand, the Netherlands, the United Kingdom and the
United States
Methods:
The survey consists of interviews with representative samples of primary care
physicians in seven countries using common questionnaire.
Harris Interactive; country affiliates and in the Netherlands, the Center for
Quality of Care Research, Radbound University Nijmegen, conducted interviews
by mail and telephone from late February through July 2006
Survey was conducted in English in the US and Canada.
The margin of sample error ranges from +3 percent to +5 percent, at 95 percent
confidence interval.
Peer Reviewed Publication Citation: Schoen, C., Osborn, R., Huynh, P.T., et al.
On the Front Lines of Care: Primary Care Doctors’ Office Systems, Experiences
and Views in Seven Countries. Health Affairs 25 (2006) w555w571
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52. Methodology: Specific Outcomes-Mortality Rates
METHODOLOGY:SPECIFIC OUTCOMESMORTALITY
RATES
Joint US, Canadian authors from McMaster University, Hamilton,
Canada
Metaanalysis of outcome studies
38 studies meeting most criteria for high quality (only one missed
criteria allowed)
Publish or unpublished prospective or retrospective observational
studies comparing health outcomes data for patients with any age
with same diagnosis in US and Canada
Sources included: EMBASE (1980Feb 2003), MEDLINE (1966 Feb
2003), healthSTAR (1975Feb 2003), EBM (2003) and dissertation
abstracts ondisc (1969 Feb 2003).
Results were pooled using a randomeffects model
Cochrane’s Qtest was assessed to check heterogeneity and relative
risk was used as a summary statistics
52
Guyatt, G. et al, “A Systematic Review of Studies Comparing Health Outcomes in Canada and the
United States”, Open Medicine 2007;1(1):E2736
53. Methodology: Measuring The Health of Nations: Mortality Amenable to Health Care, 2008
METHODOLOGY: MEASURING THEHEALTH OF NATIONS: MORTALITY
AMENABLE TO HEALTH CARE, 2008
Comparison of trends in deaths considered amenable to
healthcare in the US, Canada and in 17 other industrialized
countries.
Data and Analysis:
Mortality and population data extracted from WHO files
Data include deaths coded according to ICD9CM and ICD10 by
sex and fiveyear age band. The general Age limit was set at 75 years.
The causes of death considered are bacterial infection, diabetes, CVD, treatable
cancers, cerebrovascular disease and complications of common surgical procedures.
Agestandardized death rates (SDRs) per 100,000 population by sex was calculated
for years 1998 and 2003.
Peer Reviewed Publication Citation: Nolte, E., & McKee, C. M. (2008). Measuring
the Health Of Nations: Updating An Earlier Analysis. Health Affairs, 27(1), 5871
Previous Publication Citation: Nolte, E., & McKee, C.M. (2003). Measuring The Health Of Nations:
Analysis Of Mortality Amenable To Health Care. BM, 327, 112934
53
54.
54Chen, Duanjie, and Jack M. Mintz. 2009. “The Path to Prosperity: International Competitive Rates and a Level Playing
Field.” C.D. Howe Institute Commentary. No. 295. Toronto: C.D. Howe Institute. September