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Healthcare
This area includes a broad range of organizations and professions involved in the delivery of healthcare. Included are managed care models, healthcare trends, and ancillary services provided.
Healthcare from a Canadian Perspective
Posted by:
Sean Hardiman on
November 11, 2009 at
5:32PM EST
Hi all,
I posted a note a few weeks back about health care reform in the US and was asked to post about my experiences with the Canadian system. Due to a job change and a large move, I haven't had a chance to follow-up on the request to talk about the Canadian experience yet, and in order to stimulate some discussion, I thought I'd post it as a new thread. Writing on the Canadian health care system could take a up a whole book, and others have done that already, so I'm going to try to hit a few of the pros and cons to the way the system operates here. I've worked in Canadian health care for more than ten years (I'm fairly early on in my career with many years to go). I've worked as a paramedic, a mid-level health services manager, and as an executive for a large regional health authority. I've also worked in the pharmaceutical industry in sales, marketing, and government relations, so my perspective is a bit of an unusual one, so like any opinion, consider the source. :) Generally, Canadians view health care services as a birthright. It was born in Saskatchewan (Canadian province) with the Premier at the time, a guy named Tommy Douglas. Douglas' view was that people shouldn't lose their farm (literally) because they got sick, so the provincial government began covering hospital services through a provincial insurance program. Over time, this caught on and was expanded to all provinces, and was consolidated through the Canada Health Act, a piece of federal legislation that ensures that health care is comprehensive, accessible, portable, universal, and publicly administered. The idea was that people should have care that comprehensive, was not limited by geography, was available to everyone, and was administered on behalf of the public. Douglas was recently voted "The Greatest Canadian" by the public a few years back, so that gives you an idea how important health care is to Canadians. So, what works? Believe it or not, a lot of stuff works really well in the Canadian system. We do a very good job managing urgent and emergent patients who have very immediate needs. If your case requires immediate intervention, you will get immediate intervention. Cancer patients are very well managed with very good outcomes. Patients generally have pretty ready access to primary care, though the more rural the area, the more difficult it is to find a physician. We have good hospitals that do a lot of research and offer cutting edge services. We have highly qualified physicians, surgeons, and nurses, who are recruited around the world for their skills. There are many academic medical centres that do great research and train physicians from around the world. Our health outcomes are pretty good across the board, and we have far more vertically integrated health care systems in Canada, where all services, be they public health, acute care services, residential care, and increasingly, primary care services, are offered under the auspices of one organization whose role is to get all of these parts of the orchestra playing the same tune from the same songbook. Not easy, but some substantial advantages. I also think we do primary care really well - philosphically, I really like the idea of having a family physician who sees patients over a lifetime and who can help to coordinate care among specialists. I think the lack of same in the US is a real challenge for you to overcome. Also, health care in Canada is free for everyone. Whether you're rich or poor, you get the care you need, when you need it, and everyone goes into the same line where they are prioritized by who the sickest person is. What doesn't work? Well, this is where people go a bit haywire in the media about how the Canadian system really operates. The Canadian system basically runs on the triage principle - if you need immediate care and the resources associated, you get it, because we (as a system) focus our needs there. What this means is that if you need a surgical procedure (particularly hip and knee replacements, as well as cataract surgery) that is deemed to be a lower priority relative to cardiac, respiratory, or cancer procedures, you're going to have to wait. As well, the incidence of catracts and large joint arthritis is such that demand for these services are greater than the allocated supply, so you end up waiting a long time. Governments have finally got a handle on this concept and have been investing additional resources to increase resources for these targeted areas. This has helped a lot, but it's far from perfect. One of the other challenges we have is around the adoption of technology in the health care system. One of the stats that is frequently trotted out is how many more MRIs are in use in the United States than in Canada - Canada is slower to adopt these technologies because government, as the single payer, wants to know *exactly* what they're getting for the extra cash. The government can very much act like an insurance company, but different, in that instead of refusing the MRI study at the time of the procedure as an insurance company might, the government pre-empts the dicussion by not allowing the hospital to have the equipment in the first place. The hospital also couldn't buy the machine itself because it couldn't charge anyone for its use when that services is deemed 'medically necessary'. There are also aren't the incentives in the Canadian system to promote innovative approaches to health care. For example, if I'm running a surgical program funding would come in two forms: one was global funding, where I'd get an envelope and they'd say go meet the surgical needs of the community for the next year, or I'd get case-based funding, where I'd get paid x amount per case. In both circumstances, I only had access to x amount of dollars each year. I had no ability to generate revenue to increase my capacity to meet varying needs, nor were their incentives to do more because there would be no payoff for being more innovative. Instead of being measured on my ability to meet the needs of the community, I got measured based on whether I hit my budget targets (first and foremost), and then evaluated on whether or not the community was up in arms, and then somewhere down the road, would be outcomes and patient satisfaction (that never really came up), though it was my main focus. In contrast, if I was running the same program in the US, the more patients I moved through, and the better the outcomes, the more efficient, and therefore, more profitable, we could be. Surgical services really lends itself to the US style of health care, I think. Politics is also a major problem for Canadian health services managers - government, because they foot the bill, wants health organizations to do what is politically expedient. Sometimes that's what's good for the communities, sometimes, it isn't, but almost always, it's what the voice of the public is telling the politicians they want. In that sense, it's representative of the desires of the community, though they don't feel the cost directly because they don't get a bill when they leave the hospital. Another big challenge for Canada is the use of IT and how it relates to patient safety and measuring outcomes. The few outcome measures we have say we're doing a good job, generally, but we don't have the detailed case-level outcomes data that would help us manage the system better. The information is there, but it's generally hidden and inaccessible. We also spend way too much money for the outcomes we get - other countries are spending less money and getting the same or better outcomes, so there appears to be room for improvement. This has ended up being quite long, but hopefully it's of some interest. I'm happy to answer any questions (remember, just my somewhat-informed opinion). SCH
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