The Health systems of Canada & the USA

The Health systems of Canada & the USA

THE HEALTH SYSTEMS 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 OVERVIEW Describe 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 THE FIVE PILLARS OF THE CANADA HEALTH ACT Public administration Comprehensiveness Portability Universality Accessibility 3 LIVING AND WORKING IN THE 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 - 25-50% federal. 4 THE CANADIAN HEALTH SYSTEM: 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 5 THE CANADIAN HEALTH SYSTEM: TRUE OR FALSE?

The Canadian government controls the health 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. 6 THE CANADIAN HEALTH

SYSTEM: 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. 7 USA COSTS WAY MORE THAN OTHER COUNTRIES 8 Health expenditure per capita varies widely across OECD countries. The United States spends almost two-and-a-half times the OECD 20 Average 07 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 See slide : Commonwealth Fund International Health Policy Survey: Adults Health Experiences in seven Countries, 2007 for methodology INTERNATIONAL COMPARISON OF SPENDING ON HEALTH, 19802008 Total expenditures on health as percent of GDP Average spending on health per capita ($US PPP) 16 7000 6000 5000 4000 United States

Norway Switzerland Canada Netherlands Germany France Denmark Australia Sweden United Kingdom New Zealand 14 12 10 8 2000 4 1000

2 0 0 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 3000 6 Source: OECD Health Data 2010 (June 2010). United States France Switzerland Germany Canada

Netherlands New Zealand Denmark Sweden United Kingdom Norway Australia 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 8000 12 See slide : Commonwealth Fund International Health Policy Survey: Adults Health Experiences in seven Countries, 2007 for methodology WHY IS DOES THE US HEALTH SYSTEM 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 Pozen and Cutler. Inquiry. 2010 Summer;47(2):124-34 EXHIBIT 12. HIGH U.S. INSURANCE OVERHEAD: INSURANCE-RELATED 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* $600 $516 $500 $400 Insurance and providers

Variation in benefits; lack of coherence in payment Time and people expense for doctors/hospitals $300 $247 $220 $200 $198 $191 $140 $86 $100 $76

$0 US FR SWIZ NETH GER CAN * 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). AUS*

OECD Median AND IT IS ALSO ABOUT GOVERNMENT 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 PHARMACEUTICAL SPENDING PER CAPITA: 1995 AND 2007 ADJUSTED FOR DIFFERENCES IN COST OF LIVING $210

NETH 1995 $422 2007 $228 AUS $431 $317 GER $542 * $335

FR $588 $319 CAN $691 $385 US $878 $0 $200 * 2006 Source: OECD Health Data 2009 (June 2009). $400

$600 $800 $1,000 ANNUAL SALARY RANGE FOR REGISTERED 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 HOW MEDICINE IS PRACTICED IN CANADA AND THE USA: FROM THE PATIENTS POINT OF VIEW ABOUT THE SAME 19 20 See slide : Commonwealth Fund International Health Policy Survey of Primary Care Physicians, 2006 for methodology 21 See slide : Commonwealth Fund International Health Policy Survey of Primary Care Physicians, 2006 for methodology

22 See slide : Commonwealth Fund International Health Policy Survey of Primary Care Physicians, 2006 for methodology 23 See slide : Commonwealth Fund International Health Policy Survey of Primary Care Physicians, 2006 for methodology HOW DO DOCTORS AND HOSPITALS GET PAID IN CANADA AND THE USA 24 PAYMENTS IN CANADA

http://www.health.gov.bc.ca/msp/infoprac/physbilling/payschedule/index.html http://www.health.gov.bc.ca/msp/infoprac/physbilling/payschedule/pdf/26.%20ob stetrics_gynecology.pdf 25 Fee for service for most primary care and specialists bills sent to the province Extra-billing 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 population-based 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.

HOW DOCTORS BILL IN CANADA Billing 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 wont be paid for doing an appendectomy. The amount billed must be for the amount allowed by the fee schedule (Medical Services Plan) 26 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 OUTCOMES IN THE CANADIAN HEALTH SYSTEM:CANADA DOESNT DO TOO BADLY 28 OVERVIEW: AMERICANS AND CANADIANS 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. 124-134. 29 BUT THERE ARE WIDE VARIATIONS ON HEALTH LIFESTYLES 30

Reference: Krueger, Bhaloo, & Rosenau; Health Lifestyles in the U.S. and Canada: Are We Really So Different? Forthcoming Social Science Quarterly, December 2009 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 The BEST Outcomes Measure 32 See slide : Measuring The Health of Nations: Mortality Amenable to Health Care, 2008 for methodology SPECIFIC OUTCOMES MORTALITY RATES Seven diseases favored Canada Colorectal cancer Childhood leukemia

Kidney Liver One transplants transplants 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 SPECIFIC OUTCOMESMORTALITY RATES Overall

RR of mortality 0.95 in favor of Canada (CI 0.92 to 0.98) Results No quite heterogeneous 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):E27-36 34 WAIT TIMES Historically this has been the Achilles heel of the Canadian system Result

of budget cuts 1990s 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 See slide : Commonwealth Fund International Health Policy Survey: Adults Health Experiences in seven Countries, 2007 for methodology

37 See slide : Commonwealth Fund International Health Policy Survey: Adults Health Experiences in seven Countries, 2007 for methodology SUMMING IT ALL UP Strengths and Weaknesses And figuring out why. CANADA HEALTH POLICY STRENGTHS 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 essential medical records are not 39 WHAT CANADIANS SEE AS THEIR SYSTEMS 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 USA - STRENGTHS Quality generally high Lots of evidence that more is not always

better when it comes to healthcare But many patients dont understand this or believe it. technology is available if you are well insured if not insured or underinsured ? No waiting if you pay out of pocket. 41 Medical USA - WEAKNESSES Cost

- 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 WHY DO THE TWO COUNTRIES DIFFER AS TO HEALTH SYSTEM PREFERENCE? Culture maybe History Yes but USA and Canada are converging; media,

proximity, culture diffusion, geographic mobility and immigration 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 SENATOR MITCH MCCONNELL SAID CANADIAN SHONA HOLMES 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/story339.html Diagnosis: Rathkes

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 EXAMPLE OF MEDIA COVERAGE IN THE USA The Case of Shona Holmes: http://www.youtube.com/watch?v=cahvnCBVXXU&feature=related http://factcheck.org/2009/08/dying-on-a-wait-list/ same as above with Fact Check information

Mayo clinic charged 100,000$ - Shonas story is no longer posted at Mayo Clinics website Dr. Jason Huse, a pathologist at the Sloan-Kettering Cancer Center, in the USA . Factcheck.org says: He told us something different. "By strict definitions its 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 couldnt 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 dont know what Holmes American doctors told her. However, Huse said, RCC "is not typically a malignant lesion and it is not typically life-threatening." 45 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 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 U.S. NEWSPAPER COVERAGE 2 Findings: 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. 47 REFERENCES FOR LEARNING MORE

And documentation for this lecture 48 RESOURCES FOR LEARNING MORE ABOUT CANADA 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):1803-4, http://jama.ama-assn.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=undefine d&size=undefined Listen: Audio Interview and Review of Sicko by Jonathan Oberlander University of North Carolina; for NPRs program, Fresh Air 2007. only the first 15 minutes are relevant - about Sickos 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/ 49

METHODOLOGY: COMMONWEALTH FUND INTERNATIONAL 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) w717-w734 50 METHODOLOGY: COMMONWEALTH FUND 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) w555-w571 51 METHODOLOGY:

SPECIFIC OUTCOMES-MORTALITY RATES Joint US, Canadian authors from McMaster University, Hamilton, Canada Meta-analysis 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 (1980-Feb 2003), MEDLINE (1966Feb 2003), healthSTAR (1975-Feb 2003), EBM (2003) and dissertation abstracts ondisc (1969- Feb 2003). Results were pooled using a random-effects model Cochranes Q-test 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):E27-36 METHODOLOGY: MEASURING THE HEALTH 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 ICD-9-CM and ICD-10 by sex and five-year 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. Age-standardized 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), 58-71 Previous Publication Citation: Nolte, E., & McKee, C.M. (2003). Measuring The Health Of Nations: Analysis Of Mortality Amenable To Health Care. BM, 327, 1129-34 53 54 Chen, 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

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